Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-45 - Administered Waiver Service Providers › Section 5160-45-01 - Ohio department of medicaid (ODM) -administered waiver program: definitions

Current through all regulations passed and filed through July 1, 2024
The following terms apply to Ohio department of medicaid (ODM)
				-administered waiver programs:
(A)
			 "Abuse" has the same meaning as set forth in rule
			 5160-44-05 of the Administrative
			 Code.
(B) "Accreditation commission
			 for health care" or "(ACHC)" is a national organization that evaluates and
			 accredits agencies seeking to participate in the medicare and medicaid
			 programs. For the purpose of providing services to individuals enrolled on an
			 ODM-administered waiver, ACHC-accredited agencies are "otherwise-accredited
			 agencies" that can provide the same ODM-administered waiver services that
			 community health accreditation program (CHAP) -accredited and the joint
			 commission-accredited agencies provide.
(C) "Activity of daily living" has the same
			 meaning as set forth in rule
			 5160-3-05 of the Administrative
			 Code.
(D) "Agency provider" is an
			 entity that is eligible to furnish services in the medicaid program upon
			 execution of a medicaid provider agreement in accordance with rule
			 5160-1-17.2 of the
			 Administrative Code.
(E)
			 "Applicant" is a person who is requesting a determination of eligibility for
			 enrollment in an ODM-administered waiver.
(F) "Authorized representative" is a person
			 the individual appoints to act on his or her behalf in accordance with rule
			 5160-1-33 of the Administrative
			 Code.
(G) "Case management
			 contractor" is the entity designated by ODM to provide case management services
			 to individuals enrolled on an ODM-administered waiver. This may include a
			 contracted case management agency, a MyCare Ohio plan and/or ODM
			 itself.
(H) "Case management
			 services" are the administrative activities that link, coordinate and monitor
			 the services, supports and resources provided to an individual enrolled on an
			 ODM-administered waiver.
(I) "Case
			 manager" is a registered nurse (RN), licensed social worker (LSW) or licensed
			 independent social worker (LISW) employed by the case management contractor who
			 provides case management services to individuals enrolled on an
			 ODM-administered waiver. The case manager is responsible for developing and
			 monitoring the individual's person-centered services plan as described in rule
			 5160-44-02 of the Administrative
			 Code.
(J) "Case manager contact" is
			 a phone conversation, email exchange or other electronic communication with an
			 individual or provider that ensures the exchange of information between the
			 case manager and the individual. Electronic communications without response are
			 not considered a case manager contact.
(K) "Case manager visit" is
			 
								an
			 in-person encounter between an individual and a case manager in the
			 individual's residence. Meetings and encounters at locations other than the
			 individual's place of residence are only considered visits when completed in an
			 institutional or other service delivery location for the purpose of completing
			 an assessment for waiver eligibility and/or developing a discharge plan. Case
			 managers 
								will interact (i.e., converse, make visual contact and
			 otherwise engage the individual at his or her functional ability) during every
			 case manager visit. .
(L) "Clinical
			 record" is a record containing written documentation that
			 
								will be
			 maintained by each ODM-administered waiver service provider.
(M) "Community health accreditation program"
			 or "(CHAP)" is a national organization that evaluates and accredits agencies
			 seeking to participate in the medicare and medicaid programs. For the purpose
			 of providing services to individuals enrolled on an ODM-administered waiver,
			 CHAP-accredited agencies are "otherwise-accredited agencies" that can provide
			 the same ODM-administered waiver services that ACHC-accredited and the joint
			 commission-accredited agencies provide.
(N) "Comprehensive assessment" is an
			 evaluation of an individual's long-term service and support needs that is used
			 to determine level of care and eligibility for enrollment in an
			 ODM-administered waiver, and to inform service planning. The comprehensive
			 assessment includes 
								an in-person evaluation and examines an
			 individual's activities of daily living, instrumental activities of daily
			 living, natural supports, cognition, health status, behavioral health status,
			 safety and environment.
(O)
			 "Electronic Visit Verification" or "EVV" has the same meaning as set forth in
			 rule 5160-1-40 of the Administrative
			 Code.
(P) "Group rate" has the same
			 meaning as set forth in rules
			 5160-46-06 and
			 5160-46-06.1 of the
			 Administrative Code.
(Q) "Group
			 setting" has the same meaning as set forth in rules
			 5160-44-22,
			 5160-44-27,
			 5160-46-04,
			 5160-46-06, and
			 5160-46-06.1 of the
			 Administrative Code.
(R) "Health
			 and safety action plan" or "HSAP" is the document created between ODM and its
			 designee and an individual enrolled on an ODM-administered waiver that
			 identifies the interventions recommended by the case management contractor to
			 remedy risks to the health, safety and welfare of the individual.
(S) "Health and welfare" is the basis for an
			 assurance to CMS made by ODM that necessary safeguards are taken to protect the
			 health, safety and welfare of individuals enrolled on an ODM-administered
			 waiver. CMS will not grant an ODM-administered waiver, and may terminate an
			 existing ODM-administered waiver, if ODM fails to assure compliance with this
			 requirement. Health and welfare safeguards include policies and procedures that
			 direct the following:
(1) Risk and safety
			 evaluations and planning;
(2)
			 Incident management;
(3) Housing
			 and environmental safety evaluations and planning;
(4) Restraint, seclusion and restrictive
			 intervention evaluations and planning;
(5) Medication management; and
(6) Natural disaster and public emergency
			 response planning.