Current through all regulations passed and filed through March 18, 2024
A member and/or an authorized representative who is acting on
behalf of a member (hereinafter "member") who is enrolled in the MyCare Ohio
waiver in accordance with rule 5160-58-02.2 of the Administrative Code has
choice and control over the arrangement and provision of home and
community-based services (HCBS). Members also have choice over the selection
and control over the direction of approved waiver service providers.
(A) A member may choose to receive MyCare
Ohio waiver services from any combination of providers on the provider panel of
the MyCare Ohio plan selected by the member pursuant to paragraph (B) of rule
5160-58-04
of the Administrative Code.
(B) A
member receiving waiver services from any MyCare Ohio waiver provider shall:
(1) Participate with the waiver service
coordinator in the development of the person centered services plan as defined
in rule
5160-44-02
of the Administrative Code.
(2)
Decide who from their trans-disciplinary care management team will participate
in the face-to-face development of the person-centered services plan.
(3) Communicate to the service provider and,
as appropriate, the provider's management staff, personal preferences about the
manner in which duties, tasks and procedures are to be performed.
(4) Work with the waiver service coordinator
and the provider to identify and secure additional service provider
orientation, training and/or continuing education within the provider's scope
of practice in order to meet the member's specific needs.
(5) Not direct the provider to act in a
manner that is contrary to any relevant MyCare Ohio waiver requirements,
medicaid rules and regulations, or the provider's policies and
procedures.
(6) Understand the
incident management and reporting responsibilities of the member as set forth
in rule 5160-58-05.3 or 5160-44-05 of the Administrative Code.
(7) Communicate to the waiver service
coordinator and/or MyCare Ohio plan care manager any significant changes, as
defined in rule
5160-58-01
of the Administrative Code, that may affect the provision of services or result
in a need for more or fewer hours of service.
(8) Sign a complete and accurate timesheet or
other documentation, as appropriate, to verify services have been furnished.
The member shall never approve blank timesheets, or timesheets that have been
completed before services have been furnished. Verification may be written or
electronic at the discretion of the MyCare Ohio plan, unless otherwise required
by rule
5160-1-40
of the Administrative Code. If the individual is unable
to provide the signature required to verify a service at the time of the
service, the individual will submit an electronic signature or standard
signature via regular mail, or otherwise provide a signature in no instance any
later than at the next face-to-face visit with the provider.
(9) Participate in the recruitment, selection
and dismissal of providers in collaboration with the trans-disciplinary care
management team.
(10) In the manner
specified by the waiver service coordinator, notify the provider if the member
is going to miss a scheduled visit.
(11) Notify the waiver service coordinator if
the assigned provider misses a scheduled visit.
(12) Notify the waiver service coordinator
when any change in provider is necessary. Notification shall include the
desired end date of the current provider.
(13) Participate in the monitoring of the
performance of the provider.
(C) If a member chooses to receive waiver
services from any non-agency provider, or is exercising participant-direction
over the services in paragraph (F) of rule
5160-58-04
of the Administrative Code using one or more participant-directed individual
providers or participant-directed personal care providers, the following
additional requirements shall apply as appropriate to the service being
furnished:
(1) In accordance with paragraph
(B)(9) of this rule, members shall take a proactive role in the delivery of
their MyCare Ohio waiver services. This includes identifying prospective
providers, recruiting and training MyCare Ohio providers to furnish tasks in
accordance with the member's needs and preferences, and working with the MyCare
Ohio care manager or waiver service coordinator to schedule and manage the
delivery of authorized MyCare Ohio waiver services.
(2) The member shall designate a location in
their home in which the member and, as appropriate, the provider can safely
store a copy of the member's records in a manner that protects the
confidentiality of the records, and for the purpose of contributing to the
continuity of the member's care.
(3) The member or, as appropriate, the
provider shall make the member's records available upon request by the MyCare
Ohio plan, the Ohio department of medicaid (ODM) and/or ODM's
designee.
(4) The member shall not
aid the provider in furnishing a service in a manner that does not comply with
any rule or law that regulates the provider.
(5) Members who exercise
participant-direction of providers under the MyCare Ohio waiver shall work with
ODM's designated financial management service.
(D) If the member elects to receive services
from a participant-directed provider, the waiver service coordinator shall
assess the member's strengths and weaknesses (and if the member has an
authorized representative, the authorized representative's strengths and
weaknesses) and ability to direct a provider. The waiver service coordinator
shall allow the member to direct a provider if the waiver service coordinator
determines that the member demonstrates the following:
(1) An understanding of the elements of the
service the provider shall furnish;
(2) An understanding of how to direct the
provider; and
(3) An ability to
perform the responsibilities of an employer, including:
(a) Completion of any training required by
ODM or the MyCare Ohio plan;
(b)
Understanding which service activities are covered according to rule
5160-58-04
of the Administrative Code;
(c)
Understanding the methods for selecting and dismissing participant-directed
service providers including the requirements for providers to furnish services
in the MyCare Ohio waiver;
(d)
Understanding the methods for entering into written agreements with
participant-directed service providers for specific activities;
(e) Understanding the methods for training
participant-directed service providers to meet the member's specific
needs;
(f) Understanding the
methods for supervising and monitoring the participant directed service
provider's performance of specific activities, including written approval of
the provider's time sheets;
(g)
Development of a back-up plan if a provider is unable to furnish the agreed
upon service;
(h) Understanding the
methods for filing grievances, including use of the regional and state long
term care ombudsman;
(i)
Familiarity with the MyCare Ohio plan grievance process and the state appeal
and fair hearing request procedures;
(j) Understanding and compliance with the
state's record-retention requirements; and
(k) An ability to manage the
participant-directed service provider when he or she furnishes a
service.
(E) If
the waiver service coordinator determines that the member cannot meet the
requirements set forth in paragraph (C) or (D) of this rule, as appropriate,
the waiver service coordinator may require the member to appoint an authorized
representative to assist the member with directing services.
(F) If the waiver service coordinator, in
consultation with the trans-disciplinary care management team, determines that
the member and/or the member's authorized representative cannot meet the
requirements set forth in paragraph (C) or (D) of this rule, or the health and
welfare of the member receiving services from a non-agency or
participant-directed provider cannot be ensured, the waiver service coordinator
may require the member to receive services from only agency providers. The
member will be afforded notice and hearing rights in accordance with division
5101:6 of the Administrative Code.