Current through all regulations passed and filed through December 16, 2024
(A)
Scope. This rule sets forth provisions governing
coverage for secondary flex funds 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)
"Emergency funds"
are an additional allotment of waiver funding used for the purchase of approved
secondary flex funds based on a youth's unmet needs as determined by the
OhioRISE plan.
(2)
"Participant direction" means the opportunity for an
OhioRISE waiver youth to exercise choice and control in managing a budget for
the applicable waiver service in accordance with their needs.
(3)
"Participant-directed budget for secondary flex funds" is the waiver-enrolled
youth's maximum approved, non-emergency funding allowable for the purchase of
secondary flex funds under the OhioRISE 1915(c) waiver.
(4)
"Secondary flex
funds" is defined as the additional services, equipment, or supplies available
through the waiver that are not otherwise provided through the medicaid state
plan benefit or the OhioRISE program that address a youth's identified need as
documented in the child and family-centered care plan. Secondary flex funds are
intended to enhance and supplement the array of services available to a youth
enrolled on the OhioRISE program and are discussed, recommended, and
implemented through the care coordination process as described in rule
5160-59-03.2 of the
Administrative Code. Secondary flex funds is inclusive of emergency funds and
the participant-directed budget as described in this rule.
(5)
"Waiver cost
limit" is the maximum amount of funding, excluding emergency funds, available
to a youth enrolled in the waiver. The waiver cost limit for the waiver is
fifteen thousand dollars per twelve month period.
(C)
With the
exception of additional criteria defined in paragraph (D) of this rule, all
provisions of rule
5160-59-03.5 of the
Administrative Code apply to secondary flex funds provided under the
waiver.
(D)
The following additional criteria apply to secondary
flex funds provided under the waiver:
(1)
The total
participant-directed budget for secondary flex funds is limited to three
thousand dollars within three hundred sixty-five calendar days. The
participant-directed budget is included in the waiver cost
limit.
(2)
The waiver enrolled youth may access up to the total
participant-directed budget for secondary flex funds when all primary flex
funds, described in rule
5160-59-03.5 of the
Administrative Code, provided under the OhioRISE plan are
exhausted.
(3)
The total emergency funds available to a youth is
limited to two thousand dollars within three hundred sixty-five days calendar
days. Emergency funds are not included in the waiver cost cap.
(a)
Emergency funds
are only available to a youth when the youth has exhausted all primary flex
funds, as described in rule
5160-59-03.5 of the
Administrative Code, and all available funds in their participant-directed
budget, and still have a demonstrated need which may be met through the
emergency funds available under secondary flex funds.
(b)
The youth's unmet
need and desired outcome, resulting from the use of emergency funds, will be
detailed in the child and family-centered care plan.
(4)
Secondary flex
fund services are additive to the primary flex funds described in rule
5160-59-03.5 of the
Administrative Code.
(5)
The OhioRISE plan will need to approve the waiver
enrolled youth's participant-directed budget for secondary flex funds as part
of the child and family care plan prior to use of the service.
(6)
When the OhioRISE
plan denies, reduces, terminates or suspends secondary flex funds services,
this constitutes an adverse benefit determination, and can be appealed in
accordance with rule
5160-26-08.4 of the
Administrative Code.