Ohio Administrative Code › Title 5123 - Department of Developmental Disabilities › Chapter 5123-9 - Home and Community-Based Services Waivers › Section 5123-9-07 - 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
This rule establishes 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 an
				individual enrolled in the individual options waiver.
(B) Definitions
For the purposes of this rule, the
				following definitions apply:
(1)
			 "Cost projection tool" means the web-based analytical tool
			 that is a component of the medicaid services
			 system, developed and administered by the department, used to project the
			 cost of 
									home and community-based services
			 identified in an individual service plan.
(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
			 5123-9-06 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,
			 career planning, group employment support, individual employment support,
			 non-medical transportation, vocational habilitation, waiver nursing delegation,
			 and waiver nursing services. 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,
			 
									the
			 person's 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 5123-9 of the Administrative
			 Code to the units of all waiver services other than adult day support, career
			 planning, group employment support, individual employment support, non-medical
			 transportation, vocational habilitation, waiver nursing delegation, and waiver
			 nursing services 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 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
			 
									5123-5-02 of the Administrative Code.
(12) "Waiver eligibility span" means the
			 twelve-month period following either an individual's initial waiver enrollment
			 date or a subsequent eligibility redetermination date.