5123-9-25. Home and community-based services waivers - specialized medical equipment and supplies under the individual options and level one waivers

(A) Purpose

This rule defines specialized medical equipment and supplies 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) "Assistive technology" has the same meaning as in rule 5123-9-12 of theAdministrative Code.

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

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

(5) "Environmental accessibility adaptations" has the same meaning as in rule 5123-9-23 of the Administrative Code.

(6) "Home-delivered meals" has the same meaning as in rule 5123-9-29 of the Administrative Code.

(7) "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.

(8) "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.

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

(10) "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.

(11) "Specialized medical equipment and supplies" means adaptive and assistive equipment and other specialized medical equipment and supplies such as devices, controls, or appliances, specified in the individual service plan, which enable an individual to increase his or her ability to perform activities of daily living, or to perceive, control, or communicate with the environment in which he or she lives. Specialized medical equipment and supplies includes items necessary for life support, ancillary supplies and equipment necessary to the proper functioning of such items, and durable and non-durable medical equipment not available under the medicaid state plan. All items shall meet applicable standards of manufacture, design, and installation. Specialized medical equipment and supplies does not include:

(a) Items that are not of direct medical or remedial benefit to the individual;

(b) Items otherwise available as assistive technology; or

(c) For individuals less than twenty-one years of age, equipment and supplies that are available under the medicaid state plan or covered under the provisions of 1905(r) of the Social Security Act, 42 U.S.C. 1396d, as in effect on the effective date of this rule.

(12) "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.

(13) "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) Specialized medical equipment and supplies 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 pursuant to section 5126.13 of the Revised Code by two or more county boards may provide specialized medical equipment and supplies only when no other certified provider is willing and able.

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

(4) An applicant seeking approval to provide specialized medical equipment and supplies shall submit to the department documentation verifying the applicant's experience in providing specialized medical equipment and supplies.

(5) A veterinarian who is attending to service animals shall be licensed to engage in the practice of veterinary medicine in accordance with Chapter 4741. of the Revised Code.

(6) 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) Specialized medical equipment and supplies 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 specialized medical equipment and supplies shall:

(a) Ensure proper installation of equipment, if required;

(b) Provide training to the individual, family, and other persons, as applicable, in the proper utilization of equipment;

(c) Properly maintain rental equipment, if required;

(d) Repair equipment as authorized by the county board representative; and

(e) Assume full liability for equipment improperly installed or maintained.

(E) Documentation of services

Service documentation for specialized medical equipment and supplies 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 specialized medical equipment and supplies are contained in the appendix to this rule.

(2) Under the level one waiver, specialized medical equipment and supplies is subject to the payment limitation set forth in paragraph (D)(2) of rule 5123-9-06 of the Administrative Code.

Click to view Appendix

Effective: 1/1/2019
Five Year Review (FYR) Dates: 6/1/2023
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, 06/01/2018