Ohio Administrative Code
Title 5123:2 - Community Services
Chapter 5123:2-9 - Home and Community-Based Services Waivers
Section 5123:2-9-07 - Home and community-based services waivers - request for prior authorization for individuals enrolled in the individual options waiver
Universal Citation: OH Admin Code 5123:2-9-07
Current through all regulations passed and filed through September 16, 2024
(A) Purpose
The purpose of this rule is to establish standards and procedures for prior authorization of waiver services when an individual funding level exceeds the funding range determined by the Ohio developmental disabilities profile for individuals enrolled in the individual options waiver.
(B) Definitions
(1)
"Cost projection tool" means the web-based analytical tool,
developed and administered by the department, used to project the cost of
waiver services identified in the individual service plans of individuals
enrolled in individual options and level one waivers.
(2)
"County board"
means a county board of developmental disabilities.
(3)
"Department"
means the Ohio department of developmental disabilities.
(4)
"Funding range"
means one of the dollar ranges contained in appendix A to rule
5123:2-9-06
of the Administrative Code to which individuals enrolled in the individual
options waiver have been assigned for the purpose of funding services other
than adult day support, non-medical transportation, supported
employment-community, supported employment-enclave, and vocational
habilitation. The funding range applicable to an individual is determined by
the score derived from the Ohio developmental disabilities profile that has
been completed by a county board employee qualified to administer the
tool.
(5)
"Individual" means a person with a developmental
disability or for purposes of giving, refusing to give, or withdrawing consent
for services, his or her guardian in accordance with section
5126.043 of the Revised Code or
other person authorized to give consent.
(6)
"Individual
funding level" means the total funds, calculated on a twelve-month basis, that
result from applying the payment rates in service-specific rules in Chapter
5123:2-9 of the Administrative Code to the units of all waiver services other
than adult day support, non-medical transportation, supported
employment-community, supported employment-enclave, and vocational habilitation
established by the individual service plan development process to be sufficient
in frequency, duration, and scope to meet the health and welfare needs of an
individual enrolled in the individual options waiver.
(7)
"Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual.
(8)
"Medicaid
services system" means the comprehensive information system that integrates
cost projection, prior authorization, daily rate calculation, and payment
authorization of waiver services.
(9)
"Ohio
developmental disabilities profile" means the standardized instrument utilized
by the department to assess the relative needs and circumstances of an
individual enrolled in the individual options waiver compared to others. The
individual's responses are scored and the individual is linked to a funding
range, which enables similarly situated individuals to access comparable waiver
services paid in accordance with rules adopted by the
department.
(10)
"Prior authorization" means the process to be followed
in accordance with this rule to authorize an individual funding level for an
individual enrolled in the individual options waiver that exceeds the maximum
value of the funding range.
(11)
"Service and
support administrator" means a person, regardless of title, employed by or
under contract with a county board to perform the functions of service and
support administration and who holds the appropriate certification in
accordance with rule
5123:2-5-02
of the Administrative Code.
(12)
"Waiver
eligibility span" means the twelve-month period following either an
individual's initial enrollment date or a subsequent eligibility
redetermination date.
(C) Standards
(1)
The county board
shall inform an individual, in writing, of the individual's right to request
prior authorization whenever development or proposed revision of the individual
service plan results in an individual funding level that exceeds the funding
range assigned to the individual.
(2)
Unless a request
for prior authorization has been approved in accordance with this rule, the
individual funding level for services shall be within or below the funding
range assigned to the individual.
(3)
Approval of a
request for prior authorization is valid only for the duration of the
individual's waiver eligibility span for which the request was
made.
(D) Procedures
(1)
An individual shall initiate the prior authorization
process by submitting a signed and dated request to the county board. A county
board shall assist in the preparation of the request when the individual
requests assistance.
(2)
The county board shall submit the request for prior
authorization with the current or proposed individual service plan and
supporting documentation to the department through the medicaid services system
within ten business days of receiving the individual's request. Supporting
documentation shall provide evidence that requested services are medically
necessary in accordance with criteria set forth in paragraph (D)(6) of this
rule.
(3)
When the county board is unable to support the request
based on the county board's documentation that the services do not meet the
criteria set forth in paragraph (D)(6) of this rule, the county board shall
provide to the department:
(a)
A detailed description of the county board's efforts
to develop an individual service plan that results in an individual funding
level within the funding range assigned to the individual; and
(b)
An alternative
cost projection that ensures the health and safety of the individual and the
date the alternative cost projection was reviewed and declined by the
individual.
(4)
Within ten business days of receiving the request, the
department shall notify the county board if additional information is needed to
make a determination.
(5)
The department shall review the request and make a
determination within ten business days of receiving all necessary
information.
(6)
When reviewing a request, the department shall
determine whether the waiver services for which prior authorization is
requested are medically necessary. The department shall determine the services
to be medically necessary if the services:
(a)
Are appropriate
for the individual's health and welfare needs, living arrangement,
circumstances, and expected outcomes; and
(b)
Are of an
appropriate type, amount, duration, scope, and intensity; and
(c)
Are the most
efficient, effective, and lowest cost alternative that, when combined with
non-waiver services, ensure the health and welfare of the individual receiving
the services; and
(d)
Protect the individual from substantial harm expected
to occur if the requested services are not authorized.
(7)
The
department may limit its review to the individual's request in the medicaid
services system and the cost projection tool that produced an individual
funding level that exceeds the funding range assigned to the individual when
the county board supports the request and:
(a)
The projected
individual funding level exceeds the funding range assigned to the individual
by no more than ten per cent; or
(b)
The request is
for an individual for whom prior authorization has been approved for a previous
waiver eligibility span and the request includes an attestation by the service
and support administrator that the individual's needs, waiver services, and
cost of waiver services have not changed since the preceding
request.
(8)
Based on its review, the department shall:
(a)
Approve the
request if it finds that the services for which prior authorization is
requested meet the criteria set forth in paragraph (D)(6) of this rule;
or
(b)
Deny the request; or
(c)
Approve the
request for a partial or full waiver eligibility span for all or some of the
services provided the criteria set forth in paragraph (D)(6) of this rule are
met.
(9)
When the department approves a request for prior
authorization, the department shall:
(a)
Issue written
notification to the individual which reflects the total amount authorized for
the current waiver eligibility span and includes the individual's right to
request a hearing in accordance with section
5101.35 of the Revised Code and
division 5101:6 of the Administrative Code; and
(b)
Update the prior
authorization status to reflect its determination in the medicaid services
system.
(10)
When the department denies a request for prior
authorization, the department shall:
(a)
Issue written notification to the individual which
includes the individual's right to request a hearing in accordance with section
5101.35 of the Revised Code and
division 5101:6 of the Administrative Code; and
(b)
Update the prior
authorization status to reflect its determination in the medicaid services
system.
(11)
When the request for prior authorization is denied,
the individual and the service and support administrator shall meet to revise
the individual service plan.
(E) If the individual requests a hearing in accordance with paragraph (D)(9)(a) or (D)(10)(a) of this rule, the county board shall offer a county conference in accordance with rule 5101:6-5-01 of the Administrative Code and comply with applicable requirements of division 5101:6 of the Administrative Code.
(F) Failure by a county board or the department to comply with the timelines established in this rule shall not constitute approval of a request for prior authorization.
(G) The department shall submit to the Ohio office of medical assistance, on a quarterly basis, a summary of requests for prior authorization received. The department shall also systematically evaluate compliance with prior authorization requirements by verifying that each individual funding level is maintained within the prior authorized amount and providing the results of this evaluation in writing to the Ohio office of medical assistance no less than quarterly.
Replaces: Part of 5101:3-41-12
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