Ohio Admin. Code 5160-59-03.5 - OhioRISE: primary flex funds

(A) Scope. This rule sets forth provisions governing coverage for primary flex funds provided as part of the Ohio resilience through integrated systems and excellence (OhioRISE) program.

(B) Definitions.

(1) "Primary flex funds" are services, equipment, or supplies not otherwise provided through the medicaid state plan benefit or the OhioRISE program that address a youth's identified need as documented in the child and family-centered care plan. Primary flex funds are intended to enhance and supplement the array of services available to a youth enrolled in the OhioRISE program and are discussed, recommended, and implemented through the care coordination process as described in rule 5160-59-03.2 of the Administrative Code.

(2) "Financial management services" (FMS) means an entity contracted with the OhioRISE plan to perform necessary financial transactions on behalf of individuals enrolled in the OhioRISE program

(3) "Participant direction" means the opportunity for a youth enrolled in OhioRISE to exercise choice and control in managing a budget for the applicable service in accordance with their needs.

(4) "Participant-directed budget for primary flex funds" is the OhioRISE enrollee's maximum approved funding for the purchase of primary flex funds under the OhioRISE program.

(C) Eligible providers and conditions of participation.

(1) The provider of primary flex funds will be the FMS entity under contract with the OhioRISE plan to complete the purchase and reimbursement of primary flex funds approved by the OhioRISE plan.

(2) With the exception of paragraph (B)(14) of rule 5160-44-31 of the Administrative Code, the provider will comply with conditions of participation as set forth in rule 5160-44-31 of the Administrative Code.

(D) Coverage.

(1) Coverage of primary flex funds will occur through participant-direction and will incorporate discussion and education with the youth and their primary caregiver of their ability to exercise budget authority during the participant-directed process.

(2) The youth's care coordinator working within a care management entity (CME), or the OhioRISE plan, will assist the youth and their primary caregiver in determining the need for the use of primary flex funds while ensuring the least costly appropriate service, equipment, or supply is evaluated.

(3) The youth's care coordinator working within the CME, or the OhioRISE plan, will document the recommendation for approval of the participant-directed budget for primary flex funds on the child and family-centered care plan as evidence of the necessity of primary flex funds to meet a youth's needs:

(a) The primary flex funds will decrease the need for other Ohio department of medicaid (ODM) services;

(b) The primary flex funds will promote the youth's inclusion in the community; or

(c) The primary flex funds will increase the youth's safety in the home environment.

(4) The OhioRISE plan will need to approve the youth's requested goods and services, and the participant-directed budget for primary flex funds as part of the child and family-centered care plan prior to use of the service.

(E) Limitations.

(1) The following items are excluded for primary flex funds purchase:

(a) Experimental treatments as outlined in rule 5160-1-61 of the Administrative Code;

(b) Items used solely for entertainment or recreational purposes;

(c) Pools, spas, or saunas;

(c)(d) Tobacco or alcoholic products;

(e) Food;

(f) Internet service;

(g) Items of general utility;

(d)(h) More than one of the same item for the same youth unless there is a documented change in the item's condition that warrants replacement;

(e)(i) Home modifications that are of general utility or that add to the total square footage of the home;

(f)(j) Items or treatments that are illegal or otherwise excluded through federal or state regulations; and

(g)(k) The costs of room and board as described in 42 CFR 441.310 (October 1, 2021 2023).

(2) The total available budget for primary flex funds is limited to one thousand five hundred dollars within three hundred sixty-five days.

(3) Approval for primary flex funds by the OhioRISE plan will not occur when:

(a) The youth or their primary caregiver has the funds to purchase the services, equipment, or supplies; or

(b) There is another available funding source for the services, equipment, or supplies.

(4) Primary flex funds will first be submitted for consideration under the medicaid state plan or other available OhioRISE plan services including, but not limited to, value-add services, when the primary flex funds provider is purchasing the item from an active ODM provider of like services.

(5) When the OhioRISE plan denies, reduces, terminates or suspends primary flex funds, this constitutes an adverse benefit determination, and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.

(6) Primary flex funds cannot be given directly to the youth or caregiver for purchase or reimbursement, and neither the youth nor caregiver can be a provider of goods and services purchased with flex funds.

(7) The youth will be the direct recipient of any goods or services purchased using primary flex funds.

(F) Service documentation for primary flex funds will include each of the following to validate reimbursement for medicaid services:

(1) Documentation on the child and family-centered care plan indicating at least one of the concepts in paragraphs (D)(3)(a) to (D)(3)(c) of this rule will be addressed by approving primary flex funds;

(2) An invoice containing the youth's name and medicaid identification number;

(3) A description of the item or service provided;

(4) Identification of the purchaser of service;

(5) The date the item or service was purchased and provided;

(6) The amount paid by the provider for primary flex funds.

Notes

Ohio Admin. Code 5160-59-03.5

Effective: 3/17/2024
Five Year Review (FYR) Dates: 6/30/2027
Promulgated Under: 119.03
Statutory Authority: 5167.02, 5164.02
Rule Amplifies: 5162.03, 5167.10
Prior Effective Dates: 07/01/2022