Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-59 - OhioRISE › Section 5160-59-04 - OhioRISE home and community-based services waiver

Current through all regulations passed and filed through July 1, 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.