Rule 5160-26-03.2 | Managed care: long-term services and supports respite services for children.
(A) This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code.
(B) The managed care organization (MCO) is responsible for payment of long-term services and supports (LTSS) respite services as defined in rule 5160-26-01 of the Administrative Code.
(C) To be eligible for respite services, the member has to:
(1) Reside with his or her informal, unpaid primary caregiver in a home that is not owned, leased, or controlled by a provider of any health-related treatment or support services;
(2) Not be a foster child, as defined in Chapter 5101:2-1 of the Administrative Code;
(3) Be under twenty-one years of age;
(4) Have long-term services and supports (LTSS) needs resulting in the need for respite services as indicated by:
(a) Skilled nursing or skilled rehabilitation services at least once per week; or
(b) Having a need for at least fourteen hours per week of home health aide services for at least two consecutive months immediately preceding the date respite services are requested; or
(c) Being determined eligible for social security income for children with disabilities or supplemental security income; or
(d) Having an LTSS needs as determined by the MCO through an institutional level of care determination as set forth in rule 5123-8-01 or 5160-3-08, of the Administrative Code.
(5) Be participating in a care management or coordination arrangement.
(D) Authorization for LTSS respite.
(1) Prior authorization of LTSS respite services will be in accordance with rule 5160-26-03.1 of the Administrative Code.
(2) Respite services can be provided on a planned or unplanned basis.
(3) The MCO has to determine that the member's primary caregiver has a need for temporary relief from the care of the member as a result of the member's LTSS needs, or in order to prevent an inpatient, institutional, or out-of-home stay.
(E) LTSS respite services have to be provided by individuals employed by medicaid enrolled agency providers that are either medicare-certified home health agencies pursuant to Chapter 3701-60 of the Administrative Code, or accredited by the "Joint Commission," the "Community Health Accreditation Program," or the "Accreditation Commission for Health Care."
(1) LTSS respite providers have to comply with the criminal records check set forth in rules 5160-45-07 and 5160-45-11 of the Administrative Code.
(2) The provider has to be awake when the member is awake during the provision of respite services.
(3) Respite providers has to not be the member's "legally responsible family member," as defined in rule 5160-45-01 of the Administrative Code.
(4) Before commencing service delivery, the LTSS provider agency employee has to:
(a) Obtain a certificate of completion of either a competency evaluation program or a training and competency evaluation program approved or conducted by the director of health under section 3721.31 of the Revised Code, and be registered as active or in good standing on the Ohio nurse aide registry maintained by the director of health under section 3721.32 of the Revised Code.
(b) Obtain and maintain first aid certification from a class that is not solely internet-based and that includes hands-on training by a certified first aid instructor and a successful return demonstration of what was learned in the course. At its discretion, ODM may accept training conducted by a solely internet-based class as sufficient for the purposes of first aid certification.
(c) After commencing service delivery, the LTSS provider agency employee has to:
(i) Maintain evidence of completion of twelve hours of in-service continuing education within a twelve-month period, excluding agency and program-specific orientation, and
(ii) Receive supervision from an Ohio-licensed registered nurse (RN) and meet any additional supervisory requirements pursuant to the agency's certification or accreditation.
Last updated March 25, 2024 at 9:11 AM
Supplemental Information