Rule 5123-9-48 | Home and community-based services waivers - community transition under the under the individual options waiver.
(A) Purpose
This rule defines community transition 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 shall apply:
(1) "Agency provider" has the same meaning as in rule 5123-2-08 of the Administrative Code.
(2) "Community transition" means reimbursement for non-recurring household start-up expenses for which an individual who previously resided in an intermediate care facility for individuals with intellectual disabilities or a nursing facility for at least ninety days and is transitioning to enrollment in the individual options waiver is directly responsible.
(a) Community transition includes expenses that do not constitute room and board, necessary to enable an individual to establish a basic household. Community transition includes, but is not limited to:
(i) Security deposits and rental start-up expenses required to obtain a lease on an apartment or house;
(ii) Essential household furnishings required to occupy and use a community domicile such as furniture, window coverings, food preparation items, and bed or bath linens;
(iii) Start-up fees or deposits for utility or service access such as telephone, electricity, heating, and water;
(iv) Moving expenses;
(v) Pre-transition transportation services necessary to secure housing and benefits; and
(vi) Initial cleaning products and household supplies.
(b) Community transition does not include:
(i) Grocery expenses;
(ii) Internet expenses;
(iii) Ongoing monthly rent or mortgage expenses;
(iv) Ongoing utility or service charges;
(v) Items intended for entertainment or recreational purposes; or
(vi) Tobacco products or alcohol.
(3) "County board" means a county board of developmental disabilities.
(4) "Department" means the Ohio department of developmental disabilities.
(5) "Independent provider" has the same meaning as in rule 5123-2-09 of the Administrative Code.
(6) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her 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) "Intermediate care facility for individuals with intellectual disabilities" has the same meaning as in section 5124.01 of the Revised Code.
(9) "Nursing facility" has the same meaning as in section 5165.01 of the Revised 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 shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.
(C) Provider qualifications
(1) Community transition shall be provided by an agency 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 to provide community transition shall complete and submit an application through the department's website (http://dodd.ohio.gov).
(3) A county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards may provide community transition only when no other qualified provider is available.
(4) Community transition shall not be provided by an independent provider.
(D) Requirements for service delivery
(1) Community transition shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code.
(2) Community transition may be authorized for up to one hundred eighty calendar days prior to the date on which an individual enrolls in the individual options waiver.
(3) Community transition may be authorized for up to thirty calendar days after the date on which an individual enrolls in the individual options waiver.
(4) Expenses are reimbursable as community transition only to the extent:
(a) No other person, including a landlord, has a legal or contractual responsibility to provide the item or service or pay the expense;
(b) They are reasonable and necessary as determined through the person-centered planning process and clearly identified in the individual service plan;
(c) The individual is unable to pay such expenses and the item or service cannot be obtained from other sources such as family, friends, neighbors, or community agencies; and
(d) They take into consideration the appropriateness and availability of a lower cost alternative for comparable services that meet the individual's needs.
(5) An individual shall be involved in selection of any item or service authorized as community transition and purchased on his or her behalf.
(E) Documentation of services
Service documentation for community transition shall include each of the following to validate payment for medicaid services:
(1) Type of service.
(2) Date of service.
(3) Name of individual receiving service.
(4) Medicaid identification number of individual receiving service.
(5) Name of provider.
(6) Provider identifier/contract number.
(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.
(8) A detailed description of each expense.
(9) A receipt for each expense with the individual's signature, mark, stamp, or other method identified in the individual service plan to verify his or her receipt of the purchased item or service.
(F) Payment standards
(1) The billing unit, service code, and payment rate for community transition are contained in the appendix to this rule.
(2) Community transition shall not exceed two thousand dollars per individual.
(3) Pre-transition transportation services covered as community transition shall not exceed five hundred dollars.
(4) The date of service for purposes of reimbursement shall be the date an individual enrolls in the individual options waiver upon discharge from the intermediate care facility for individuals with intellectual disabilities or the nursing facility.
(5) If for any unforeseen reason an individual does not enroll in the individual options waiver and transition to the community as planned (e.g., due to death or significant change in condition), the county board shall submit the individual's expenses to the department within one year. Expenses incurred in these circumstances are reimbursable to the county board by the department and to the department by the Ohio department of medicaid.
Last updated November 18, 2024 at 1:14 PM
Supplemental Information