Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-58 - MyCare Ohio › Section 5160-58-01 - MyCare Ohio plans: definitions

Current through all regulations passed and filed through July 1, 2024
(A) The definitions set forth in rule
			 5160-26-01 of the Administrative
			 Code apply to the MyCare Ohio rules set forth in Chapter
			 5160-58 of the Administrative
			 Code.
(B) In addition to the
			 definitions set forth in rule
			 5160-26-01 of the Administrative
			 Code, the following definitions apply to Chapter
			 5160-58 of the Administrative
			 Code:
(1) "Assessment" means a comprehensive
			 evaluation of an individual's medical, behavioral health, long-term services
			 and supports, and social needs. Results of the assessment process are used to
			 develop the integrated, individualized care plan, inclusive of the waiver
			 services plan.
(2) "Creditable
			 insurance" or "creditable coverage" means health insurance coverage as defined
			 in 42 U.S.C.
			 300gg-3(c) (October 1,2021).
(3) "Dual benefits member" or "opt-in member"
			 means a member for whom a MyCare Ohio plan is responsible for the coordination
			 and payment of both medicare and medicaid benefits.
(4) "Financial management service (FMS)"
			 means a support that is provided to waiver participants who direct some or all
			 of their waiver services. When used in conjunction with the employer authority,
			 this support includes, but is not limited to, operating a payroll service for
			 participant employed workers and making required payroll withholdings. When
			 used in conjunction with the budget authority, this support includes, but is
			 not limited to, paying invoices for waiver goods and services and tracking
			 expenditures against the participant-directed budget.
(5) "Health and welfare" means a requirement
			 that necessary safeguards are taken to protect the health and welfare of
			 individuals enrolled in a home and community-based services (HCBS) waiver. It
			 includes the following:
(a) Risk and safety
			 planning and evaluations;
(b)
			 Critical incident management;
(c)
			 Housing and environmental safety evaluations;
(d) Behavioral interventions;
(e) Medication management; and
(f) Natural disaster and public emergency
			 response planning.
(6)
			 "Home and community-based services (HCBS)" means services available to
			 individuals to help maintain their health and safety in a community setting in
			 lieu of institutional care as described in 42 C.F.R. 440 subpart A (October 1,
			 2021).
(7) "Individual care plan"
			 means an integrated, individualized, person-centered care plan developed by the
			 member and his or her MyCare Ohio plan's trans-disciplinary care management
			 team that addresses clinical and non-clinical needs identified in the
			 assessment and includes goals, interventions, and expected outcomes.
(8) "Medicaid only member" or "opt-out
			 member" means a member for whom a MyCare Ohio plan is responsible for
			 coordination and payment of medicaid benefits, and, upon request, responsible
			 to assist with coordination of medicare benefits.
(9) "MyCare Ohio plan (MCOP)" means a health
			 insuring corporation (HIC) contracted to comprehensively manage medicaid
			 benefits for medicare and medicaid eligible members, including HCBS. An MCOP is
			 also a managed care organization as defined in rule
			 5160-26-01 of the Administrative
			 Code. For the purpose of this chapter, an MCOP does not include entities
			 approved to operate as a program for the all-inclusive care of the elderly
			 (PACE) site as defined in rule
			 5160-36-01 of the Administrative
			 Code.
(10) "Nursing facility-based
			 level of care" means the intermediate and skilled levels of care, as described
			 in rule 5160-3-08 of the Administrative
			 Code.
(11) "Participant direction"
			 means the opportunity for a MyCare Ohio waiver member to exercise choice and
			 control in identifying, accessing, and managing waiver services and other
			 supports in accordance with their needs and personal preferences.
(12) "Significant change event" is a change
			 experienced by a member that warrants further evaluation. Significant changes
			 include, but are not limited to, a change in health status, caregiver status,
			 or location/residence; referral to or active involvement on the part of a
			 protective service agency; institutionalization; and when the waiver-enrolled
			 individual has not received MyCare Ohio waiver services for ninety calendar
			 days.
(13) "Trans-disciplinary care
			 management team" means a team of appropriately qualified individuals comprised
			 of the member, the member's family/caregiver, the MyCare Ohio plan manager, the
			 waiver service coordinator, if appropriate, the primary care provider,
			 specialists, and other providers, as applicable, that is designed to
			 effectively meet the enrollee's needs.
(14) "Waiver services plan" is a component of
			 the care plan that identifies specific goals, objectives and measurable
			 outcomes for a waiver-enrolled member's health and functioning expected as a
			 result of HCBS provided by both formal and informal caregivers, and that
			 addresses the physical and medical conditions of the individual. At a minimum,
			 the waiver services plan shall include:
(a)
			 Essential information needed to provide care to the member that assures the
			 member's health and welfare;
(b)
			 Signatures indicating the member's acceptance or rejection of the waiver
			 services plan. If the member is unable to provide the signature when the
			 services plan is initially developed, the individual will submit an electronic
			 signature or standard signature via regular mail, or otherwise provide a
			 signature in no instance any later than at the next face-to-face visit with the
			 case manager; and
(c) Information
			 that the waiver services plan is not the same as the physician's plan of
			 care.