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 criteria to be an eligible provider of behavioral health services in accordance with rule 5160-27-01 of the Administrative Code.
(b) The Ohio 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 that either:
(i) Are not currently fostering other youth; or
(ii) If currently fostering other youth, meets one of the criteria identified in paragraphs (C)(1)(f)(ii)(a) to (C)(1)(f)(ii)(c) of this rule, and the foster caregiver has determined that the youth in need of behavioral health respite services can be safely served together with the youth residing in the home:
(a) Has a relationship, established via a face-to-face meeting, a telephone call, or a video call, with the youth who will receive respite services in the foster home;
(b) Is fostering siblings or kin of the youth who will receive respite services in the foster home; or
(c) Is fostering the child of a parenting youth who will receive respite services in the foster home.
(2) Behavioral health respite providers are subject to the criminal records check criteria set forth in rule 5160-45-07 or 5160-45-08 of the Administrative Code, as applicable.
(3) Behavioral health respite 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) Behavioral health respite providers 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 have been 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 a 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;
(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.
(b) Has behavioral health needs for the behavioral health respite service as determined by the OhioRISE plan.
(3) The behavioral health respite service may be provided either during normal awake hours or overnight. The provider of the behavioral health respite 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) The behavioral health respite service 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 residential setting 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 the behavioral health respite service 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) The behavioral health respite service 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 service does not duplicate reimbursement for otherwise available respite services in a foster home or treatment foster home;
(c) The medicaid reimbursement for this service 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;
(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; and
(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 March 18, 2024 at 11:44 AM
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