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Ohio Home Care

5160-51-01       HOME Choice ("Helping Ohioans Move, Expanding Choice") Demonstration Program: Definitions

*Formerly*5101:3-51-01         HOME Choice ("Helping Ohioans Move, Expanding Choice") Demonstration Program: Definitions

CSTL 10-05

Effective Date: September 9, 2010

Most Current Prior Effective Date: July 1, 2008

The requirements set forth in this rule begin when the Ohio department of job and family services (ODJFS) receives approval of the HOME choice demonstration program from the centers for medicare and medicaid services (CMS), or on the effective date of this rule, whichever is later. The requirements shall remain in effect through the duration of the HOME choice demonstration program.

The following definitions are applicable to Chapter 5101:3-51 of the Administrative Code:

(A)      "Activities of daily living" are personal or self-care skills performed on a regular basis, with or without the use of adaptive and assistive devices that enable a consumer to meet basic life needs for food, hygiene and appearance as defined in rule 5101:3-3-06 of the Administrative Code.

(B)      "Agency provider" is an agency that is eligible to participate in the HOME choice demonstration program.

(C)     "All service services plan" is the ODJFS-administered waiver service coordination and payment authorization document that identifies specific goals, objectives and measurable outcomes for consumer health and functioning expected as a result of services provided by both formal and informal caregivers, and that addresses the physical and medical conditions of the consumer.

(1)      At a minimum, the all service services plan shall include:

(a)      Essential information needed to provide care to the consumer that assures the consumer's health and welfare;

(b)      Billing authorization; and

(c)      Signatures indicating the consumer's acceptance or rejection of the all services plan.

(2)      The all service services plan is not the same as the physician's plan of care.

(D)     "Authorized representative"

(1)      For a HOME choice demonstration program participant enrolled on an ODJFS-administered waiver, authorized representative has the same meaning as set forth in rule 5101:3-45-01 of the Administrative Code;

(2)      For a HOME choice demonstration program participant enrolled on the ODA-administered choices waiver, authorized representative has the same meaning as set forth in rule 173-37-01 of the Administrative Code;

(3)      For a HOME choice demonstration program participant enrolled on the ODA-administered PASSPORT waiver, authorized representative has the same meaning as set forth in rule 173-42-01 of the Administrative Code;

(4)      For a HOME choice demonstration program participant enrolled on an ODMR/DD a DODD -administered waiver, authorized representative has the same meaning as set forth in rule 5101:1-2-01 of the Administrative Code; and

(5)      For a HOME choice demonstration program participant who is not enrolled on an HCBS waiver, authorized representative has the same meaning as set forth in rule 5101:3-45-01 of the Administrative Code.

(E)      "Case management agency" or "CMA" is the entity under contract with ODJFS that provides case management services to consumers enrolled on an ODJFS-administered waiver , and to HOME choice demonstration program participants who are not enrolled on an HCBS waiver .

(F)      "Case manager" or "CM" is the CMA or PAA employee who provides a variety of case management services and care coordination activities for individuals enrolled on an ODJFS- or ODA-administered waiver , and to HOME choice demonstration program participants who are not enrolled on an HCBS waiver .

(G)     "CDJFS" is a county department of job and family services.

(H)     "Choices waiver program" or "choices" is the CMS-approved HCBS waiver program administered by ODA in accordance with Chapters 5101:3-31 and 173-37 of the Administrative Code.

(I)       "Classroom rate" is the amount that HOME choice independent living skills training service providers are reimbursed when the service is provided in a classroom setting. The rate is equivalent to fifty per cent of the reimbursement rate set forth in rule 5101:3-51-06 of the Administrative Code that is paid to a provider for furnishing HOME choice independent living skills training services to a single individual.

(J)      "Classroom setting" is a situation in which a HOME choice independent living skills training service provider furnishes the same type of services to four or more individuals at the same address, during the same visit. The services provided in the classroom setting can be either the same type of HOME choice independent living skills training service, or a combination of HOME choice independent living skills training services and similar independent living skills training services.

(K)      "County board" means a county board of mental retardation and developmental disabilities established under Chapter 5126. of the Revised Code, or a person or government entity, including a council of governments, with which a county board has contracted for assistance with its local medicaid administrative authority pursuant to division (E) of section 5126.055 of the Revised Code. The county board provides case management services to consumers enrolled on an ODMR/DD- a DODD- administered waiver.

(L)      "Demonstration services" are services available to the HOME choice demonstration program participant for up to three hundred sixty-five days beginning on the day a participant moves from an institutional setting into the community. Demonstration services include independent living skills training, community support coaching, social work/counseling, nutritional consultation , services and HOME choice nursing services and respite services . Ohio is entitled to enhanced federal financial participation (FFP) from CMS for demonstration services.

(M)      "DODD" is the Ohio department of developmental disabilities.

(N)      "DODD-administered waiver" is a CMS-approved HCBS waiver administered by DODD in accordance with section 5111.871 of the Revised Code and Chapters 5101:3-40, 5101:3-42, 5123:2-8, 5123:2-9 and 5123:2-13 of the Administrative Code.

(M) (O)           "Financial management services" or "FMS" are federally-mandated administrative services that an ODJFS-designated governmental entity and/or another ODJFS-designated third-party entity perform on behalf of the HOME choice demonstration program participant.

(N) (P) "Group rate" is the amount that HOME choice demonstration program nursing service providers, or HOME choice independent living skills training service providers are reimbursed when the service is provided in a group setting. The rate is equivalent to seventy-five per cent of the reimbursement rate set forth in rule 5101:3-51-06 of the Administrative Code that is paid to a provider for delivering the HOME choice nursing services or HOME choice independent living skills training services to a single individual.

(O) (Q)           "Group setting" is a situation in which a HOME choice demonstration nursing service provider, or the HOME choice independent living skills training service provider furnishes the same type of services to two or three individuals at the same address, during the same visit. The services provided in the group setting can be either the same type of HOME choice nursing service or HOME choice independent living skills training service, or a combination of HOME choice nursing services and similar nursing services, or HOME choice independent living skills training services and similar independent living skills training services.

(P) (R) "Home and community-based services" or "HCBS" means medicaid-funded home and community-based services as set forth in Chapter 5111. of the Revised Code.

(Q) (S) "HOME choice demonstration program" means "Helping Ohioans Move, Expanding Choice."

(R) (T) "HOME choice demonstration program application" is a formal request for a determination of HOME choice demonstration program eligibility that is made by an individual who is relocating from an institutional setting into the community. The ODJFS-approved application must be signed by the individual or the individual's authorized representative.

(S) (U) "HOME choice demonstration program participant" is a person receiving HOME choice demonstration program services who may or may not be enrolled on a CMS-approved HCBS waiver.

(T) (V) "HOME choice demonstration program period" is the three hundred sixty-five day period that begins the day an individual moves from an institutional setting into the community, and during which the HOME choice demonstration program participant is eligible for HOME choice demonstration program services.

(U) (W)           "HOME choice demonstration program services" are pre-transition, demonstration, qualified, and supplemental services available through the HOME choice demonstration program.

(V) (X) "ICF-MR" is an intermediate care facility for persons with mental retardation.

(W) (Y)           "ICF-MR level of care" is the institutional level of care set forth in rule 5101:3-3-07 of the Administrative Code.

(X) (Z) "Individual options waiver" or "IO waiver" is a CMS-approved HCBS waiver administered by the Ohio department of mental retardation and developmental disabilities (ODMR/DD) (DODD) in accordance with Chapters 5101:3-40, 5123:2-9 and 5123:2-13 of the Administrative Code.

(Y) (AA)          "Individual service plan" or "ISP" is a written description of the services, supports and activities to be provided to a consumer enrolled on an ODMR/DD a DODD -administered waiver. The ISP is not the same as the physician's plan of care.

(Z) (BB)          "Institutional level of care" is any of the levels of care set forth in rules 5101:3-3-05 , 5101:3-3-06 and 5101:3-3-07 of the Administrative Code.

(AA) (CC)       "Institutional setting" is any hospital, nursing facility (NF) , residential treatment facility (RTF) or ICF-MR. Hospitals include institutions for mental diseases (IMD) only to the extent that medical assistance is available under the medicaid state plan for services provided by such institutions.

(BB) (DD)       "Instrumental activity of daily living" is a community living skill performed on a regular basis, with or without the use of adaptive and assistive devices, that enables a consumer to independently manage his or her living arrangement as defined in rule 5101:3-3-08 of the Administrative Code.

(CC) (EE)       "Intermediate level of care" or "ILOC" is the institutional level of care set forth in rule 5101:3-3-06 of the Administrative Code.

(DD) (FF)        "Level one waiver" is a CMS-approved HCBS waiver administered by ODMR/DD DODD in accordance with Chapters 5101:3-42, 5123:2-8 and 5123:2-9 of the Administrative Code.

(EE) (GG)       "Medical necessity" and "medically necessary" have the same meaning as set forth in rule 5101:3-1-01 of the Administrative Code.

(FF) (HH)        "Non-agency provider" is an independent provider who is not employed by an agency, and who is eligible to participate in the HOME choice demonstration program.

(GG) (II)         "Non-waiver HOME choice demonstration program service plan" is the service coordination and payment authorization document that identifies the services, supports and activities to be provided to a HOME choice demonstration program participant who is not enrolled on an HCBS waiver. The non-waiver HOME choice demonstration program service plan is not the same as the physician's plan of care.

(HH) (JJ)        "ODA" is the Ohio department of aging.

(II) (KK)          "ODA-administered waiver" is a CMS-approved HCBS waiver administered by the Ohio department of aging ODA in accordance with Chapters 5101:3-31, 5101:3-32, 173-37 and 173-42 of the Administrative Code.

(JJ) (LL)         "ODJFS-administered waiver program" is the Ohio home care program benefit package that consists of CMS-approved HCBS waivers administered by ODJFS in accordance with rules 5101:3-12-28 to 5101:3-12-30 of the Administrative Code and Chapters 5101:3-45, 5101:3-46, 5101:3-47 and 5101:3-50 of the Administrative Code.

(MM)   "ODMH" is the Ohio department of mental health.

(KK)   "ODJFS HOME choice demonstration program care coordinator" is a person employed by ODJFS for the purpose of providing case management and care coordination services to HOME choice demonstration program participants who are not enrolled on an HCBS waiver.

(LL)    "ODMR/DD" is the Ohio department of mental retardation and developmental disabilities.

(MM)  "ODMR/DD-administered waiver" is a CMS-approved HCBS waiver administered by ODMR/DD in accordance with section 5111.871 of the Revised Code and Chapters 5101:3-40, 5101:3-42, 5123:2-8, 5123:2-9 and 5123:2-13 of the Administrative Code.

(NN)   "Ohio home care waiver" is a CMS-approved HCBS waiver administered by ODJFS that serves consumers in accordance with rules 5101:3-12-28 to 5101:3-12-30 of the Administrative Code, and Chapters 5101:3-45 and 5101:3-46 of the Administrative Code.

(OO)  "PAA" means the local PASSPORT administrative agency that provides case management services to consumers enrolled on an ODA-administered waiver.

(PP)    "Participant" means an individual who has been approved by ODJFS to participate in the HOME choice demonstration program.

(PP) (QQ)       "PASSPORT waiver program" means the CMS-approved PASSPORT HCBS waiver program administered by ODA in accordance with Chapters 5101:31 and 173-42 of the Administrative Code.

(QQ) (RR)      "Plan of care" is the medical treatment plan that is established, approved and signed by the treating physician. The plan of care must be signed by the treating physician prior to when a provider requests reimbursement for a service. The plan of care is not the same as the all services plan, service plan or ISP, if the participant is enrolled on an ODJFS-, ODA- or ODMR/DD DODD -administered waiver, respectively, or the non-waiver HOME choice demonstration program service plan if the HOME choice demonstration program participant is not enrolled on an HCBS waiver.

(RR) (SS)       "Pre-transition services" are administrative activities and supplemental services that can be provided to a HOME choice demonstration program participant up to one hundred eighty days before the participant moves from a NF, ICF-MR , RTF or hospital into the community. Pre-transitional services and activities include transition coordination services and community transitions services.

(SS) (TT)        "Qualified residence" is:

(1)      A home owned or leased by the HOME choice demonstration program participant or the HOME choice demonstration program participant's family member;

(2)      An apartment with an individual lease, that has lockable access and egress, and which includes living, sleeping, bathing and cooking areas over which the HOME choice demonstration program participant or the HOME choice demonstration program participant's family has domain and control. An apartment includes only the following:

(a)      A private apartment,

(b)      A public housing unit, or

(c)      Residential care facility units designated for assisted living that meet the requirements of paragraph (SS)(2) (RR)(2) of this rule; or

(3)      A residence in a community-based residential setting in which no more than four unrelated individuals reside. A community-based residential setting only includes the following:

(a)      Adult foster homes,

(b)      Adult family homes,

(c)      HCBS adult foster care certified by ODMR/DD DODD ,

(d)      Supported living arrangements for individuals with MR/DD a developmental disability who receive services through an ODMR/DD a DODD -administered waiver,

(e)      Non-ICF-MR residential facilities licensed by ODMR/DD DODD ,

(f)       Type 1 residential facilities licensed by the Ohio department of mental health (ODMH),

(g)      Type 2 residential facilities licensed by ODMH,

(h)      Foster homes for children that are certified by ODJFS,

(i)       Medically fragile foster homes for children that are certified by ODJFS, or

(j)       Group homes for children that are licensed or certified by ODJFS.

(TT) (UU)        "Qualified home and community-based program" or "qualified HCB program" is the medicaid service package that shall be made available to a HOME choice demonstration program participant when the participant moves from an institutional setting into the community, and which will remain in effect at the conclusion of the HOME choice demonstration program. Qualified HCB programs include: HCBS waivers and the medicaid state plan.

(UU) (VV)       "Qualified services" are existing waiver services, as well as the medicaid state plan services that have been determined by ODJFS to be non-acute, long term support services. They do not include demonstration and supplemental services.

(WW) "Residential treatment facility," for the purposes of the HOME choice demonstration program, is a facility greater than sixteen beds, or a facility located on a campus of multiple facilities that total more than sixteen beds, and that serves children and is licensed as a type 1 residential facility by ODMH in accordance with rule 5122-30-03 of the Administrative Code.

(VV) (XX)        "Service and support administrator" or "SSA" is a county board of MR/DD developmental disabilities employee who provides a variety of coordination activities for individuals enrolled on an ODMR/DD a DODD -administered waiver in accordance with section 5126.15 of the Revised Code.

(WW) (YY)      "Service plan" is the written outline of an ODA-administered waiver consumer's services, including certified long term care services and all other services regardless of funding source. The service plan is not the same as the physician's plan of care.

(XX) (ZZ)        "Skilled level of care" or "SLOC" is the institutional level of care set forth in rule 5101:3-3-05 of the Administrative Code.

(YY) (AAA)      "Supplemental services" are HOME choice demonstration program services that are available to the HOME choice demonstration program participant during the three hundred sixty-five day demonstration period after a participant moves from an institution to the community that are not entitled to enhanced FFP. Supplemental services include:

(1)      Communication aid services as set forth in paragraph (F) of rule 5101:3-51-04 of the Administrative Code; and

(2)      Service animal services as set forth in paragraph (G) of rule 5101:3-51-04 of the Administrative Code.

(ZZ) (BBB)      "Transitions Carve-Out Waiver" is a CMS-approved HCBS waiver administered by ODJFS that serves consumers in accordance with rules 5101:3-12-28 to 5101:3-12-30 of the Administrative Code, and Chapters 5101:3-45 and 5101:3-50 of the Administrative Code.

(AAA) (CCC)   "Transitions MR/DD DD Waiver" is a CMS-approved HCBS waiver administered by ODJFS that serves consumers in accordance with rules 5101:3-12-28 to 5101:3-12-30 of the Administrative Code, and Chapters 5101:3-45 and 5101:3-47 of the Administrative Code.

Effective: 09/09/2010

R.C. 119.032 review dates: 07/01/2013

Certification: CERTIFIED ELECTRONICALLY

Date: 08/30/2010

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.85

Rule Amplifies: 5111.01, 5111.02, 5111.85, Section 309.30.90 of Am. Sub. H.B. 1, 128th G.A.

Prior Effective Dates: 7/1/2008

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