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

Chapter 5160-59 | OhioRISE

 
 
 
Rule
Rule 5160-59-01 | OhioRISE: definitions.
 

(A) The definitions set forth in rule 5160-26-01 of the Administrative Code, with the exceptions noted in paragraphs (A)(1) and (A)(2) of this rule, apply to the Ohio resilience through integrated systems and excellence (OhioRISE) rules set forth in Chapter 5160-59 of the Administrative Code. Definitions that reference managed care organizations (MCOs) in Chapter 5160-26 of the Administrative Code apply to the OhioRISE plan.

(1) Definitions that reference rule 5160-26-03 of the Administrative Code are replaced by reference to rule 5160-59-03 of the Administrative Code.

(2) Definitions that reference rule 5160-26-03.1 of the Administrative Code are replaced by reference to rule 5160-59-03.1 of the Administrative Code.

(B) In addition to the definitions set forth in rule 5160-26-01 of the Administrative Code, the following definitions apply to Chapter 5160-59 of the Administrative Code:

(1) "Back-up waiver service plan" means a plan that is in place for substitute coverage of 1915(c) waiver services for a youth when a provider is unable to or unresponsive in providing scheduled services. A back-up plan can include natural supports or other certified providers as the substitute of coverage. The child and family team identifies possible back-up options and includes them in the child and family-centered care plan.

(2) "Care coordination" means the model described in rule 5160-59-03.2 of the Administrative Code.

(3) "Care management entity (CME)" means the agency described in rule 5160-59-03.2 of the Administrative Code.

(4) "Child and adolescent needs and strengths (CANS) assessment" means either the "Ohio Children's Initiative Brief CANS assessment" or the "Ohio Children's Initiative Comprehensive CANS assessment" found at https://www.medicaid.ohio.gov administered by an individual who has successfully completed training and is certified by the Ohio department of medicaid (ODM) designated entity to administer the CANS assessment.

(5) "Child and family-centered care plan" means the individualized, child-centered, strength-based and family-focused plan of services and supports developed by the child and family team (CFT), the care management entity (CME), the OhioRISE plan, or a combination thereof. When including OhioRISE 1915(c) waiver services described in rule 5160-59-05 of the Administrative Code, the child and family-centered care plan will be developed in accordance with rule 5160-44-02 of the Administrative Code for these services.

(6) "Child and family team (CFT)" means a group of people composed of natural supports (relatives, friends, neighbors, etc.) and formal helpers (teachers, therapists, other professionals, etc.), who are involved with the child and family and who play an important role in the child's life.

(7) "Electronic health record (EHR)" means a record in digital format that is a systematic collection of electronic health information. EHRs may contain a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics such as age and weight, and billing information.

(8) "Family" means any individual or caregiver related by blood or affinity whose close association with the person is the equivalent of a family relationship as identified by the person, including kinship and foster care.

(9) "Incident" has the same meaning as in rule 5160-44-05 of the Administrative Code.

(10) "Individual Crisis and Safety Plan" means a plan developed through care coordination and the child and family team (CFT) to determine specific steps to ensure child and family safety and reduce the risk of harm in the home and community. The individual crisis and safety plan should include individualized, trauma-informed, interventions and de-escalation strategies. The individual crisis and safety plan encompasses what is also referred to as a behavior support plan, which details when an individual's intensive behavior warrants the use of restraints, seclusion, or restrictive intervention to ensure the safety of the individual and those with whom they interact. For members with behaviors that pose safety concerns for the member or others, the interventions and de-escalation strategies should be designed with the goal of preventing the use of restraints, seclusion, or restrictive interventions.

(11) "Natural supports" means a uniquely identified network of individuals or groups upon which a primary caregiver or the member rely for voluntary assistance in addressing the member's behavioral health diagnosis, community integration, and management of typical activities of daily living.

(12) "OhioRISE plan" means a prepaid inpatient health plan (PIHP) as defined in C.F.R. 438.2 (October 1, 2021) and a health insuring corporation (HIC) as defined in Ohio Rev. Code 1751.01 which enters into an OhioRISE plan provider agreement with ODM.

(13) "System of care" means a spectrum of effective, community-based services and supports for children and youth with, or at risk for, mental health or other challenges and their families. The system of care is organized into a coordinated network, builds meaningful partnerships with families and youth, and addresses their cultural and linguistic needs in order to help them function better at home, in school, in the community, and throughout life.

(14) "Telehealth" has the same meaning as in rule 5160-1-18 of the Administrative Code.

Last updated July 1, 2022 at 1:12 PM

Supplemental Information

Authorized By: 5167.02, 5162.02
Amplifies: 5162.03, 5167.10
Five Year Review Date: 7/1/2027
Rule 5160-59-01.1 | OhioRISE: application of general managed care rules.
 

(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan has to adhere to all of the requirements applicable to managed care organizations (MCOs) or managed care entities (MCEs) in the following rules:

(1) Rule 5160-26-05 of the Administrative Code with the exception of paragraphs (B)(4), (B)(5), (D)(21), (D)(25), and (D)(26);

(2) Rule 5160-26-05.1 of the Administrative Code with the exception of paragraph (B)(1);

(3) Rule 5160-26-06 of the Administrative Code;

(4) Rule 5160-26-08.3 of the Administrative Code with the exception of paragraphs (A)(19) and (A)(25);

(5) Rule 5160-26-08.4 of the Administrative Code;

(6) Rule 5160-26-09.1 of the Administrative Code;

(7) Rule 5160-26-10 of the Administrative Code with the exceptions of paragraphs (B)(2)(c), (B)(2)(d), and (B)(2)(e); and

(8) Rule 5160-26-11 of the Administrative Code.

(B) For all rules listed in paragraph (A) of this rule, the following provisions apply to the OhioRISE program described in Chapter 5160-59 of the Administrative Code:

(1) All references to rule 5160-26-01 of the Administrative Code are replaced by references to rule 5160-59-01 of the Administrative Code.

(2) All references to rule 5160-26-02 and 5160-26-02.1 of the Administrative Code are replaced by references to rule 5160-59-02 of the Administrative Code.

(3) All references to rule 5160-26-03 of the Administrative Code are replaced by references to rule 5160-59-03 of the Administrative Code.

(4) All references to rule 5160-26-03.1 of the Administrative Code are replaced by references to rule 5160-59-03.1 of the Administrative Code.

(C) The following rules in Chapter 5160-26 of the Administrative Code do not apply to OhioRISE:

(1) Rule 5160-26-02 of the Administrative Code;

(2) Rule 5160-26-02.1 of the Administrative Code;

(3) Rule 5160-26-03 of the Administrative Code;

(4) Rule 5160-26-03.1 of the Administrative Code.

Last updated July 1, 2022 at 1:13 PM

Supplemental Information

Authorized By: 5167.02, 5162.02
Amplifies: 5162.03, 5167.10
Five Year Review Date: 7/1/2027
Rule 5160-59-02 | OhioRISE: eligibility and enrollment.
 

(A) To be eligible for enrollment in the Ohio resilience through integrated systems and excellence (OhioRISE) program, an individual has to meet the criteria for first day eligibility and enrollment in rule 5160-59-02.1 of the Administrative Code or the criteria in paragraphs (A)(1) to (A)(3) and either paragraph (A)(4), (A)(5), (A)(6) or (B) of this rule.

(1) Be twenty years of age or younger at the time of enrollment;

(2) Be determined eligible for Ohio medicaid in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code;

(3) Not be enrolled in a MyCare Ohio plan as described in Chapter 5160-58 of the Administrative Code;

(4) For youth age six through twenty years of age, have an Ohio children's initiative brief or comprehensive "child and adolescent needs and strengths" (CANS) assessment, using the tool available on https://www.medicaid.ohio.gov (September 20, 2021), and completed by a certified Ohio CANS assessor within ninety days prior to eligibility determination that indicates paragraph (A)(4)(a) and either paragraph (A)(4)(b) or (A)(4)(c) of this rule have been met:

(a) For behavioral/emotional needs domain items, at least one of the following items is dangerous or disabling and needs immediate action or at least one of the following items is interfering with functioning and needs action to ensure that the identified need is addressed:

(i) Psychosis;

(ii) Impulsivity/hyperactivity;

(iii) Depression;

(iv) Anxiety;

(v) Oppositional behavior;

(vi) Conduct;

(vii) Adjustment to trauma;

(viii) Anger control;

(ix) Substance use;

(x) Eating disturbance;

(xi) Attachment difficulties;

(xii) For youth age fourteen or older, interpersonal problems.

(b) For risk behavior domain items, at least one of the following items is dangerous or disabling and needs immediate action or at least one of the following items is interfering with functioning and needs action to ensure that the identified need is addressed:

(i) Suicide risk;

(ii) Non-suicidal self-injury behavior;

(iii) Other self-harm;

(iv) Danger to others;

(v) Delinquent behavior;

(vi) Runaway;

(vii) Intentional misbehavior;

(viii) Fire setting;

(ix) Victimization/exploitation;

(x) Sexually problematic behavior.

(c) For life functioning domain items, at least one of the following items is dangerous or disabling and needs immediate action or at least one of the following items is interfering with functioning and needs action to ensure that the identified need is addressed:

(i) Family functioning;

(ii) Living situation;

(iii) Social functioning;

(iv) Sleep;

(v) School.

(5) For youth age birth through five years of age, have an Ohio children's initiative brief or comprehensive CANS assessment, using the tool available on https://www.medicaid.ohio.gov (September 20, 2021), and completed by a certified Ohio children's initiative CANS assessor within ninety days prior to eligibility determination that indicates paragraph (A)(5)(a) and either paragraph (A)(5)(b), (A)(5)(c), or (A)(5)(d) of this rule have been met:

(a) For early childhood challenge domain items, at least one of the following items is dangerous or disabling and needs immediate action or at least one of the following items is interfering with functioning and needs action to ensure that the identified need is addressed:

(i) Impulsivity/hyperactivity;

(ii) Depression;

(iii) Anxiety;

(iv) Oppositional behavior;

(v) Attachment difficulties;

(vi) Adjustment to trauma;

(vii) Regulatory.

(b) For caregiver resources and needs domain items, at least one of the following items is dangerous or disabling and needs immediate action or at least one of the following items is interfering with functioning and needs action to ensure that the identified need is addressed:

(i) Supervision;

(ii) Residential stability;

(iii) Medical/physical;

(iv) Mental health;

(v) Substance use;

(vi) Developmental;

(vii) Family stress;

(viii) Caregiver post-traumatic stress reaction;

(ix) Marital/partner violence;

(x) Family relationship with the system;

(xi) Legal involvement;

(xii) Early childhood domain item developmental/ intellectual.

(c) The caregiver resources and needs domain item "safety" is identified as a need that at least needs monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.

(d) For early childhood domain items, at least one of the following items is dangerous or disabling and needs immediate action or at least one of the following items is interfering with functioning and needs action to ensure that the identified need is addressed:

(i) Sleep;

(ii) Family functioning;

(iii) Early education;

(iv) Social and emotional functioning;

(v) Medical/physical;

(vi) Failure to thrive.

(6) For youth who meet one of the following but do not meet the criteria in paragraph (A)(4) or (A)(5) of this rule;

(a) Meets the criteria for moderate care coordination as described in paragraph (A)(1) or (A)(3) of rule 5160-59-03.2 of Administrative Code; or

(b) Meets the criteria to receive intensive home-based treatment (IHBT) service as described in rule 5122-29-28 of the Administrative Code.

(B) Youth who meet the criteria in paragraphs (A)(1) to (A)(3) of this rule are eligible for OhioRISE enrollment under any of the following conditions and will remain in OhioRISE until the youth meets the criteria for disenrollment in paragraph (D) of this rule.

(1) Be an inpatient in a hospital, as defined in in Chapter 5160-2 of the Administrative Code, with a primary diagnosis of mental illness or substance use disorder.

(2) Be an inpatient in a psychiatric residential treatment facility (PRTF), as described in 42 CFR 441.150 to 42 CFR 441.184 (October 1, 2021).

(C) Enrollment in OhioRISE is mandatory for eligible youth who meet the criteria in paragraph (A) or (B) of this rule. Except for youth eligible for first day eligibility and enrollment in rule 5160-59-02.1 of the Administrative Code, enrollment begins the earlier of:

(1) The submission date of the CANS assessment that determines the youth meets the criteria in paragraph (A)(4), (A)(5), or (A)(6)(a) of this rule; or

(2) The date of admission to an inpatient hospital with a primary diagnosis of mental illness or substance use disorder; or

(3) The date of admission to a PRTF as described in paragraph (B)(2) of this rule; or

(4) The effective date of enrollment in the OhioRISE 1915(c) waiver as described in rule 5160-59-04 of the Administrative Code.

(5) The date the youth met criteria for IHBT in paragraph (A)(6)(b) of this rule.

(D) Disenrollment from OhioRISE occurs upon the earliest of any of the following:

(1) The last day of the following month when the youth:

(a) Turns twenty-one years of age, except for as described in paragraph (D)(2) of this rule; or

(b) Has already been enrolled in OhioRISE for at least three hundred sixty-five continuous days and subsequently:

(i) Has not had a CANS assessment meeting the eligibility criteria in paragraph (A)(4), (A)(5), or (A)(6)(a) of this rule; and

(ii) Does not meet the criteria for IHBT in paragraph (A)(6)(b) of this rule; and

(iii) Has not experienced either of the conditions described in paragraph (B)(1) or (B)(2) of this rule in the last three hundred sixty-five days.

(2) Youth who are receiving inpatient psychiatric services in a hospital or PRTF upon turning twenty-one years of age, will remain enrolled in OhioRISE until the youth is discharged or upon turning twenty-two years of age, whichever occurs first.

(3) The date the youth begins enrollment in a MyCare Ohio plan, as described in Chapter 5160-58 of the Administrative Code.

(4) The date of the youth's death.

(5) The date the youth is no longer eligible for medicaid.

(E) Member initiated disenrollment.

(1) In accordance with 42 C.F.R. 438.56(d)(2) (October 1, 2021), a change or termination of OhioRISE plan enrollment may be permitted for any of the following just cause reasons:

(a) The youth moves out of the OhioRISE plan's service area;

(b) The OhioRISE plan does not, for moral or religious objections, cover the service the youth seeks;

(c) The youth needs related services to be performed at the same time, not all related services are available within the OhioRISE plan's network, and the youth's primary care provider or another provider determines that receiving services separately would subject the youth to unnecessary risk;

(d) The youth has experienced poor quality of care and the services are not available from another provider within the OhioRISE plan's network; or

(e) The youth cannot access medically necessary medicaid-covered services or cannot access the type of providers experienced in dealing with the youth's care needs.

(2) The following provisions apply when a youth seeks a termination in OhioRISE enrollment for just cause:

(a) The youth will contact the OhioRISE plan to identify providers of services before seeking a determination of just cause from ODM.

(b) The youth may make the request for just cause directly to ODM or an ODM-approved entity, either orally or in writing.

(c) ODM will review all requests for just cause within seven working days of receipt. ODM may request documentation as necessary from both the youth and the OhioRISE plan. ODM will make a decision within forty-five days from the date ODM receives the just cause request. If ODM fails to make the determination within this timeframe, the just cause request is considered approved.

(d) ODM may establish retroactive termination dates and recover capitation payments as determined necessary and appropriate.

(e) The effective date of an approved just cause request will be no later than the first day of the second month following the month in which the member requests change or termination.

(f) Requests for just cause may be processed at the individual level or case level as ODM determines necessary and appropriate.

(F) If a youth is denied enrollment in the program pursuant to paragraph (A) or (B) of this rule, is disenrolled from the program pursuant to paragraph (D) of this rule, or if the youth-initiated disenrollment is denied pursuant to paragraph (E) of this rule, the youth will be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

Last updated January 3, 2023 at 9:26 AM

Supplemental Information

Authorized By: 5162.02, 5167.02
Amplifies: 5162.03, 5166.02, 5167.02, 5167.10
Five Year Review Date: 7/1/2027
Prior Effective Dates: 7/1/2022
Rule 5160-59-02.1 | OhioRISE: first day eligibility and enrollment.
 

(A) Scope. This rule sets forth the provisions for eligibility and enrollment into Ohio resilience through integrated systems and excellence (OhioRISE) on the first day the program is effective. Individuals that do not meet the OhioRISE first day eligibility criteria described in paragraph (B) of this rule will have the opportunity to be enrolled in OhioRISE as set forth in rule 5160-59-02 of the Administrative Code.

(B) Eligibility. For individuals who meet criteria in paragraphs (B)(1) to (B)(4) of this rule, enrollment will be mandatory in the OhioRISE program on the first day the program is in effect:

(1) Be twenty years of age or younger;

(2) Be determined eligible for Ohio medicaid in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code;

(3) Not enrolled in a MyCare Ohio plan as described in Chapter 5160-58 of the Administrative Code on the first day the program is in effect; and

(4) Meet one or more of the following criteria:

(a) Within six months prior to the effective date of the OhioRISE program had an admission into an out of state psychiatric residential treatment facility (PRTF) as defined in 42 C.F.R. 441.150 (October 1, 2021) through 42 C.F.R. 441.184 (October 1, 2021), or had an inpatient admission to a hospital, as defined in Chapter 5160-2 of the Administrative Code, with a primary diagnosis of mental illness or substance use disorder; or

(b) Within three months prior to the effective date of the OhioRISE program:

(i) Received intensive home-based treatment (IHBT) as described in rule 5160-27-05 of the Administrative Code; or

(ii) Met the criteria described in either paragraph (A)(4) or (A)(5) in rule 5160-59-02 of the Administrative Code; or

(iii) Received the intensive behavioral support rate add-on at an intermediate care facility for individuals with intellectual disabilities as described in rule 5123-7-28 of the Administrative Code; or

(iv) Be seventeen years of age or younger and receive services in a developmental center as defined in section 5124.01 of the Ohio Revised Code; or

(c) Within two months prior to the effective date of the OhioRISE program:

(i) Received substance use disorder residential treatment services as described in rule 5122-29-09 of the Administrative Code; or

(ii) While in the custody of a Title IV-E agency as defined in rule 5101:2-1-01 of the Administrative Code, was placed in a children's residential center or was a parent in a residential parenting facility as described in rule 5101:2-9 of the Administrative Code.

(C) For individuals enrolled by meeting the criteria in paragraph (B) of this rule, the conditions for disenrollment from OhioRISE set forth in rule 5160-59-02 of the Administrative Code apply.

Last updated December 22, 2022 at 8:37 AM

Supplemental Information

Authorized By: 5164.02, 5166.02, 5167.02
Amplifies: 5164.02, 5166.02, 5167.02, 5167.10
Five Year Review Date: 7/1/2027
Rule 5160-59-03 | OhioRISE: covered services.
 

(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan has to ensure:

(1) Services are sufficient in amount, duration, and scope to reasonably be expected to achieve the purpose for which the services are provided;

(2) The amount, duration, and scope of a medically necessary service is not arbitrarily denied or reduced solely because of the diagnosis, type of illness, or condition;

(3) Prior authorization is available for services on which the OhioRISE plan has placed a preidentified limitation to ensure the limitation may be exceeded when medically necessary;

(4) Coverage decisions are based on the coverage and medical necessity criteria published in agency 5160 of the Administrative Code and practice guidelines specified in rule 5160-26-05.1 of the Administrative Code; and

(5) If a member is unable to obtain medically necessary services described in this rule through an OhioRISE plan network provider, the OhioRISE plan has to adequately and timely cover the services out of network, until the OhioRISE plan is able to provide the services from a network provider.

(6) Providers delivering services in the OhioRISE program will adhere to the incident management criteria set forth in rule 5160-44-05 of the Administrative Code.

(B) The OhioRISE plan has to ensure members have access to the following services when medically necessary:

(1) Care coordination as described in rule 5160-59-03.2 of the Administrative Code.

(2) Intensive home-based treatment (IHBT) as described in rule 5160-59-03.3 of the Administrative Code.

(3) Respite services for members twenty years of age or younger with behavioral health needs in accordance with rule 5160-59-03.4 of the Administrative Code.

(4) Inpatient hospital services provided in accordance with Chapter 5160-2 of the Administrative Code in a free-standing psychiatric hospital or a general acute care hospital that are:

(a) Inpatient psychiatric services; or

(b) Inpatient substance use disorder (SUD) services (including withdrawal management) provided in accordance with American society of addiction medicine (ASAM) level of care four.

(5) Psychiatric residential treatment facility (PRTF) services as described in 42 C.F.R. 441.150 (October 1, 2021) through 42 C.F.R 441.184 (October 1, 2021).

(6) Opioid treatment program (OTP) services delivered by community SUD programs licensed by Ohio department of mental health and addiction services and/or certified by the substance abuse and mental health services administration (SAMHSA) as an OTP.

(7) Behavioral health services provided in accordance with Chapter 5160-27 of the Administrative Code.

(8) Behavioral health services provided in accordance with rule 5160-8-05 of the Administrative Code.

(9) Behavioral health services rendered by psychiatrists and physician assistants under the supervision of psychiatrists in accordance with Chapter 5160-4 of the Administrative Code and psychiatric advanced practice registered nurses in accordance with rule 5160-4-04 of the Administrative Code.

(10) Behavioral health services rendered by outpatient hospital providers in accordance with Chapter 5160-2 of the Administrative Code except for emergency department services.

(11) Behavioral health services rendered in federally qualified health centers (FQHCs) and rural health clinics (RHCs) in accordance with Chapter 5160-28 of the Administrative Code.

(12) Physician administered drugs in accordance with rule 5160-4-12 of the Administrative Code for the treatment of mental health and SUD conditions.

(13) Primary flex funds as described in rule 5160-59-03.5 of the Administrative Code.

(14) Services and supports included in the OhioRISE 1915(c) home and community-based services waiver in accordance with rule 5160-59-05 of the Administrative Code.

(C) The OhioRISE plan may place appropriate limits on a service:

(1) On the basis of medical necessity for the member's condition or diagnosis; or

(2) For the purposes of utilization control, provided the services can be reasonably expected to achieve their purpose as specified in paragraph (A)(1) of this rule.

(D) The OhioRISE plan has to ensure that the services described in paragraph (B) of this rule that are emergency services, as described in rule 5160-26-01 of the Administrative Code, are provided and covered twenty-four hours a day, seven days a week. At a minimum, covered services described in paragraph (B) of this rule that are emergency services have to be provided and reimbursed in accordance with the following:

(1) The OhioRISE plan will not deny reimbursement for treatment obtained when a member had an emergency medical condition.

(2) The OhioRISE plan cannot limit what constitutes an emergency medical condition on the basis of diagnoses or symptoms.

(3) The OhioRISE plan has to cover emergency services without requiring prior authorization.

(4) The OhioRISE plan has to cover services as described in paragraph (B) in this rule related to the member's emergency medical condition when the member is instructed to go to an emergency facility by a representative of the OhioRISE plan, the member's managed care organization (MCO), or the member's primary care provider (PCP).

(5) The OhioRISE plan cannot deny reimbursement of emergency services based on the treating provider, hospital, or fiscal representative not notifying the member's PCP of the visit.

(6) The OhioRISE plan has to cover the services described in paragraph (B) of this rule that are emergency services when the services are delivered by a non-contracting provider of emergency services. Such services will be reimbursed by the OhioRISE plan at the lesser of billed charges or one hundred per cent of the Ohio medicaid program fee-for-service reimbursement rate (less any reimbursements for indirect costs of medical education and direct costs of graduate medical education that is included in the Ohio medicaid program fee-for-service reimbursement rate) in effect for the date of service. If an inpatient admission results, the OhioRISE plan has to reimburse at this rate only until the member can be transferred to a provider designated by the OhioRISE plan.

(7) The OhioRISE plan has to cover the services as described in paragraph (B) of this rule that are emergency services until the member is stabilized and can be safely discharged or transferred.

(8) The OhioRISE plan has to adhere to the judgment of the attending provider when the attending provider requests a member's transfer to another facility or discharge. The OhioRISE plan may establish arrangements with hospitals whereby the OhioRISE plan may designate one of its contracting providers to assume the attending provider's responsibilities to stabilize, treat and transfer the member.

(9) A member who has had an emergency medical condition will not be held liable for reimbursement of any subsequent screening and treatment needed to diagnose the specific condition or stabilize the member.

(E) The OhioRISE plan has to establish, in writing, the process and procedures for the submission of claims for services delivered by non-contracting providers, including non-contracting providers of emergency services. Such information will be made available upon request to non-contracting providers, including non-contracting providers of emergency services. The OhioRISE plan will not establish claims filing and processing procedures for non-contracting providers, including non-contracting providers of emergency services, that are more stringent than those established for their contracting providers.

(F) The OhioRISE plan has to ensure any services described in paragraph (B) of this rule that are post-stabilization care services, as described in rule 5160-26-01 of the Administrative Code, are provided and covered twenty-four hours a day, seven days a week.

(1) The OhioRISE plan has to designate a telephone line that is available twenty-four hours a day to receive provider requests for coverage of post-stabilization care services. The OhioRISE plan has to document that the telephone number and process for obtaining authorization has been provided to each emergency facility in the service area. The OhioRISE plan has to maintain a record of any request for coverage of post-stabilization care services that is denied including, at a minimum, the time of the provider's request and the time the OhioRISE plan communicated the decision in writing to the provider.

(2) At a minimum, the services described in paragraph (B) of this rule that are post-stabilization care services have to be provided and reimbursed in accordance with the following:

(a) The OhioRISE plan has to cover services obtained within or outside the OhioRISE plan's network that are pre-approved in writing to the requesting provider by a plan provider or other OhioRISE plan representative.

(b) The OhioRISE plan has to cover services obtained within or outside the OhioRISE plan's network that are not pre-approved by a plan provider or other OhioRISE plan representative but are administered to maintain the member's stabilized condition within one hour of a request to the OhioRISE plan for pre-approval of further post-stabilization care services.

(c) The OhioRISE plan has to cover services obtained within or outside the OhioRISE plan's network that are not pre-approved by a plan provider or other OhioRISE plan representative but are administered to maintain, improve or resolve the member's stabilized condition if:

(i) The OhioRISE plan fails to respond within one hour to a provider request for authorization to provide such services;

(ii) The provider has documented an attempt to contact the OhioRISE plan to request authorization, but the OhioRISE plan cannot be contacted; or

(iii) The OhioRISE plan's representative and treating provider cannot reach an agreement concerning the member's care and a plan provider is not available for consultation. In this situation, the OhioRISE plan will give the treating provider the opportunity to consult with an OhioRISE plan provider and the treating provider may continue with care until a plan provider is reached or one of the criteria specified in paragraph (F)(3) of this rule is met.

(3) The OhioRISE plan's financial responsibility for services described in paragraph (B) of this rule that are post-stabilization care services not pre-approved ends when:

(a) An OhioRISE plan provider with privileges at the treating hospital assumes responsibility for the member's care;

(b) An OhioRISE plan provider assumes responsibility for the member's care through transfer;

(c) An OhioRISE plan representative and the treating provider reach an agreement concerning the member's care; or

(d) The member is discharged.

(G) OhioRISE plan responsibilities for reimbursement of other services.

(1) ODM may approve referral of the OhioRISE plan's members to certain OhioRISE plan non-contracting hospitals, as specified in rule 5160-26-11 of the Administrative Code, for non-emergency hospital services that are OhioRISE covered services as described in paragraph (B) of this rule. When ODM permits such authorization, ODM will notify the OhioRISE plan and the OhioRISE plan's non-contracting hospital of the terms and conditions of the approval, including the duration, and the OhioRISE plan will reimburse the OhioRISE plan's non-contracting hospital at one hundred per cent of the current Ohio medicaid program fee-for-service reimbursement rate in effect for the date of service for all medicaid-covered non-emergency hospital services delivered by the OhioRISE plan's non-contracting hospital. ODM will base its determination of when an OhioRISE plan's members can be referred to an OhioRISE plan non-contracting hospital pursuant to the following:

(a) The OhioRISE plan's submission of a written request to ODM for the approval to refer members to a hospital that has declined to contract with the OhioRISE plan. The request will document the OhioRISE plan's contracting efforts and why the OhioRISE plan believes it will be necessary for members to be referred to this hospital; and

(b) ODM consultation with the OhioRISE plan non-contracting hospital to determine the basis for the hospital's decision to decline to contract with the OhioRISE plan, including but not limited to whether the OhioRISE plan's contracting efforts were unreasonable and/or that contracting with the OhioRISE plan would have adversely impacted the hospital's business.

(2) Paragraph (G)(1) of this rule is not applicable when the OhioRISE plan and an OhioRISE plan non-contracting hospital have mutually agreed that the non-contracting hospital will provide non-emergency OhioRISE covered hospital services to the OhioRISE plan's members. The OhioRISE plan will ensure that such arrangements comply with rule 5160-26-05 of the Administrative Code.

(3) The OhioRISE plan is not responsible for reimbursement of services provided through the medicaid school program (MSP) pursuant to Chapter 5160-35 of the Administrative Code. The OhioRISE plan will ensure access to services described in paragraph (B) of this rule for members who are unable to timely access services or are unwilling to access services through MSP providers.

(4) The OhioRISE plan is not required to cover services provided to members outside the United States.

(5) The OhioRISE plan will ensure that eligible members receive all behavioral health early and periodic screening, diagnosis and treatment (EPSDT) services in accordance with rule 5160-1-14 of the Administrative Code.

Last updated July 1, 2022 at 1:11 PM

Supplemental Information

Authorized By: 5162.03, 5167.02, 5167.10
Amplifies: 5162.03, 5167.02, 5167.03, 5167.04, 5167.10, 5167.12
Five Year Review Date: 7/1/2027
Rule 5160-59-03.1 | OhioRISE: utilization management.
 

(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan will have a utilization management (UM) program with clearly defined structures and processes designed to maximize the effectiveness of the care provided to the member.

(1) The OhioRISE plan has to ensure decisions rendered through the UM program are based on medical necessity.

(2) The UM program has to be based on written policies and procedures that include, at a minimum:

(a) The information sources used to make determinations of medical necessity;

(b) The criteria, based on sound clinical evidence, to make UM decisions and the specific procedures for appropriately applying the criteria;

(c) A specification that written UM criteria will be made available to both contracting and non-contracting providers; and

(d) A description of how the OhioRISE plan will monitor the impact of the UM program to detect and correct potential under-and over-utilization.

(3) The OhioRISE plan's UM program has to ensure and document the following:

(a) An annual review and update of the UM program;

(b) The involvement of a designated senior physician in the UM program;

(c) The use of appropriate qualified licensed health professionals to assess the clinical information used to support UM decisions;

(d) Review and consideration of the child and family centered care plan;

(e) The use of board-certified consultants to assist in making medical necessity determinations, as necessary;

(f) That UM decisions are consistent with clinical practice guidelines as specified in rule 5160-26-05.1 of the Administrative Code. The OhioRISE plan may not impose conditions around the coverage of a medically necessary-covered service unless they are supported by such clinical practice guidelines;

(g) The reason for each denial of a service, based on sound clinical evidence;

(h) That compensation by the OhioRISE plan to individuals or entities that conduct UM activities does not offer incentives to deny, limit, or discontinue medically necessary services to any member; and

(i) Adherence to the Mental Health Parity and Addiction Equity Act (MHPAEA) requirements outlined in 42 CFR Part 438 Subpart K (October 1, 2021).

(B) The OhioRISE plan has to process requests for initial and continuing authorizations of services from their providers and members.

(1) The OhioRISE plan has to have written policies and procedures to process requests. Upon request, the OhioRISE plan's policies and procedures have to be made available for review by the Ohio department of medicaid (ODM).

(2) The OhioRISE plan's written policies and procedures for initial and continuing authorization of services have to also be made available to contracting and non-contracting providers upon request.

(C) The OhioRISE plan has to ensure and document the following occurs when processing requests for initial and continuing authorizations of services:

(1) Consistent application of review criteria for authorization decisions.

(2) Consultation with the requesting provider, when necessary.

(3) Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested has to be made by a health care professional who has appropriate clinical expertise in treating the member's condition or disease.

(4) That a written notice will be sent to the member and the requesting provider of any decision to reduce, suspend, terminate, or deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice to the member has to meet the requirements of division 5101:6 and rule 5160-26-08.4 of the Administrative Code.

(5) For standard authorization decisions, the OhioRISE plan has to provide notice to the provider and member as expeditiously as the member's health condition requires but no later than ten calendar days following receipt of the request for service. If requested by the member, provider, or the OhioRISE plan, standard authorization decisions may be extended up to fourteen additional calendar days. If requested by the OhioRISE plan, the OhioRISE plan has to submit to ODM for prior-approval, documentation as to how the extension is in the member's interest. If ODM approves the OhioRISE plan's extension request, the OhioRISE plan has to give the member written notice of the reason for the decision to extend the time frame and inform the member of the right to file a grievance if the member disagrees with that decision. The OhioRISE plan has to carry out its determination as expeditiously as the member's health condition requires and no later than the date the extension expires.

(6) If a provider indicates or the OhioRISE plan determines that following the standard authorization timeframe could seriously jeopardize the member's life or health or ability to attain, maintain, or regain maximum function, the OhioRISE plan has to make an expedited authorization decision and provide notice of the authorization decision as expeditiously as the member's health condition requires but no later than forty-eight hours after receipt of the request for service. If requested by the member or OhioRISE plan, expedited authorization decisions may be extended up to fourteen additional calendar days. If requested by the OhioRISE plan, the OhioRISE plan has to submit to ODM for prior-approval, documentation as to how the extension is in the member's interest. If ODM approves the OhioRISE plan's extension request, the OhioRISE plan has to give the member written notice of the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if he or she disagrees with that decision. The OhioRISE plan has to carry out its determination as expeditiously as the member's health condition requires and no later than the date the extension expires.

(D) The OhioRISE plan has to maintain and submit as directed by ODM a record of all authorization requests, including standard and expedited authorization requests and any extensions granted. The OhioRISE plan's records have to include member identifying information, service requested, date initial request received, any extension requests, decision made, date of decision, date of member notice, and basis for denial, if applicable.

Last updated July 1, 2022 at 1:12 PM

Supplemental Information

Authorized By: 5162.03, 5167.02
Amplifies: 5162.02, 5162.03, 5167.02
Five Year Review Date: 7/1/2027
Rule 5160-59-03.2 | OhioRISE: care coordination.
 

(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan will assign a care coordination tier for all youth eligible for enrollment in the OhioRISE plan. Tier assignment of limited, moderate, or intensive is based on assessed or indicated needs and may be modified to be based on individual circumstances or to best fit the youth or family capacity and choice.

(1) Moderate care coordination (MCC) is recommended for youth six years of age and older when paragraph (A)(1)(a) and either paragraph (A)(1)(b) or (A)(1)(c) of this rule are met:

(a) An Ohio children's initiative child and adolescent needs and strengths (CANS) assessment, the tool available on https://www.medicaid.ohio.gov (September 20, 2021), indicates for behavioral/emotional needs domain items, at least one of the following items is dangerous or disabling and needs immediate action or two or more of the following items are at least interfering with functioning and need action to ensure that the identified need is addressed:

(i) psychosis;

(ii) impulsivity/hyperactivity;

(iii) depression;

(iv) anxiety;

(v) oppositional behavior;

(vi) conduct;

(vii) adjustment to trauma;

(viii) anger control;

(ix) substance use;

(x) eating disturbance;

(xi) interpersonal problems (for youth age fourteen and older);

(b) For risk behavior domain items, at least one of the following items is dangerous or disabling and needs immediate action or two or more of the following items are interfering with functioning and need action to ensure that the identified behavior is addressed:

(i) suicide risk;

(ii) non-suicidal self-injury behavior;

(iii) other self-harm;

(iv) danger to others;

(v) delinquent behavior;

(vi) runaway;

(vii) intentional misbehavior;

(viii) fire setting;

(ix) victimization/exploitation;

(x) sexually problematic behavior;

(c) For life functioning domain items, at least one of the following items is dangerous or disabling and needs immediate action or two or more of the following items are interfering with functioning and need action to ensure that the identified need is addressed:

(i) family functioning;

(ii) living situation;

(iii) social functioning;

(iv) developmental/intellectual;

(v) legal;

(vi) medical/physical;

(vii) sleep;

(viii) decision making;

(ix) school.

(2) Intensive care coordination (ICC) is recommended for youth six years of age and older when:

(a) Criteria for MCC are met as described in paragraph (A)(1) of this rule; and

(b) An Ohio children's initiative CANS assessment, the tool available on https://www.medicaid.ohio.gov (September 20, 2021), indicates for caregiver resources and needs domain items, at least one of the following items is dangerous or disabling and needs immediate action or two or more of the following items are at least interfering with functioning and need action to ensure that the identified need is addressed:

(i) supervision;

(ii) knowledge;

(iii) residential stability;

(iv) medical/ physical;

(v) mental health;

(vi) substance use;

(vii) family stress;

(3) MCC is recommended for youth under six years of age when paragraphs (A)(3)(a), (A)(3)(b), and either paragraph (A)(3)(c) or (A)(3)(d) of this rule are met.

(a) An Ohio children's initiative CANS assessment, the tool available on https://www.medicaid.ohio.gov (September 20, 2021), indicates for early childhood domain items, at least one of the following items is dangerous or disabling and needs immediate action or two or more of the following items are at least interfering with functioning and need action to ensure that the identified behavior is addressed:

(i) impulsivity/hyperactivity;

(ii) depression;

(iii) anxiety;

(iv) oppositional behavior;

(v) adjustment to trauma;

(vi) regulatory;

(b) For caregiver resources and needs domain items, at least one of the following items prevents the provision of care and needs immediate and/or intensive action or at least one of the following items is interfering with the provision of care and action is needed to ensure that the identified need is addressed:

(i) supervision;

(ii) residential stability;

(iii) medical/physical;

(iv) mental health;

(v) substance use;

(vi) developmental;

(vii) family stress;

(viii) caregiver post-traumatic stress reaction;

(ix) marital/partner violence;

(x) family relationship with the system;

(xi) legal involvement;

(xii) early childhood domain item developmental/intellectual;

(c) For early childhood domain items, at least one of the following items is dangerous or disabling and needs immediate action or at two or more of the following items are at least interfering with functioning and need action to ensure that the identified need is addressed:

(i) sleep;

(ii) family functioning;

(iii) early education;

(iv) social and emotional functioning;

(v) medical/physical;

(vi) failure to thrive;

(d) For early childhood domain items, at least one of the following items is dangerous or disabling and needs immediate action or at least one of the following items is interfering with functioning and needs action to ensure that the identified need is addressed:

(i) aggressive behaviors;

(ii) atypical behaviors;

(iii) self-harm;

(iv) exploited;

(v) problematic sexual behavior.

(4) ICC is recommended for youth under six years of age when paragraphs (A)(4)(a), (A)(4)(b) and either paragraph (A)(4)(c) or (A)(4)(d) of this rule are met.

(a) An Ohio children's initiative CANS assessment, the tool available on https://www.medicaid.ohio.gov (September 20, 2021) indicates for early childhood domain items, at least one of the following items is dangerous or disabling and needs immediate action or two or more of the following items are at least interfering with functioning and need action to ensure that the identified behavior is addressed:

(i) impulsivity/hyperactivity;

(ii) depression;

(iii) anxiety;

(iv) oppositional behavior;

(v) adjustment to trauma;

(vi) regulatory;

(b) For caregiver resources and needs domain items, two or more of the following items prevents the provision of care and needs immediate and needs immediate and/or intensive action or three or more of the following items are at least interfering with the provision of care and action is needed to ensure that the identified need is addressed:

(i) supervision;

(ii) residential stability;

(iii) medical/physical;

(iv) mental health;

(v) substance use;

(vi) developmental;

(vii) family stress;

(viii) caregiver post-traumatic stress reaction;

(ix) marital/partner violence;

(x) family relationship with the system;

(xi) legal involvement;

(xii) early childhood domain item developmental/intellectual;

(c) For early childhood domain items, at least one of the following items is dangerous or disabling and needs immediate action or two or more of the following items are at least interfering with functioning and need action to ensure that the identified behavior is addressed:

(i) sleep;

(ii) family functioning;

(iii) early education;

(iv) social and emotional functioning;

(v) medical/physical;

(vi) failure to thrive;

(d) For early childhood domain items, at least one of the following items is dangerous or disabling and needs immediate action or at least one of the following items is interfering with functioning and needs action to ensure that the identified need is addressed:

(i) aggressive behaviors;

(ii) atypical behaviors;

(iii) self-harm;

(iv) exploited;

(v) problematic sexual behavior.

(5) MCC or ICC may also be recommended when the CANS assessment alone does not indicate MCC or ICC as described in paragraphs (A)(1) through (A)(4) of this rule, but other documentation supports the need for the frequency and intensity of MCC or ICC activities. Other supporting documentation that provides clinical justification may include a comprehensive assessment, psychological evaluation, biopsychosocial assessment, or documentation illustrating a history of unsuccessful past services.

(6) Limited care coordination delivered by the OhioRISE plan is recommended when the youth's needs do not meet the ICC or MCC recommendations, or for youth that meet criteria for ICC or MCC but decline to participate in ICC or MCC.

(7) Denials of assignment to ICC or MCC are subject to the appeal process described in rule 5160-26-08.4 of the Administrative Code.

(B) Care management entities (CMEs).

(1) ICC and MCC are delivered by care management entities (CMEs) designated by the OhioRISE plan.

(2) CMEs will:

(a) Maintain an active, valid medicaid provider agreement as defined and set forth in rule 5160-1-17.2 of the Administrative Code;

(b) Comply with all applicable provider requirements set forth in this rule;

(c) Participate in initial and ongoing training, coaching, and supports from an independent validation entity recognized by the Ohio department of medicaid (ODM) to ensure consistency in delivering care coordination;

(d) Have documentation of completion of an initial readiness review by an independent validation entity recognized by ODM within sixty calendar days of billing for ICC or MCC;

(e) Ensure that all child and family-centered care plans (including initial plans, changes to plans, and transition plans) are submitted to the OhioRISE plan for review and approval;

(f) Exchange electronic, bidirectional data and other information regarding the youth and family receiving ICC and MCC with the OhioRISE plan and the independent validation entity recognized by ODM;

(g) Report incidents in accordance with rule 5160-44-05 of the Administrative Code;

(h) Implement quality improvement activities related to the CME's performance consistent with ODM's population health management strategy;

(i) Provide all staff with training regarding cultural and trauma-informed care competency within three months of the date of hire and annually thereafter;

(j) Conduct virtual, in-person, or telephonic outreach to the youth's family within two business days of referral to ICC or MCC to explain the service and obtain consent;

(k) Have administrative and program staff, in sufficient quantity to meet all the CME requirements to achieve the quality, performance, and outcome measures set by ODM;

(l) Ensure care coordination staff and supervisors have the experience necessary to manage complex cases and the ability to navigate state and local child serving systems:

(m) Have sufficient care coordination staff to meet care coordinator-to-youth ratio requirements described in this rule;

(n) Have supervisory personnel to provide coaching and support for ICC and MCC care coordinators, not to exceed the supervisor ratio described in this rule;

(o) Provide real-time or on demand clinical and psychiatric consultation for youth engaged in ICC or MCC;

(p) Respond to the youth and family twenty-four hours a day;

(q) Ensure youth and family choice is incorporated regarding the services and supports they receive and from whom;

(r) Ensure that all care coordination services are provided in a conflict-free manner, with particular attention to ensuring care coordination services, functions, and staff are separated from the organization's function and staff related to other services. If the CME has multiple lines of business, the CME must establish firewalls between its care coordination services and staff and the functions and staff of its other services;

(s) Identify and inform the OhioRISE plan of unmet needs and barriers to effective care and assist in developing community resources to meet youth and families' needs; and

(t) Assist with required activities related to the OhioRISE 1915(b)/(c) waivers, including:

(i) Gather and submit information to assist ODM in determining OhioRISE 1915(c) waiver eligibility;

(ii) Assess the initial and ongoing settings where youth will receive 1915(c) home and community-based services for settings requirements using the review tool designated by ODM; and

(iii) Help youth and caregivers in determining the need for OhioRISE 1915(b)/(c) waiver services.

(C) Care coordination activities.

(1) CMEs delivering ICC will:

(a) Provide structured service planning and care coordination through high-fidelity wraparound as established by the national wraparound initiative, found at https://nwi.pdx.edu (October 1, 2021), including:

(i) Offering initial face-to-face contact within two calendar days of conducting initial outreach contact for ICC; and

(ii) Completing an initial comprehensive assessment within fourteen calendar days of the youth's referral to ICC that includes:

(A) Information from a new Ohio children's initiative CANS assessment or existing Ohio children's initiative CANS assessment that was completed within the ninety calendar days prior to the comprehensive assessment; and

(B) Other tools as determined necessary that inform and result in the development of the child and family-centered care plan;

(iii) Completing an Ohio children's initiative comprehensive CANS assessment within thirty calendar days of referral to ICC;

(iv) Updating the Ohio children's initiative CANS assessment at a minimum of every ninety calendar days or whenever there is a significant change in the youth's needs or circumstances;

(v) Convening and facilitating the child and family team within thirty calendar days of referral for ICC that will:

(A) Develop and implement the initial child and family-centered care plan within the thirty-calendar day period; and

(B) Review the child and family-centered care plan every thirty calendar days, and whenever there is a significant change in the youth's needs or circumstances.

(C) For individuals enrolled in the OhioRISE 1915(c) waiver, develop the back-up waiver service plan, as described in rule 5160-59-01 of the Administrative Code, to be included in the child and family-centered care plan. The back-up waiver service plan should be updated when the child and family-centered care plan is updated

(vi) Developing an individual crisis and safety plan within fourteen calendar days of referral for ICC, for incorporation into the child and family-centered care plan. For youth with behaviors that pose safety concerns for the youth or others, a licensed clinician working within or for the CME will consult on the individual crisis and safety plan, recommend de-escalation strategies that can be learned and used by the youth, parents, other caregivers to support the youth and prevent the use of restrictive interventions, and approve of the crisis and safety plan prior to its submission to the OhioRISE plan;

(vii) Monitoring the child and family-centered care plan to ensure that services are delivered in accordance with the plan;

(viii) Performing referrals and linkages to appropriate services and supports, including natural supports, along the continuum of care;

(ix) Facilitating discharge planning activities for youth admitted to a psychiatric residential treatment facility or an inpatient behavioral health facility; and

(x) Facilitating transition planning and activities for youth exiting the OhioRISE program or the OhioRISE 1915(c) waiver. For youth receiving ICC who are enrolled in the OhioRISE 1915(c) waiver, transition planning must identify supports the youth will need for the ninety calendar days following disenrollment from the OhioRISE 1915(c) waiver.

(b) Have documentation of annual fidelity review, monitoring, and adherence to high-fidelity wraparound by an independent validation entity recognized by ODM. The fidelity review will assess for consistent use of high-fidelity wraparound standards established by the national wraparound initiative.

(c) Submit the child and family-centered care plan to the OhioRISE plan within one business day of completion of the child and family-centered care plan.

(2) CMEs delivering MCC will:

(a) Provide structured service planning and care coordination based on wraparound principles, as established by the national wraparound initiative, found at https://nwi.pdx.edu (October 1, 2021), including;

(i) Offering an initial face-to-face contact within seven calendar days of conducting initial outreach contact for MCC; and

(ii) Completing an initial comprehensive assessment within fourteen calendar days of the youth's referral to MCC that includes:

(A) Information from a new Ohio children's initiative CANS assessment or existing Ohio children's initiative CANS assessment completed within the ninety calendar days prior to the comprehensive assessment; and

(B) Other tools as determined necessary that inform and result in the development of the child and family-centered care plan.

(iii) Completing an Ohio children's initiative comprehensive CANS assessment within thirty calendar days of referral to MCC;

(iv) Updating the Ohio children's initiative CANS assessment at a minimum of every ninety calendar days or whenever there is a significant change in the youth's behavioral health needs or circumstances;

(v) Convening and facilitating the child and family team within thirty calendar days of referral for MCC that will:

(A) Develop and implement the initial child and family-centered care plan within the thirty-calendar day period; and

(B) Review the child and family-centered care plan every sixty calendar days, and whenever there is a significant change in the youth's needs or circumstances.

(C) For individuals enrolled in the OhioRISE 1915(c) waiver, develop the back-up waiver service plan, as described in rule 5160-59-01 of the Administrative Code, to be included in the child and family-centered care plan. The back-up waiver service plan should be updated when the child and family-centered care plan is updated

(vi) Developing an individual crisis and safety plan within fourteen calendar days of referral for MCC, for incorporation into the child and family-centered plan. For youth with behaviors that pose safety concerns for the youth or others, a licensed clinician working within or for the CME will consult on the individual crisis and safety plan, recommend de-escalation strategies that can be learned and used by the youth, parents, other caregivers to support the youth and prevent the use of restrictive interventions, and approve of the crisis and safety plan prior to its submission to the OhioRISE plan;

(vii) Monitoring the child and family-centered care plan to ensure that services are delivered in accordance with the plan;

(viii) Performing referrals and linkages to appropriate services and supports, including natural supports, along the continuum of care;

(ix) Facilitating discharge planning activities for youth admitted to a PRTF or an inpatient behavioral health facility; and

(x) Facilitating transition planning and activities for youth exiting the OhioRISE program or the OhioRISE 1915(c) waiver. For youth receiving MCC who are enrolled in the OhioRISE 1915(c) waiver, transition planning must identify supports the youth will need for the ninety calendar days following disenrollment from the OhioRISE 1915(c) waiver.

(b) Have documentation of annual fidelity review, monitoring, and adherence to MCC by an independent validation entity recognized by ODM. The fidelity review will assess for consistent application of system of care principles adherence to the MCC planning process and service components.

(c) Submit the child and family-centered care plan to the OhioRISE plan within one business day of completion of the child and family-centered care plan.

(D) CME care coordinator qualifications.

(1) An ICC or MCC care coordinator will be a licensed or an unlicensed practitioner in accordance with rule 5160-27-01 of the Administrative Code, except that an ICC or MCC care coordinator will be employed by or under contract with a CME as described in this rule.

(2) ICC and MCC care coordinators will complete the high-fidelity wraparound training program provided by an independent validation entity recognized by ODM. Care coordinators will successfully complete skill and competency-based training to provide ICC and MCC.

(3) ICC and MCC care coordinators will:

(a) Have experience providing community-based services and supports to children and youth and their families or caregivers in areas of children's behavioral health, child welfare, intellectual and developmental disabilities, juvenile justice, or a related public sector human services or behavioral health care field for:

(i) three years with a high school diploma or equivalent; or

(ii) two years with an associate's degree or bachelor's degree; or

(iii) one year with a master's degree or higher; or

(iv) With ODM or its designee approval, partially meets years of experience in paragraph (D)(3)(a)(i), (D)(3)(a)(ii), or (D)(3)(a)(iii) of this rule and meets the following until experience requirements are met:

(A) Demonstrates specific skills and competencies needed for the care coordination activities described in paragraph (C) of this rule; and

(B) Receives additional supervision to monitor skills and competencies to ensure effective care coordination; and

(C) Receives additional quarterly training to improve skills and competencies to ensure effective care coordination.

(b) Have a background and experience in one or more of the following areas of expertise:

(i) Family systems;

(ii) Community systems and resources;

(iii) Case management;

(iv) Child and family counseling or therapy;

(v) Child protection; or

(vi) Child development.

(c) Be culturally competent or responsive with training and experience necessary to manage complex cases; and

(d) Have the qualifications and experience needed to work with children and families who are experiencing serious emotional disturbance (SED), trauma, co-occurring behavioral health disorders and who are engaged with one or more child-serving systems (e.g., child welfare, intellectual and developmental disabilities, juvenile justice, education).

(E) CME care coordinator supervisory qualifications.

(1) A supervisor of ICC or MCC will meet CME care coordinator qualifications described in paragraph (D), with exception of (D)(3)(a)(iv), of this rule.

(2) A supervisor that is an unlicensed practitioner will have regular supervision with a licensed practitioner and real-time access to a psychiatrist for case consultation.

(3) Supervisors of ICC or MCC will complete the high-fidelity wraparound training program provided by an independent validation entity recognized by ODM. Supervisors will successfully complete skill and competency-based training to supervise delivery of ICC and MCC.

(F) ICC and MCC staffing requirements.

(1) ICC will be facilitated by a care coordinator with a ratio of one full-time care coordinator to no more than ten OhioRISE youth receiving ICC.

(2) MCC will be facilitated by a care coordinator with a ratio of one full-time care coordinator to no more than twenty-five OhioRISE youth receiving MCC.

(3) Supervisory staffing ratios will not exceed one supervisor to eight care coordinators.

(G) Care coordination documentation will include:

(1) Care coordination activities set forth in paragraphs (C)(1) and (C)(2) of this rule will be identified on claims submitted in accordance with rule 5160-26-05.1 of the Administrative Code;

(2) Progress notes to document the care coordination activities described in this rule, including face-to-face and telehealth meetings with the youth and the youth's family and/or collateral contacts;

(3) An individual crisis and safety plan for each youth receiving ICC or MCC;

(4) A back-up plan for each youth receiving ICC or MCC who is enrolled in the OhioRISE 1915(c) waiver;

(5) Assessments and child and family-centered care plans, including specifications for standard assessment and plan elements in CME's electronic health records; and

(6) Upon transition of a youth from ICC or MCC to a different care coordination tier, the CME will document the circumstances regarding transition.

(H) Transition from ICC or MCC.

(1) A youth or the youth's guardian may request to transition out of ICC or MCC at their discretion. The CME will notify the OhioRISE plan of the transition request.

(2) The CME or OhioRISE plan may pursue transition of a youth to other care coordination tiers when a CANS assessment or the child and family-centered care plan indicates that the youth's needs are no longer appropriate for the current tier.

(I) Limitations.

(1) The following activities are not reimbursable as ICC or MCC:

(a) Transportation for the youth or family; and

(b) Direct services to which the youth has been referred such as medical, behavioral, educational, or social services.

(2) Reimbursement for substance use disorder targeted case management is not allowable when a youth is enrolled in ICC or MCC.

(J) Reimbursement for MCC and ICC services as described in the rule is listed in Appendix A of this rule.

(K) Reimbursement for a CANS assessment is listed in the Appendix to rule 5160-27-03 of the Administrative Code.

(L) Care coordination activities described in paragraph (C) of this rule may be provided via telehealth in accordance with rule 5160-1-18 of the Administrative Code.

(M) For the first ninety days from the effective date of this rule, the established timeframes for CME activities in paragraph (B) of this rule and care coordination activities in paragraph (C) of this rule will not be enforced.

Last updated July 1, 2022 at 1:11 PM

Supplemental Information

Authorized By: 5162.03, 5167.02
Amplifies: 5167.02, 5167.03, 5167.04, 5167.10
Five Year Review Date: 7/1/2027
Rule 5160-59-03.3 | OhioRISE: intensive home-based treatment service.
 

(A) Scope. This rule sets forth provisions governing medicaid coverage of intensive home-based treatment (IHBT) services.

(B) Definition. IHBT is the service and activities as set forth by the Ohio department of mental health and addiction services (OhioMHAS) in rule 5122-29-28 of the Administrative Code.

(C) Eligible providers of IHBT services.

(1) Providers eligible for medicaid payment for IHBT will:

(a) Meet the criteria in paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code; and

(b) Provide the service in accordance with rule 5122-29-28 of the Administrative Code.

(D) Coverage.

(1) Payment may be made for IHBT services rendered face-to-face in person or via telehealth in accordance with rule 5122-29-31.

(2) Payment may be made for services rendered by IHBT staff described in rule 5122-29-28 of the Administrative Code that are eligible as a provider of behavioral health services in accordance with rule 5160-27-01 of the Administrative Code.

(3) Medicaid rates for services described in this rule are listed in the appendix A of this rule.

(E) Limitations.

(1) The following activities are not reimbursable as part of IHBT:

(a) Time spent doing, attending, or participating in recreational activities.

(b) Child care services or services provided as a substitute for the parent or other individual responsible for providing care or supervision.

(c) Respite care.

(d) Transportation for the beneficiary or family.

(e) Any art, movement, dance, drama, or animal therapies, unless incorporated into the IHBT treatment modality.

(f) Services provided to teach academic subjects or as a substitute for educational personnel including, but not limited to a teacher, teacher's aide, or an academic tutor.

(2) A separate medicaid payment will not be made for any of the following services or treatments while the youth is enrolled in IHBT services, unless the service is prior authorized by the OhioRISE plan:

(a) Behavioral health assessments, screenings, and diagnostic evaluations, except of an Ohio children's initiative "child and adolescent needs and strengths" (CANS) assessment completed in accordance with rule 5160-59-03.2 of the Administrative Code that is separately reimbursable.

(b) Individual, group, or family psychotherapy and counseling.

(c) Therapeutic behavioral services, except for therapeutic behavioral group service - hourly and per diem as defined in rule 5160-27-06 of the Administrative Code.

(d) Community psychiatric supportive treatment as described in rule 5122-29-17 of the Administrative Code.

(e) Psychosocial rehabilitation as described in rule 5160-27-08 of the Administrative Code.

(f) Substance use disorder (SUD) residential treatment services as described in rule 5160-27-09 of the Administrative Code.

(g) Assertive community treatment as described in rule 5160-27-04 of the Administrative Code.

(h) Stabilization services as defined in rule 5160-27-13 of the Administrative Code and rendered by a mobile response and stabilization service (MRSS) provider in accordance with rule 5160-27-13 of the Administrative Code.

(i) SUD targeted case management as described in rule 5160-27-10 of the Administrative Code.

(3) When the OhioRISE plan denies, reduces, terminates or suspends IHBT, this constitutes an adverse benefit determination, and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.

View Appendix

Last updated July 1, 2022 at 1:12 PM

Supplemental Information

Authorized By: 5167.02, 5164.02
Amplifies: 5162.02, 5162.03, 5167.04, 5167.12, 5167.10
Five Year Review Date: 7/1/2027
Rule 5160-59-03.4 | OhioRISE: behavioral health respite service.
 

(A) This rule sets forth provisions governing coverage for behavioral health respite services delivered as part of the Ohio resilience through integrated systems and excellence (OhioRISE) program.

(B) Definitions. For this rule, the following definitions apply:

(1) "Behavioral health respite services" are services that provide short-term, temporary relief to the primary caregiver of an OhioRISE plan enrolled youth, in order to support and preserve the primary caregiving relationship.

(2) "Foster home" has the same meaning as "certified foster home" in rule 5101:2-1-01 of the Administrative Code.

(3) "Kin" has the same meaning as in rule 5101:2-1-01 of the Administrative Code.

(4) "Public children services agency" (PCSA) has the same meaning as in rule 5101:2-1-01 of the Administrative Code.

(5) "Treatment foster home" has the same meaning as in rule 5101:2-1-01 of the Administrative Code.

(C) Eligible providers of OhioRISE respite services.

(1) Behavioral health respite services can be provided by the following individuals or organizations:

(a) Behavioral health entities operating in accordance with paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code. Rendering practitioners will meet the critera to be an eligible provider of behavioral health services in accordance with rule 5160-27-01 of the Administrative Code.

(b) Department of developmental disabilities (DODD)-certified providers of community respite as set forth in rule 5123-9-22 of the Administrative Code;

(c) DODD-certified providers of informal respite as set forth in rule 5123-9-21 of the Administrative Code;

(d) Family, who do not also meet the definition of "legally responsible family member" as defined in rule 5160-45-01 of the Administrative Code, and who do not reside in the home with the youth;

(e) Natural supports; or

(f) Foster care settings as described in rule 5101:2-47-16 of the Administrative Code are excluded from being eligible providers of behavioral health respite services when these settings are currently fostering youth, unless the foster home:

(i) Has an established relationship with the youth who will receive respite services in the foster home;

(ii) Is fostering siblings or kin of the youth who will receive respite services in the foster home; or

(iii) Is fostering the child of a parenting youth who will receive respite services in the foster home.

(2) Behavioral health respite providers will adhere to the criminal records check criteria set forth in rule 5160-43-09 of the Administrative Code.

(3) All eligible providers of behavioral health respite will obtain and maintain first aid certification from instruction which includes hands-on training by a certified first aid instructor. At its discretion, ODM may accept training conducted by a solely internet-based class as sufficient for the purposes of first aid certification.

(4) All eligible providers of behavioral health respite will complete training in trauma-informed care practices as set forth in rule 5101:2-9-42 of the Administrative Code.

(5) Behavioral health respite providers serving an OhioRISE youth with behaviors that pose safety concerns for the youth or others, will be trained in de-escalation strategies that can be used to support the youth and prevent the use of restrictive interventions.

(D) Coverage.

(1) Components of the behavioral health respite service may include:

(a) Assistance with activities of daily living;

(b) Transportation; and

(c) Supports in home and community-based settings.

(2) Reimbursement may be made for behavioral health respite when rendered to youth enrolled in the OhioRISE plan in accordance with rules 5160-59-02, 5160-59-02.1, and 5160-59-04 of the Administrative Code who:

(a) Resides:

(i) With the youth's primary caregiver in a home that is not owned, leased, or controlled by a provider of any health-related treatment or support services; and

(ii) In a foster home licensed by the Ohio department of job and family services (ODJFS);

(iii) In the home of kin; or

(iv) In a medically fragile or treatment foster home; and

(b) Have behavioral health needs for the behavioral health respite as determined by the OhioRISE plan.

(3) Respite services may be provided either during normal awake hours or overnight. The provider of the behavioral health services will be awake when the youth is awake during the provision of behavioral health respite services. The child and family-centered care plan will document when a provider will need to be awake during overnight hours dependent on a youth's assessed needs.

(4) The behavioral health respite service may be provided on a planned or emergency basis. An emergency behavioral health respite service may be provided to address either a primary caregiver's unexpected need for behavioral health respite or to address an urgent need related to the youth's behavioral health diagnosis.

(5) Respite services delivery may occur in the following locations:

(a) The primary caregiver's home that is not owned, leased, or controlled by a provider of any health-related treatment or support services;

(b) A qualifying provider's place of residence when approved by the youth's legal guardian;

(c) A foster home licensed by ODJFS;

(d) In the home of kin;

(e) In a treatment foster home certified by ODJFS; or

(f) A community setting in which the general public has access.

(6) Coverage of behavioral health respite is subject to authorization by the OhioRISE plan in accordance with rule 5160-59-03.1 of the Administrative Code.

(a) Behavioral health respite services may be authorized in an amount, scope, and duration consistent with the youth's needs and behavioral health history.

(b) Coverage of the behavioral health respite services is based on a determination that the youth's primary caregiver has a demonstrated need for temporary relief from the care of the youth as a result of the youth's behavioral health needs.

(c) Behavioral health respite is identified on a youth's child and family-centered care plan developed by the care management entity or the OhioRISE plan.

(E) Limitations.

(1) Reimbursement is allowed for behavioral health respite delivered in a foster home or treatment foster home when:

(a) The behavioral health respite need is determined to meet the provisions set forth in this rule for behavioral health respite;

(b) The behavioral health respite does not duplicate reimbursement for otherwise available respite services in a foster home or treatment foster home;

(c) The medicaid reimbursement does not cover room and board costs; and.

(d) Title IV-E funding is not used for coverage of the OhioRISE behavioral health respite service.

(2) Reimbursement for behavioral health respite is not allowable when the youth is receiving otherwise available respite services as defined in rules 5160-26-03.2, 5160-44-17, and 5160-59-05.1 of the Administrative Code, or in Chapter 5123-9 of the Administrative Code.

(3) Reimbursement for the behavioral health respite services is not allowable when delivered by the youth's "legally responsible family member" as defined in rule 5160-45-01 of the Administrative Code.

(4) Transportation activities that do not include the provision of behavioral health respite are not reimbursable as behavioral health respite.

(5) When the OhioRISE plan denies, reduces, terminates or suspends behavioral health respite services, this constitutes an adverse benefit determination, and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.

(F) Service documentation for behavioral health respite will include each of the following to validate reimbursement for medicaid services:

(1) Date of service;

(2) Place of service;

(3) Name of youth receiving services;

(4) Medicaid identification number of youth receiving services;

(5) Name of provider;

(6) Provider identifier;

(7) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider; and

(8) A summary of the amount, scope, duration, and frequency of services delivered that directly relate to the services specified in the approved child and family-centered care plan to be provided.

(9) A summary of when restrictive interventions were used including a date, time, the de-escalation techniques used to prevent the restrictive intervention, and whether or not the use of restrictive intervention was included on the individual crisis and safety plan.

Last updated July 1, 2022 at 1:11 PM

Supplemental Information

Authorized By: 5167.02, 5164.02
Amplifies: 5162.03, 5167.02, 5167.10
Five Year Review Date: 7/1/2027
Rule 5160-59-03.5 | OhioRISE: primary flex funds.
 

(A) Scope. This rule sets forth provisions governing coverage for primary flex funds provided as part of the Ohio resilience through integrated systems and excellence (OhioRISE) program.

(B) Definitions.

(1) "Primary flex funds" are services, equipment, or supplies not otherwise provided through the medicaid state plan benefit or the OhioRISE program that address a youth's identified need as documented in the child and family-centered care plan. Primary flex funds are intended to enhance and supplement the array of services available to a youth enrolled in the OhioRISE program and are discussed, recommended, and implemented through the care coordination process as described in rule 5160-59-03.2 of the Administrative Code.

(2) "Financial management services" (FMS) means an entity contracted with the OhioRISE plan to perform necessary financial transactions on behalf of individuals enrolled in the OhioRISE program

(3) "Participant direction" means the opportunity for a youth enrolled in OhioRISE to exercise choice and control in managing a budget for the applicable service in accordance with their needs.

(4) "Participant-directed budget for primary flex funds" is the OhioRISE enrollee's maximum approved funding for the purchase of primary flex funds under the OhioRISE program.

(C) Eligible providers and conditions of participation.

(1) The provider of primary flex funds will be the FMS entity under contract with the OhioRISE plan to complete the purchase and reimbursement of primary flex funds approved by the OhioRISE plan.

(2) With the exception of paragraph (B)(14) of rule 5160-44-31 of the Administrative Code, the provider will comply with conditions of participation as set forth in rule 5160-44-31 of the Administrative Code.

(D) Coverage.

(1) Coverage of primary flex funds will occur through participant-direction and will incorporate discussion and education with the youth and their primary caregiver of their ability to exercise budget authority during the participant-directed process.

(2) The youth's care coordinator working within a care management entity (CME), or the OhioRISE plan, will assist the youth and their primary caregiver in determining the need for the use of primary flex funds while ensuring the least costly appropriate service, equipment, or supply is evaluated.

(3) The youth's care coordinator working within the CME, or the OhioRISE plan, will document the recommendation for approval of the participant-directed budget for primary flex funds on the child and family-centered care plan as evidence of the necessity of primary flex funds to meet a youth's needs:

(a) The primary flex funds will decrease the need for other Ohio department of medicaid (ODM) services;

(b) The primary flex funds will promote the youth's inclusion in the community; or

(c) The primary flex funds will increase the youth's safety in the home environment.

(4) The OhioRISE plan will need to approve the youth's participant-directed budget for primary flex funds as part of the child and family-centered care plan prior to use of the service.

(E) Limitations.

(1) The following items are excluded for primary flex funds purchase:

(a) Experimental treatments as outlined in rule 5160-1-61 of the Administrative Code;

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

(c) Tobacco or alcoholic products;

(d) More than one of the same item for the same youth unless there is a documented change in the item's condition that warrants replacement;

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

(f) Items or treatments that are illegal or otherwise excluded through federal or state regulations; and

(g) The costs of room and board as described in 42 CFR 441.310 (October 1, 2021).

(2) The total available budget for primary flex funds is limited to one thousand five hundred dollars within three hundred sixty-five days.

(3) Approval for primary flex funds by the OhioRISE plan will not occur when:

(a) The youth or their primary caregiver has the funds to purchase the services, equipment, or supplies; or

(b) There is another available funding source for the services, equipment, or supplies.

(4) Primary flex funds will first be submitted for consideration under the medicaid state plan or other available OhioRISE plan services including, but not limited to, value-add services, when the primary flex funds provider is purchasing the item from an active ODM provider of like services.

(5) When the OhioRISE plan denies, reduces, terminates or suspends primary flex funds, this constitutes an adverse benefit determination, and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.

(F) Service documentation for primary flex funds will include each of the following to validate reimbursement for medicaid services:

(1) Documentation on the child and family-centered care plan indicating at least one of the concepts in paragraphs (D)(3)(a) to (D)(3)(c) will be addressed by approving primary flex funds;

(2) An invoice containing the youth's name and medicaid identification number;

(3) A description of the item or service provided;

(4) Identification of the purchaser of service;

(5) The date the item or service was purchased and provided;

(6) The amount paid by the provider for primary flex funds.

Last updated July 1, 2022 at 1:12 PM

Supplemental Information

Authorized By: 5167.02, 5164.02
Amplifies: 5162.03, 5167.10
Five Year Review Date: 7/1/2027
Rule 5160-59-04 | OhioRISE home and community-based services waiver: eligibility and enrollment.
 

(A) To be eligible for the Ohio resilience through integrated systems and excellence (OhioRISE) home and community-based services (HCBS) 1915(c) waiver (waiver), a youth will be determined by the Ohio department of medicaid (ODM) to meet all of the following:

(1) Meet eligibility criteria set forth in paragraphs (A)(1) to (A)(3) of rule 5160-59-02 of the Administrative Code;

(2) Be determined to meet the following level of care (LOC) criteria for an inpatient psychiatric (IP) services through an IP LOC assessment:

(a) For youth age six through twenty years of age have a comprehensive Ohio children's initiative child and adolescent needs and strengths (CANS) assessment, using the tool available on https://www.medicaid.ohio.gov (September 20, 2021), completed by a certified Ohio children's initiative CANS assessor employed by or under contract with the care management entity (CME) described in rule 5160-59-03.2 of the Administrative Code, indicating paragraphs (A)(2)(a)(i), (A)(2)(a)(ii), and either paragraph (A)(2)(a)(iii) or (A)(2)(a)(iv) of this rule are met:

(i) For behavioral/emotional needs domain items, at least two of the following items are dangerous or disabling and need immediate action or three or more of the following items are at least interfering with functioning and need action to ensure that the identified need is addressed:

(A) psychosis;

(B) impulsivity/hyperactivity;

(C) depression;

(D) anxiety;

(E) oppositional behavior;

(F) conduct;

(G) adjustment to trauma;

(H) anger control;

(I) substance use;

(J) eating disturbance;

(K) attachment difficulties;

(L) or interpersonal problems (for youth age fourteen and older).

(ii) For risk behaviors domain items, at least two of the following items are dangerous or disabling and need immediate action or three or more of the following items are at least interfering with functioning and need action to ensure that the identified need is addressed:

(A) suicide risk;

(B) non-suicidal self-injury behavior;

(C) other self-harm;

(D) danger to others;

(E) delinquent behavior;

(F) runaway;

(G) intentional misbehavior;

(H) fire setting;

(I) victimization/exploitation;

(J) sexually problematic behavior.

(iii) For the caregiver resources and needs domain, at least one of the following items is dangerous or disabling and needs immediate action or two or more of the following items are at least interfering with functioning and need action to ensure that the identified need is addressed:

(A) supervision;

(B) residential stability;

(C) medical/physical;

(D) mental health

(E) substance use;

(F) family stress.

(iv) the youth has no current viable caregiver.

(b) For youth age birth through five years of age, have a comprehensive Ohio children's initiative CANS assessment, using the tool available on https://www.medicaid.ohio.gov (September 20, 2021), completed by a certified Ohio children's initiative CANS assessor employed by or under contract with the CME described in rule 5160-59-03.2 of the Administrative Code, indicating paragraphs (A)(2)(b)(i), (A)(2)(b)(ii), and either paragraph (A)(2)(b)(iii) or (A)(2)(b)(iv) of this rule are met:

(i) For early childhood domain items, at least two of the following items are dangerous or disabling and need immediate action or three or more of the following items are at least interfering with functioning and need action to ensure that the identified need is addressed:

(A) impulsivity/hyperactivity;

(B) depression;

(C) anxiety;

(D) oppositional behavior;

(E) adjustment to trauma;

(F) regulatory;

(G) sleep.

(ii) For risk behavior and functioning domain items, at least two of the following items are dangerous or disabling and need immediate action or three or more the following items are at least interfering with functioning and need action to ensure that the identified need is addressed:

(A) self-harm;

(B) exploited;

(C) problematic sexual behavior;

(D) aggressive behavior;

(E) family functioning;

(F) social and emotional functioning.

(iii) For the caregiver resources and needs domain, at least one of the following items is dangerous or disabling and needs immediate action or two or more of the following items are at least interfering with functioning and need action to ensure that the identified need is addressed:

(A) supervision;

(B) residential stability;

(C) medical/physical;

(D) mental health;

(E) substance use;

(F) family stress;

(iv) the youth has no current viable caregiver.

(c) Have a diagnosis of serious emotional disturbance (SED) as defined in rule 5122-24-01 of the Administrative Code; and

(d) Have documented functional impairment and behaviors that substantially interfere with or limit the youth's role or functioning in family, school, or community activities which result in recommended institutionalization and potential relinquishment of custody to the child welfare system. Documented functional impairment and behaviors include one or more of the following:

(i) Youth's persistent physical abuse or violence that results in physical injury or emotional distress to caregivers, family members, others in the home and community; or physical destruction of property that impacts the youth's housing stability.

(ii) Youth's history of suicidal ideation with intent, or history of suicide attempts, within the past six months.

(iii) Youth's sexually problematic behavior that creates a safety risk for themselves or others without a high-level of direct supervision.

(iv) Youth's suspension or expulsion from school; or withdrawal from school, daycare, or preschool program as the result of the youth's actions/intensive behaviors.

(v) Law enforcement or child welfare contact or involvement due to the youth's intensive behaviors.

(vi) Youth has a history of victimization or exploitation, including human trafficking within the past twelve months, and re-victimization may be imminent. This may include physical or sexual abuse, sexual exploitation, or violent crime.

(3) Have a completed IP LOC assessment as follows:

(a) A LOC assessment determining a youth meets an IP LOC will be completed prior to initial enrollment on the waiver;

(b) A LOC assessment determining a youth meets an IP LOC will be completed within three hundred sixty-five calendar days of the previous LOC assessment for continued enrollment on the waiver; and

(c) Once enrolled in the waiver, all youth who experience a significant change in situation impacting health and welfare will receive an IP LOC assessment following the event to determine continued enrollment on the waiver.

(4) Be determined to have a need for, and agree to receipt of, at least one service available under the waiver that is otherwise unavailable through another source (including, but not limited to private pay, community resources, or the medicaid state plan) on at least a monthly basis.

(5) Have waiver needs which are less than or equal to the waiver services cost cap of fifteen thousand dollars in a twelve-month period. Once enrolled in the waiver, youth may have access to additional emergency funding as described in rule 5160-59-05.3 of the Administrative Code.

(6) Have been informed of, as recorded during the course of an assessment or in an alternative manner at the discretion of ODM, all of the following:

(a) Service alternatives including the choice and election to receive services on an HCBS program in lieu of institutional services; and

(b) Choice of providers who meet provider qualifications as described in Chapter 5160-59 of the Administrative Code to provide services under the waiver.

(7) Have needs that can be safely met in an HCBS setting through the waiver as determined by ODM or its designee.

(8) Meet the following age criteria:

(a) Be between the ages of birth and twenty years of age at the time of initial enrollment; and

(b) Once enrolled, youth may continue enrollment on the waiver through the age of twenty-two, so long as the youth meets the other eligibility criteria set forth in paragraphs (A) and (B) of this rule.

(9) Agrees to participate in the waiver, and while enrolled in the waiver, will not be simultaneously enrolled in another HCBS 1915(c) waiver or the specialized recovery services program as defined in rule 5160-43-01 of the Administrative Code.

(B) Once eligibility to the OhioRISE 1915(c) waiver has been determined and before the OhioRISE 1915(c) waiver services described in rule 5160-59-05 of the Administrative Code can be provided, the youth will:

(1) Participate in the development and implementation of the child and family-centered care plan in accordance with the process and criteria set forth in rule 5160-44-02 of the Administrative Code. The youth or their authorized representative will consent to the child and family-centered plan by signing and dating it by the thirtieth calendar day of eligibility; and

(2) Reside, and will continue to reside, in a setting that possesses the home and community-based setting characteristics set forth in rule 5160-44-01 of the Administrative Code.

(C) All youth enrolled into the OhioRISE 1915(c) waiver will be automatically enrolled with a managed care organization as defined in rule 5160-26-01 of the Administrative Code.

(D) If, at any time, a youth does not meet any of the eligibility criteria set forth in paragraphs (A) and (B) of this rule, with the exception of paragraph (A)(8)(b) of this rule, the youth will be denied enrollment to, or be disenrolled from, the waiver.

(E) If a youth resides in an institution, as described in rule 5160-44-01 of the Administrative Code, for more than ninety consecutive days, the OhioRISE plan will initiate disenrollment from the OhioRISE 1915(c) waiver.

(F) When a youth is disenrolled from the waiver for any reason, the following will occur:

(1) Dependent in which care coordination tier a youth is enrolled, in accordance with rule 5160-59-03.2 of the Administrative Code, either the care management entity (CME) manager or the OhioRISE plan will work to develop a transition of care plan at least thirty calendar days prior to disenrollment.

(2) Either the CME or the OhioRISE plan will work to identify needed supports for the ninety calendar days following disenrollment from the OhioRISE program.

(G) When a youth is denied enrollment to, or disenrolled from, the waiver for failure to meet eligibility criteria as set forth in paragraph (A) or (B) of this rule, the youth or their authorized representative will be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

(H) The number of individuals enrolled in the waiver program will not exceed the centers for medicare and medicaid authorized limit for the waiver program year.

Last updated July 1, 2022 at 1:14 PM

Supplemental Information

Authorized By: 5167.02, 5166.04
Amplifies: 5162.03, 5166.02
Five Year Review Date: 7/1/2027
Rule 5160-59-05 | OhioRISE home and community-based services waiver: covered services and providers.
 

(A) This rule establishes the services available under the Ohio resilience through integrated systems and excellence (OhioRISE) home and community-based services (HCBS) 1915(c) waiver program (waiver) established in accordance with 1915(c) of the Social Security Act 42 U.S.C. 1396n (January 1, 2022), and the providers eligible to deliver those services to youth enrolled on the waiver.

(B) Providers seeking to deliver services in the waiver program will meet the criteria in Chapter 5160-59 and set forth in rules 5160-44-02 and 5160-44-31 of the Administrative Code, as appropriate. Providers that have responsibility for developing the child and family-centered care plan cannot provide other direct 1915(c) waiver services to the youth.

(C) Prior to a qualified waiver provider delivering services to waiver recipients, the services will be documented on the youth's child and family-centered care plan as described in Chapter 5160-59 of the Administrative Code and approved by the OhioRISE plan. The child and family-centered care plan will be developed in accordance with person-centered practices as set forth in rule 5160-44-02 of the Administrative Code.

(D) Waiver covered services are limited to the following and are subject to any reimbursement provisions in the Ohio Administrative Code rules cited therein:

(1) Out-of-home respite as set forth in rule 5160-59-05.1 of the Administrative Code;

(2) Transitional services and supports as set forth in rule 5160-59-05.2 of the Administrative Code; and

(3) Secondary flex funds as set forth in rule 5160-59-05.3 of the Administrative Code. secondary flex funds service is subject to participant-direction through budget authority.

(E) When the OhioRISE plan denies, reduces, terminates or suspends an OhioRISE waiver service, this constitutes an adverse benefit determination, and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.

Last updated July 1, 2022 at 1:13 PM

Supplemental Information

Authorized By: 5167.02, 5166.04
Amplifies: 5162.03, 5166.02, 5167.03
Five Year Review Date: 7/1/2027
Rule 5160-59-05.1 | OhioRISE home and community-based services waiver: out-of-home respite.
 

(A) Scope. This rule sets forth provisions governing coverage for out-of-home respite services delivered as part of the Ohio resilience through integrated systems and excellence (OhioRISE) 1915(c) waiver program (waiver) established in accordance with 1915(c) of the Social Security Act, 42 U.S.C. 1396n (January 1, 2022).

(B) Definitions. For this rule, the following definitions apply:

(1) "Community respite" has the same meaning as set forth in rule 5123-9-22 of the Administrative Code.

(2) "Intermediate care facility for individuals with intellectual disabilities" (ICF/IID) has the same meaning as set forth in section 5124.01 of the Revised Code.

(3) "Out-of-home respite" is a service provided to youth unable to care for themselves who are enrolled on the waiver. The service is provided on a short-term basis because of the absence or need for relief of those persons who normally provide care for the youth.

(4) "Residential respite" has the same meaning as set forth in rule 5123-9-34 of the Administrative Code.

(C) Eligible providers and conditions of participation.

(1) The following providers are eligible to provide the out-of-home respite service available under the waiver program:

(a) An ICF/IID who is certified by the Ohio department of health (ODH), holds certification as a residential respite provider, and has an active license with the Ohio department of developmental disabilities (DODD).

(b) An agency provider holding certification for community respite services.

(c) A psychiatric residential treatment facility (PRTF) as described in 42 C.F.R. 441.150 (October 1, 2021) through 42 C.F.R 441.184 (October 1, 2021) that is licensed by the Ohio department of mental health and addiction services (MHAS) and holds the appropriate waiver certification with the Ohio department of medicaid (ODM);

(d) A class one residential facility licensed by Ohio MHAS in accordance with Chapter 5122-30 of the Administrative Code.

(2) With the exception of paragraph (B)(14) of rule 5160-44-31 of the Administrative Code, providers will comply with conditions of participation as set forth in rule 5160-44-31 of the Administrative Code.

(3) Providers will obtain and maintain first aid certification from instruction which includes hands-on training by a certified first aid instructor. At its discretion, ODM may accept training conducted by a solely internet-based class as sufficient for the purposes of first aid certification.

(4) Out-of-home respite providers serving an OhioRISE youth with behaviors that pose safety concerns for the youth or others, will be trained in de-escalation strategies that can be used to support the youth and prevent the use of restraints, seclusion, and restrictive interventions.

(5) Out-of-home respite providers serving an OhioRISE youth with an individual crisis and safety plan including the use of restraints, seclusion, or restrictive intervention will be trained in the appropriate use of restraints, seclusion, and restrictive interventions.

(6) Providers will maintain all initial and subsequent child and family-centered care plans.

(7) Providers are subject to compliance reviews specific to their licensure or certification criteria in addition to ongoing monitoring conducted by the OhioRISE plan.

(D) Coverage.

(1) Out-of-home respite may be provided on a planned or emergency basis. An emergency out-of-home respite service may be provided to address either a primary caregiver's unexpected need for out-of-home respite or to address an urgent need related to the youth.

(2) Service delivery is not permitted in the youth's primary residence.

(3) The out-of-home respite service available under the waiver program is additive to the behavioral health respite as set forth in rule 5160-59-03.4 of the Administrative Code.

(4) The youth's care coordinator working within the care management entity (CME), as defined in rule 5160-59-01 of the Administrative Code, or OhioRISE Plan, will assist the youth and their primary caregiver in determining the need for the use of planed and emergency out-of-home respite.

(5) The youth's care coordinator working within the CME, as defined in rule 5160-59-01 of the Administrative Code, or OhioRISE plan may recommend planned and emergency out-of-home respite, as well as the providers of out-of-home respite services, as part of the child and family-centered care plan.

(6) The OhioRISE plan will need to approve out-of-home respite service as part of the child and family-centered care plan prior to receipt and reimbursement of out-of-home respite service.

(E) Limitations.

(1) Out-of-home respite will not be provided to a youth prior to establishment of initial or ongoing enrollment and eligibility criteria for the waiver as set forth in rule 5160-59-04 of the Administrative Code.

(2) Out-of-home respite will be provided only to a youth enrolled on the waiver at the time of service delivery.

(3) The out-of-home respite service is available for a total of ninety calendar days within a three hundred-sixty-five day period while a youth is enrolled on the waiver. Dependent on the care coordination tier a youth is enrolled, in accordance with rule 5160-59-03.2 of the Administrative Code, either the CME care coordinator or the OhioRISE care coordinator is responsible for tracking and maintaining records for the purposes of tracking out-of-home respite utilization within each three hundred sixty-five -day period.

(4) Reimbursement for out-of-home respite is not allowable on the same day when the youth is receiving behavioral health respite as set forth in rule 5160-59-03.4 of the Administrative Code.

(5) When the OhioRISE plan denies, reduces or terminates or suspends out-of-home respite services, this constitutes and adverse benefit determination and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.

(F) Service documentation for out-of-home respite will include each of the following to validate reimbursement for medicaid services:

(1) Date of service;

(2) Place of service;

(3) Name of youth receiving services;

(4) Medicaid identification number of youth receiving services;

(5) Name of provider;

(6) Provider identifier;

(7) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider; and

(8) A summary of the amount, scope, duration, and frequency of services delivered that directly relate to the services specified in the approved child and family-centered care plan to be provided.

(9) A summary of when restraints, seclusion, and restrictive interventions were used including a date, time, the de-escalation techniques used to prevent the restraints, seclusion, and restrictive interventions and whether or not the use of restraints, seclusion, and restrictive interventions was included on the individual crisis and safety plan.

(G) Reimbursement.

(1) Only one provider may bill out-of-home respite for the same youth on any given day.

(2) Reimbursement for the out-of-home respite service does not include room and board.

(3) Reimbursement for the out-of-home respite service does not include transportation costs.

Last updated July 1, 2022 at 1:13 PM

Supplemental Information

Authorized By: 5167.02, 5166.02
Amplifies: 5162.03, 5166.04, 5167.03
Five Year Review Date: 7/1/2027
Rule 5160-59-05.2 | OhioRISE home and community-based services waiver: transitional services and supports.
 

(A) Scope. This rule sets forth provisions governing coverage for transitional services and supports provided as part of the Ohio resilience through integrated systems and excellence (OhioRISE) 1915(c) waiver program (waiver) established in accordance with 1915(c) of the Social Security Act 42, U.S.C. 1396n (January 1, 2022).

(B) Definitions. For this rule, the following definitions apply:

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

(2) "Transitional services and supports" (TSS) is a service designed to provide family stability supports for the youth, primary caregiver and family as a pathway to creating a stable environment for the youth and the family that lives in the home. It is meant to assist the youth, in conjunction with their family/primary caregiver, as a means to overcome the functional limitations as identified due to the result of the youth's intensive behaviors. TSS is used to support youths and their families in understanding, mitigating, and transitioning to long term solutions for behavior challenges. TSS is used to support a youth and their family to stabilize during a transition of care and is not intended to de-escalate crises. TSS is an additional service for OhioRISE 1915(c) waiver enrollees and is limited care not otherwise covered under the state plan, including early and periodic screening, diagnostic, and treatment (EPSDT) covered services set forth in rule 5160-1-14 of the Administrative Code.

(C) Eligible providers and conditions of participation.

(1) The following providers are eligible to provide TSS under the waiver program:

(a) An entity operating in accordance with paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code. Eligible rendering practitioners employed by or under contract with the entity include those described in paragraph (A)(3), (A)(4), (A)(5), or (A)(6)(a) of rule 5160-27-01 of the Administrative Code.

(b) An agency provider holding certification for homemaker/personal care services in accordance with rule 5123-9-30 of the Administrative Code.

(c) An individual provider who meets the criteria of an independent practitioner or licensed psychologist as described in rule 5160-8-05 of the Administrative Code.

(d) An individual provider holding certification for homemaker/personal care services in accordance with rule 5123-9-30 of the Administrative Code.

(2) Providers who hold certification for homemaker/personal care services, as designated in paragraphs (C)(1)(b) and (C)(1)(d) of this rule, will also complete behavioral health support trainings sponsored by the Ohio department of developmental disabilities (DODD) or an Ohio department of medicaid (ODM) approved behavioral health training prior to rendering the TSS service.

(3) With the exception of paragraph (B)(14) of rule 5160-44-31 of the Administrative Code, providers will comply with conditions of participation as set forth in rule 5160-44-31 of the Administrative Code.

(4) Providers will obtain and maintain first aid certification from an instruction which includes hands-on training by a certified first aid instructor. At its discretion, ODM may accept training conducted by a solely internet-based class as sufficient for the purposes of first aid certification.

(5) TSS providers serving an OhioRISE youth with behaviors that pose safety concerns for the youth or others, will be trained in de-escalation strategies that can be used to support the youth and prevent the use of restraints, seclusion, and restrictive interventions.

(6) TSS providers serving an OhioRISE youth with an individual crisis and safety plan including the use of restraints, seclusion, or restrictive intervention will be trained in the appropriate use of restraints, seclusion, and restrictive interventions.

(7) Providers will maintain all initial and subsequent child and family-centered care plans.

(8) Providers are subject to compliance reviews specific to conditions of their licensure or certification in addition to ongoing monitoring conducted by the OhioRISE plan.

(D) Coverage.

(1) Primary components of the TSS service may include:

(a) Training the youth and family or caregivers in behavior stabilization techniques related to the youth's serious emotional disturbance diagnosis;

(b) Working with the youth and family or caregivers to identify triggers and developing person-centered approaches for preventing behavioral crisis prior to occurrence;

(c) Assistance to the youth in acquiring, retaining, and improving areas of self-help and socialization.

(d) Training and skill-building for families and caregivers regarding mitigation and support techniques for when crises occur;

(e) Training and skill-building for families and caregivers to understand and implement positive coping strategies to directly address crisis or escalation of risk behaviors;

(f) Acting as a conduit between the family or caregivers, the youth and the youth's care coordinator to assist in system navigation;

(g) Assistance to the youth with engagement in the broader community; and

(h) Assistance to the youth and family or caregivers with coping skills both in home and community settings.

(2) Other family stability supports activities related to youth and family or caregivers stabilization and transition beyond those listed in paragraphs (D)(1) and (D)(2) of this rule may be considered as permissible tangential activities allowable under the TSS service only when approved by the OhioRISE plan as part of the child and family-centered care plan prior to a provider rendering and receiving reimbursement for the service.

(3) Staffing may be provided to a youth at a ratio of up to two to one when there is a demonstrated need for the staffing level and when approved by the OhioRISE plan and documented on the child and family-centered care plan by the youth's care coordinator working within the CME as defined in rule 5160-59-01 of the Administrative Code, or the OhioRISE plan.

(4) TSS may be made available within twenty-four hours upon a change in circumstance or qualifying condition as described in paragraph (E) of this rule.

(5) The youth's care coordinator working within the CME or OhioRISE plan will assist the youth and their primary caregiver in determining the need for the TSS.

(6) The youth's care coordinator working within the CME or OhioRISE plan may recommend TSS, as well as the providers of TSS, as part of the child and family-centered care plan.

(7) The OhioRISE plan will need to approve TSS as part of the child and family-centered care plan prior to receipt and reimbursement of TSS service

(E) Limitations.

(1) TSS will only be provided to youth meeting eligibility criteria for the waiver as set forth in rule 5160-59-04 of the Administrative Code and who are enrolled on the waiver at the time of service delivery.

(2) TSS will not be provided to a youth prior to establishment of initial or ongoing enrollment and eligibility criteria for the waiver as set forth in rule 5160-59-04 of the Administrative Code.

(3) TSS is only approved when a youth experiences one of the following changes in circumstances or qualifying conditions:

(a) Within twenty-four hours of the youth enrolling on the waiver following a discharge from one of the following settings:

(i) A psychiatric residential treatment facility (PRTF) as described in 42 C.F.R. 441.150 (October 1, 2021) through 42 C.F.R 441.184 (October 1, 2021);

(ii) An intermediate care facility for individuals with an intellectual disability (ICF/IID) as defined in section 5124.01 of the Revised Code;

(iii) An inpatient psychiatric hospital as defined in 42 CFR 440.160 (October 1, 2021);

(iv) A residential facility as defined in rule 5122-30-03 of the Administrative Code; or

(v) A qualified residential treatment program (QRTP) as described in rule 5101:2-9-42 of the Administrative Code.

(b) Within twenty-four hours of when the youth is transitioning between custodians and/or caregivers, for example, following a transition into a kinship caregiver's home.

(4) Reimbursement may be made for TSS when rendered by a provider in accordance with paragraph (C) of this rule to a youth enrolled in the OhioRISE 1915(c) waiver program in accordance with rule 5160-59-04 of the Administrative Code.

(5) When determined eligible for the OhioRISE 1915(c) waiver, the initial seventy-two hours will be approved with the child and family-centered care plan, or until other appropriate behavioral health service provided under the OhioRISE plan are scheduled to begin, or whichever occurs first. When TSS is needed beyond a seventy-two hour period, the child and family-centered care plan will need to be updated, reviewed, and approved by the OhioRISE plan prior to additional TSS services being provided.

(6) When the OhioRISE plan denies, reduces, terminates or suspends TSS services, this constitutes an adverse benefit determination and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.

(F) Service documentation for TSS will include each of the following to validate reimbursement for medicaid services:

(1) Date of service;

(2) Place of service;

(3) Name of youth receiving service;

(4) Medicaid identification number of youth receiving service;

(5) Name of provider;

(6) Provider identifier;

(7) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider; and

(8) A summary of the amount, scope, duration, and frequency of services delivered that directly relate to the services specified in the approved child and family-centered care plan to be provided.

(9) A summary of when restraints, seclusion, and restrictive interventions were used including a date, time, the de-escalation techniques used to prevent the restraints, seclusion, and restrictive interventions and whether or not the use of restraints, seclusion, and restrictive interventions was included on the individual crisis and safety plan.

Last updated July 1, 2022 at 1:13 PM

Supplemental Information

Authorized By: 5167.02, 5166.02
Amplifies: 5162.03, 5166.04, 5167.03
Five Year Review Date: 7/1/2027
Rule 5160-59-05.3 | OhioRISE home and community-based services waiver: secondary flex funds.
 

(A) Scope. This rule sets forth provisions governing coverage for secondary flex funds delivered as part of the Ohio resilience through integrated systems and excellence (OhioRISE) 1915(c) waiver program (waiver) established in accordance with 1915(c) of the Social Security Act, 42 U.S.C. 1396n (January 1, 2022).

(B) Definitions. For this rule, the following definitions apply:

(1) "Emergency funds" are an additional allotment of waiver funding used for the purchase of approved secondary flex funds based on a youth's unmet needs as determined by the OhioRISE plan.

(2) "Participant direction" means the opportunity for an OhioRISE waiver youth to exercise choice and control in managing a budget for the applicable waiver service in accordance with their needs.

(3) "Participant-directed budget for secondary flex funds" is the waiver-enrolled youth's maximum approved, non-emergency funding allowable for the purchase of secondary flex funds under the OhioRISE 1915(c) waiver.

(4) "Secondary flex funds" is defined as the additional services, equipment, or supplies available through the waiver that are not otherwise provided through the medicaid state plan benefit or the OhioRISE program that address a youth's identified need as documented in the child and family-centered care plan. Secondary flex funds are intended to enhance and supplement the array of services available to a youth enrolled on the OhioRISE program and are discussed, recommended, and implemented through the care coordination process as described in rule 5160-59-03.2 of the Administrative Code. Secondary flex funds is inclusive of emergency funds and the participant-directed budget as described in this rule.

(5) "Waiver cost limit" is the maximum amount of funding, excluding emergency funds, available to a youth enrolled in the waiver. The waiver cost limit for the waiver is fifteen thousand dollars per twelve month period.

(C) With the exception of additional criteria defined in paragraph (D) of this rule, all provisions of rule 5160-59-03.5 of the Administrative Code apply to secondary flex funds provided under the waiver.

(D) The following additional criteria apply to secondary flex funds provided under the waiver:

(1) The total participant-directed budget for secondary flex funds is limited to three thousand dollars within three hundred sixty-five calendar days. The participant-directed budget is included in the waiver cost limit.

(2) The waiver enrolled youth may access up to the total participant-directed budget for secondary flex funds when all primary flex funds, described in rule 5160-59-03.5 of the Administrative Code, provided under the OhioRISE plan are exhausted.

(3) The total emergency funds available to a youth is limited to two thousand dollars within three hundred sixty-five days calendar days. Emergency funds are not included in the waiver cost cap.

(a) Emergency funds are only available to a youth when the youth has exhausted all primary flex funds, as described in rule 5160-59-03.5 of the Administrative Code, and all available funds in their participant-directed budget, and still have a demonstrated need which may be met through the emergency funds available under secondary flex funds.

(b) The youth's unmet need and desired outcome, resulting from the use of emergency funds, will be detailed in the child and family-centered care plan.

(4) Secondary flex fund services are additive to the primary flex funds described in rule 5160-59-03.5 of the Administrative Code.

(5) The OhioRISE plan will need to approve the waiver enrolled youth's participant-directed budget for secondary flex funds as part of the child and family care plan prior to use of the service.

(6) When the OhioRISE plan denies, reduces, terminates or suspends secondary flex funds services, this constitutes an adverse benefit determination, and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.

Last updated July 1, 2022 at 1:09 PM

Supplemental Information

Authorized By: 5167.02, 5166.02
Amplifies: 5162.03, 5166.04, 5167.03
Five Year Review Date: 7/1/2027