Rule 5123-9-21 | Home and community-based services waivers - informal respite under the level one waiver.
(A) Purpose
This rule defines informal respite and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.
(B) Definitions
For the purposes of this rule, the following definitions apply:
(1) "Agency provider" means an entity that directly employs at least one person in addition to a director of operations for the purpose of providing services for which the entity is certified in accordance with rule 5123-2-08 of the Administrative Code.
(2) "County board" means a county board of developmental disabilities.
(3) "Department" means the Ohio department of developmental disabilities.
(4) "Fifteen-minute billing unit" means a billing unit that equals fifteen minutes of service delivery time or is greater or equal to eight minutes and less than or equal to twenty-two minutes of service delivery time. Minutes of service delivery time accrued throughout a day will be added together for the purpose of calculating the number of fifteen-minute billing units for the day.
(5) "Independent provider" means a self-employed person who provides services for which the person is certified in accordance with rule 5123-2-09 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.
(6) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.
(7) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.
(8) "Informal respite" means care and support services furnished to an individual by a person known to the individual, on a short-term basis because of the absence or need for relief of those persons routinely providing care. Informal respite may be provided in the individual's home or place of residence, home of a friend or family member, or at sites of community activities.
(9) "Major unusual incident" has the same meaning as in rule 5123-17-02 of the Administrative Code.
(10) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that includes the items delineated in paragraph (E) of this rule to validate payment for medicaid services.
(11) "Unusual incident" has the same meaning as in rule 5123-17-02 of the Administrative Code.
(12) "Waiver eligibility span" means the twelve-month period following either an individual's initial waiver enrollment date or a subsequent eligibility re-determination date.
(C) Provider qualifications
(1) Informal respite will be provided by an independent provider known to the individual who:
(a) Meets the requirements of this rule;
(b) Has a medicaid provider agreement with the Ohio department of medicaid; and
(c) Has completed and submitted an application and adheres to the requirements of rule 5123-2-09 of the Administrative Code.
(2) Informal respite will not be provided by an agency provider, a county board, or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards.
(3) Failure to comply with this rule and rule 5123-2-09 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.
(D) Requirements for service delivery
(1) Informal respite will be provided pursuant to an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code.
(2) In order to be eligible for informal respite, an individual or the individual's designee must be able and willing to accept responsibility for training the provider and monitoring health management activities, behavioral support, major unusual incident reporting, and other activities required to meet the needs of the individual as identified in the individual service plan. The individual or the individual's designee will document the following on forms and according to procedures prescribed by the department:
(a) Orientation and training of the provider, prior to the delivery of services, about activities required to meet the needs and preferences of the individual, including any training specified for the individual in the individual service plan and other information related to health and welfare needs of the individual.
(b) Annual training of the provider to ensure that the provider understands the following:
(i) The requirements set forth in rule 5123-17-02 of the Administrative Code and the reasonable steps necessary to prevent the occurrence or recurrence of unusual incidents and major unusual incidents;
(ii) The rights of individuals set forth in section 5123.62 of the Revised Code; and
(iii) The activities required to meet the needs and preferences of the individual, including any training specified for the individual in the individual service plan and other information related to health and welfare needs of the individual.
(3) The individual or the individual's designee will:
(a) Ensure the provider is delivering informal respite as specified in the individual service plan.
(b) Ensure the provider is documenting the delivery of informal respite in accordance with paragraph (E) of this rule.
(c) Upon knowledge of an unusual incident or a major unusual incident, take immediate actions as necessary to maintain the health, safety, and welfare of the individual receiving informal respite.
(4) Failure of the individual or the individual's designee to fulfill the requirements of this rule will render the individual ineligible for informal respite under the waiver and, subsequent to prior notice and hearing rights in accordance with section 5160.31 of the Revised Code and rules implementing that statute, informal respite will be terminated.
(E) Documentation of services
Service documentation for informal respite will include each of the following to validate payment for medicaid services:
(1) Type of service.
(2) Date of service.
(3) Place of service.
(4) Name of individual receiving service.
(5) Medicaid identification number of individual receiving service.
(6) Name of provider.
(7) Provider identifier/contract number.
(8) Times the delivered service started and stopped.
(9) Written or electronic signature of the person delivering the service.
(10) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.
(F) Payment standards
The billing unit, service code, and payment rate for informal respite provided January 1, 2024 through June 30, 2024 are contained in appendix A to this rule. The billing unit, service code, and payment rate for informal respite provided on or after July 1, 2024 are contained in appendix B to this rule.
Last updated January 2, 2024 at 9:48 AM
Supplemental Information