Ohio Admin. Code 5123-9-25 - [Effective until 7/1/2025] Home and community-based services waivers - specialized medical equipment and supplies under the individual options and level one waivers
(A) Purpose
This rule defines specialized medical equipment and supplies and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.
(B) Definitions
(3)(2) "County board"
means a county board of developmental disabilities.
(4)(3) "Department" means
the Ohio department of developmental disabilities.
(5)(4) "Independent
provider" has the same meaning as in
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.
(6)(5) "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.
(7)(6)
"Individual service plan" means the written description of services, supports,
and activities to be provided to an individual.
(8)(7) "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
includes the items delineated in paragraph (E) of
this rule to validate payment for medicaid services.
(9)(8) "Specialized
medical equipment and supplies" means adaptive and assistive
equipment and other specialized medical equipment
and supplies such as devices, controls, or appliances, specified in
the individual service plan, which enable an individual to increase ability to
perform activities of daily living, or to perceive, control, or communicate
with the environment in which the individual lives. Specialized medical
equipment and supplies includes items necessary for life support, ancillary
supplies and equipment necessary to the proper functioning of such items, and
durable and non-durable medical equipment not available under the medicaid
state plan. Specialized medical equipment and supplies
includes repair or maintenance of a previously approved item which is within
its useful life, as well as replacement of a previously approved item which is
beyond its useful life. All items shall
will meet
applicable standards of manufacture, design, and installation. Specialized
medical equipment and supplies does not include:
(a)(b) Items that are not
of direct medical or remedial benefit to the individual;
(b)(c)
Items otherwise available as assistive technology described in rule
5123-9-12 of the Administrative
Code; or
(c)(d) For individuals
less than twenty-one years of age, equipment and
or supplies that
are available under the medicaid state plan
or covered under the provisions of 1905(r)
of the Social Security Act, 42 U.S.C. 1396d, as in effect on the effective date
of this rule.
"Early and Periodic Screening,
Diagnostic, and Treatment Program"; or
For the purposes of this rule, the following definitions apply:
(1) "Agency provider"
has the same meaning as in
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) "Assistive technology" has the
same meaning as in rule 5123-9-12 of the Administrative Code.
(a)
Repair or
replacement of a previously approved item that has been damaged as a result of
confirmed misuse, abuse, or negligence;
(e)
Equipment or
supplies that are covered under the medicaid state plan described in Chapter
5160-10 of the Administrative Code.
(9)
"Useful life"
means the amount of time during which an item is expected to be in service, as
determined by the manufacturer of the item.
(10) "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
(3)(2) An applicant
seeking approval to provide specialized medical equipment and supplies
shall
will
complete and submit an application through the
department's website (http://dodd.ohio.gov)
and adhere to the requirements of as applicable, rule
5123-2-08 or
5123-2-09 of the Administrative
Code.
(4)(3) An applicant
seeking approval to provide specialized medical equipment and supplies
shall
will
submit to the department documentation verifying
demonstrating the applicant's qualifications and experience in providing specialized
medical equipment and supplies.
(1) Specialized medical equipment and
supplies shall
will be provided by an independent provider or an
agency provider that meets the requirements of this rule and that has a
medicaid provider agreement with the Ohio department of medicaid.
(2) A county board or a regional
council of governments formed pursuant to section 5126.13 of the Revised Code
by two or more county boards may provide specialized medical equipment and
supplies only when no other certified provider is willing and
able.
(4)
An agency provider will ensure personnel engaged in the
provision of specialized medical equipment and supplies possess appropriate
knowledge, skills, and abilities relative to the type of equipment or supplies
they are providing.
(5) A veterinarian who is attending
to service animals shall be licensed to engage in the practice of veterinary
medicine in accordance with Chapter 4741. of the Revised Code.
(D)
Requirements for service delivery(2)(4) The provider of
specialized medical equipment and supplies shall
will:
(1)
Specialized medical equipment and supplies shall
will be
provided pursuant to an individual service plan that conforms to the
requirements of rule
5123-4-02 of the Administrative
Code.
(2)
Prior to authorizing specialized medical equipment and
supplies, an individual's service and support administrator will document that
the item is not covered under the medicaid state plan. In accordance with rule
5160-10-01 of the Administrative
Code, only the Ohio department of medicaid can determine coverage. A provider
cannot determine whether an item or service is not covered or would not be
covered by the Ohio department of medicaid. Documentation of non-coverage will
include:
(a)
Notification received from the Ohio department of medicaid
or its designee that a properly submitted prior authorization request has been
processed; or
(b)
Guidance published by the department or the Ohio
department of medicaid specifying items not covered under the medicaid state
plan.
(3)
When prior authorization is required, an individual's
service and support administrator will, upon request by the department, submit
the provider- completed certificate of medical necessity and all supporting
documentation described in rule
5160-10-01 of the Administrative
Code.
(a) Ensure proper installation of equipment,
if required;
(b) Provide training
to the individual, family, and other persons, as
applicable, in the proper utilization of equipment
if required;
(c) Properly maintain rental equipment, if
required; and
(d) Repair equipment as authorized by the
county board representative; and
.
(e) Assume full liability for
equipment improperly installed or maintained.
(E) Documentation of
services
Service documentation for specialized medical equipment and
supplies shall
will include each of the following to validate payment
for medicaid services:
(1) Type of
service.
(2) Date of
service.
(3) Place of
service.
(4) Name of individual
receiving service.
(5) Medicaid
identification number of individual receiving service.
(6) Name of provider.
(7) Provider identifier/contract
number.
(8) 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.
(9) 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 unit, service codes,
and payment rates
rate for specialized medical equipment and supplies
are contained in the appendix to this rule.
(2) Payment for specialized medical equipment
and supplies shall
will not exceed ten thousand dollars per item.
When the cost of a needed item exceeds this limit, the
department and the county board will collaborate with the individual and the
individual's team to ensure the individual's health and welfare needs are met.
When necessary:
(a)
Prior authorization may be requested in accordance with
rule 5123-9-07 of the Administrative
Code for an individual enrolled in the individual options
waiver.
(b)
Non-medicaid funds available to purchase the item will
be identified for an individual enrolled in the level one waiver.
Notes
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.049, 5123.1611
Rule Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Prior Effective Dates: 04/28/2003, 07/01/2006, 03/19/2012, 09/01/2013, 06/01/2018, 01/01/2019, 07/01/2022
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(A) Purpose
This rule defines specialized medical equipment and supplies and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.
(B) Definitions (3)(2) "County board" means a county board of developmental disabilities. (4)(3) "Department" means the Ohio department of developmental disabilities. (5)(4) "Independent provider" has the same meaning as in 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. (6)(5) "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. (7)(6) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual. (8)(7) "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 includes the items delineated in paragraph (E) of this rule to validate payment for medicaid services. (9)(8) "Specialized medical equipment and supplies" means adaptive and assistive equipment and other specialized medical equipment and supplies such as devices, controls, or appliances, specified in the individual service plan, which enable an individual to increase ability to perform activities of daily living, or to perceive, control, or communicate with the environment in which the individual lives. Specialized medical equipment and supplies includes items necessary for life support, ancillary supplies and equipment necessary to the proper functioning of such items, and durable and non-durable medical equipment not available under the medicaid state plan. Specialized medical equipment and supplies includes repair or maintenance of a previously approved item which is within its useful life, as well as replacement of a previously approved item which is beyond its useful life. All items shall will meet applicable standards of manufacture, design, and installation. Specialized medical equipment and supplies does not include: (a)(b) Items that are not of direct medical or remedial benefit to the individual; (b)(c) Items otherwise available as assistive technology described in rule 5123-9-12 of the Administrative Code; or (c)(d) For individuals less than twenty-one years of age, equipment and or supplies that are available under the medicaid state plan or covered under the provisions of 1905(r) of the Social Security Act, 42 U.S.C. 1396d, as in effect on the effective date of this rule. "Early and Periodic Screening, Diagnostic, and Treatment Program"; or
For the purposes of this rule, the following definitions apply:
(1) "Agency provider" has the same meaning as in 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) "Assistive technology" has the same meaning as in rule 5123-9-12 of the Administrative Code.
(a) Repair or replacement of a previously approved item that has been damaged as a result of confirmed misuse, abuse, or negligence;
(e) Equipment or supplies that are covered under the medicaid state plan described in Chapter 5160-10 of the Administrative Code.
(9) "Useful life" means the amount of time during which an item is expected to be in service, as determined by the manufacturer of the item.
(10) "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 (3)(2) An applicant seeking approval to provide specialized medical equipment and supplies shall will complete and submit an application through the department's website (http://dodd.ohio.gov) and adhere to the requirements of as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code. (4)(3) An applicant seeking approval to provide specialized medical equipment and supplies shall will submit to the department documentation verifying demonstrating the applicant's qualifications and experience in providing specialized medical equipment and supplies.
(1) Specialized medical equipment and supplies shall will be provided by an independent provider or an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid.
(2) A county board or a regional council of governments formed pursuant to section 5126.13 of the Revised Code by two or more county boards may provide specialized medical equipment and supplies only when no other certified provider is willing and able.
(4) An agency provider will ensure personnel engaged in the provision of specialized medical equipment and supplies possess appropriate knowledge, skills, and abilities relative to the type of equipment or supplies they are providing.
(5) A veterinarian who is attending to service animals shall be licensed to engage in the practice of veterinary medicine in accordance with Chapter 4741. of the Revised Code.
(D) Requirements for service delivery(2)(4) The provider of specialized medical equipment and supplies shall will:
(1) Specialized medical equipment and supplies shall will be provided pursuant to an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code.
(2) Prior to authorizing specialized medical equipment and supplies, an individual's service and support administrator will document that the item is not covered under the medicaid state plan. In accordance with rule 5160-10-01 of the Administrative Code, only the Ohio department of medicaid can determine coverage. A provider cannot determine whether an item or service is not covered or would not be covered by the Ohio department of medicaid. Documentation of non-coverage will include:
(a) Notification received from the Ohio department of medicaid or its designee that a properly submitted prior authorization request has been processed; or
(b) Guidance published by the department or the Ohio department of medicaid specifying items not covered under the medicaid state plan.
(3) When prior authorization is required, an individual's service and support administrator will, upon request by the department, submit the provider- completed certificate of medical necessity and all supporting documentation described in rule 5160-10-01 of the Administrative Code.
(a) Ensure proper installation of equipment, if required;
(b) Provide training to the individual, family, and other persons, as applicable, in the proper utilization of equipment if required;
(c) Properly maintain rental equipment, if required; and
(d) Repair equipment as authorized by the county board representative; and .
(e) Assume full liability for equipment improperly installed or maintained.
(E) Documentation of services
Service documentation for specialized medical equipment and supplies shall will include each of the following to validate payment for medicaid services:
(1) Type of service.
(2) Date of service.
(3) Place of service.
(4) Name of individual receiving service.
(5) Medicaid identification number of individual receiving service.
(6) Name of provider.
(7) Provider identifier/contract number.
(8) 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.
(9) 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 unit, service codes, and payment rates rate for specialized medical equipment and supplies are contained in the appendix to this rule.
(2) Payment for specialized medical equipment and supplies shall will not exceed ten thousand dollars per item. When the cost of a needed item exceeds this limit, the department and the county board will collaborate with the individual and the individual's team to ensure the individual's health and welfare needs are met. When necessary:
(a) Prior authorization may be requested in accordance with rule 5123-9-07 of the Administrative Code for an individual enrolled in the individual options waiver.
(b) Non-medicaid funds available to purchase the item will be identified for an individual enrolled in the level one waiver.
Notes
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.049, 5123.1611
Rule Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Prior Effective Dates: 04/28/2003, 07/01/2006, 03/19/2012, 09/01/2013, 06/01/2018, 01/01/2019, 07/01/2022