Current through all regulations passed and filed through September 16, 2024
(A)
Scope. This rule sets forth provisions governing
coverage for self-directed goods and services provided as part of an Ohio
department of medicaid-(ODM) administered waiver program.
(B)
"Self-directed
goods and services" are services, equipment, or supplies that:
(1)
Are not available
through the medicaid state plan benefit or a home and community-based services
(HCBS) waiver program;
(2)
Address an individual's assessed need and are included
on the person-centered services plan; and
(3)
Supplement the
medicaid state plan benefit and HCBS waiver services to help the individual
successfully remain in the community.
(C)
The ODM
contracted financial management services (FMS) entity is the provider of
self-directed goods and services. The FMS completes the purchase and
reimbursement of self-directed goods and services approved in the
person-centered services plan.
(D)
Coverage.
(1)
Self-directed
goods and services are covered through self-direction budget authority, as
described in rule 5160-45-03.2 of the Administrative Code.
(2)
Self-directed
goods and services may be approved if it is determined they will:
(a)
Increase the
individual's independence, safety, and/or community
participation;
(b)
Decrease the individual's need for other medicaid
services; or
(c)
Support the individual who does not have funds to
purchase the services, equipment, or supplies, and they are not available
through another source.
(3)
Self-directed
goods and services are individualized; therefore an exhaustive list cannot be
developed. Goods and services include any needed equipment, supplies or
services not covered by medicaid or another approved HCBS waiver service. This
may include but is not limited to:
(a)
Community classes, memberships, training or
coaching;
(b)
Household related items or devices;
(c)
Camps;
and
(d)
Art, music, or other alternative
therapies.
(E)
Limitations.
(1)
The following items cannot be purchased as
self-directed goods and services:
(a)
Experimental treatments as outlined in rule
5160-1-61 of the Ohio
Administrative Code;
(b)
Items used solely for entertainment or recreational
purposes;
(c)
Monthly rent, utilities or internet service;
and
(d)
Items that are illegal or otherwise prohibited through
federal or state regulations.
(2)
Self-directed
goods and services are limited to two-thousand five hundred dollars within
three-hundred and sixty-five days.
(3)
The individual,
representative, or self-directed caregiver cannot be a vendor of supplies or
items purchased with the self-directed goods and services
funds.
(F)
Service documentation for self-directed goods and
services will include each of the following to validate reimbursement for
medicaid services:
(1)
Receipts to validate purchase of items are submitted to
the case manager containing all the following:
(a)
Item or service
description;
(b)
Vendor name;
(c)
Purchase date;
and
(d)
Paid amount.
(2)
An invoice for
payment to a vendor is submitted to the FMS containing all the following:
(a)
Individual's name
and Medicaid identification number;
(b)
Item or service
description;
(c)
Vendor name;
(d)
Purchaser of
service if not the individual;
(e)
Purchase date,
delivery or service date; and
(f)
Paid
amount.
