Ohio Admin. Code 5123-9-33 - Home and community-based services waivers - shared living under the individual options waiver
(A) Purpose
This rule defines shared living and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.
(B) Definitions
(1)(2) "Adult" means a
person eighteen years of age or older.
(2)(3) "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.
(4)(5) "County board"
means a county board of developmental disabilities.
(5)(6) "Department" means
the Ohio department of developmental disabilities.
(6)(7) "Group size" means
the number of individuals who are sharing services, regardless of the funding
source for those services.
(7)(8) "Homemaker/personal
care" has the same meaning as in rule
5123-9-30 of the Administrative
Code.
(8)
(9) "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.
(9)(10) "Individual" means
a person with a developmental disability or for purposes of giving, refusing to
give, or withdrawing consent for services, his or
her
the person's guardian in accordance
with section 5126.043 of the Revised Code
or other person authorized to give
consent.
(10)(11) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual.
(11)(12) "Ohio
developmental disabilities profile" has the same
meaning as in rule 5123-9-06 of the Administrative Code
means the standardized instrument used by the
department to assess the relative needs and circumstances of an individual
compared to others. The individual's responses are scored and the individual is
linked to a funding range, which enables similarly situated individuals to
access comparable waiver services paid in accordance with rules adopted by the
department.
(12)(14) "Related to"
means the caregiver is, by blood, marriage, or
adoption, the individual's:(d)(e) Aunt, uncle,
nephew, or niece;
(e)(f) Cousin;
or
(f)(g) Child or
stepchild.
(13)(15) "Residential
respite" has the same meaning as in rule
5123-9-34 of the Administrative
Code.
(14)(16) "Service and
support administrator" means a person, regardless of title, employed by or
under contract with a county board to perform the functions of service and
support administration and who holds the appropriate certification in
accordance with rule 5123:2-5-02
5123-5-02 of the Administrative Code.
(15)(17)
"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.
(16)(18) "Shared living"
means individual-specific personal care and support necessary to meet the
day-to-day needs of an adult enrolled in the individual options waiver,
by an adult caregiver who resides
when twenty per cent or more of the personal care and
support is provided by one or more adult caregivers who reside in the
same home as the individual receiving the services. Shared living is provided
in conjunction with residing in the home and is part of the rhythm of life that
naturally occurs when people live together in the same home. Due to the
environment provided by living together in the same home, segregating these
activities into discrete services is impractical.
(17)(19)
"Significant change" means a change experienced by an individual including but
not limited to:
For the purposes of this rule, the following definitions apply:
(1)
"Acute care hospital" means a hospital that provides
inpatient medical care and other related services for surgery, acute medical
conditions, or injuries (usually for a short-term illness or
condition).
(13)
"Primary legal residence" means the residence where a
shared living caregiver has a permanent and principal establishment, where that
person has a right to reside, and to where, whenever that person is absent,
that person intends to return. A person has one, and only one, primary legal
residence at a time.
(a)
Parent or stepparent;
(b) Sibling
or stepsibling;
(c)
Grandparent;
(d)
Grandchild;
(a) Shared living:
(i) Enables the individual to experience
genuine community life;
(ii)
Nurtures stability of long-term relationships within the home and the broader
community;
(iii) Contributes to
development of life routines chosen by the individual;
(iv) Assists the individual to routinely
participate in and make positive contributions to his or her
the
individual's community;
(v)
Supports shared decision-making between the individual and other members of the
household; and
(vi) Enhances,
rather than replaces, existing family relationships and other community
connections.
(b)
Examples of supports that may be provided as shared living include:
(i) Basic personal care and grooming,
including bathing, care of the hair, and assistance with clothing;
(ii) Assistance with bladder and/or bowel
requirements or problems, including helping
the individual to and from the bathroom or assisting the individual with bedpan
routines;
(iii) Assisting the
individual with self-medication or provision of medication administration and
assisting the individual with, or performing, health care activities;
(iv) Performing household services essential
to the individual's health and comfort in the home (e.g., necessary changing of
bed linens or rearranging of furniture to enable the individual to move about
more easily in his or her
the home);
(v) Assessing, monitoring, and supervising
the individual to ensure the individual's safety, health, and
welfare;
(vi) Light cleaning tasks
in areas of the home used by the individual;
(vii) Preparation of a shopping list
appropriate to the individual's dietary needs and financial circumstances,
performance of grocery shopping activities as necessary, and preparation of
meals;
(viii) Personal
laundry;
(ix) Incidental
neighborhood errands as necessary, including accompanying the individual to
medical and other appropriate appointments and accompanying the individual for
walks outside the home;
(x) Skill
development to prevent the loss of skills and enhance skills that are already
present that lead to greater independence and community integration;
(xi) Exploration of community resources and
natural supports and development of methods to access additional resources and
supports to ensure the individual is integrated in and has full access to the
community to pursue interests and activities of his
or her
the individual's choosing;
and
(xii) When provided in
conjunction with other components of shared living, assistance with personal
finances which may include training, planning, and decision-making regarding
the individual's personal finances.
(a) A change in health status
or caregiver status;
(b) Referral
to or active involvement on the part of a protective services agency;
or
(c)
Institutionalization.
(C) Provider qualifications
(1) Shared living shall
will be
provided by an agency provider or an independent provider that meets the
requirements of this rule and that has a medicaid provider agreement with the
Ohio department of medicaid.
(2)
Shared living shall
will not be provided by a county board or a regional
council of governments formed under section
5126.13 of the Revised Code by
two or more county boards.
(3) An
individual's legal guardian may provide shared living to that individual only
when the legal guardian is related to the individual and has been approved by the probate court to provide the
services.
(4) An applicant
seeking approval to provide shared living 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.
(5) Failure of an
agency provider or an independent provider 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.
(6) Failure of a
licensed residential facility to comply with this rule and Chapter 5123-3 of
the Administrative Code may result in denial, suspension, or revocation of the
residential facility's license.
(D) Requirements for service delivery
(5)(4) An independent
provider shall
will reside in the home where shared living is
provided and that home shall
must be the independent provider's primary, legal residence.
(6)(5) An agency provider
shall
will
employ or contract with a person to be the caregiver who
shall
will
reside in the home where shared living is provided and that home
shall
must be
the person's primary, legal
residence.
(7)(6) Shared living
shall
will
not be provided to an individual who is receiving foster care services funded
through Title IV-E of the Social Security Act as in effect on the effective
date of this rule.
(8)(7) An independent
provider of shared living shall
will not bill homemaker/personal care or deliver
state plan home health aide services as an employee of an agency to an
individual for whom he or she
the independent provider provides shared
living.
(9)(8) An individual who
receives
resides in
a shared living setting may
also choose to receive community respite
at the full day billing unit or residential
respite at the daily billing unit during a
short-term absence or need for relief of the shared living caregiver
on a day the shared living caregiver does not bill for
provision of shared living.
(1) Shared living shall be
authorized for an individual when one or more adult caregivers who reside with
the individual provide twenty per cent or more of the individual's personal
care and support services.
(1)
Except as
provided in paragraph (G) of this rule, residential supports will be authorized
as shared living for an individual enrolled in the individual options waiver
who receives services meeting the definition of shared living as set forth in
this rule.
(2) Shared living
shall
will be
provided pursuant to an individual service plan that conforms to the
requirements of rule
5123-4-02 of the Administrative
Code.
(3) The total number of
persons with developmental disabilities living in a home in which an individual
receives shared living shall
will not exceed four.
(4) Except as provided in paragraph
(G) of this rule, only shared living may be authorized for an individual
enrolled in the individual options waiver who receives services meeting the
definition of shared living as set forth in this rule.
(9)
An individual who
resides in a shared living setting may receive residential respite at the
fifteen-minute billing unit for the temporary relief of the shared living
caregiver on a day the shared living caregiver bills for provision of shared
living as long as:
(a)
Residential respite and shared living services are not
delivered at the same time;
(b)
Residential
respite is not provided by the shared living caregiver or any other person who
resides in the shared living setting;
(c)
No more than
twelve hours of residential respite are provided to the individual on that day;
and
(d)
No more than two hundred eight fifteen-minute billing
units of residential respite are provided per calendar month.
(10) An individual who receives
shared living may receive homemaker/personal care on the same day as long as
the services are not delivered at the same time or by the same
person.
(10)
An individual
who resides in a shared living setting may receive homemaker/personal care on a
day the shared living caregiver does not bill for provision of shared living
when the services are provided by an approved provider of homemaker/personal
care who is not the shared living caregiver or any other person who resides in
the shared living setting.
(a)
An agency provider may contract for these services. If
the agency provider opts to contract, the daily rate for shared living may be
billed by the shared living provider for that day.
(b)
In situations
where an agency provider does not contract for these services or in situations
where an individual served by an independent provider seeks homemaker/personal
care services, the shared living provider will not bill for shared living on a
day when homemaker/personal care is rendered. This prohibition exists
regardless of whether claims for homemaker/personal care are submitted to the
department for the entire twenty-four-hour period or for a lesser amount of
time that day.
(11)
Shared living
may be provided to an individual in an acute care hospital to address the
individual's intensive personal care, behavioral support/stabilization, or
communication needs when the following conditions are met:
(a)
Shared living is
necessary to ensure smooth transition between the acute care hospital and the
individual's home and to preserve the individual's functional
abilities;
(b)
Shared living is not a substitute for services the
acute care hospital provides or is obligated to provide (e.g., attendant care)
through its conditions of participation, federal law, state law, or other
applicable requirement; and
(c)
An individual may
receive shared living in an acute care hospital on no more than thirty calendar
days per waiver eligibility span.
(11) In circumstances where a shared
living caregiver is temporarily unavailable to provide services, substitute
coverage may be provided in the individual's shared living home or in another
community setting agreed to by the individual.
(a) For independent providers, a
provider of homemaker/personal care is arranged to deliver substitute coverage
and the service is billed as homemaker/personal care. Independent providers
shall work with the individual's service and support administrator to arrange
for substitute coverage when needed.
(b) For agency providers, a provider
of shared living is arranged to deliver substitute coverage and the service is
billed as shared living.
(12) A provider of shared living
shall
will
develop, maintain, and implement for each individual for whom shared living is
provided, a detailed written protocol to be followed in the event that
substitute coverage is necessary. The protocol shall
will include
contact information for and a requirement to notify:
(a) As applicable, the individual or legally
responsible person in the event that substitute coverage is necessary;
and
(b) The person identified in
the individual service plan when substitute coverage is not available to allow
such person to make other arrangements.
(E) Documentation of services
Service documentation for shared living
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) Group size
in which the service was provided.
(10) 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 for shared living provided January 1,
2024 through June 30, 2024 are contained in appendix A to this rule.
The billing unit, service codes, and payment rates for
shared living provided on or after July 1, 2024 are contained in appendix B to
this rule.
(2) Payment for
shared living shall
will be at a daily rate
billing unit.
Payment rates are adjusted based on the county cost-of-doing-business category.
The cost-of-doing-business categories are contained in appendix
B
C to this
rule.
(3) Payment rates for shared
living are established separately for independent providers and agency
providers.
(4) The rate paid to a
provider of shared living shall be
is adjusted to reflect the group size:
(a) Payment for one individual
shall be at
is one hundred per cent of the daily rate for the
individual's Ohio developmental disabilities profile range.
(b) Payment for a group size of two
shall be at
is eighty-five per cent of the daily rate for the Ohio
developmental disabilities profile range for each individual.
(c) Payment for a group size of three
shall be at
is seventy-five per cent of the daily rate for the
Ohio developmental disabilities profile range for each individual.
(d) Payment for a group size of four
shall be at
is sixty-five per cent of the daily rate for the Ohio
developmental disabilities profile range for each individual.
(5) Shared living
shall
will
not be billed on the same day as community respite at the full day billing unit
or residential respite at the daily billing
unit.
(6) Only one provider
per day may bill for providing shared living to a specific
individual.
(7) An individual who
receives shared living may request prior authorization in accordance with rule
5123-9-07 of the Administrative
Code for services other than shared living. In no instance
shall
will
prior authorization result in a daily rate in excess of the highest rate within
the applicable county cost-of-doing-business category as set forth in
as applicable, appendix A or appendix B to this rule.
(8) Payment for shared living does not
include room and board, items of comfort or convenience, or costs for the
maintenance, upkeep, and improvement of the home in which shared living is
provided.
(G) Exemption
An individual who, on July 15, 2011,
was receiving homemaker/personal care under the individual options waiver
provided by a caregiver related to the individual and residing in the same home
as the individual may continue to receive homemaker/personal care from that
same caregiver, unless the individual experiences a significant
change.
(G)
Exemptions from
shared living
(1)
An individual who, on July 15, 2011, was receiving
homemaker/personal care under the individual options waiver provided by a
caregiver related to the individual and residing in the same home as the
individual may choose to continue to receive homemaker/personal care from that
caregiver as an alternative to shared living, unless the individual experiences
a significant change.
(2)
An individual enrolled in the individual options waiver
who receives services meeting the definition of shared living as set forth in
this rule may choose to receive homemaker/personal care from that caregiver as
an alternative to shared living when the individual:
(a)
Has been assessed
to need two-to-one staffing; or
(b)
Has been assessed
to need awake staff present around the clock; or
(c)
Meets the
criteria for the behavioral support rate modification described in paragraph
(F)(4) of rule
5123-9-30 of the Administrative
Code; or
(d)
Meets the criteria for the complex care rate
modification described in paragraph (F)(5) of rule
5123-9-30 of the Administrative
Code.
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: 10/01/2007, 07/15/2011, 03/19/2012, 01/01/2016, 10/01/2017, 06/11/2020 (Emer.), 11/19/2020, 06/17/2021 (Emer.), 10/15/2021, 01/01/2022
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.