Rule 173-38-03 | Assisted living program (medicaid-funded component): enrollment and reassessment of individuals.
(A) Initial contact: An individual may initially contact either ODM's administrative agency or ODA's designee to apply for the medicaid-funded component of the assisted living program. The two agencies coordinate processing applications for enrollment as follows:
(1) If the individual makes initial contact with ODM's administrative agency, then ODM's administrative agency shall help the individual to apply and process the applications for medicaid (unless already enrolled in medicaid) and the medicaid-funded component of the assisted living program. If ODM's administrative agency notifies ODA's designee that the individual meets all financial eligibility requirements, then ODA's designee shall initiate contact with the individual to conduct an assessment by telephone, video conference, or in person to determine if the individual meets all non-financial eligibility requirements in rule 5160-33-03 of the Administrative Code.
(2) If the individual makes initial contact with ODA's designee, then ODA's designee shall help the individual apply for medicaid (unless already enrolled in medicaid) and the medicaid-funded component of the assisted living program and conduct an assessment by telephone, video conference, or in person to determine if the individual meets all non-financial eligibility requirements in rule 5160-33-03 of the Administrative Code.
(3) After the individual applies for the medicaid-funded component of the assisted living program, ODA or its designee shall notify the individual of the existence of the state-funded component of the assisted living program in Chapter 173-51 of the Administrative Code and offer the individual an opportunity to apply for enrollment in the state-funded component of the program.
(B) Denial: If ODM's administrative agency or ODA's designee determines the individual does not meet all eligibility requirements for the program under rule 5160-33-03 of the Administrative Code, the following responsibilities apply:
(1) If ODM's administrative agency determines the individual does not meet all financial eligibility requirements, it shall notify ODA's designee and notify individual of the denied application and appeal rights under section 5101.35 of the Revised Code and division 5101:6 of the Administrative Code.
(2) If ODA's designee determines the individual does not meet all non-financial eligibility requirements, it shall notify ODM's administrative agency and, in turn, ODM's administrative agency shall notify the individual of the denied application and appeal rights under section 5101.35 of the Revised Code and division 5101:6 of the Administrative Code.
(C) Enrollment: If ODM's administrative agency or ODA's designee determines the individual meets all eligibility requirements for the medicaid-funded component of the assisted living program under rule 5160-33-03 of the Administrative Code, then ODA's designee shall calculate the individual's medicaid waiver program enrollment date according to paragraph (C)(1) of this rule and enroll the individual according to paragraph (C)(2) or (C)(3) of this rule.
(1) Medicaid waiver program enrollment date:
(a) The individual's medicaid waiver program enrollment date is the latest of the following dates:
(i) The individual's basic medicaid effective date.
(ii) The date the individual meets all level of care requirements to participate in the medicaid waiver program.
(iii) The date the individual met all medicaid waiver program requirements listed in rule 5160-33-03 of the Administrative Code.
(iv) The date ODA's designee approved the individual's person-centered services plan with authorization for at least one medicaid waiver service.
(v) The date the individual began residing in an ODA-certified provider's RCF in a resident unit that complies with rule 173-39-02.16 of the Administrative Code.
(b) The medicaid-funded component of the assisted living program does not pay for any service provided to an individual before ODA's designee establishes the medicaid waiver program enrollment date according to paragraph (C)(1)(a) of this rule.
(c) The individual's medicaid waiver program enrollment date for the medicaid-funded component of the assisted living program may differ from the basic medicaid effective date.
(2) Available slot: ODA's designee shall enroll the individual in the program without placing the individual on the unified waiting list if all the following conditions exist:
(a) A waiver slot in the medicaid-funded component of the assisted living program is available.
(b) ODA's designee established the individual's medicaid waiver program enrollment date.
(c) The individual continues to meet the eligibility requirements for the program.
(d) The individual continues to want to enroll in the program.
(3) No available slot: If a waiver slot is not available in the medicaid-funded component of the assisted living program, ODA's designee may enroll the eligible individual when a waiver slot becomes available by one of the following two means:
(a) Unified waiting list: ODA's designee shall place the individual on the unified waiting list according to rule 173-44-04 of the Administrative Code, unless the individual qualifies for the home first component of the medicaid-funded component of the assisted living program, as addressed in paragraph (C)(3)(b) of this rule.
(b) Home first: If an individual meets all requirements for the home first component of the assisted living program in section 173.542 of the Revised Code, ODA's designee shall enroll the individual before enrolling any individual from the unified waiting list.
(D) Reassessment: ODA's designee shall reassess each individual enrolled in the medicaid-funded component of the assisted living program no less often than one time before each anniversary date of enrollment. After ODA's designee conducts each reassessment, if the individual continues to qualify for the medicaid-funded component of the program, the individual may decide if the individual wishes to remain in the program by signing an ODA-approved enrollment agreement as a condition of continued enrollment. During an emergency declared by the governor or a federal public health emergency, ODA's designee may collect the individual's handwritten or electronic signature on the enrollment agreement on a date later than the date the individual agrees to continue in the program, but no later than the next reassessment of the individual.
(E) An authorized representative may represent an individual in the enrollment and reassessment processes.
(F) As used in this rule, "basic medicaid effective date" means the date an individual becomes eligible to receive services under the medicaid state plan. Rule 5160:1-2-03 of the Administrative Code establishes the basic medicaid effective date.
Last updated January 2, 2024 at 8:42 AM
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