Ohio Admin. Code 5160-59-05.2

Current through all regulations passed and filed through October 28, 2024

Section 5160-59-05.2 - OhioRISE home and community-based services waiver: transitional services and supports

(A) Scope. This rule sets forth provisions governing coverage for transitional services and supports provided as part of the Ohio resilience through integrated systems and excellence (OhioRISE) 1915(c) waiver program (waiver) established in accordance with 1915(c) of the Social Security Act 42, U.S.C. 1396n (January 1, 2022).

(B) Definitions. For this rule, the following definitions apply:

(1) "Homemaker/personal care" has the same meaning as set forth in rule 5123-9-30 of the Administrative Code.

(2) "Transitional services and supports" (TSS) is a service designed to provide family stability supports for the youth, primary caregiver and family as a pathway to creating a stable environment for the youth and the family that lives in the home. It is meant to assist the youth, in conjunction with their family/primary caregiver, as a means to overcome the functional limitations as identified due to the result of the youth's intensive behaviors. TSS is used to support youth and their caregivers in understanding, mitigating, and transitioning to long term solutions for behavior challenges. TSS is used to support a youth and their caregiver to stabilize during a transition of care and is not intended to de-escalate crises. TSS is an additional service for OhioRISE 1915(c) waiver enrollees and is limited to care not otherwise covered under the state plan, including early and periodic screening, diagnostic, and treatment (EPSDT) covered services set forth in rule 5160-1-14 of the Administrative Code.

(C) Eligible providers and conditions of participation.

(1) The following providers are eligible to provide TSS under the waiver program:

(a) An entity operating in accordance with paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code. Eligible rendering practitioners employed by or under contract with the entity include those described in paragraph (A)(3), (A)(4), (A)(5), or (A)(6)(a) of rule 5160-27-01 of the Administrative Code.

(b) An agency provider holding certification for homemaker/personal care services in accordance with rule 5123-9-30 of the Administrative Code.

(c) An individual provider who meets the criteria of an independent practitioner or licensed psychologist as described in rule 5160-8-05 of the Administrative Code.

(d) An individual provider holding certification for homemaker/personal care services in accordance with rule 5123-9-30 of the Administrative Code.

(2) Providers who hold certification for homemaker/personal care services, as designated in paragraphs (C)(1)(b) and (C)(1)(d) of this rule, will also complete behavioral health support trainings sponsored by the Ohio department of developmental disabilities (DODD) or an Ohio department of medicaid (ODM) approved behavioral health training prior to rendering the TSS service.

(3) With the exception of paragraph (B)(14) of rule 5160-44-31 of the Administrative Code, providers will comply with conditions of participation as set forth in rule 5160-44-31 of the Administrative Code.

(4) TSS providers will obtain and maintain first aid certification from an instruction which includes hands-on training by a certified first aid instructor. At its discretion, ODM may accept training conducted by a solely internet-based class as sufficient for the purposes of first aid certification.

(5) TSS providers serving an OhioRISE youth with behaviors that pose safety concerns for the youth or others will have been trained in de-escalation strategies that can be used to support the youth and prevent the use of restraints, seclusion, and restrictive interventions.

(6) TSS providers serving an OhioRISE youth with an individual crisis and safety plan including the use of restraints, seclusion, or restrictive intervention will be trained in the appropriate use of restraints, seclusion, and restrictive interventions.

(7) TSS providers will retain all initial and subsequent child and family-centered care plans.

(8) TSS providers are subject to compliance reviews specific to conditions of their licensure or certification in addition to ongoing monitoring conducted by the OhioRISE plan.

(9) For youth under age eighteen, authorized representatives, legal guardians, birth parents, adoptive parents, foster parents, and stepparents of the OhioRISE-enrolled youth are prohibited from providing or receiving payment for TSS services.

(D) Coverage.

(1) Primary components of the TSS service may include:

(a) Training the youth and family or caregivers in behavior stabilization techniques related to the youth's serious emotional disturbance diagnosis;

(b) Working with the youth and family or caregivers to identify triggers and developing person-centered approaches for preventing behavioral crisis prior to occurrence;

(c) Assistance to the youth in acquiring, retaining, and improving areas of self-help and socialization.

(d) Training and skill-building for families and caregivers regarding mitigation and support techniques for when crises occur;

(e) Training and skill-building for families and caregivers to understand and implement positive coping strategies to directly address crisis or escalation of risk behaviors;

(f) Acting as a conduit between the family or caregivers, the youth and the youth's care coordinator to assist in system navigation;

(g) Assistance to the youth with engagement in the broader community; and

(h) Assistance to the youth and family or caregivers with coping skills both in home and community settings.

(2) Other family stability supports activities related to youth and family or caregivers stabilization and transition beyond those listed in paragraphs (D)(1) and (D)(2) of this rule may be considered as permissible tangential activities allowable under the TSS service only when approved by the OhioRISE plan as part of the child and family-centered care plan prior to a provider rendering and receiving reimbursement for the service.

(3) Staffing may be provided to a youth at a ratio of up to two to one when there is a demonstrated need for the staffing level and when approved by the OhioRISE plan and documented on the child and family-centered care plan by the youth's care coordinator working within the CME as defined in rule 5160-59-01 of the Administrative Code, or the OhioRISE plan.

(4) The TSS service may be made available within twenty-four hours upon a change in circumstance or qualifying condition as described in paragraph (E) of this rule.

(5) The youth's care coordinator working within the CME or OhioRISE plan will assist the youth and their primary caregiver in determining the need for the TSS service.

(6) The youth's care coordinator working within the CME or OhioRISE plan may recommend TSS services, as well as the providers of TSS, as part of the child and family-centered care plan.

(7) The OhioRISE plan will need to approve TSS services as part of the child and family-centered care plan prior to receipt and reimbursement of the TSS service.

(E) Limitations.

(1) The TSS service will only be provided to youth meeting eligibility criteria for the waiver as set forth in rule 5160-59-04 of the Administrative Code and who are enrolled on the waiver at the time of service delivery.

(2) The TSS service will not be provided to a youth prior to establishment of initial or ongoing enrollment and eligibility criteria for the waiver as set forth in rule 5160-59-04 of the Administrative Code.

(3) The TSS service will assist a youth who experiences changes in circumstances or qualifying conditions, which include but are not limited to:

(a) Within twenty-four hours of the youth enrolling on the waiver following a discharge from one of the following settings:

(i) A psychiatric residential treatment facility (PRTF) as described in 42 C.F.R. 441.150 (October 1, 2023) through 42 C.F.R 441.184 (October 1, 2023);

(ii) An intermediate care facility for individuals with an intellectual disability (ICF/IID) as defined in section 5124.01 of the Revised Code;

(iii) An inpatient psychiatric hospital as defined in 42 CFR 440.160 (October 1, 2023);

(iv) A residential facility as defined in rule 5122-30-03 of the Administrative Code; or

(v) A qualified residential treatment program (QRTP) as described in rule 5101:2-9-42 of the Administrative Code.

(b) Within twenty-four hours of when the youth is transitioning between custodians or caregivers, for example, following a transition into a kinship caregiver's home.

(4) Reimbursement may be made for the TSS service when rendered by a provider in accordance with paragraph (C) of this rule to a youth enrolled in the OhioRISE 1915(c) waiver program in accordance with rule 5160-59-04 of the Administrative Code.

(5) When determined eligible for the OhioRISE 1915(c) waiver, the initial seventy-two hours will be approved with the child and family-centered care plan, or until other appropriate behavioral health service provided under the OhioRISE plan are scheduled to begin, or whichever occurs first. When the TSS service is needed beyond a seventy-two hour period, the child and family-centered care plan will need to be updated, reviewed, and approved by the OhioRISE plan prior to additional TSS services being provided.

(6) When the OhioRISE plan denies, reduces, terminates or suspends TSS services, this constitutes an adverse benefit determination and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.

(F) Service documentation for TSS will include each of the following to validate reimbursement for medicaid services:

(1) Date of service;

(2) Place of service;

(3) Name of youth receiving service;

(4) Medicaid identification number of youth receiving service;

(5) Name of provider;

(6) Provider identifier;

(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; and

(8) A summary of the amount, scope, duration, and frequency of services delivered that directly relate to the services specified in the approved child and family-centered care plan to be provided.

(9) A summary of when restraints, seclusion, and restrictive interventions were used including a date, time, the de-escalation techniques used to prevent the restraints, seclusion, and restrictive interventions and whether or not the use of restraints, seclusion, and restrictive interventions was included on the individual crisis and safety plan.

Ohio Admin. Code 5160-59-05.2

Effective: 3/17/2024
Five Year Review (FYR) Dates: 7/1/2027
Promulgated Under: 119.03
Statutory Authority: 5167.02, 5166.02
Rule Amplifies: 5162.03, 5166.04, 5167.03
Prior Effective Dates: 07/01/2022