Ohio Admin. Code 5123-9-34 - Home and community-based services waivers - residential respite under the individual options, level one, and self- empowered life funding waivers
(A) Purpose
This rule defines residential respite and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.
(B) Definitions
(4)(5) "Homemaker/personal
care" has the same meaning as in rule
5123-9-30 of the Administrative
Code.
(5)(6) "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.
(6)(7) "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)(8)
"Individual service plan" means the written description of services, supports,
and activities to be provided to an individual.
(8)(9) "Intermediate care
facility for individuals with intellectual disabilities" has the same meaning
as in section 5124.01 of the Revised
Code.
(9)(10)
"Participant-directed homemaker/personal care" has the same meaning as in rule
5123-9-32 of the Administrative
Code.
(10)(11) "Residential
facility" means a home or facility, including an intermediate care facility for
individuals with intellectual disabilities, in which an individual with a
developmental disability resides, that is licensed by the department pursuant
to section 5123.19 of the Revised
Code.
(11)(12) "Residential
respite" means care and support services furnished to an individual on a
short-term basis because of the absence or need for relief of those persons
routinely providing care. Depending on the circumstances of service provision,
residential respite is billed at a daily billing unit or at a fifteen- minute
billing unit:
(12)(13) "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.
(14)(15) "Waiver
eligibility span" means the twelve-month period following either an
individual's initial waiver enrollment date or a subsequent eligibility re-
determination date.
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)
"Group size" means the number of individuals who are
sharing services, regardless of the funding source for those
services.
(a) Residential respite at the
daily billing unit
(i) Residential respite at
the daily billing unit will be used when:
(a)
Residential respite is provided to an individual for more than seven hours
during a twenty-four hour period and the individual stays overnight at the
residential respite service delivery location; and
(b) A shared living caregiver does not bill
for provision of shared living to the individual on that day.
(ii) Residential respite at the
daily billing unit will be provided by:
(a) A
residential facility;
(b) An agency
provider; or
(c) An independent
provider.
(iii)
Residential respite at the daily billing unit may be provided at:
(a) A residential facility;
(b) The individual's home;
(c) The home of the employee of an agency
provider who is providing the service; or
(d) The home of the independent provider who
is providing the service.
(b) Residential respite at the fifteen-minute
billing unit
(i) Residential respite at the
fifteen-minute billing unit is available only to an individual who resides in a
shared living setting and will be used when residential respite is provided to
the individual on the same day the shared living caregiver bills for provision
of shared living.
(ii) Residential
respite at the fifteen-minute billing unit may be provided by:
(a) A residential facility other than an
intermediate care facility for individuals with intellectual
disabilities;
(b) An agency
provider; or
(c) An independent
provider.
(iii)
Residential respite at the fifteen-minute billing unit will be provided at:
(a) A residential facility other than an
intermediate care facility for individuals with intellectual
disabilities;
(b) The individual's
home;
(c) The home of the employee
of an agency provider who is providing the service;
(d) The home of the independent provider who
is providing the service; or
(e)
Another location chosen by the individual.
(iv) The residential respite fifteen-minute
billing unit equals fifteen minutes of service delivery time or is greater or
equal to eight minutes and less than or equal to twenty-two minutes of service
delivery time. Minutes of service delivery time accrued throughout a day will
be added together for the purpose of calculating the number of fifteen-minute
billing units for the day.
(C)
Provider qualifications
(1) Residential
respite will be provided by a residential facility, 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) An applicant seeking approval to provide
residential respite 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) Failure of a certified
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.
(4) Failure of a
licensed provider to comply with this rule and Chapter 5123-3 of the
Administrative Code may result in denial, suspension, or revocation of the
provider's license.
(D)
Requirements for service delivery
(1)
Residential respite will be provided pursuant to an individual service plan
that conforms to the requirements of rule
5123-4-02 of the Administrative
Code.
(2) The individual service
plan will address emergency and replacement coverage should the individual
unexpectedly need to leave the residential respite service delivery
location.
(3) Residential respite
at the daily billing unit may be provided at a residence other than a
residential facility only when:
(a) Each
individual who receives homemaker/personal care or participant- directed
homemaker/personal care and permanently resides at the residence consents to
the provision of residential respite at the residence; and
(b) The total number of persons with
developmental disabilities being served at the residence does not exceed
four.
(4) Residential
respite at the daily billing unit is limited to ninety calendar days of service
per waiver eligibility span.
(5)
Residential respite at the fifteen-minute billing unit is limited to two
hundred eight units per calendar month.
(6) Residential respite will not be provided
to an individual at the same time as homemaker/personal care,
participant-directed homemaker/personal care, or shared living.
(7) An individual who resides in a shared
living setting may receive 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.
(8) 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; and
(c) No more
than twelve hours of residential respite are provided to the individual on that
day.
(9) A provider
delivering residential respite in fifteen-minute billing units will utilize
electronic visit verification in accordance with rule
5160-1-40
5160-32-01 of the Administrative Code.
(E) Documentation of services
Service documentation for residential respite will include each of the following to validate payment for medicaid services:
(1) Type of service (i.e., residential
respite daily billing unit or residential respite fifteen-minute billing
unit).
(2) Date of
service.
(3) Times the delivered
service started and stopped.
(4)
Place of service.
(5) Name of
individual receiving service.
(6)
Medicaid identification number of individual receiving service.
(7) Name of provider.
(8) Provider identifier/contract
number.
(9) 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.
(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(3)(4) Only one provider
may bill a daily billing unit for provision of residential respite for the same
individual on any given day.
(4)(5) Residential respite
provided to individuals enrolled in the individual options waiver is subject to
the funding ranges and individual funding levels set forth in rule
5123-9-06 of the Administrative
Code.
(5)(6) Payment for
residential respite does not include payment for room and board or
transportation.
(1) The billing units, service
codes, and payment rates for residential respite provided January 1, 2024 through June 30, 2024 are contained
in appendix A to this rule. The billing units, service codes, and payment rates
for residential respite provided on or after July 1, 2024 are contained in
appendix B
are contained in the appendix
to this rule.
(2) The payment rates
for residential respite vary by type of provider.
(3)
The rate paid to
a provider delivering residential respite in fifteen-minute billing units is
adjusted to reflect the group size:
(a)
Payment for serving an individual in a group size of
two is eighty-five per cent of the rate for serving one
individual.
(b)
Payment for serving an individual in a group size of
three is seventy-five per cent of the rate for serving one
individual.
(c)
Payment for serving an individual in a group size of
four is sixty-five per cent of the rate for serving one
individual.
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: 07/15/2011, 07/01/2012, 09/01/2013, 01/01/2016, 04/01/2017, 07/05/2018, 01/01/2019, 06/11/2020(Emer.), 11/19/2020, 01/01/2022, 01/01/2024
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