5160-31-03 Eligibility for enrollment in the PASSPORT HCBS waiver program.

 

 

 

5160-31-03                  Eligibility  for  enrollment  in  the  PASSPORT  HCBS  waiver program.

 

 

 

(A)   Before an individual can be eligible for enrollment in the pre-admission screening system providing options and resources today (PASSPORT) home and community based services (HCBS) waiver program, all of the following criteria must be met:

 

(1)   A county department of job and family services (CDJFS) must have determined the individual to beThe individual must have been determined eligible for medicaid in accordance with rules 5160:1-2-01.6 and 5160:1-2-01.85160:1-2-03 and 5160:1-1-58 of the Administrative Code.

 

(2)   The waiver service cost of the twelve-month service plan does not exceed the individual cost limit. The individual cost limit is calculated by the Ohio department of aging (ODA) at least biennially. The cost limit is a dollar amount equal to sixty per cent of the total medicaid cost for nursing facility (NF) services. The total medicaid cost for NF services is obtained by multiplying the average annual medicaid NF per diem rate by the number of days in the most recent state fiscal year in which data is availableequal to fourteen thousand and seven hundred dollars per month for waiver services.

 

(a)     If the PASSPORT administrative agency (PAA) determines that the applicant's waiver service needs cannot be met within the individual cost limit, the individual shall not be enrolled. However, if an individual who has been enrolled and is receiving PASSPORT services experiences a change in his or her condition that causes the cost of care to exceed the cost limit, the individual may remain on the waiver at a higher cost not to exceed one hundred per cent of the total medicaid cost for NF services to avoid service disruption to the individual if the PAA grants approval to do so.

 

(b) Once enrolled in PASSPORT, additional waiver services may not be authorized in excess of the fourteen thousand and seven hundred dollars per month individual cost limit. When a change in condition occurs that necessitates the provision of additional waiver services, referrals to other community services, including institutional services, will be explored.

 

(b)(c) If the individual's waiver service needs exceed one hundred per cent of the total medicaid cost for NF servicesthe individual cost limit of fourteen thousand and seven hundred dollars per month, the individual shall be disenrolled from the waiver.

 

(3)   The needed services are not readily available through another source at the level required to allow the individual to live in the community.

 

 

(4)       The individual agrees to participate in PASSPORT and shall not be simultaneously enrolled in another HCBS medicaid waiver, the residential state supplement (RSS) program, or the program of all inclusive care for the elderly (PACE) while enrolled in PASSPORT.

(5)    The individual's health related needs can be safely met in a home setting as determined by the PAA.

(6)   Prior to PASSPORT enrollment, the attending physician must approve that the services are appropriate to meet the individual's needs. The physician's approval may be either verbal or written. If the approval is verbal, written approval must be obtained within thirty days of the enrollment date. The PAA shall be responsible for obtaining the physician's approval.

(7)    While receiving PASSPORT, the individual must not be a resident of either a Keys amendment facility, a hospital or a nursing facility (NF) as defined in rule 5160-31-02 of the Administrative Code. For purposes of this rule, a resident of a Keys amendment facility is an individual who receives services from the facility and is not a family member of the owner or operator of the facility.

(8)   The individual is age sixty or older at the time of enrollment.

(9)    The individual must be determined to meet the criteria for an intermediate or skilled level of care in accordance with rule 5160-3-05 or 5160-3-06 5160-3-08 of the Administrative Code and, in the absence of PASSPORT, would require NF services as defined in 42 C.F.R. 440.40 and 42 C.F.R.

440.150 (datedas in effect on October 1, 20072014).

(10)    PASSPORT has not reached the centers for medicare and medicaid services (CMS)-authorized limit on the number of individuals who may enroll on the waiver during the current year.

(11) An individual who has been enrolled in and is receiving PASSPORT services may subsequently be enrolled in and receive hospice services under medicaid or medicare. A person who is enrolled in hospice under medicaid or medicare is not eligible to enroll in PASSPORT if that hospice enrollment occurred prior to PASSPORT enrollment.

(12)(11) The individual must require the provision of at least one waiver service on a monthly basis as documented in the individual's approved service plan.

(B)    If, at any time, the individual fails or ceases to meet any of the eligibility criteria identified in this rule, the individual shall be denied or disenrolled from PASSPORT. In such instances, the individual shall be notified by the CDJFS and

entitled toof his or her hearing rights in

accordance

with Chapters 5101:6-1 to

5101:6-9division 5101:6 of the Administrative Code.

Effective:                                                             04/01/2015

Five Year Review (FYR) Dates:                         12/08/2014 and 04/01/2020

CERTIFIED ELECTRONICALLY

Certification

03/12/2015

Date

Promulgated Under:                           119.03

Statutory Authority:                           5166.02

Rule Amplifies:                                  5166.02, 173.52

Prior Effective Dates:                         12/22/86 (Emer.), 3/23/87, 1/14/96, 2/22/01, 1/31/05,

7/1/08, 3/17/11, 3/1/14