Rule 5123-9-34 | Home and community-based services waivers - residential respite under the individual options, level one, and self-empowered life funding waivers.
(A) Purpose
This rule defines residential 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) "Group size" means the number of individuals who are sharing services, regardless of the funding source for those services.
(5) "Homemaker/personal care" has the same meaning as in rule 5123-9-30 of the Administrative Code.
(6) "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.
(7) "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.
(8) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.
(9) "Intermediate care facility for individuals with intellectual disabilities" has the same meaning as in section 5124.01 of the Revised Code.
(10) "Participant-directed homemaker/personal care" has the same meaning as in rule 5123-9-32 of the Administrative Code.
(11) "Residential facility" means a home or facility, including an intermediate care facility for individuals with intellectual disabilities, in which an individual with a developmental disability resides, that is licensed by the department pursuant to section 5123.19 of the Revised Code.
(12) "Residential respite" means care and support services furnished to an individual on a short-term basis because of the absence or need for relief of those persons routinely providing care. Depending on the circumstances of service provision, residential respite is billed at a daily billing unit or at a fifteen-minute billing unit:
(a) Residential respite at the daily billing unit
(i) Residential respite at the daily billing unit will be used when:
(a) Residential respite is provided to an individual for more than seven hours during a twenty-four hour period and the individual stays overnight at the residential respite service delivery location; and
(b) A shared living caregiver does not bill for provision of shared living to the individual on that day.
(ii) Residential respite at the daily billing unit will be provided by:
(a) A residential facility;
(b) An agency provider; or
(c) An independent provider.
(iii) Residential respite at the daily billing unit may be provided at:
(a) A residential facility;
(b) The individual's home;
(c) The home of the employee of an agency provider who is providing the service; or
(d) The home of the independent provider who is providing the service.
(b) Residential respite at the fifteen-minute billing unit
(i) Residential respite at the fifteen-minute billing unit is available only to an individual who resides in a shared living setting and will be used when residential respite is provided to the individual on the same day the shared living caregiver bills for provision of shared living.
(ii) Residential respite at the fifteen-minute billing unit may be provided by:
(a) A residential facility other than an intermediate care facility for individuals with intellectual disabilities;
(b) An agency provider; or
(c) An independent provider.
(iii) Residential respite at the fifteen-minute billing unit will be provided at:
(a) A residential facility other than an intermediate care facility for individuals with intellectual disabilities;
(b) The individual's home;
(c) The home of the employee of an agency provider who is providing the service;
(d) The home of the independent provider who is providing the service; or
(e) Another location chosen by the individual.
(iv) The residential respite fifteen-minute billing unit 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.
(13) "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.
(14) "Shared living" has the same meaning as in rule 5123-9-33 of the Administrative Code.
(15) "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) Residential respite will be provided by a residential facility, an agency provider, or an independent provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid.
(2) An applicant seeking approval to provide residential respite will complete and submit an application and adhere to the requirements of as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code.
(3) Failure of a certified provider to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may result in denial, suspension, or revocation of the provider's certification.
(4) Failure of a licensed provider to comply with this rule and Chapter 5123-3 of the Administrative Code may result in denial, suspension, or revocation of the provider's license.
(D) Requirements for service delivery
(1) Residential 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) The individual service plan will address emergency and replacement coverage should the individual unexpectedly need to leave the residential respite service delivery location.
(3) Residential respite at the daily billing unit may be provided at a residence other than a residential facility only when:
(a) Each individual who receives homemaker/personal care or participant-directed homemaker/personal care and permanently resides at the residence consents to the provision of residential respite at the residence; and
(b) The total number of persons with developmental disabilities being served at the residence does not exceed four.
(4) Residential respite at the daily billing unit is limited to ninety calendar days of service per waiver eligibility span.
(5) Residential respite at the fifteen-minute billing unit is limited to two hundred eight units per calendar month.
(6) Residential respite will not be provided to an individual at the same time as homemaker/personal care, participant-directed homemaker/personal care, or shared living.
(7) An individual who resides in a shared living setting may receive residential respite at the daily billing unit during a short-term absence or need for relief of the shared living caregiver on a day the shared living caregiver does not bill for provision of shared living.
(8) An individual who resides in a shared living setting may receive residential respite at the fifteen-minute billing unit for the temporary relief of the shared living caregiver on a day the shared living caregiver bills for provision of shared living as long as:
(a) Residential respite and shared living services are not delivered at the same time;
(b) Residential respite is not provided by the shared living caregiver or any other person who resides in the shared living setting; and
(c) No more than twelve hours of residential respite are provided to the individual on that day.
(9) A provider delivering residential respite in fifteen-minute billing units will utilize electronic visit verification in accordance with rule 5160-32-01 of the Administrative Code.
(E) Documentation of services
Service documentation for residential respite will include each of the following to validate payment for medicaid services:
(1) Type of service (i.e., residential respite daily billing unit or residential respite fifteen-minute billing unit).
(2) Date of service.
(3) Times the delivered service started and stopped.
(4) Place of service.
(5) Name of individual receiving service.
(6) Medicaid identification number of individual receiving service.
(7) Name of provider.
(8) Provider identifier/contract number.
(9) 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.
(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
(1) The billing units, service codes, and payment rates for residential respite are contained in the appendix to this rule.
(2) The payment rates for residential respite vary by type of provider.
(3) The rate paid to a provider delivering residential respite in fifteen-minute billing units is adjusted to reflect the group size:
(a) Payment for serving an individual in a group size of two is eighty-five per cent of the rate for serving one individual.
(b) Payment for serving an individual in a group size of three is seventy-five per cent of the rate for serving one individual.
(c) Payment for serving an individual in a group size of four is sixty-five per cent of the rate for serving one individual.
(4) Only one provider may bill a daily billing unit for provision of residential respite for the same individual on any given day.
(5) Residential respite provided to individuals enrolled in the individual options waiver is subject to the funding ranges and individual funding levels set forth in rule 5123-9-06 of the Administrative Code.
(6) Payment for residential respite does not include payment for room and board or transportation.
Last updated July 1, 2024 at 4:37 PM
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