Ohio Admin. Code 5123-9-27 - Home and community-based services waivers - health care assessment under the individual options, level one, and self-empowered life funding waivers
(A)
Purpose
This rule defines health care assessment and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service. Health care assessment is intended to provide right-on-time health assessment to determine the best clinical course of action, often avoiding unnecessary emergency room visits and decreasing the need for inpatient admissions; health care assessment is not intended to replace services provided by an individual's primary care physician.
(B)
Definitions
For the purposes of this rule, the following definitions apply:
(1)
"Advanced practice nurse" has the same meaning as in
section 4723.01 of the Revised
Code.
(2)
"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.
(3)
"Department" means the Ohio department of developmental
disabilities.
(4)
"Health care assessment" means using technology to
facilitate real-time consultation and support provided by a physician, a
physician assistant, or an advanced practice nurse to assist an individual
and/or the individual's authorized caregivers to understand the individual's
presenting health symptoms and identify appropriate next steps. Health care
assessment:
(a)
Is consultative in nature, reflects the presentations and
treatments unique to individuals with developmental disabilities, and provides
disability-specific guidance on when best to seek additional or in-person
medical treatment.
(b)
Includes support and consultation, which is based on
expertise in developmental disabilities, to an individual and/or the
individual's paid and unpaid caregivers and seeks to empower the individual and
build the capacity of caregivers to better understand the best approach for
supporting the individual based on the individual's symptom
presentation.
(c)
Includes clinical transition of care, conducted
immediately after conclusion of the consultation, from the provider of health
care assessment to the receiving provider to help guide care and provider
coordination, when the provider of health care assessment refers the individual
to the emergency room, urgent care facility, or primary care
physician.
(d)
Includes follow-up and aftercare, as needed, via a
follow-up consultation with the treated individual and/or the individual's
caregiver, within eighteen hours after the initial
consultation.
(e)
Will not duplicate or replace other home and
community-based services.
(f)
Is limited to additional services not otherwise covered
under the medicaid state plan (such as the "Early and Periodic Screening,
Diagnostic, and Treatment Program" or in-person medical examinations as needed)
but consistent with waiver objectives of avoiding
institutionalization.
(g)
Will not be used for routine, ongoing care, thus
replacing an individual's primary care physician.
(5)
"Individual"
means a person with a developmental disability or for the 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)
"Physician" means
a person authorized by Chapter 4731. of the Revised Code and rules adopted
thereunder to practice medicine and surgery or osteopathic medicine and
surgery.
(8)
"Physician Assistant" means a person authorized by
Chapter 4730. of the Revised Code and rules adopted thereunder to practice as a
physician assistant.
(9)
"Plan of care" means the medical treatment plan that is
established, approved, and signed by the treating physician, physician
assistant, or advanced practice nurse.
(10)
"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.
(C)
Provider
qualifications
(1)
Health care assessment will be provided only by 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 health care
assessment will complete and submit an application and adhere to the
requirements of rule
5123-2-08 of the Administrative
Code except that paragraphs (G)(3), (G)(4), (G)(7), (J)(2), (J)(3), (K), (M),
and (R) of that rule do not apply to providers of health care assessment. The
application will include documented evidence of:
(a)
The applicant's
demonstration of at least four years of experience providing medical care to
individuals with developmental disabilities as well as capability to address,
and as necessary triage, medical needs of individuals with developmental
disabilities.
(b)
The applicant's achievement of positive outcomes for
individuals with developmental disabilities served (e.g., reducing emergency
room visits or individual/caregiver satisfaction with services
provided).
(3)
At the point of application for certification and upon
request by the department, a provider of health care assessment will provide a
certificate of a continuing policy of professional liability insurance in an
amount of at least one million dollars.
(4)
A provider of
health care assessment will ensure the person providing health care assessment
is a physician, a physician assistant, or an advanced practice nurse who:
(a)
Is properly
credentialed and in good standing in accordance with Ohio law or laws of other
states that govern the person's practice.
(b)
Has successfully
completed, prior to delivering health care assessment, twenty-five hours of
training specifically related to serving individuals with developmental
disabilities.
(5)
Failure of a provider of health care assessment to
comply with this rule and rule
5123-2-08 of the Administrative
Code may result in denial, suspension, or revocation of the provider's
certification.
(D)
Requirements for service delivery
(1)
Health care
assessment will be provided pursuant to an individual service plan that
conforms to the requirements of rule
5123-4-02 of the Administrative
Code.
(2)
To receive health care assessment, an individual
will:
(a)
Be
determined by the individual's team to have a need for health care assessment
and subscribed with a certified provider of the service.
(b)
Have access to a
mobile smart device or webcam that has internet service and is capable of
two-way audio and video interactions.
(c)
Be able to
operate the mobile smart device or webcam or be accompanied by a paid or unpaid
caregiver who is able to operate the mobile smart device or
webcam.
(3)
A provider of health care assessment will:
(a)
Be available to
provide the service twenty-four hours a day, three hundred sixty-five days per
year.
(b)
Have capacity to participate in two-way audio and video
interactions with individuals and caregivers and provide immediate evaluations,
video-assisted examinations, and development of plans of care by professionals
with extensive specialized expertise in supporting individuals with
developmental disabilities.
(c)
Ensure that
persons providing health care assessment are located in a private location that
guarantees the privacy of the individual being served.
(d)
Ensure that
communication with individuals and caregivers is secure and compliant with
state and federal regulations governing health care assessment services,
technology, and privacy, including the Health Insurance Portability and
Accountability Act.
(e)
Follow-up on each call that involves an individual
being attended by a physician, physician assistant, or advanced practice nurse
by contacting the individual and persons authorized by the individual within
eighteen hours of the initial call.
(f)
Follow-up on each
call that involves an individual being referred to an emergency room, urgent
care facility, or primary care physician, by contacting the emergency room,
urgent care facility, or primary care physician to coordinate care and ensure
advance preparation.
(4)
Health care
assessment requires face-to-face evaluation by a treating physician, physician
assistant, or advanced practice nurse who is directly engaged with the
individual (and not merely engaged to authorize health care).
(5)
Health care
assessment will be provided on a one-to-one basis.
(E)
Documentation of
services
(1)
Service documentation for health care assessment will
include each of the following to validate payment for medicaid services:
(a)
Type of
service.
(b)
Name of individual receiving service.
(c)
Medicaid
identification number of individual receiving service.
(d)
Name of
provider.
(e)
Provider identifier/contract number.
(f)
Calendar month
and year during which individual is subscribed.
(g)
A documentation
sheet for each calendar month during which an individual is subscribed that
includes the date, time, and description of consultation and support provided
to the individual and/or the individual's caregiver or indicates no
consultation or support were provided during the month. The documentation sheet
will include written or electronic signature of the person delivering the
service or initials of the person delivering the service if signatures and
corresponding initials are on file with the provider.
(2)
Providers of health care assessment will collect and submit
service utilization data by county to the department on a monthly basis in the
format prescribed by the department, including but not limited to:
(a)
Dates and times
consultation and support were provided to an individual or an individual's
caregiver.
(b)
Reasons individuals and/or their caregivers used the
service.
(c)
Service outcomes.
(3)
Within
forty-eight hours of providing support and consultation to an individual or an
individual's caregiver, a provider of health care assessment will:
(a)
Make available to
the individual and persons authorized by the individual, formal documentation
of the encounter and, when appropriate, written instructions regarding actions
the individual and/or caregiver should take post-consultation.
(b)
Send via secure
fax or other means, documentation of the encounter to the individual's primary
care physician as a means to coordinate care.
(F)
Payment standards
(1)
The billing unit, service codes, and payment rate for
health care assessment are contained in the appendix to this
rule.
(2)
Health care assessment will be provided as a
subscription service billed on a calendar month basis.
(3)
Health care
assessment may be billed for an individual who is available for services at
least one day in the calendar month.
(4)
Health care
assessment will not be billed for an individual who is receiving services in a
hospital, nursing facility, or intermediate care facility for individuals with
intellectual disabilities.
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
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