Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-59 - OhioRISE
Section 5160-59-05.1 - OhioRISE home and community-based services waiver: out-of-home respite
Universal Citation: OH Admin Code 5160-59-05.1
Current through all regulations passed and filed through September 16, 2024
(A) Scope. This rule sets forth provisions governing coverage for out-of-home respite services delivered as part of the Ohio resilience through integrated systems and excellence (OhioRISE) 1915(c) waiver program (waiver) established in accordance with 1915(c) of the Social Security Act, 42 U.S.C. 1396n (January 1, 2022).
(B) Definitions. For this rule, the following definitions apply:
(1) "Community respite" has
the same meaning as set forth in rule
5123-9-22 of the Administrative
Code.
(2) "Intermediate care
facility for individuals with intellectual disabilities" (ICF/IID) has the same
meaning as set forth in section
5124.01 of the Revised
Code.
(3) "Out-of-home respite" is
a service provided to youth unable to care for themselves who are enrolled on
the waiver. The service is provided on a short-term basis because of the
absence or need for relief of those persons who normally provide care for the
youth.
(4) "Residential respite"
has the same meaning as set forth in rule
5123-9-34 of the Administrative
Code.
(C) Eligible providers and conditions of participation.
(1)
The following providers are eligible to provide the out-of-home respite service
available under the waiver program:
(a) An
ICF/IID who is certified by the Ohio department of health (ODH), holds
certification with the Ohio department of developmental
disabilities (DODD) as a residential respite provider
as set forth in rule
5123-9-34 of the Administrative
Code, and has an active license with DODD.
(b)
An agency provider holding certification for DODD
community respite services as set forth in rule
5123-9-22 of the Administrative
Code.
(c) A class one
residential facility licensed by Ohio MHAS in accordance with Chapter 5122-30
of the Administrative Code.
(2) With the exception of paragraph (B)(14)
of rule 5160-44-31 of the Administrative
Code, out-of-home respite providers will comply
with conditions of participation as set forth in rule
5160-44-31 of the Administrative
Code.
(3)
Out-of-home respite providers will obtain and maintain first aid
certification from instruction which includes hands-on training by a certified
first aid instructor. At its discretion, ODM may accept training conducted by a
solely internet-based class as sufficient for the purposes of first aid
certification.
(4) Out-of-home
respite providers serving an OhioRISE youth with behaviors that pose safety
concerns for the youth or others, will be trained in de-escalation strategies
that can be used to support the youth and prevent the use of restraints,
seclusion, and restrictive interventions.
(5) Out-of-home respite providers serving an
OhioRISE youth with an individual crisis and safety plan including the use of
restraints, seclusion, or restrictive intervention will have been
trained in the appropriate use of restraints, seclusion, and restrictive
interventions.
(6)
Out-of-home respite providers will retain all
initial and subsequent child and family-centered care plans.
(7)
Out-of-home
respite providers are
subject to compliance reviews specific to their licensure or certification
criteria in addition to ongoing monitoring conducted by the OhioRISE
plan.
(D) Coverage.
(1)
The
out-of-home respite service may be provided on a planned or emergency
basis. An emergency out-of-home respite service may be provided to address
either a primary caregiver's unexpected need for out-of-home respite or to
address an urgent need related to the youth.
(2) Service delivery is not permitted in the
youth's primary residence.
(3) The
out-of-home respite service available under the waiver program is additive to
the behavioral health respite service as set
forth in rule
5160-59-03.4 of the
Administrative Code.
(4) The
youth's care coordinator working within the care management entity (CME), as
defined in rule
5160-59-01 of the Administrative
Code, or OhioRISE plan, will assist the youth and their primary caregiver in
determining the need for the use of planed and emergency out-of-home
respite.
(5) The youth's care
coordinator working within the CME, as defined in rule
5160-59-01 of the Administrative
Code, or OhioRISE plan may recommend planned and emergency out-of-home respite,
as well as the providers of out-of-home respite services, as part of the child
and family-centered care plan.
(6)
The OhioRISE plan will need to approve out-of-home respite service as part of
the child and family-centered care plan prior to receipt and reimbursement of
out-of-home respite service.
(E) Limitations.
(1)
The
out-of-home respite service will not be provided to a youth prior to
establishment of initial or ongoing enrollment and eligibility criteria for the
waiver as set forth in rule
5160-59-04 of the Administrative
Code.
(2)
The
out-of-home respite service will be provided only to a youth enrolled on
the waiver at the time of service delivery.
(3) The out-of-home respite service is
available for a total of ninety calendar days within a three hundred-sixty-five
day period while a youth is enrolled on the waiver. Dependent on the care
coordination tier a youth is enrolled, in accordance with rule
5160-59-03.2 of the
Administrative Code, either the CME care coordinator or the OhioRISE care
coordinator is responsible for tracking and maintaining records for the
purposes of tracking out-of-home respite utilization within each three hundred
sixty-five -day period.
(4)
Reimbursement for out-of-home respite is not allowable on the same day when the
youth is receiving behavioral health respite as set forth in rule
5160-59-03.4 of the
Administrative Code.
(5) When the
OhioRISE plan denies, reduces or terminates or suspends out-of-home respite
services, this constitutes an adverse benefit determination and can be
appealed in accordance with rule
5160-26-08.4 of the
Administrative Code.
(F) Service documentation for out-of-home respite will include each of the following to validate reimbursement for medicaid services:
(1) Date of service;
(2) Place of service;
(3) Name of youth receiving
services;
(4) Medicaid
identification number of youth receiving services;
(5) Name of provider;
(6) Provider identifier;
(7) Written or electronic signature of the
person delivering the service, or initials of the person delivering the service
if a signature and corresponding initials are on file with the provider;
and
(8) A summary of the amount,
scope, duration, and frequency of services delivered that directly relate to
the services specified in the approved child and family-centered care plan to
be provided.
(9) A summary of when
restraints, seclusion, and restrictive interventions were used including a
date, time, the de-escalation techniques used to prevent the restraints,
seclusion, and restrictive interventions and whether or not the use of
restraints, seclusion, and restrictive interventions was included on the
individual crisis and safety plan.
(G) Reimbursement.
(1) Only one provider may bill out-of-home
respite for the same youth on any given day.
(2) Reimbursement for the out-of-home respite
service does not include room and board.
(3) Reimbursement for the out-of-home respite
service does not include transportation costs.
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