5123-9-23. Home and community-based services waivers - environmental accessibility adaptations under the individual options and level one waivers

(A) Purpose

This rule defines environmental accessibility adaptations and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

For the purposes of this rule, the following definitions shall apply:

(1) "Agency provider" means an entity that directly employs at least one person in addition to the chief executive officer for the purpose of providing services for which the entity must be certified in accordance with rule 5123:2-2-01 of the Administrative Code.

(2) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Environmental accessibility adaptations" means those physical adaptations to the home, required by the individual service plan, which are necessary to ensure the health, welfare, and safety of the individual, or which enable the individual to function with greater independence in the home, and without which, the individual would require institutionalization. Such adaptations may include the installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities, or installation of specialized electric and plumbing systems that are necessary to accommodate the medical equipment and supplies that are necessary for the welfare of the individual. Excluded are adaptations that add to the total square footage of the home and adaptations or improvements to the home that are of general utility, and are not of direct medical or remedial benefit to the individual, such as carpeting, roof repair, or central air conditioning. All adaptations shall be provided in accordance with applicable state or local building codes.

(5) "Independent provider" means a self-employed person who provides services for which he or she must be certified in accordance with rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(6) "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.

(7) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(8) "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 shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(9) "Three-year period" means the three-year period beginning with the individual's initial waiver enrollment date and ending three years later. Subsequent three-year periods begin with the ending date of the previous three-year period and end three years later.

(10) "Waiver eligibility span" means the twelve-month period following either an individual's initial waiver enrollment date or a subsequent eligibility re-determination date.

(C) Provider qualifications

(1) Environmental accessibility adaptations shall be provided by an independent provider or an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid.

(2) A county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards may provide environmental accessibility adaptations only when no other certified provider is willing and able.

(3) An applicant seeking approval to provide environmental accessibility adaptations shall complete and submit an application through the department's website (http://dodd.ohio.gov).

(4) An applicant seeking approval to provide environmental accessibility adaptations shall submit to the department documentation verifying the applicant's experience in providing environmental accessibility adaptations.

(5) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

(1) Environmental accessibility adaptations shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123:2-1-11 of the Administrative Code.

(2) The provider of environmental accessibility adaptations shall comply with all applicable state and local regulations that apply to the operation of the provider's business or trade.

(E) Documentation of services

Service documentation for environmental accessibility adaptations shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(F) Payment standards

(1) The billing unit, service codes, and payment rates for environmental accessibility adaptations are provided in the appendix to this rule.

(2) Claims for payment for environmental accessibility adaptations shall be submitted to the department with verification from the county board that the project meets the requirements specified in the approved individual service plan, the project is satisfactorily completed, and the project is in compliance with applicable state and local requirements, including building codes. The verification shall be submitted in the format prescribed by the department.

(3) Under the individual options waiver, payment for environmental accessibility adaptations shall not exceed ten thousand dollars per project.

(4) Under the level one waiver, environmental accessibility adaptations is subject to the payment limitation set forth in paragraph (D)(2) of rule 5123-9-06 of the Administrative Code.

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Replaces: 5123:2-9-23

Effective: 1/1/2019
Five Year Review (FYR) Dates: 01/01/2024
Promulgated Under: 119.03
Statutory Authority: 5123.1611, 5123.049, 5123.04
Rule Amplifies: 5123.04 , 5166.21, 5123.1611, 5123.161 , 5123.16 , 5123.049, 5123.045
Prior Effective Dates: 04/28/2003, 07/01/2006, 03/19/2012, 09/01/2013, 09/01/2017