Ohio Admin. Code 5123-9-25 - [Effective 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

For the purposes of this rule, the following definitions apply:

(1) "Agency provider" 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) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Independent provider" 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.

(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.

(6) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(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 includes the items delineated in paragraph (E) of this rule to validate payment for medicaid services. that:

(a) Are created and maintained as services are delivered, and completed prior to billing for services;

(b) Are kept in a manner that fully discloses the extent of services delivered;

(c) Include the items delineated in paragraph (E) of this rule; and

(d) May be created or maintained in electronic software programs.

(8) "Specialized medical equipment and supplies" means adaptive and assistive 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 will meet applicable standards of manufacture, design, and installation. Specialized medical equipment and supplies does not include:

(a) Repair or replacement of a previously approved item that has been damaged as a result of confirmed misuse, abuse, or negligence;

(b) Items that are not of direct medical or remedial benefit to the individual;

(c) Items otherwise available as assistive technology described in rule 5123-9-12 of the Administrative Code;

(d) Items otherwise available as vehicle modification described in rule 5123-9-44 of the Administrative Code;

(d)(e) For individuals less than twenty-one years of age, equipment or supplies that are covered under the "Early and Periodic Screening, Diagnostic, and Treatment Program"; or

(e)(f) 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.

(C) Provider qualifications

(1) Specialized medical equipment and supplies 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) An applicant seeking approval to provide specialized medical equipment and supplies will complete and submit an application and adhere to the requirements of as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code.

(3) An applicant seeking approval to provide specialized medical equipment and supplies will submit to the department documentation demonstrating the applicant's qualifications and experience in providing specialized medical equipment and supplies.

(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) Failure to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may result in denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

(1) Specialized medical equipment and supplies 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.

(4) The provider of specialized medical equipment and supplies will:

(a) Ensure proper installation of equipment, if required;

(b) Provide training to the individual, family, and other persons, if required;

(c) Properly maintain rental equipment, if required; and

(d) Repair equipment as authorized by the county board representative.

(E) Documentation of services Service documentation for specialized medical equipment and supplies 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 rate for specialized medical equipment and supplies are contained in the appendix to this rule.

(2) Payment for specialized medical equipment and supplies will not exceed ten thousand dollars per item unless the county board documents the need for an exception in accordance with paragraph (F)(3) of this rule. 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.

(3) When the cost of a needed item exceeds ten thousand dollars, 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 either through waiver funding or non-medicaid funds. When waiver funding is necessary, the county board will submit documentation to the department establishing how the project will ensure the individual's health and welfare.

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Notes

Ohio Admin. Code 5123-9-25

Effective: 7/1/2025
Five Year Review (FYR) Dates: 7/1/2029
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, 07/01/2024