Section 5123-9-48 - Home and community-based services waivers - community transition under the under the individual options waiver(A) Purpose This rule defines community transition 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 apply:
(1) "Agency provider" means an entity that employs at least one person in addition to a director of operations for the purpose of providing services for which the entity is certified in accordance with rule 5123-2-08 of the Administrative Code.(2) "Community transition" means reimbursement for non-recurring household start-up expenses for which an individual who previously resided in an intermediate care facility for individuals with intellectual disabilities or a nursing facility for at least ninety days and is transitioning to enrollment in the individual options waiver is directly responsible.(a) Community transition includes expenses that do not constitute room and board, necessary to enable an individual to establish a basic household. Community transition includes, but is not limited to:(i) Security deposits and rental start-up expenses required to obtain a lease on an apartment or house;(ii) Essential household furnishings required to occupy and use a community domicile such as furniture, window coverings, food preparation items, and bed or bath linens;(iii) Start-up fees or deposits for utility or service access such as telephone, electricity, heating, and water;(v) Pre-transition transportation services necessary to secure housing and benefits; and(vi) Initial cleaning products and household supplies.(b) Community transition does not include:(iii) Ongoing monthly rent or mortgage expenses;(iv) Ongoing utility or service charges;(v) Items intended for entertainment or recreational purposes; or(vi) Tobacco products or alcohol.(3) "County board" means a county board of developmental disabilities.(4) "Department" means the Ohio department of developmental disabilities. (5) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.(6) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.(7) "Intermediate care facility for individuals with intellectual disabilities" has the same meaning as in section 5124.01 of the Revised Code.(8) "Nursing facility" has the same meaning as in section 5165.01 of the Revised Code.(9) "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 includes the items delineated in paragraph (E) of this rule to validate payment for medicaid services.(C) Provider qualifications (1) Community transition will be provided only by an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid.(2) An applicant seeking to provide community transition will complete and submit an application and adhere to the requirements of rule 5123-2-09 of the Administrative Code.(3) 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 community transition only when no other qualified provider is available. (D) Requirements for service delivery (1) Community transition will be provided pursuant to an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code.(2) Community transition may be authorized for up to one hundred eighty calendar days prior to the date on which an individual enrolls in the individual options waiver.(3) Community transition may be authorized for up to thirty calendar days after the date on which an individual enrolls in the individual options waiver.(4) Expenses are reimbursable as community transition only to the extent: (a) No other person, including a landlord, has a legal or contractual responsibility to provide the item or service or pay the expense;(b) They are reasonable and necessary as determined through the person-centered planning process and clearly identified in the individual service plan;(c) The individual is unable to pay such expenses and the item or service cannot be obtained from other sources such as family, friends, neighbors, or community agencies; and(d) They take into consideration the appropriateness and availability of a lower cost alternative for comparable services that meet the individual's needs.(5) An individual will be involved in selection of any item or service authorized as community transition and purchased on the individual's behalf.(E) Documentation of services Service documentation for community transition will include each of the following to validate payment for medicaid services:
(3) Name of individual receiving service.(4) Medicaid identification number of individual receiving service.(6) Provider identifier/contract number.(7) 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.(8) A detailed description of each expense.(9) A receipt for each expense with the individual's signature, mark, stamp, or other method identified in the individual service plan to verify the individual's receipt of the purchased item or service.(F) Payment standards (1) The billing unit, service code, and payment rate for community transition are contained in the appendix to this rule.(2) Community transition will not exceed two thousand dollars per individual.(3) Pre-transition transportation services covered as community transition will not exceed five hundred dollars.(4) The date of service for purposes of reimbursement is the date an individual enrolls in the individual options waiver upon discharge from the intermediate care facility for individuals with intellectual disabilities or the nursing facility.(5) If for any unforeseen reason an individual does not enroll in the individual options waiver and transition to the community as planned (e.g., due to death or significant change in condition), the county board will submit the individual's expenses to the department within one year. Expenses incurred in these circumstances are reimbursable to the county board by the department and to the department by the Ohio department of medicaid. Click to view Appendix
Ohio Admin. Code 5123-9-48
Effective: 12/1/2024
Five Year Review (FYR) Dates: 9/12/2024 and 12/01/2029
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.049, 5123.1611
Rule Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Prior Effective Dates: 01/01/2019, 10/15/2021