Ohio Administrative Code › Title 5123:2 - Community Services › Chapter 5123:2-9 - Home and Community-Based Services Waivers › Section 5123:2-9-07 - Home and community-based services waivers - request for prior authorization for individuals enrolled in the individual options waiver

Current through all regulations passed and filed through July 1, 2024
(A)
								 Purpose
The purpose of this rule is to
				establish standards and procedures for prior authorization of waiver services
				when an individual funding level exceeds the funding range determined by the
				Ohio developmental disabilities profile for individuals enrolled in the
				individual options waiver.
(B)
								
			 Definitions
(1)
									 "Cost projection tool" means the web-based analytical tool,
			 developed and administered by the department, used to project the cost of
			 waiver services identified in the individual service plans of individuals
			 enrolled in individual options and level one waivers.
(2)
									 "County board"
			 means a county board of developmental disabilities.
(3)
									 "Department"
			 means the Ohio department of developmental disabilities.
(4)
									 "Funding range"
			 means one of the dollar ranges contained in appendix A to rule
			 5123:2-9-06
			 of the Administrative Code to which individuals enrolled in the individual
			 options waiver have been assigned for the purpose of funding services other
			 than adult day support, non-medical transportation, supported
			 employment-community, supported employment-enclave, and vocational
			 habilitation. The funding range applicable to an individual is determined by
			 the score derived from the Ohio developmental disabilities profile that has
			 been completed by a county board employee qualified to administer the
			 tool.
(5)
									 "Individual" means a person with a developmental
			 disability or for 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.
(6)
									 "Individual
			 funding level" means the total funds, calculated on a twelve-month basis, that
			 result from applying the payment rates in service-specific rules in Chapter
			 5123:2-9 of the Administrative Code to the units of all waiver services other
			 than adult day support, non-medical transportation, supported
			 employment-community, supported employment-enclave, and vocational habilitation
			 established by the individual service plan development process to be sufficient
			 in frequency, duration, and scope to meet the health and welfare needs of an
			 individual enrolled in the individual options waiver.
(7)
									 "Individual
			 service plan" means the written description of services, supports, and
			 activities to be provided to an individual.
(8)
									 "Medicaid
			 services system" means the comprehensive information system that integrates
			 cost projection, prior authorization, daily rate calculation, and payment
			 authorization of waiver services.
(9)
									 "Ohio
			 developmental disabilities profile" means the standardized instrument utilized
			 by the department to assess the relative needs and circumstances of an
			 individual enrolled in the individual options waiver compared to others. The
			 individual's responses are scored and the individual is linked to a funding
			 range, which enables similarly situated individuals to access comparable waiver
			 services paid in accordance with rules adopted by the
			 department.
(10)
									 "Prior authorization" means the process to be followed
			 in accordance with this rule to authorize an individual funding level for an
			 individual enrolled in the individual options waiver that exceeds the maximum
			 value of the funding range.
(11)
									 "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.
(12)
									 "Waiver
			 eligibility span" means the twelve-month period following either an
			 individual's initial enrollment date or a subsequent eligibility
			 redetermination date.