Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-40 - HCBS Waiver VI Program
Section 5160-40-01 - Medicaid home and community-based services program - individual options waiver

Universal Citation: OH Admin Code 5160-40-01

Current through all regulations passed and filed through September 16, 2024

(A) Purpose

(1) The Ohio department of developmental disabilities (DODD) is responsible for the daily operations of the individual options (IO) waiver which will be administered pursuant to sections 5166.02 and 5166.20 of the Revised Code.

(2) DODD operates the IO waiver program pursuant to an interagency agreement with the Ohio department of medicaid (ODM) in accordance with section 5162.35 of the Revised Code.

(B) Definitions

(1) "County board" means a county board of developmental disabilities established under Chapter 5126. of the Revised Code.

(2) "Funding range" means the dollar range to which an individual has been assigned for the purpose of funding waiver services. The funding range applicable to an individual is determined by the score derived from an assessment using the Ohio developmental disabilities profile "ODDP" that has been completed by a county board employee qualified to administer the tool.

(3) "Home and community-based services" (HCBS) means any federally approved medicaid waiver service provided to a waiver enrollee as an alternative to institutional care under Section 1915(c) of the Social Security Act, 49 Stat. 620 (1935), 42 U.S.C.A. 1396n, as in effect on January 1, 2024, under which federal reimbursement is provided for designated home and community-based services to eligible individuals.

(4) "Individual" means a person with a developmental disability who is eligible to receive HCBS as an alternative to placement in an intermediate care facility for individuals with intellectual disabilities (ICF/IID) under the applicable HCBS waiver. A guardian or authorized representative may give, refuse to give or withdraw consent for services and may receive notice on behalf of an individual to the extent permitted by applicable law.

(5) "Individual funding level" means the total funds, calculated on a twelve month basis, that are necessary for payment for waiver services that have been determined through the individual service plan (ISP) development process to be sufficient in amount, duration and scope to meet the health and welfare needs of an individual.

(6) "Individual Service Plan" (ISP) means a written description of the services, supports, and activities to be provided to an individual. The ISP is developed using a person-centered planning process.

(7) "Participant direction" means an individual has authority to make decisions about the individual's waiver services and accepts responsibility for taking a direct role in managing the services. Participant direction includes the exercise of budget authority and employer authority.

(8) "Person-centered planning" is a process directed by the individual, that identifies his or her strengths, values, capacities, preferences, needs, and desired outcomes. The process includes team members who assist and support the individual to identify and access medically necessary services and supports needed to achieve his or her defined outcomes in the most inclusive community setting.

(9) "Provider" means a person or agency who is eligible per Chapter 5123-2 of the Administrative Code and rule 5160-1-17.2 of the Administrative Code to provide IO waiver services as specified in this rule.

(10) "SSA" means a service and support administrator who is eligible to perform the functions of service and support administration per rules 5123-4-02 and 5123-5-02 of the Administrative Code.

(C) Eligibility

To be eligible for the IO waiver program:

(1) The individual's medicaid eligibility has been established in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code;

(2) The individual has been determined to have a developmental disabilities level of care in accordance with rule 5123-8-01 of the Administrative Code;

(3) The individual's health and welfare can be ensured through the utilization of IO waiver services at or below the federally approved cost limitation, and other formal and informal supports regardless of funding source;

(4) The individual participates in the development of a person-centered services plan in accordance with the process and requirements set forth in rules 5123-9-02 and 5123-4-02 of the Administrative Code; and

(5) The individual requires the provision of at least one waiver service monthly as documented in the individual's approved person-centered services plan.

(D) Enrollment

(1) Requests for the IO waver program are set forth in rules 5160:1-2-03 and 5123-9-01 of the Administrative Code utilizing ODM 02399 form Request for Medicaid Home and Community Based Services (HCBS) Waiver.

(2) Individuals who meet the eligibility criteria in paragraph (C) of this rule, or their legal representative, will be informed of the following:
(a) All services available on the IO waiver, and any choices that the individual may make regarding those services;

(b) Any viable alternative to the waiver; and

(c) The right to choose either institutional or home and community-based services.

(3) DODD allocates waivers to the county board in accordance with section 5166.22 of the Revised Code.

(4) The county board offers an available IO waiver to eligible individuals in accordance with applicable waiting list category requirements set forth in rules 5160-41-05 and 5123-9-04 of the Administrative Code.

(5) An individual's continued enrollment in the IO waiver program is redetermined no less frequently than every twelve months beginning with the individual's initial enrollment date or subsequent redetermination date. Individuals must continue to meet the eligibility criteria specified in paragraph (C) of this rule to continue enrollment in the waiver program.

(6) The maximum number of individuals that can be enrolled in the IO waiver program statewide will not exceed the allowable number specified in the federally approved waiver document.

(E) Benefit Package

(1) The IO waiver program provides necessary home and community-based services to individuals of any age as an alternative to institutional care in an intermediate care facility for individuals with intellectual disabilities (ICF/IID).
(a) The IO waiver program benefit package, as indicated in the federally approved waiver application, is limited to the services specified in Chapter 5123-9 of Administrative Code.

(b) The IO waiver program supports individuals who want to direct some of their services through participant direction. The individual or the individual's guardian or the individual's designee perform the duties associated with participant direction.

(2) All services will be provided to an individual enrolled in the IO waiver program pursuant to a written person-centered ISP.
(a) The ISP will be developed by qualified persons with input from the individual in accordance with rule 5123-4-02 of the Administrative Code;

(b) The ISP will be developed to include only waiver services which are consistent with efficiency, economy and quality of care and identify non-waiver services, regardless of funding source; and

(c) The ISP will include an individual funding level. If the county board, with the involvement of the individual enrolled on the IO waiver program, is unable to recommend an ISP that includes a funding level within or below the funding range, the county board will inform the individual of the right to request prior authorization as specified in rule 5123-9-07 of the Administrative Code and will provide the individual notification of hearing rights.

(3) The ISP is subject to approval by ODM and DODD pursuant to section 5166.05 of the Revised Code. Notwithstanding the procedures set forth in this rule, ODM may in its sole discretion, and in accordance with section 5166.05 of the Revised Code direct the county board or DODD to amend ISPs for individuals.

(4) When DODD, ODM, or the county board takes action to approve, deny, or terminate enrollment in the IO waiver program, or to deny or change the level of waiver services delivered to an enrollee, the individual will be notified of his or her hearing rights in accordance with division 5101:6 of the Administrative Code.

(5) The county board shall offer an available IO waiver to eligible individuals in accordance with applicable waiting list category requirements set forth in rules 5160-41-05 and 5123-9-04 of the Administrative Code.

(F) Service Provision

(1) Authorized IO waiver services will be provided by persons or agencies who:
(a) Are eligible per rule 5160-1-17.2 of the Administrative Code and

(b) Are eligible in accordance with chapter 5123-2 and if applicable chapter 5123-3 of the Administrative Code.

(2) Services will be provided utilizing person-centered practices and in settings in accordance with 42 C.F.R. 441.530 (as in effect January 1, 2024).

(3) Individuals enrolled, or their legal representative, will be informed of freedom of choice in qualified providers in accordance with rule 5160-41-08 of the Administrative Code and 42 C.F.R. 431.51 (as in effect on January 1, 2024).

(4) IO waiver program payment standards are operated in accordance with rule 5160-41-18 of the Administrative Code.
The maximum allowable payment rates of the IO waiver program services are provided in Chapter 5123-9 of the Administrative Code.

(5) ODM may conduct periodic monitoring and compliance reviews in accordance with section 5162.10 of the Revised Code.
Reviews may consist of, but are not limited to, physical inspections of records and sites where services are provided, interviews of providers, recipients, and administrators of waiver services.

(6) Records related to the administration and provision of IO waiver services may be reviewed by ODM, the auditor of the state, the attorney general, and the medicaid fraud control unit or their designees per sections 5162.10 and 5160.22 of the Revised Code.

(7) Individuals enrolled in the IO waiver program are responsible for the provision of information to administering agencies as set forth in Chapter 5160:1-2 of the Administrative Code.

Replaces: 5160-40-01

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