Rule 5160-59-05.1 | OhioRISE home and community-based services waiver: out-of-home respite.
(A) Scope. This rule sets forth provisions governing coverage for out-of-home respite services delivered as part of the Ohio resilience through integrated systems and excellence (OhioRISE) 1915(c) waiver program (waiver) established in accordance with 1915(c) of the Social Security Act, 42 U.S.C. 1396n (January 1, 2022).
(B) Definitions. For this rule, the following definitions apply:
(1) "Community respite" has the same meaning as set forth in rule 5123-9-22 of the Administrative Code.
(2) "Intermediate care facility for individuals with intellectual disabilities" (ICF/IID) has the same meaning as set forth in section 5124.01 of the Revised Code.
(3) "Out-of-home respite" is a service provided to youth unable to care for themselves who are enrolled on the waiver. The service is provided on a short-term basis because of the absence or need for relief of those persons who normally provide care for the youth.
(4) "Residential respite" has the same meaning as set forth in rule 5123-9-34 of the Administrative Code.
(C) Eligible providers and conditions of participation.
(1) The following providers are eligible to provide the out-of-home respite service available under the waiver program:
(a) An ICF/IID who is certified by the Ohio department of health (ODH), holds certification with the Ohio department of developmental disabilities (DODD) as a residential respite provider as set forth in rule 5123-9-34 of the Administrative Code, and has an active license with DODD.
(b) An agency provider holding certification for DODD community respite services as set forth in rule 5123-9-22 of the Administrative Code.
(c) A class one residential facility licensed by Ohio MHAS in accordance with Chapter 5122-30 of the Administrative Code.
(2) With the exception of paragraph (B)(14) of rule 5160-44-31 of the Administrative Code, out-of-home respite providers will comply with conditions of participation as set forth in rule 5160-44-31 of the Administrative Code.
(3) Out-of-home 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) Out-of-home respite providers serving an OhioRISE youth with behaviors that pose safety concerns for the youth or others, will be trained in de-escalation strategies that can be used to support the youth and prevent the use of restraints, seclusion, and restrictive interventions.
(5) Out-of-home respite providers serving an OhioRISE youth with an individual crisis and safety plan including the use of restraints, seclusion, or restrictive intervention will have been trained in the appropriate use of restraints, seclusion, and restrictive interventions.
(6) Out-of-home respite providers will retain all initial and subsequent child and family-centered care plans.
(7) Out-of-home respite providers are subject to compliance reviews specific to their licensure or certification criteria in addition to ongoing monitoring conducted by the OhioRISE plan.
(D) Coverage.
(1) The out-of-home respite service may be provided on a planned or emergency basis. An emergency out-of-home respite service may be provided to address either a primary caregiver's unexpected need for out-of-home respite or to address an urgent need related to the youth.
(2) Service delivery is not permitted in the youth's primary residence.
(3) The out-of-home respite service available under the waiver program is additive to the behavioral health respite service as set forth in rule 5160-59-03.4 of the Administrative Code.
(4) The youth's care coordinator working within the care management entity (CME), as defined in rule 5160-59-01 of the Administrative Code, or OhioRISE plan, will assist the youth and their primary caregiver in determining the need for the use of planed and emergency out-of-home respite.
(5) The youth's care coordinator working within the CME, as defined in rule 5160-59-01 of the Administrative Code, or OhioRISE plan may recommend planned and emergency out-of-home respite, as well as the providers of out-of-home respite services, as part of the child and family-centered care plan.
(6) The OhioRISE plan will need to approve out-of-home respite service as part of the child and family-centered care plan prior to receipt and reimbursement of out-of-home respite service.
(E) Limitations.
(1) The out-of-home respite service will not be provided to a youth prior to establishment of initial or ongoing enrollment and eligibility criteria for the waiver as set forth in rule 5160-59-04 of the Administrative Code.
(2) The out-of-home respite service will be provided only to a youth enrolled on the waiver at the time of service delivery.
(3) The out-of-home respite service is available for a total of ninety calendar days within a three hundred-sixty-five day period while a youth is enrolled on the waiver. Dependent on the care coordination tier a youth is enrolled, in accordance with rule 5160-59-03.2 of the Administrative Code, either the CME care coordinator or the OhioRISE care coordinator is responsible for tracking and maintaining records for the purposes of tracking out-of-home respite utilization within each three hundred sixty-five -day period.
(4) Reimbursement for out-of-home respite is not allowable on the same day when the youth is receiving behavioral health respite as set forth in rule 5160-59-03.4 of the Administrative Code.
(5) When the OhioRISE plan denies, reduces or terminates or suspends out-of-home 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 out-of-home 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; and
(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.
(9) A summary of when restraints, seclusion, and restrictive interventions were used including a date, time, the de-escalation techniques used to prevent the restraints, seclusion, and restrictive interventions and whether or not the use of restraints, seclusion, and restrictive interventions was included on the individual crisis and safety plan.
(G) Reimbursement.
(1) Only one provider may bill out-of-home respite for the same youth on any given day.
(2) Reimbursement for the out-of-home respite service does not include room and board.
(3) Reimbursement for the out-of-home respite service does not include transportation costs.
Last updated March 18, 2024 at 11:44 AM
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