5123:2-9-34 Home and community-based services waivers - residential respite under the individual options, level one, and self-empowered life funding waivers.

 

 

 

5123:2-9-34                 Home and community-based services waivers - residential respite and community respite under the individual options waiver.

 

 

 

(A)Purpose

 

The purpose of this rule is to define residential respite and community respite and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the services.

 

(B)Definitions

 

(1)"Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

 

(2)"Community respite" means services provided to individuals unable to care for themselves that are furnished on a short-term basis because of the absence or need for relief of those persons who normally provide care for the individuals. Community respite shall only be provided outside of an individual's home in a camp, recreation center, or other place where an organized community program or activity occurs.

 

(3)"Community respite 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.

 

(4)"Community respite full day billing unit" means a billing unit that shall be used when community respite is provided for more than seven hours during the day and the individual stays overnight at the community respite service delivery location.

 

(5)"Community respite partial day billing unit" means a billing unit that shall be used when community respite is provided for between five and seven hours during the day and the individual does not stay overnight at the community respite service delivery location.

 

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

 

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

 

(8)"Funding range" means one of the dollar ranges contained in appendix C to rule 5123:2-9-06 of the Administrative Code, to which individuals have been assigned for the purpose of funding services for individuals enrolled on the individual options waiver. 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.

 

 

(9) "Homemaker/personal care" has the same meaning as in rule 5123:2-13-04 of the Administrative Code.

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

(11) "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.

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

(13) "Intermediate care facility for the mentally retarded" means an intermediate care facility for the mentally retarded certified by the Ohio department of health.

(14) "Ohio developmental disabilities profile" means the standardized instrument utilized by the department to assess the relative needs and circumstances of an individual enrolled on the individual options waiver 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.

(15) "Residential respite" means services provided to individuals unable to care for themselves that are furnished on a short-term basis because of the absence or need for relief of those persons who normally provide care for the individuals. Residential respite shall only be provided in the following locations:

(a) An intermediate care facility for the mentally retarded;

(b) A residential facility, other than an intermediate care facility for the mentally retarded, licensed by the department under section 5123.19 of the Revised Code; or

(c) A residence, other than an intermediate care facility for the mentally retarded or a facility licensed by the department under section 5123.19 of the Revised Code, where residential respite is provided by an agency provider.

(16) "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 paragraphs (C)(3)(b) and (E)(3)(b) of this rule, as applicable, to validate payment for medicaid services.

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

(C)General provisions for residential respite and community respite

(1) Provider qualifications

(a) An applicant seeking approval to provide residential respite or community respite shall meet the requirements of this rule and complete and submit an application and adhere to the requirements of either rule 5123:2-2-01 or 5123:2-3-19 of the Administrative Code, as applicable.

(b) Failure of a certified provider 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.

(c) Failure of a licensed provider to comply with this rule and Chapter 5123:2-3 of the Administrative Code may result in denial, suspension, or revocation of the provider's license.

(2) Requirements for service delivery

(a) Residential respite and community respite shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-40-01 of the Administrative Code.

(b) The individual service plan shall address all emergency and replacement coverage should the individual unexpectedly need to leave the residential respite or community respite service delivery location.

(3) Documentation of services

(a) The requirements of paragraph (B) of rule 5123:2-9-05 of the Administrative Code do not apply to service documentation for residential respite or community respite.

(b) Service documentation for residential respite and community respite shall include each of the following to validate payment for medicaid services:

(i) Type of service (i.e., residential respite, community respite full day

billing  unit,  community  respite  partial  day  billing  unit,  or community respite fifteen-minute billing unit).

(ii) Date of service.

(iii) Place of service.

(iv) Name of individual receiving service.

(v) Medicaid identification number of individual receiving service.

(vi) Name of provider.

(vii) Provider identifier/contract number.

(viii) 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.

(ix) 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.

(4) Payment standards

(a) The billing units, service codes, and payment rates for residential respite and community respite are contained in appendix A to this rule.

(b) Residential respite and community respite are subject to the  funding ranges and individual funding levels set forth in paragraph (C) of rule 5123:2-9-06 of the Administrative Code.

(c) Payment for residential respite and community respite shall not include payment for room and board or transportation.

(d)Only one provider of residential respite or community respite shall use a daily billing unit on any given day.

(D)Specific provisions for residential respite

(1) Provider qualifications

(a) Residential respite shall be provided by one of the following entities that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of job and family services:

(i) An intermediate care facility for the mentally retarded;

(ii) A  residential  facility  licensed  by  the  department  under  section 5123.19 of the Revised Code; or

(iii) An agency provider that is approved to provide residential respite in accordance with this rule.

(2) Requirements for service delivery

(a) When residential respite is provided in a residence other than an intermediate care facility for the mentally retarded or a residential facility licensed by the department under section 5123.19 of the Revised Code, each individual who receives homemaker/personal care and permanently resides at the residence shall consent to the provision of residential respite in the residence.

(b) When residential respite is provided at a residence other than an intermediate care facility for the mentally retarded or a residential facility licensed by the department under section 5123.19 of the Revised Code, the total number of persons with developmental disabilities being served at the residence shall not exceed four.

(c) Residential respite is limited to ninety calendar days of service per waiver eligibility span.

(d)Residential respite shall not be provided to an individual at the same time as homemaker/personal care.

(3) Payment standards

(a) Only one provider shall bill residential respite for the same individual on any given day.

(b) Paragraphs (F), (G), and (H) of rule 5123:2-9-06 of the Administrative Code do not apply to residential respite.

(E)Specific provisions for community respite

(1) Provider qualifications

(a) Community respite shall be provided by an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of job and family services.

(b) Community respite shall not be provided by an independent provider, a county board, or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards.

(c) The provider shall provide written assurance and ensure that all employees, contractors, and employees of contractors delivering community respite shall hold the required certification or license (e.g., water safety instructor) or be trained for any specialized activity (e.g., high ropes or archery) in which the individual may participate.

(2) Requirements for service delivery

(a) Community respite is limited to sixty calendar days of service per waiver eligibility span.

(b) Community respite shall not be simultaneously provided to an individual at the same location where homemaker/personal care is being provided to that individual.

(c) Community respite shall not be provided in any residence.

(d)Community respite shall not be simultaneously provided at the same location where adult day services are being provided.

(3) Documentation of services

(a) Service documentation for community respite shall include the items delineated in paragraph (C)(3)(b) of this rule to validate payment for medicaid services.

(b) Service documentation for community respite shall also include the date and time of the individual's arrival at and departure from the community respite service delivery location.

(4) Payment standards

(a) Payment rates for community respite include an adjustment based on the county cost-of-doing-business category. The cost-of-doing-business categories are contained in appendix B to this rule.

(b) Payment rates for community respite are subject to behavior support and medical assistance rate modifications in accordance with criteria established in paragraph (F) of rule 5123:2-9-06 of the Administrative Code.

(c) Paragraphs (G) and (H) of rule 5123:2-9-06 of the Administrative Code do not apply to community respite.

(d)The  community  respite  full  day  billing  unit  shall  be  used  when community respite is provided for more than seven hours during the day

and the individual stays overnight at the community respite service delivery location.

(e) The community respite partial day billing unit shall be used when community respite is provided for between five and seven hours on a given day and the individual does not stay overnight at the community respite service delivery location.

(f)The community respite fifteen-minute billing unit shall be used for all other community respite scenarios not addressed in paragraph (E)(4)(d) or (E)(4)(e) of this rule.

(g) The community respite full day billing unit, the community respite partial day billing unit, and the community respite fifteen-minute billing unit shall not be combined during the same calendar day for the same individual.

(h) Services delivered prior to October 1, 2011 that meet the definition of community respite as set forth in paragraph (B)(2) of this rule, may be billed as homemaker/personal care.

Effective:	07/15/2011
R.C. 119.032 review dates:	07/15/2016
CERTIFIED ELECTRONICALLY
Certification
06/21/2011
Date
Promulgated Under:	119.03
Statutory Authority:	5111.871, 5111.873, 5123.04, 5123.045, 5123.049,
	5123.16
Rule Amplifies:	5111.871, 5111.873, 5123.04, 5123.045, 5123.049,
	5123.16