(A) The purpose of
this rule is to establish the level one waiver as a component of the medicaid
home and community-based services program pursuant to sections
5166.20 and
5166.02 of the Revised Code.
(1) The level one waiver program provides
necessary waiver services to individuals of any age who meet the criteria for a
developmental disabilities level of care in accordance with rule
5123-8-01
of the Administrative Code, and other eligibility requirements established in
this rule.
(2) The Ohio department
of developmental disabilities (DODD), through an interagency agreement with the
Ohio department of medicaid (ODM), administers the level one waiver on a daily
basis in accordance with section
5162.35 of the Revised
Code.
(B) Definitions
(1) "County board" means a county board of
developmental disabilities established under Chapter 5126. of the Revised
Code.
(2) "Home and community-based
services" (HCBS) means any federally approved medicaid waiver service provided
to a waiver enrollee as an alternative to institutional care under Section
1915(c) of the Social Security Act, 49 Stat.
620 (1935),
42 U.S.C.A.
1396n, as in effect on October 1, 2019, under
which federal reimbursement is provided for designated home and community-based
services to eligible individuals.
(3) "Individual" means a person with a
developmental disability who is eligible to receive HCBS as an alternative to
placement in an intermediate care facility for individuals with intellectual
disabilities (ICF/IID) under the applicable HCBS waiver. A guardian or
authorized representative may give, refuse to give, or withdraw consent for
services or may receive notice on behalf of an individual to the extent
permitted by applicable law.
(4)
"Individual Service Plan" (ISP) means a written description of the services,
supports, and activities to be provided to an individual in accordance with
paragraph (H) of this rule.
(5)
"Provider" means a person or agency certified or licensed by DODD that has met
the provider qualification requirements to provide specific waiver services, as
specified in paragraph (J)(1) of this rule, with a valid medicaid provider
agreement as specified in paragraph (J)(2) of this rule.
(6) "SSA" means a service and support
administrator who is certified in accordance with rule
5123:2-5-02
of the Administrative Code and who provides the functions of service and
support administration.
(C) Request for a referral for the level one
waiver
(1) Individuals seeking to enroll in
the level one waiver program may do one of the following:
(a) Request a referral through a local county
job and family services (CDJFS);
(b) Request a referral to a local county
board;
(d) Request a referral over the phone
(800-324-8680).
(2) The
county board is responsible for explaining to individuals requesting HCBS, the
services available through the level one waiver benefit package, including the
amount, scope and duration of services and the benefit package limitations.
(D) Eligibility criteria
for the level one waiver
(1) The individual
requesting a referral for the level one waiver program must be determined to
meet the criteria for a developmental disabilities level of care in accordance
with rule
5123-8-01
of the Administrative Code upon initial enrollment and no later than every
twelve months thereafter; and
(2)
The individual's medicaid eligibility has been determined in accordance with
Chapters 5160:1-1 to 5160:1-6 of the Administrative Code; and
(3) The individual's health and welfare needs
can be met through the utilization of level one waiver services at or below the
benefit limitations designated in paragraph (G) of this rule, and other formal
and informal supports regardless of funding source. Other formal or informal
supports are not subject to the benefit limitations in this
rule.
(E) Level one
waiver enrollment, continued enrollment, and disenrollment
(1) Individuals who meet the eligibility
criteria established in paragraph (D) of this rule, or their legal
representative shall be informed of the following:
(a) All services available on the level one
waiver, and any choices that the individual may make regarding those
services;
(b) Any feasible
alternative to the waiver program; and
(c) The right to choose either institutional
or home and community-based services.
(2) Individuals determined eligible for the
level one waiver program in accordance with paragraph (D) of this rule who are
seeking to, but are not yet enrolled in the level one waiver program must
participate in a prescreening assessment process. This process evaluates
whether the individual's health and welfare needs can be met with the level of
service provided through the level one waiver program, combined with other
non-waiver services regardless of funding source, and within the benefit
package limitations specified in paragraph (G) of this rule.
(a) If the prescreening assessment process
indicates that the eligible individual's health and welfare needs cannot be met
with the level of services provided through the level one waiver program,
combined with other non-waiver services regardless of funding sources, and
within the benefit package limitations specified in paragraph (G) of this rule,
then the individual shall not be enrolled in the level one waiver program and
notification of hearing rights shall be provided as established in paragraph
(M) of this rule; or
(b) If the
prescreening assessment process indicates that the eligible individual's health
and welfare needs can be met with the level of services provided through the
level one waiver program, when combined with other nonwaiver services
regardless of funding source, and within the benefit package limitations
specified in paragraph (G) of this rule, then the individual shall be enrolled
in the level one waiver program in accordance with this rule.
(3) The county board shall offer
an available level one waiver to eligible individuals in accordance with
applicable waiting list category requirements as set forth in rules
5160-41-05
and
5123-9-04
of the Administrative Code.
(4) An
individual's continued enrollment in the level one waiver program shall be
redetermined no less frequently than every twelve months after the individual's
initial enrollment or subsequent redetermination date. Individuals must
continue to meet the eligibility criteria specified in paragraph (D) of this
rule to continue enrollment in the waiver program.
(5) The individual must require at least one
waiver service monthly, or, if less than monthly, require monthly monitoring of
the individual's health and welfare. If no services are planned to be delivered
in a month, monthly monitoring of the individual's health and welfare must be
required in the ISP, as designated in paragraph (H) of this rule, and must
include at least periodic face-to-face monitoring.
(6) While enrolled in the level one waiver,
if the enrollee does not receive any waiver services for one month, the county
board shall assess the enrollee's current need for waiver services, monitor the
individual to verify the individual's ongoing need for waiver enrollment, and
discuss these needs with the enrollee and their representative. As a result of
the assessment and discussion, if no waiver services are needed, the enrollee
shall be recommended for disenrollment from the waiver program and shall be
given notification of hearing rights.
(7) Disenrollment of level one waiver
participants shall be done in accordance with the provisions set forth in this
rule.
(a) Individuals enrolled in the level
one waiver program shall not be disenrolled from the waiver due to an increase
in the need for a covered service(s) that causes the total need for the covered
service(s) to exceed the benefit package limitations, as specified in paragraph
(G) of this rule. The county board shall evaluate the individual, as set forth
in rule
5123:2-9-01
of the Administrative Code, and submit a recommendation to DODD regarding
whether or not the individual can remain enrolled in the waiver and have his or
her health and welfare assured by one or more of the following measures:
(i) Adding a higher level of available
natural supports; and/or
(ii)
Recommending additional services covered through the level one waiver benefit
package; and/or
(iii) Accessing
emergency services covered through the level one waiver benefit package;
and/or
(iv) Accessing additional
non-waiver services other than natural supports.
(b) If the activities identified in paragraph
(E)(7)(a) of this rule do not result in an ISP that contains covered services
that are within the benefit package limitations outlined in paragraph (G) of
this rule and it is determined that services are not sufficient to assure the
individual's health and welfare, then the following will apply:
(i) The individual will be given the
opportunity to apply for an alternate home and community-based waiver program,
to the extent that such waiver openings exist, that may be more adequate in
meeting the individual's service needs. An individual shall be enrolled in
accordance with rule
5123-9-04
of the Administrative Code; and
(ii) The individual will be offered an
opportunity for placement in an ICF/ IID.
(c) Individuals enrolled in the level one
waiver program who are recommended for disenrollment from the waiver program
shall be given notification of hearing rights as established in paragraph (M)
of this rule.
(F) The level one waiver program benefit
package, as included in the federally approved waiver application, is limited
to the services specified in Chapters 5123:2-9 and 5123-9 of the Administrative
Code.
(G) Limits on sets of level
one waiver services
(1) Level one waiver
benefit limitations shall be in accordance with the benefit limitations as
established in rule
5123-9-06
of the Administrative Code.
(2) The
following benefits are subject to specific benefit limitations that, when
combined cannot exceed the maximum amount as specified in appendix B to rule
5123:2-9-19
of the Administrative Code, effective in twelve month periods beginning with
the individual's enrollment or redetermination date:
(a) Adult day support;
(b) Career planning;
(c) Group employment support;
(d) Individual employment support;
(e) Vocational
habilitation.
(3)
Non-medical transportation services are subject to a benefit limitation not to
exceed the amount specified in appendix B to rule
5123:2-9-19
of the Administrative Code.
(H) Level one waiver individual service plan
requirements
(1) All services shall be
provided to individuals enrolled on the level one waiver pursuant to a written
ISP.
(2) The ISP shall be developed
by qualified persons with input from the level one waiver enrollee and the SSA
in accordance with section
5126.15 of the Revised Code.
Providers shall participate in the ISP meetings when a request for their
participation is made by the individual enrollee.
(3) The ISP shall contain the following
required criteria, and will comport with the outlined procedures for review and
revision:
(a) The ISP shall list the level
one waiver services and the non-waiver services, regardless of funding source,
that are necessary to ensure the enrollee's health and welfare.
(b) The ISP shall contain the following
medicaid required elements:
(i) Type of
service to be provided; and
(ii)
Amount of service to be provided; and
(iii) Frequency and duration of each service;
and
(iv) Type of provider to
furnish each service.
(c)
The ISP shall be reviewed on at least an annual basis consistent with the
individual's redetermination as referenced in paragraph (E)(2) of this rule or
as the individual's needs change and in accordance with rule
5123:2-1-11
of the Administrative Code.
(d) The
SSA shall review and revise the ISP more frequently than the required annual
basis under the following circumstances:
(i)
At the request of the individual or a member of the individual's team;
or
(ii) Whenever the individual's
assessed needs, situation, circumstances or status changes; or
(iii) If the individual chooses a new
provider or type of service or support; or
(iv) As a result of the continuous review
process of the ISP; or
(v)
Identified trends and patterns of unusual or major unusual incidents;
or
(vi) When services are reduced,
denied, or terminated.
(e) The ISP shall be developed to include
only waiver services which are consistent with efficiency, economy and quality
of care. When reasonable, waiver services are not provided entirely at a one to
one ratio. When combined with other non-waiver services, waiver services must
ensure the health and welfare for the individual for whom the ISP is developed;
and
(f) The ISP is subject to
approval by ODM and DODD pursuant to section
5166.05 of the Revised Code.
Notwithstanding the procedures set forth in this rule, ODM may in its sole
discretion, and in accordance with section
5166.05 of the Revised Code,
authorize services and direct the county board or DODD to amend ISPs for
individuals if ODM determines that such services are medically necessary and
the procedures set forth in this rule would not accommodate a request for such
medically necessary services.
(I) Free choice of provider
Individuals enrolled in the level one waiver program shall be
given a free choice of qualified level one waiver providers in accordance with
rules
5160-41-08
and
5123:2-9-11
of the Administrative Code. A provider is qualified if they meet the standards
established in paragraph (J) of this rule. DODD shall create and maintain an
online database of those providers who are qualified to provide level one
waiver services. This list will be accessible to county boards and individuals
applying for or receiving services. county board shall assist an individual, as
needed, with exercising the right to free choice of provider in accordance with
rule
5123:2-9-11
of the Administrative Code.
(J) Provision of level one waiver services
(1) Level one waiver services shall be
provided by persons or agencies who hold certification or licensure for each
service they provide in accordance with section
5123.045 of the Revised Code,
and
division 5123:2 of the Administrative
Code
administrative rules promulgated by
DODD;
and
or
(2)
At the discretion of DODD, any provider approved by ODM
or certified by the Ohio department of aging (ODA) may also be eligible to
provide waiver services so long as the provider has satisfied the requirements
for certification by DODD for the same or similar services; and
(2)
(3)
Level one waiver services shall be provided only by persons or agencies who
have a valid medicaid provider agreement in accordance with rule 5160-1-17.2 of
the Administrative Code; and
(3)
(4) Level one waiver
services shall be provided only to individuals who have met the eligibility
requirements in paragraph (D) of this rule and have been enrolled in the level
one waiver program at the time of service delivery; and
(4)
(5)
Level one waiver services shall be provided in accordance with each enrollee's
individual service plan as specified in paragraph (H) of this rule.
(5)
(6)
No provider of level one waiver services shall enter into or maintain any
contract with the enrollee for the provision of waiver services except as noted
in paragraph (J)(2) of this rule.
(K) Provider payment standards
Provider payment standards for the level one waiver are
established in Chapters 5160-41, 5123:2-9, and 5123-9 of the Administrative
Code.
(L) Monitoring,
compliance and sanctions
ODM shall conduct periodic monitoring and compliance reviews
related to the level one waiver program in accordance with section
5162.10 of the Revised Code.
Reviews may consist of, but are not limited to, physical inspections of records
and sites where services are provided, interviews of providers, enrollees, and
administrators of waiver services. Certified or licensed level one waiver
providers, in accordance with the medicaid provider agreement, DODD, and county
board shall furnish to ODM, the center for medicare and medicaid services
(CMS), and the medicaid fraud control unit or their designees any records
related to the administration and/or provision of level one waiver services.
Individuals enrolled in the level one waiver program shall cooperate with all
monitoring, compliance and quality assurance reviews conducted by ODM, CMS and
the medicaid fraud control unit or their designee.
(M) Due process
(1) When DODD, ODM, or the county board takes
action to approve, deny, or terminate enrollment in the level one waiver, or to
deny or change the level and/or type of waiver services delivered to a level
one waiver enrollee, the entity recommending or taking action will provide
medicaid due process in accordance with section
5101.35 of the Revised Code
through the state fair hearing process, and as specified in Chapters 5101:6-1
to 5101:6-9 of the Administrative Code.
(2) When an individual requests a hearing, as
specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code, the
participation of DODD and the county board are required during the hearing
proceedings to justify the decision under appeal.
Notes
Ohio Admin. Code
5160-42-01
Effective:
10/17/2020
Five Year Review (FYR) Dates:
7/28/2020 and
10/01/2025
Promulgated
Under: 119.03
Statutory
Authority: 5166.02
Rule
Amplifies: 5164.25,
5166.04,
5166.20,
5162.35
Prior
Effective Dates: 04/28/2003, 07/01/2005, 07/01/2006, 01/01/2007, 07/01/2007,
09/15/2011, 09/01/2013, 05/01/2017, 02/01/2018, 01/01/2019,
01/01/2020