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 1,2021).
(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,
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, and, upon request, responsible
to assist with coordination of medicare 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. An MCOP is
also a managed care organization as defined in 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, 07/18/2022
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(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 1,2021).
(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, 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, and, upon request, responsible to assist with coordination of medicare 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. An MCOP is also a managed care organization as defined in 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, 07/18/2022