Ohio Admin. Code 5160-33-03 - Eligibility for the medicaid funded component of the assisted living program

(A) The purpose of this rule is to outline the requirements that must be met for an individual to be eligible to enroll in the medicaid funded component of the assisted living program.

(B) To be eligible for the medicaid funded component of the assisted living program, an individual must meet all of the following:

(1) Be eligible for medicaid in accordance with Chapters 5160:1-3 to 5160:1-6 of the Administrative Code.

(2) Have an intermediate or skilled level of care in accordance with rule 5160-3-08 of the Administrative Code. If the individual requires skilled nursing care beyond supervision of special diets, application of dressings, or administration of medication, it must be provided in accordance with rule 3701-16-09.1 of the Administrative Code.

(3) Be age twenty-one years old or older at the time of enrollment.

(4) 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.

(5) Have the ability to make room and board payments calculated at the current supplemental security income (SSI) federal benefit level minus fifty dollars. Providers shall not charge or collect room and board payments from individuals in excess of the room and board payment calculated in accordance with this paragraph. In the event an individual does not have sufficient personal income:

(a) An individual may arrange for informal supports to provide a supplemental payment to the provider in order to meet room and board requirements;

(i) The supplemental payment shall represent no more than the difference between the individual's personal income and the maximum room and board payment established in paragraph (B)(5) of this rule.

(ii) The amount of the supplemental payment shall not be considered when calculating the individual's patient liability as described in rule 5160:1-6-07.1 of the Administrative Code.

(b) A provider may elect to accept a reduced room and board rate.

(6) Have health and safety related needs met, as determined by the Ohio department of aging's (ODA) designee.

(C) The individual must reside in a residential care facility (RCF) licensed by the Ohio department of health. At the time of initial and continued enrollment, the individual must reside in a certified living unit, in an RCF certified by ODA that possesses the home and community-based setting characteristics set forth in rule 5160-44-01 of the Administrative Code.

(D) If the individual fails to meet any of the eligibility requirements identified in this rule, the individual shall be denied enrollment in the assisted living HCBS waiver. In such instances, the individual shall be notified of his or her hearing rights in accordance with division 5101:6 of the Administrative Code.

(E) Once enrolled in the assisted living HCBS waiver, an individual will not be disenrolled unless the individual requests disenrollment, moves out of state, transitions between the assisted living HCBS waiver and the mycare Ohio waiver, or expires. An individual will not be disenrolled from the assisted living HCBS waiver if disenrollment will result in losing eligibility for Ohio medicaid, unless the individual requests disenrollment, moves out of state, or dies.

Notes

Ohio Admin. Code 5160-33-03

Effective: 7/1/2021
Five Year Review (FYR) Dates: 4/15/2021 and 06/30/2026
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 173.54
Prior Effective Dates: 07/01/2006, 03/22/2008, 09/19/2009, 09/29/2011, 10/04/2015, 11/25/2016, 10/01/2019, 06/12/2020 (Emer.), 10/17/2020