Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-59 - OhioRISE
Section 5160-59-04 - OhioRISE home and community-based services waiver
Universal Citation: OH Admin Code 5160-59-04
Current through all regulations passed and filed through December 16, 2024
(A) To be eligible for the Ohio resilience through integrated systems and excellence (OhioRISE) home and community-based services (HCBS) 1915(c) waiver (waiver), a youth will be determined by the Ohio department of medicaid (ODM) to meet all of the following:
(1) Meet eligibility criteria set forth in
paragraphs (A)(1) to (A)(3) of rule
5160-59-02 of the Administrative
Code;
(2) Be determined to meet the
following level of care (LOC) criteria for an inpatient psychiatric (IP)
services through an IP LOC assessment:
(a) For
youth age six through twenty years of age have a comprehensive Ohio children's
initiative child and adolescent needs and strengths (CANS) assessment, using
the tool available on https://www.medicaid.ohio.gov
(September 20, 2021), completed by a certified Ohio children's initiative CANS
assessor employed by or under contract with the care management entity (CME)
described in rule
5160-59-03.2 of the
Administrative Code, indicating paragraphs (A)(2)(a)(i), (A)(2)(a)(ii), and
either paragraph (A)(2)(a)(iii) or (A)(2)(a)(iv) of this rule are met:
(i) For behavioral/emotional needs domain
items, at least two of the following items are dangerous or disabling and need
immediate action or three or more of the following items are at least
interfering with functioning and need action to ensure that the identified need
is addressed:
(a) Psychosis;
(b) Impulsivity/hyperactivity;
(c) Depression;
(d) Anxiety;
(e) Oppositional behavior;
(f) Conduct;
(g) Adjustment to trauma;
(h) Anger control;
(i) Substance use;
(j) Eating disturbance;
(k) Attachment difficulties;
(l) or Interpersonal problems (for youth age
fourteen and older).
(ii)
For risk behaviors domain items, at least two of the following items are
dangerous or disabling and need immediate action or three or more of the
following items are at least interfering with functioning and need action to
ensure that the identified need is addressed:
(a) Suicide risk;
(b) Non-suicidal self-injury
behavior;
(c) Other
self-harm;
(d) Danger to
others;
(e) Delinquent
behavior;
(f) Runaway;
(g) Intentional misbehavior;
(h) Fire setting;
(i) Victimization/exploitation;
(j) Sexually problematic
behavior.
(iii) For the
caregiver resources and needs domain, at least one of the following items is
dangerous or disabling and needs immediate action or two or more of the
following items are at least interfering with functioning and need action to
ensure that the identified need is addressed:
(a) Supervision;
(b) Residential stability;
(c) Medical/physical;
(d) Mental health
(e) Substance use;
(f) Family stress.
(iv)
The youth has no current viable
caregiver.
(b) For youth
age birth through five years of age, have a comprehensive Ohio children's
initiative CANS assessment, using the tool available on
https://www.medicaid.ohio.gov
(September 20, 2021), completed by a certified Ohio children's initiative CANS
assessor employed by or under contract with the CME described in rule
5160-59-03.2 of the
Administrative Code, indicating paragraphs (A)(2)(b)(i), (A)(2)(b)(ii), and
either paragraph (A)(2)(b)(iii) or (A)(2)(b)(iv) of this rule are met:
(i) For early childhood domain items, at
least two of the following items are dangerous or disabling and need immediate
action or three or more of the following items are at least interfering with
functioning and need action to ensure that the identified need is addressed:
(a) Impulsivity/hyperactivity;
(b) Depression;
(c) Anxiety;
(d) Oppositional behavior;
(e) Adjustment to trauma;
(f) Regulatory;
(g) Sleep.
(ii) For risk behavior and functioning domain
items, at least two of the following items are dangerous or disabling and need
immediate action or three or more the following items are at least interfering
with functioning and need action to ensure that the identified need is
addressed:
(a) Self-harm;
(b) Exploited;
(c) Problematic sexual behavior;
(d) Aggressive behavior;
(e) Family functioning;
(f) Social and emotional
functioning.
(iii) For
the caregiver resources and needs domain, at least one of the following items
is dangerous or disabling and needs immediate action or two or more of the
following items are at least interfering with functioning and need action to
ensure that the identified need is addressed:
(a) Supervision;
(b) Residential stability;
(c) Medical/physical;
(d) Mental health;
(e) Substance use;
(f) Family stress;
(iv)
The youth has no current viable
caregiver.
(c) Have a
diagnosis of serious emotional disturbance (SED) as defined in rule
5122-24-01 of the Administrative
Code, which needs to be documented through one of the
following:
(i)
A diagnostic
assessment dated no more than two years prior to the date of application for
the OhioRISE waiver with an applicable SED diagnosis performed by a licensed
practitioner operating within their scope of practice; or
(ii)
A treatment plan
showing an applicable SED diagnosis signed by the licensed clinician that is
the treating provider dated no more than two years prior to the date of
application for the OhioRISE waiver, accompanied by the diagnostic assessment
that resulted in the applicable SED diagnosis performed by a licensed
clinician.
(d) Have
documented functional impairment and behaviors that substantially interfere
with or limit the youth's role or functioning in family, school, or community
activities which result in recommended institutionalization and potential
relinquishment of custody to the child welfare system. Documented functional
impairment and behaviors are indicated by the youth's
CANS scores or by separate documentation provided by the youth or caregiver,
and needs to include one or more of the following:
(i) Youth's persistent physical abuse or
violence that results in physical injury or emotional distress to caregivers,
family members, others in the home and community; or physical destruction of
property that impacts the youth's housing stability.
(ii) Youth's history of suicidal ideation
with intent, or history of suicide attempts, within the past six
months.
(iii) Youth's sexually
problematic behavior that creates a safety risk for themselves or others
without a high-level of direct supervision.
(iv) Youth's suspension or expulsion from
school; or withdrawal from school, daycare, or preschool program as the result
of the youth's actions/intensive behaviors.
(v) Law enforcement or child welfare contact
or involvement due to the youth's intensive behaviors.
(vi) Youth has a history of victimization or
exploitation, including human trafficking within the past twelve months, and
re-victimization may be imminent. This may include physical or sexual abuse,
sexual exploitation, or violent crime.
(3) Have a completed IP LOC assessment as
follows:
(a) A LOC assessment determining a
youth meets an IP LOC will be completed prior to initial enrollment on the
waiver;
(b) A LOC assessment
determining a youth meets an IP LOC will be completed within three hundred
sixty-five calendar days of the previous LOC assessment for continued
enrollment on the waiver; and
(c)
Once enrolled in the waiver, all youth who experience a significant change in
situation impacting health and welfare will receive an IP LOC assessment
following the event to determine continued enrollment on the waiver.
(4) Be determined to have a need
for, and agree to receipt of, at least one service available under the waiver
that is otherwise unavailable through another source (including, but not
limited to private pay, community resources, or the medicaid state plan). If a youth is anticipated to need waiver services less
frequently than every thirty calendar days, the care coordinator is to indicate
on the child and family-centered care plan the method of monitoring they will
employ on at least a monthly basis to assure that the youth's health and
welfare needs are met.
(5) Have waiver
needs which are less than or equal to the waiver services cost cap of fifteen
thousand dollars in a twelve-month period. Once enrolled in the waiver, youth
may have access to additional emergency funding as described in rule
5160-59-05.3 of the
Administrative Code.
(6) Have been
informed of, as recorded during the course of an assessment or in an
alternative manner at the discretion of ODM, all of the following:
(a) Service alternatives including the choice
and election to receive services on an HCBS program in lieu of institutional
services; and
(b) Choice of
providers who meet provider qualifications as described in Chapter 5160-59 of
the Administrative Code to provide services under the waiver.
(7) Have needs that can be safely
met in an HCBS setting through the waiver as determined by ODM or its
designee.
(8) Meet the following
age criteria:
(a) Be between the ages of birth
and twenty years of age at the time of initial enrollment; and
(b) Once enrolled, youth may continue
enrollment on the waiver through the age of twenty-two, so long as the youth
meets the other eligibility criteria set forth in paragraphs (A) and (B) of
this rule.
(9) Agrees to
participate in the waiver, and while enrolled in the waiver, will not be
simultaneously enrolled in another HCBS 1915(c) waiver or the specialized
recovery services program as defined in rule
5160-43-01 of the Administrative
Code.
(B) Once eligibility to the OhioRISE waiver has been determined and before the OhioRISE waiver services described in rule 5160-59-05 of the Administrative Code can be provided, the youth will:
(1)
Participate in the development and implementation of the child and
familycentered care plan in accordance with the process and criteria set forth
in rule 5160-44-02 of the Administrative
Code. The youth or their authorized representative will consent to the child
and family-centered plan by signing and dating it by the thirtieth calendar day
of eligibility; and
(2) Reside, and
will continue to reside, in a setting that possesses the home and
community-based setting characteristics set forth in rule
5160-44-01 of the Administrative
Code. The youth may reside in a setting that does not
meet the characteristics of a home and community-based setting while the waiver
assessment process is being conducted. The waiver assessment process can begin
up to ninety days prior to the youth residing in a home and community-based
setting, as follows:
(a)
The youth needs to reside with family or friends in a
private residence, including family foster homes as defined in rule
5101:2-1-01 of Administrative
Code; or
(b)
The youth needs to reside alone in a private residence,
when living alone is appropriate in the context of the youth's developmental
needs and family or caregiver needs.
(C) All youth enrolled into the OhioRISE waiver will be automatically enrolled with a managed care organization as defined in rule 5160-26-01 of the Administrative Code except for those excluded from managed care enrollment as defined in paragraph (B)(5) of rule 5160-26-02 of the Administrative Code.
(D) If, at any time, a youth does not meet any of the eligibility criteria set forth in paragraphs (A) and (B) of this rule, with the exception of paragraph (A)(8)(b) of this rule, the youth will be denied enrollment to, or be disenrolled from, the waiver.
(E) If a youth resides in an institution, as described in rule 5160-44-01 of the Administrative Code, for more than ninety consecutive days, the OhioRISE plan will assess the youth for potential disenrollment from the OhioRISE waiver. When the youth resides in an institution for longer than one hundred eighty consecutive days, the OhioRISE plan will initiate disenrollment from the OhioRISE waiver.
(F) When a youth is disenrolled from the waiver for any reason, the following will occur:
(1) Dependent in which care
coordination tier a youth is enrolled, in accordance with rule
5160-59-03.2 of the
Administrative Code, either the care management entity (CME)
or the OhioRISE plan will work to
develop a transition of care plan at least thirty calendar days prior to
disenrollment.
(2) Either the CME
or the OhioRISE plan will work to identify needed supports for the ninety
calendar days following disenrollment from the OhioRISE program.
(G) When a youth is denied enrollment to, or disenrolled from, the waiver for failure to meet eligibility criteria as set forth in paragraph (A) or (B) of this rule, the youth or their authorized representative will be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.
(H) The number of individuals enrolled in the waiver program will not exceed the centers for medicare and medicaid services authorized limit for the waiver program year.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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