Ohio Admin. Code 5160-43-02 - Specialized recovery services program individual eligibility and program enrollment

(A) To An individual may be eligible for enrollment in the specialized recovery services program, an individual shall meet if they meet all of the following requirements:

(1) Be at least twenty-one years of age;

(2) Be determined eligible for Ohio medicaid in accordance with Chapters 5160:1-1 to 5160:1-5 of the Administrative Code;

(3) Have a behavioral health diagnosis, be active on the solid organ or soft tissue waiting list, or have a diagnosed chronic condition as listed in the appendix to this rule qualifying diagnosis appendix which is available on the ODM website at https://medicaid.ohio.gov/resources-for-providers/special-programs-and-initiatives/srs;

(4) Participate in an initial assessment using the "Adult Needs and Strengths Assessment (ANSA)" (7/2016) (8/2021) and obtain a qualifying score of either:

(a) Two or greater on at least one item in the "mental health behavioral/ emotional needs" or "risk behaviors" sections; or

(b) Three on at least one item in the "life domain functioning" section.

(5) Demonstrate needs related to the management of his or her behavioral health or diagnosed chronic condition as documented in the "ANSA" (7/2016) (8/2021);

(6) Have at least one of the following risk factors prior to enrollment in the program:

(a) One or more psychiatric inpatient admissions at an inpatient psychiatric hospital; or

(b) A discharge from a correctional facility with a history of inpatient or outpatient behavioral health treatment while residing in that correctional facility; or

(c) Two or more emergency department visits with a psychiatric diagnosis or diagnosed chronic condition; or

(d) A history of treatment in an intensive outpatient rehabilitation program for greater than ninety days; or

(e) One or more hospital inpatient admissions due to a diagnosed chronic condition as listed in the appendix to this rule. qualifying diagnosis appendix available at https://medicaid.ohio.gov/resources-for-providers/special-programs-and-initiatives/srs .

(7) Meet at least one of the following:

(a) Currently have a need for one or more of the specialized recovery services to maintain stability, improve functioning, prevent relapse, maintain residency in the community, and be assessed and found that, if not for the provision of home and community-based services (HCBS) for stabilization and maintenance purposes, he or she would decline to prior levels of need (i.e., subsequent medically necessary services and coordination of care for stabilization and maintenance is needed to prevent decline to previous needs-based functioning); or

(b) Previously have met the needs-based criteria described in paragraph (A) (6) of this rule within two years of the date of initial assessment, and be assessed and found that, but for the provision of HCBS for stabilization and maintenance purposes, he or she would decline to prior levels of need (i.e., subsequent medically necessary services and coordination of care for stabilization and maintenance is needed to prevent decline to previous needs-based functioning).

(8) Reside in an HCBS setting;

(9) Demonstrate a need for specialized recovery services, and not otherwise receive those services;

(10) Have needs that can be safely met through the program in an HCBS setting as determined by the Ohio department of medicaid (ODM) or its designee; and

(11) Participate in the development of a person-centered care service plan.

(B) To be enrolled in and to maintain enrollment in the specialized recovery services program, an individual shall be determined by ODM or its designee to meet all of the following requirements:

(1) Be determined eligible for the program in accordance with paragraph (A) of this rule;

(2) Maintain residency in an HCBS setting;

(3) Agree to and receive recovery management services in accordance with his or her person-centered care service plan from ODM or its designee including, but not limited to:

(a) Annual Participation in reassessments at least annually and ongoing reassessments, as needed;

(b) Participation in the development and implementation of the person-centered care service plan and consent to the plan by signing and dating it; and

(c) Participation in quality assurance and participant satisfaction activities during his or her enrollment in the program including, but not limited to, in-person visits.

(C) If an individual fails to meet any of the requirements set forth in paragraph (A) of this rule, the individual shall be denied enrollment in the program.

(D) Once enrolled in the program, an individual's level of need shall be reassessed at least annually, and more frequently if there is a significant change in the individual's condition that may impact his or her health and welfare. If the reassessment determines the individual no longer meets the requirements set forth in paragraph (B) of this rule, he or she shall be disenrolled from the program.

(E) If, at any time, it is determined that an individual enrolled in the program no longer meets the requirements set forth in paragraph (A) and/or paragraph (B) of this rule, he or she shall be disenrolled from the program. Reassessment pursuant to paragraph (D) of this rule is not required to make this determination.

(F) If an individual is denied enrollment in the program pursuant to paragraph (C) of this rule, or is disenrolled from the program pursuant to paragraph (D) or (E) of this rule, the individual shall be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

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Notes

Ohio Admin. Code 5160-43-02

Effective: 10/15/2021
Five Year Review (FYR) Dates: 7/23/2021 and 10/15/2026
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02, 5164.03
Prior Effective Dates: 08/01/2016, 07/01/2017, 07/01/2018