Ohio Administrative Code › Title 5123 - Department of Developmental Disabilities › Chapter 5123-9 - Home and Community-Based Services Waivers › Section 5123-9-06 - Home and community-based services waivers - administration of the individual options and level one waivers

Current through all regulations passed and filed through July 1, 2024
(A) Purpose
This rule establishes standards governing administration of the
				individual options and level one waivers, components of the medicaid home and
				community-based services program the Ohio department of developmental
				disabilities administers pursuant to section
				5166.21 of the Revised
				Code.
(B) Definitions
For the purposes of this rule, the following definitions
				apply:
(1) "Adult" means an individual
			 who is at least twenty-two years old or an individual who is under twenty-two
			 years old and no longer eligible for educational services based on graduation,
			 receipt of a diploma or equivalency certificate, or permanent discontinuation
			 of educational services within parameters established by the Ohio department of
			 education.
(2) "Budget authority"
			 means an individual has the authority and responsibility to manage the
			 individual's budget for participant-directed services. This authority supports
			 the individual in determining the budgeted dollar amount for each
			 participant-directed waiver service that will be provided to the individual and
			 making decisions about the acquisition of participant-directed waiver services
			 that are authorized in the individual service plan (e.g., negotiating payment
			 rates to providers within the applicable range as specified in rules adopted by
			 the department).
(3) "Child" means
			 an individual who is under twenty-two years old and eligible for educational
			 services.
(4) "Cost projection and
			 payment authorization" means the process followed and the form used by county
			 boards (including the payment authorization for waiver services) to communicate
			 the frequency, duration, scope, and amount of payment requested for each home
			 and community-based service that is identified in the individual service
			 plan.
(5) "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.
(6) "County board"
			 means a county board of developmental disabilities.
(7) "Department" means the Ohio department of
			 developmental disabilities.
(8)
			 "Employer authority" means an individual has the authority to recruit, hire,
			 supervise, and direct the staff who furnish supports. The individual functions
			 as the common law employer or the co-employer of these staff.
(9) "Fifteen-minute billing unit" means a
			 billing unit that equals fifteen minutes of service delivery time or is greater
			 or equal to eight minutes and less than or equal to twenty-two minutes of
			 service delivery time. Minutes of service delivery time accrued throughout a
			 day 
									will be added together for the purpose of calculating
			 the number of fifteen-minute billing units for the day.
(10) "Financial management services entity"
			 means a governmental entity and/or another third-party entity designated by the
			 department to perform necessary financial transactions on behalf of individuals
			 who receive participant-directed services.
(11) "Funding range" means one of the dollar
			 ranges contained in appendix A to this rule 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.
(12) "Guardian" means a guardian appointed by
			 the probate court under Chapter 2111. of the Revised Code. If the individual is
			 a minor, "guardian" means the individual's parents. If no guardian has been
			 appointed for a minor under Chapter 2111. of the Revised Code and the minor is
			 in the legal or permanent custody of a government agency or person other than
			 the minor's natural or adoptive parents, "guardian" means that government
			 agency or person. "Guardian" includes an agency under contract with the
			 department for the provision of protective service in accordance with sections
			 5123.55 to
			 5123.59 of the Revised
			 Code.
(13) "Home and
			 community-based services" has the same meaning as in section
			 5123.01 of the Revised
			 Code.
(14) "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.
(15) "Individual funding level," as
			 established for each individual enrolled in the individual options waiver,
			 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 individual's health and welfare needs. Unless prior authorization has
			 been obtained in accordance with rule
			 5123-9-07 of the Administrative
			 Code, the individual funding level for services paid in accordance with this
			 rule 
									will be within or below the funding range assigned to
			 the individual as the result of administration of the Ohio developmental
			 disabilities profile.
(16)
			 "Individual service plan" means the written description of services, supports,
			 and activities to be provided to an individual developed in accordance with
			 rule 5123-4-02 of the Administrative
			 Code.
(17) "Natural supports" means
			 the personal associations and relationships typically developed in the
			 community that enhance the quality of life for individuals. Natural supports
			 may include family members, friends, neighbors, and others in the community or
			 organizations that serve the general public who provide voluntary support to
			 help an individual achieve agreed upon outcomes through the individual service
			 plan development process.
(18)
			 "Ohio developmental disabilities profile" means the standardized instrument
			 used 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.
(19)
			 "Participant direction" means an individual has authority to make decisions
			 about the individual's waiver services and accepts responsibility for taking a
			 direct role in managing the services. Participant direction includes the
			 exercise of budget authority and/or employer authority as set forth in
			 paragraph (E) of this rule.
(20)
			 "Prior authorization" means the process to be followed in accordance with rule
			 5123-9-07 of the Administrative
			 Code to authorize an individual funding level for an individual enrolled in the
			 individual options waiver that exceeds the maximum value of the funding
			 range.
(21) "Provider" means a
			 person or entity certified or licensed by the department that has met the
			 provider qualification requirements to provide specific home and
			 community-based services and holds a valid medicaid provider agreement with the
			 Ohio department of medicaid or a person or entity that has been determined by
			 the financial management services entity to be qualified to provide
			 participant-directed goods and services or self-directed
			 transportation.
(22) "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.
(23) "Service documentation" means all
			 records and information on one or more documents, including documents that may
			 be created or maintained in electronic software programs, created and
			 maintained contemporaneously with the delivery of services, and kept in a
			 manner as to fully disclose the nature and extent of services delivered that
			 
									includes the items delineated in service-specific
			 rules in Chapter 5123-9 of the Administrative Code to validate payment for
			 medicaid services.
(24) "Team"
			 
									means the group of persons chosen by an
			 individual with the core responsibility to support the individual in directing
			 development of the individual service plan. The team includes the individual's
			 guardian or adult whom the individual has identified, as applicable, the
			 service and support administrator, direct support professionals, providers,
			 licensed or certified professionals, and any other persons chosen by the
			 individual to help the individual consider possibilities and make
			 decisions.
(25) "Waiver
			 eligibility span" means the twelve-month period following either an
			 individual's initial waiver enrollment date or a subsequent eligibility
			 re-determination date.