Ohio Administrative Code › Title 5123:2 - Community Services › Chapter 5123:2-9 - Home and Community-Based Services Waivers › Section 5123:2-9-45 - Home and community-based services waivers - participant-directed goods and services under the self-empowered life funding waiver

Current through all regulations passed and filed through July 1, 2024
(A)
								 Purpose
The purpose of this rule is to define
				participant-directed goods and services and set forth provider qualifications,
				requirements for service delivery and documentation of services, and payment
				standards for the service.
(B)
								
			 Definitions
(1)
									 "Agency provider" means an entity that employs persons for
			 the purpose of providing services.
(2)
									 "County board"
			 means a county board of developmental disabilities.
(3)
									 "Department"
			 means the Ohio department of developmental disabilities.
(4)
									 "Family member"
			 means a person who is related to the individual by blood, marriage, or
			 adoption.
(5)
									 "Independent provider" means a person who provides
			 services and does not employ, either directly or through contract, anyone else
			 to provide the services.
(6)
									 "Individual" means a person with a developmental
			 disability or for the purposes of giving, refusing to give, or withdrawing
			 consent for services, his or her guardian in accordance with section
			 5126.043 of the Revised Code or
			 other person authorized to give consent. An individual who is his or her own
			 guardian may designate another person to assist the individual with development
			 of the individual service plan and budget, selection of residence and
			 providers, and negotiation of payment rates for services; the individual's
			 designee shall not be employed by a county board or a provider, or a contractor
			 or either.
(7)
									 "Individual service plan" means the written
			 description of services, supports, and activities to be provided to an
			 individual.
(8)
									 "Medicaid program" has the same meaning as in section
			 5111.01 of the Revised
			 Code.
(9)
									 "Participant-directed goods and services" means
			 services, equipment, or supplies not otherwise provided through the
			 self-empowered life funding waiver or through the state's medicaid program that
			 address a need identified in the individual service plan (including maintaining
			 and improving an individual's opportunities for full membership in the
			 community) and meet the following requirements:
(a)
										 The services,
			 equipment, or supplies:
(i)
											 Decrease the need for other medicaid services;
(ii)
											
			 Promote inclusion in the community; or
(iii)
											 Increase the
			 individual's safety in his or her home.
(b)
										 The services,
			 equipment, or supplies are not illegal or otherwise prohibited by federal or
			 state statutes or regulations;
(c)
										 The individual
			 does not have funds to purchase the services, equipment, or supplies, and they
			 are not available through another resource; and
(d)
										 The services,
			 equipment, or supplies are required to meet the needs and outcomes identified
			 in the individual service plan; assure the health and welfare of the
			 individual; are the least costly alternative that reasonably meets the
			 individual's assessed needs; and are for the direct benefit of the individual
			 in achieving at least one of the following outcomes:
(i)
											 Improving
			 cognitive, social, or behavioral functioning;
(ii)
											 Maintaining the
			 ability of the individual to remain in the community;
(iii)
											 Enhancing
			 community inclusion and family member involvement;
(iv)
											 Developing or
			 maintaining personal, social, or physical skills;
(v)
											 Decreasing
			 dependency on formal support services; or
(vi)
											 Increasing
			 independence of the individual.
(10)
									 "Service and
			 support administrator" means a person, regardless of title, employed by or
			 under contract with a county board to perform the functions of service and
			 support administration and who holds the appropriate certification in
			 accordance with rule
			 5123:2-5-02
			 of the Administrative Code.
(11)
									 "Service
			 documentation" means all records and information on one or more documents,
			 including documents that may be created or maintained in electronic software
			 programs, created and maintained contemporaneously with the delivery of
			 services, and kept in a manner as to fully disclose the nature and extent of
			 services delivered that shall include the items delineated in paragraph (E)(2)
			 of this rule to validate payment for medicaid services.
(12)
									 "Specialized
			 services" means any program or service designed and operated to serve primarily
			 a person with a developmental disability, including a program or service
			 provided by an entity licensed or certified by the department. Programs or
			 services available to the general public are not specialized services.
(13)
									
			 "Support broker" means a person who is responsible, on a continuing basis, for
			 providing an individual with representation, advocacy, advice, and assistance
			 related to the day-to-day coordination of services (particularly those
			 associated with participant direction) in accordance with the individual
			 service plan. The support broker assists the individual with the individual's
			 responsibilities regarding participant direction, including understanding
			 employer authority and budget authority, locating and selecting providers,
			 negotiating payment rates, and keeping the focus of the services and support
			 delivery on the individual and his or her desired outcomes. The support broker,
			 working in conjunction with the service and support administrator, assists the
			 individual with creating the individual service plan, developing the waiver
			 budget, and doing day-to-day monitoring of the provision of services as
			 specified in the individual service plan.
(14)
									 "Usual and
			 customary charge" means the amount charged to other persons for the same
			 service.