Ohio Admin. Code 5160-31-03 - Eligibility for enrollment in the PASSPORT HCBS waiver program

(A) To be eligible for the medicaid-funded component of the pre-admission screening system providing options and resources today (PASSPORT) program, an individual must meet all of the following requirements:

(1) The individual must have been determined eligible for medicaid in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code.

(2) The cost of waiver services in the person-centered services plan does not exceed the individual cost limit at the time of initial enrollment. The individual cost limit is equal to fourteen thousand and seven hundred dollars per month for waiver services.

(a) If ODA's designee determines that the applicant's waiver service needs cannot be met within the individual cost limit, the individual shall not be enrolled.

(b) Once enrolled in PASSPORT, additional waiver services may be authorized in excess of the individual cost limit with prior approval from ODA.

(c) When additional waiver services that exceed the individual cost limit are not approved, the individual shall be disenrolled from the waiver.

(3) The needed services are not readily available through another source at the level required to allow the individual to live in the community.

(4) The individual agrees to participate in PASSPORT and while enrolled in PASSPORT, shall not be simultaneously enrolled in the state-funded component of the PASSPORT program, the state-funded component of the assisted living program, another medicaid home and community-based program, the residential state supplement (RSS) program, or the program of all inclusive care for the elderly (PACE).

(5) The individual's health related needs can be safely met in a home and community-based setting as determined by ODA's designee.

(6) The individual will participate in the development of a person-centered services plan in accordance with the process and requirements set forth in rule 5160-44-02 of the Administrative Code.

(7) The individual must require the provision of at least one waiver service on a monthly basis as documented in the individual's approved person-centered services plan. The individual:

(a) Has a need for and agrees to receive at least one waiver service monthly that is otherwise unavailable through another source (including, but not limited to, private pay, community resources and/or the medicaid state plan) in an amount sufficient to meet the individual's assessed needs; or

(b) Has a need for and agrees to receive all of the following:

(i) Medicaid state plan private duty nursing services,

(ii) At least monthly monitoring of the individual's health and welfare through a combination of telephonic and in-person contacts with the case manager, and

(iii) At least one waiver service annually.

(8) Services in the person-centered services plan are to be approved by one of the medical practitioners in paragraphs (A)(8)(a) to (A)(8)(c) of this rule, within the scope of his/her or their practice. Approval may be verbal or written and is to be obtained prior to initial enrollment. Written approval may be satisfied via electronic signature.

(a) A licensed physician;

(b) A licensed certified nurse practitioner;

(c) A licensed physician assistant.

(9) While enrolled in PASSPORT, the individual must reside in a setting that possesses the home and community-based setting characteristics set forth in rule 5160-44-01 of the Administrative Code and not reside in a hospital, nursing facility (NF), intermediate care facility for individuals with an intellectual disability (ICF-IID) or another licensed/certified facility, any facility covered by section 1616(e) of the Social Security Act (42 U.S.C. 1382e(e) (January 1, 2023 2024) residential care facility, adult foster home or another group living arrangement subject to state licensure or certification.

(10) The individual is age sixty or older at the time of enrollment.

(11) The individual must be determined to meet the criteria for an intermediate or skilled level of care in accordance with rule 5160-3-08 of the Administrative Code and, in the absence of PASSPORT, would require NF services as defined in 42 C.F.R. 440.40 (as in effect on October 1, 2022 2023).

(12) PASSPORT has not reached the CMS-authorized limit on the number of individuals who may enroll on the waiver during the current year.

(B) If, at any time, the individual does not meet any of the eligibility requirements identified in this rule, the individual shall be denied or disenrolled from PASSPORT. In such instances, the individual shall be notified of his or her hearing rights in accordance with division 5101:6 of the Administrative Code.

Notes

Ohio Admin. Code 5160-31-03

Effective: 1/1/2024
Five Year Review (FYR) Dates: 9/7/2028
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 173.52
Prior Effective Dates: 12/22/1986 (Emer.), 03/23/1987, 01/14/1996, 02/22/2001, 01/31/2005, 07/01/2008, 03/17/2011, 03/01/2014, 04/01/2015, 11/25/2016, 01/01/2019, 06/12/2020 (Emer.), 10/17/2020, 07/16/2021, 09/07/2023