Ohio Admin. Code 5160-45-03.5

Current through all regulations passed and filed through November 4, 2024

Section 5160-45-03.5 - ODM-administered waiver program: self-directed goods and services

(A) Scope. This rule sets forth provisions governing coverage for self-directed goods and services provided as part of an Ohio department of medicaid-(ODM) administered waiver program.

(B) "Self-directed goods and services" are services, equipment, or supplies that:

(1) Are not available through the medicaid state plan benefit or a home and community-based services (HCBS) waiver program;

(2) Address an individual's assessed need and are included on the person-centered services plan; and

(3) Supplement the medicaid state plan benefit and HCBS waiver services to help the individual successfully remain in the community.

(C) The ODM contracted financial management services (FMS) entity is the provider of self-directed goods and services. The FMS completes the purchase and reimbursement of self-directed goods and services approved in the person-centered services plan.

(D) Coverage.

(1) Self-directed goods and services are covered through self-direction budget authority, as described in rule 5160-45-03.2 of the Administrative Code.

(2) Self-directed goods and services may be approved if it is determined they will:

(a) Increase the individual's independence, safety, and/or community participation;

(b) Decrease the individual's need for other medicaid services; or

(c) Support the individual who does not have funds to purchase the services, equipment, or supplies, and they are not available through another source.

(3) Self-directed goods and services are individualized; therefore an exhaustive list cannot be developed. Goods and services include any needed equipment, supplies or services not covered by medicaid or another approved HCBS waiver service. This may include but is not limited to:

(a) Community classes, memberships, training or coaching;

(b) Household related items or devices;

(c) Camps; and

(d) Art, music, or other alternative therapies.

(E) Limitations.

(1) The following items cannot be purchased as self-directed goods and services:

(a) Experimental treatments as outlined in rule 5160-1-61 of the Administrative Code;

(b) Items used solely for entertainment or recreational purposes;

(c) Monthly rent, utilities or internet service; and

(d) Items that are illegal or otherwise prohibited through federal or state regulations.

(2) Self-directed goods and services are limited to two thousand five hundred dollars within three hundred sixty-five days.

(3) The individual, representative, or self-directed caregiver cannot be a vendor of supplies or items purchased with the self-directed goods and services funds.

(F) Service documentation for self-directed goods and services will include each of the following to validate reimbursement for medicaid services:

(1) Receipts to validate purchase of items are submitted to the case manager containing all the following:

(a) Item or service description;

(b) Vendor name;

(c) Purchase date; and

(d) Paid amount.

(2) An invoice for payment to a vendor is submitted to the FMS containing all the following:

(a) Individual's name and medicaid identification number;

(b) Item or service description;

(c) Vendor name;

(d) Purchaser of service if not the individual;

(e) Purchase date, delivery or service date; and

(f) Paid amount.

Ohio Admin. Code 5160-45-03.5

Effective: 10/1/2024
Five Year Review (FYR) Dates: 10/01/2029
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 5162.03, 5166.02