Current through all regulations passed and filed through September 16, 2024
(A) To be eligible
for enrollment in the Ohio home care waiver program, an individual must meet
all of the following requirements:
(1) Be
between the ages of birth through age fifty-nine.
(2) Be determined eligible for Ohio medicaid
in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative
Code.
(3) Participate in an initial
assessment to determine if the individual has needs that can be met through the
Ohio home care waiver program.
(4)
Be determined to have a nursing facility (NF) -based level of care (i.e.,
intermediate or skilled) in accordance with rule
5160-3-08 of the Administrative
Code.
(5) In the absence of the
Ohio home care waiver program, require hospitalization or institutionalization
in a NF to meet his or her needs.
(6)
The individual:
(a)
Has a need for and agrees to receive at least one
waiver service monthly that is otherwise unavailable through another source
(including, but not limited to, private pay, community resources and/or the
medicaid state plan) in an amount sufficient to meet the individual's assessed
needs; or
(b)
Has a need for and agrees to receive all of the
following:
(i)
Medicaid state plan private duty nursing
services,
(ii)
At least monthly monitoring of the individual's health
and welfare through a combination of telephonic and in-person contacts with the
case manager, and
(iii)
At least one waiver service
annually.
(7) Be able to establish residency in a place
that possesses the home and community-based setting characteristics set forth
in rule 5160-44-01 of the Administrative
Code, and that is not a hospital, NF, intermediate care facility for
individuals with an intellectual disability (ICF-IID) or another
licensed/certified facility, any facility covered by section 1616(e) of the
Social Security Act (42
U.S.C. 1382(e) (January 1,
2024)),
residential care facility, adult foster home or another group living
arrangement subject to state licensure or certification.
(8) Sign an agreement prior to waiver
enrollment confirming that the individual has been informed of service
alternatives, choice of qualified providers available in the Ohio home care
waiver program and the options of institutional and community-based care, and
he or she elects to receive Ohio home care waiver services. If the individual
is unable to provide a signature at the time of enrollment, the individual is
to submit an electronic signature or standard signature via regular mail, or
otherwise in no instance any later than at the next face-to-face visit with the
case manager.
(9) Have needs that
can be safely met through the Ohio home care waiver in a home or community
setting as determined by the Ohio department of medicaid (ODM) or its
designee.
(B) Subject to
paragraph (H) of this rule, to be enrolled and maintain enrollment in the Ohio
home care waiver program, an individual must be determined by ODM or its
designee to meet all of the following requirements:
(1) Be determined eligible for the Ohio home
care waiver program in accordance with paragraph (A) of this rule.
(2) Reside in a setting that possesses the
home and community-based setting characteristics set forth in rule
5160-44-01 of the Administrative
Code, and is not a hospital, NF, intermediate care facility for individuals
with an intellectual disability (ICF-IID) or another licensed/certified
facility, any facility covered by section 1616(e) of the Social Security Act
(42 U.S.C.
1382(e) (January 1,
2024)),
residential care facility, adult foster home or another group living
arrangement subject to state licensure or certification.
(3) Have his or her health and welfare
assured while enrolled on the waiver.
(4) Participate in the development and
implementation of a person-centered services plan in accordance with the
process and requirements set forth in rule
5160-44-02 of the Administrative
Code, and consent to the plan by signing and dating it;
(5) Agree to and receive case management
services from ODM or its designee including, but not limited to:
(a) Annual and other assessments, as
needed,
(b) Home safety
evaluations,
(c) Contact with the
case manager and/or the individual's team members, including, but not limited
to telephone communications, and face-to-face and in-home visits; and
(6) Agree to and participate in
quality assurance and participant satisfaction activities during his or her
enrollment on the Ohio home care waiver program including, but not limited to,
face-to-face visits.
(C)
An individual shall be given priority for assessment to determine eligibility
for enrollment in the Ohio home care waiver when ODM is made aware that he or
she meets the criteria for any of the priority categories set forth in
paragraphs (C)(1) to (C)(6) of this rule.
(1)
The individual is under twenty-one years of age, and at the time of
application:
(a) Received inpatient hospital
services for at least fourteen consecutive days; or
(b) Had at least three inpatient hospital
stays during the preceding twelve months.
(2) The individual is at least twenty-one but
less than sixty years of age and received inpatient hospital services for at
least fourteen consecutive days immediately preceding the date of
application.
(3) The individual is
under sixty years of age and received private duty nursing services in
accordance with rule
5160-12-02 of the Administrative
Code for at least twelve consecutive months immediately preceding
application.
(4) The individual is
under sixty years of age, lives in the community and is at imminent risk of
institutionalization due to the documented loss of a primary caregiver. In such
instances, there must be written evidence (such as a doctor's order, a death
certificate, or documentation that the primary caregiver is institutionalized
or relocated out of the area) that substantiates the primary caregiver is
unavailable to provide care and support, and without Ohio home care waiver
services, the individual will require care in an inpatient hospital setting or
a nursing facility (NF).
(5) The
individual is under sixty years of age and resides in a medicaid-funded NF at
the time of application.
(6) The
individual is under sixty years of age, is determined by ODM to be eligible for
the HOME choice ("Helping Ohioans Move, Expanding Choice") program in
accordance with rule
5160-51-02 of the Administrative
Code, and resides in a residential treatment facility as defined in rule
5160-51-01 of the Administrative
Code, or an inpatient hospital setting.
(D) If an individual fails to meet any of the
requirements set forth in paragraph (A) and/or paragraph (B) of this rule, the
individual shall be denied enrollment on the Ohio home care waiver
program.
(E) Once enrolled on the
Ohio home care waiver program, an individual's NF level of care shall be
reassessed at least annually, and more frequently if there is a significant
change in the individual's situation that may impact his or her health and
welfare.
(F) Subject to paragraph
(I) of this rule, if at any time, it is determined that an individual enrolled
on the Ohio home care waiver program no longer meets the requirements set forth
in paragraph (A) or paragraph (B) of this rule, individual will be disenrolled
from the Ohio home care waiver program.
(G) If an individual is denied enrollment in
the Ohio home care waiver program pursuant to paragraph (D) of this rule, or is
disenrolled from the waiver pursuant to paragraph (F) of this rule, the
individual shall be afforded notice and hearing rights in accordance with
division 5101:6 of the Administrative Code.
(H) The number of individuals enrolled in the
Ohio home care waiver shall not exceed the centers for medicare and medicaid
services (CMS) -authorized limit for the waiver program year.
(I)
Individuals aged sixty
and above who are enrolled on the Ohio home care waiver program:
(1)
Individuals who
are sixty or older, prior to January 1, 2024, will be disenrolled from the
waiver no later than March 31, 2024. Individuals will be offered an opportunity
to transition to the pre-admission screening system providing options and
resources today (PASSPORT) waiver if all program eligibility requirements are
met.
(2)
Individuals turning sixty January 1, 2024, or later
will be disenrolled from the waiver no later than one hundred twenty calendar
days following their sixtieth birthday. Individuals will be offered an
opportunity to transition to the PASSPORT waiver if all program eligibility
requirements are met.
