Section 5160-59-05.3 - OhioRISE home and community-based services waiver: secondary flex funds(A) Scope. This rule sets forth provisions governing coverage for secondary flex funds delivered 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) "Emergency funds" are an additional allotment of waiver funding used for the purchase of approved secondary flex funds based on a youth's unmet needs as determined by the OhioRISE plan.(2) "Participant direction" means the opportunity for an OhioRISE waiver youth to exercise choice and control in managing a budget for the applicable waiver service in accordance with their needs.(3) "Participant-directed budget for secondary flex funds" is the waiver-enrolled youth's maximum approved, non-emergency funding allowable for the purchase of secondary flex funds under the OhioRISE 1915(c) waiver.(4) "Secondary flex funds" is defined as the additional services, equipment, or supplies available through the waiver that are not otherwise provided through the medicaid state plan benefit or the OhioRISE program that address a youth's identified need as documented in the child and family-centered care plan. Secondary flex funds are intended to enhance and supplement the array of services available to a youth enrolled on the OhioRISE program and are discussed, recommended, and implemented through the care coordination process as described in rule 5160-59-03.2 of the Administrative Code. Secondary flex funds is inclusive of emergency funds and the participant-directed budget as described in this rule.(5) "Waiver cost limit" is the maximum amount of funding, excluding emergency funds, available to a youth enrolled in the waiver. The waiver cost limit for the waiver is fifteen thousand dollars per twelve month period.(C) With the exception of additional criteria defined in paragraph (D) of this rule, all provisions of rule 5160-59-03.5 of the Administrative Code apply to secondary flex funds provided under the waiver.(D) The following additional criteria apply to secondary flex funds provided under the waiver: (1) The total participant-directed budget for secondary flex funds is limited to three thousand dollars within three hundred sixty-five calendar days. The participant-directed budget is included in the waiver cost limit.(2) The waiver enrolled youth may access up to the total participant-directed budget for secondary flex funds when all primary flex funds, described in rule 5160-59-03.5 of the Administrative Code, provided under the OhioRISE plan are exhausted.(3) The total emergency funds available to a youth is limited to two thousand dollars within three hundred sixty-five days calendar days. Emergency funds are not included in the waiver cost cap.(a) Emergency funds are only available to a youth when the youth has exhausted all primary flex funds, as described in rule 5160-59-03.5 of the Administrative Code, and all available funds in their participant-directed budget, and still have a demonstrated need which may be met through the emergency funds available under secondary flex funds.(b) The youth's unmet need and desired outcome, resulting from the use of emergency funds, will be detailed in the child and family-centered care plan.(4) Secondary flex fund services are additive to the primary flex funds described in rule 5160-59-03.5 of the Administrative Code.(5) The OhioRISE plan will need to approve the waiver enrolled youth's participant-directed budget for secondary flex funds as part of the child and family care plan prior to use of the service.(6) When the OhioRISE plan denies, reduces, terminates or suspends secondary flex funds services, this constitutes an adverse benefit determination, and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.Ohio Admin. Code 5160-59-05.3
Effective: 7/1/2022
Five Year Review (FYR) Dates: 07/01/2027
Promulgated Under: 119.03
Statutory Authority: 5167.02, 5166.02
Rule Amplifies: 5162.03, 5166.04, 5167.03