Ohio Admin. Code 5160-58-01 - MyCare Ohio plans: definitions
(A) The definitions set forth in rule
5160-26-01
of the Administrative Code apply to the MyCare Ohio rules set forth in Chapter
5160-58 of the Administrative Code.
(B) In addition to the definitions set forth
in rule
5160-26-01
of the Administrative Code, the following definitions apply to Chapter 5160-58
of the Administrative Code:
(1) "Assessment"
means a comprehensive evaluation of an individual's medical, behavioral health,
long-term services and supports, and social needs. Results of the assessment
process are used to develop the integrated, individualized care plan, inclusive
of the waiver services plan.
(2)
"Creditable insurance" or "creditable coverage" means health insurance coverage
as defined in
42
U.S.C. 300gg-3(c) (October
1, 2020
2021 ).
(3)
"Dual benefits member" or "opt-in member" means a member for whom a MyCare Ohio
plan is responsible for the coordination and payment of both medicare and
medicaid benefits.
(4) "Financial
management service (FMS)" means a support that is provided to waiver
participants who direct some or all of their waiver services. When used in
conjunction with the employer authority, this support includes, but is not
limited to, operating a payroll service for participant employed workers and
making required payroll withholdings. When used in conjunction with the budget
authority, this support includes, but is not limited to, paying invoices for
waiver goods and services and tracking expenditures against the
participant-directed budget.
(5)
"Health and welfare" means a requirement that necessary safeguards are taken to
protect the health and welfare of individuals enrolled in a home and
community-based services (HCBS) waiver. It includes the following:
(a) Risk and safety planning and
evaluations;
(b) Critical incident
management;
(c) Housing and
environmental safety evaluations;
(d) Behavioral interventions;
(e) Medication management; and
(f) Natural disaster and public emergency
response planning.
(6)
"Home and community-based services (HCBS)" means services available to
individuals to help maintain their health and safety in a community setting in
lieu of institutional care as described in 42 C.F.R. 440 subpart A (October 1,
2020
2021 ).
(7)
"Individual care plan" means an integrated, individualized, person-centered
care plan developed by the member and his or her MyCare Ohio plan's
trans-disciplinary care management team that addresses clinical and
non-clinical needs identified in the assessment and includes goals,
interventions, and expected outcomes.
(8) "Medicaid only member" or "opt-out
member" means a member for whom a MyCare Ohio plan is responsible for
coordination and payment of medicaid benefits.
(9) "MyCare Ohio plan (MCOP)" means a health
insuring corporation (HIC) contracted to comprehensively manage medicaid
benefits for medicare and medicaid eligible members, including HCBS.
MCOPs are
An MCOP
is also a managed care
plans
organization
as defined in accordance with rule
5160-26-01
of the Administrative Code. For the purpose of this chapter, an MCOP does not
include entities approved to operate as a program for the all-inclusive care of
the elderly (PACE) site as defined in rule
5160-36-01
of the Administrative Code.
(10)
"Nursing facility-based level of care" means the intermediate and skilled
levels of care, as described in rule
5160-3-08
of the Administrative Code.
(11)
"Participant direction" means the opportunity for a MyCare Ohio waiver member
to exercise choice and control in identifying, accessing, and managing waiver
services and other supports in accordance with their needs and personal
preferences.
(12) "Significant
change event" is a change experienced by a member that warrants further
evaluation. Significant changes include, but are not limited to, a change in
health status, caregiver status, or location/residence; referral to or active
involvement on the part of a protective service agency; institutionalization;
and when the waiver-enrolled individual has not received MyCare Ohio waiver
services for ninety calendar days.
(13) "Trans-disciplinary care management
team" means a team of appropriately qualified individuals comprised of the
member, the member's family/caregiver, the MyCare Ohio plan manager, the waiver
service coordinator, if appropriate, the primary care provider, specialists,
and other providers, as applicable, that is designed to effectively meet the
enrollee's needs.
(14) "Waiver
services plan" is a component of the care plan that identifies specific goals,
objectives and measurable outcomes for a waiver-enrolled member's health and
functioning expected as a result of HCBS provided by both formal and informal
caregivers, and that addresses the physical and medical conditions of the
individual. At a minimum, the waiver services plan shall include:
(a) Essential information needed to provide
care to the member that assures the member's health and welfare;
(b) Signatures indicating the member's
acceptance or rejection of the waiver services plan. If the member is unable to
provide the signature when the services plan is initially developed, the
individual will submit an electronic signature or standard signature via
regular mail, or otherwise provide a signature in no instance any later than at
the next face-to-face visit with the case manager; and
(c) Information that the waiver services plan
is not the same as the physician's plan of care.
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5166.02, 5167.02
Rule Amplifies: 5164.02, 5166.02, 5167.02
Prior Effective Dates: 03/01/2014, 07/01/2017, 06/12/2020 (Emer.), 10/12/2020
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