Chapter 5166 | Federal Medicaid Waiver Programs

Section 5166.01 | Definitions.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

As used in this chapter:

"209(b) option" means the option described in section 1902(f) of the "Social Security Act," 42 U.S.C. 1396a(f), under which the medicaid program's eligibility requirements for aged, blind, and disabled individuals are more restrictive than the eligibility requirements for the supplemental security income program.

"Administrative agency" means, with respect to a home and community-based services medicaid waiver component, the department of medicaid or, if a state agency or political subdivision contracts with the department under section 5162.35 of the Revised Code to administer the component, that state agency or political subdivision.

"Care management system" has the same meaning as in section 5167.01 of the Revised Code.

"Dual eligible individual" has the same meaning as in section 5160.01 of the Revised Code.

"Enrollee" has the same meaning as in section 5167.01 of the Revised Code.

"Expansion eligibility group" has the same meaning as in section 5163.01 of the Revised Code.

"Federal poverty line" has the same meaning as in section 5162.01 of the Revised Code.

"Home and community-based services medicaid waiver component" means a medicaid waiver component under which home and community-based services are provided as an alternative to hospital services, nursing facility services, or ICF/IID services.

"Hospital" has the same meaning as in section 3727.01 of the Revised Code.

"Hospital long-term care unit" has the same meaning as in section 5168.40 of the Revised Code.

"ICDS participant" has the same meaning as in section 5164.01 of the Revised Code.

"ICF/IID" and "ICF/IID services" have the same meanings as in section 5124.01 of the Revised Code.

"Integrated care delivery system" and "ICDS" have the same meanings as in section 5164.01 of the Revised Code.

"Level of care determination" means a determination of whether an individual needs the level of care provided by a hospital, nursing facility, or ICF/IID and whether the individual, if determined to need that level of care, would receive hospital services, nursing facility services, or ICF/IID services if not for a home and community-based services medicaid waiver component.

"Medicaid buy-in for workers with disabilities program" has the same meaning as in section 5163.01 of the Revised Code.

"Medicaid MCO plan" has the same meaning as in section 5167.01 of the Revised Code.

"Medicaid provider" has the same meaning as in section 5164.01 of the Revised Code.

"Medicaid services" has the same meaning as in section 5164.01 of the Revised Code.

"Medicaid waiver component" means a component of the medicaid program authorized by a waiver granted by the United States department of health and human services under section 1115 or 1915 of the "Social Security Act," 42 U.S.C. 1315 or 1396n. "Medicaid waiver component" does not include the care management system or services delivered under a prepaid inpatient health plan, as defined in 42 C.F.R. 438.2.

"Medically fragile child" means an individual who is under eighteen years of age, has intensive health care needs, and is considered blind or disabled under section 1614(a)(2) or (3) of the "Social Security Act," 42 U.S.C. 1382c(a)(2) or (3).

"Nursing facility" and "nursing facility services" have the same meanings as in section 5165.01 of the Revised Code.

"Ohio home care waiver program" means the home and community-based services medicaid waiver component that is known as Ohio home care and was created pursuant to section 5166.11 of the Revised Code.

"Provider agreement" has the same meaning as in section 5164.01 of the Revised Code.

"Residential treatment facility" means a residential facility licensed by the department of mental health and addiction services under section 5119.34 of the Revised Code, or an institution certified by the department of job and family services under section 5103.03 of the Revised Code, that serves children and either has more than sixteen beds or is part of a campus of multiple facilities or institutions that, combined, have a total of more than sixteen beds.

"Skilled nursing facility" has the same meaning as in section 5165.01 of the Revised Code.

Last updated October 3, 2023 at 11:38 AM

Section 5166.02 | Rules governing medicaid waiver components.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) The medicaid director shall adopt rules in accordance with Chapter 119. of the Revised Code governing medicaid waiver components. The rules may establish all of the following:

(1) Eligibility requirements for the medicaid waiver components;

(2) The type, amount, duration, and scope of medicaid services the medicaid waiver components cover;

(3) The conditions under which the medicaid waiver components cover medicaid services;

(4) The amounts the medicaid waiver components pay for medicaid services or the methods by which the amounts are determined;

(5) The manners in which the medicaid waiver components pay for medicaid services;

(6) Safeguards for the health and welfare of medicaid recipients receiving medicaid services under a medicaid waiver component;

(7) Procedures for prioritizing and approving for enrollment individuals who are eligible for a home and community-based services medicaid waiver component and choose to be enrolled in the component;

(8) Procedures for enforcing the rules, including establishing corrective action plans for, and imposing financial and administrative sanctions on, persons and government entities that violate the rules. Sanctions shall include terminating provider agreements. The procedures shall include due process protections.

(9) Other policies necessary for the efficient administration of the medicaid waiver components.

(B) The director may adopt different rules for the different medicaid waiver components. The rules shall be consistent with the terms of the waiver authorizing the medicaid waiver component.

(C) The following apply to procedures established under division (A)(7) of this section:

(1) Any such procedures established for the medicaid-funded component of the PASSPORT program shall be consistent with section 173.521 of the Revised Code.

(2) Any such procedures established for the medicaid-funded component of the assisted living program shall be consistent with section 173.542 of the Revised Code.

(3) Any such procedures established for the Ohio home care waiver program shall be consistent with section 5166.121 of the Revised Code.

Last updated October 6, 2023 at 10:31 AM

Section 5166.03 | Notice of intent to request medicaid waiver.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The medicaid director may not submit a request to the United States secretary of health and human services for a medicaid waiver under the "Social Security Act," section 1115, 42 U.S.C. 1315, unless the director provides the speaker of the house of representatives and president of the senate written notice of the director's intent to submit the request at least ten days before the date the director submits the request to the United States secretary. The notice shall include a detailed explanation of the medicaid waiver the director proposes to seek.

Section 5166.04 | Home and community-based services medicaid waiver components.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The following requirements apply to each home and community-based services medicaid waiver component:

(A) Only an individual who qualifies for a component shall receive that component's medicaid services.

(B) A level of care determination shall be made as part of the process of determining whether an individual qualifies for a component and shall be made each year after the initial determination if, during such a subsequent year, the administrative agency determines there is a reasonable indication that the individual's needs have changed.

(C) A written plan of care or individual service plan based on an individual assessment of the medicaid services that an individual needs to avoid needing admission to a hospital, nursing facility, or ICF/IID shall be created for each individual determined eligible for a component.

(D) Each individual determined eligible for a component shall receive that component's medicaid services in accordance with the individual's level of care determination and written plan of care or individual service plan.

(E) No individual may receive medicaid services under a component while the individual is a hospital inpatient or resident of a skilled nursing facility, nursing facility, or ICF/IID.

(F) No individual may receive prevocational, educational, or supported employment services under a component if the individual is eligible for such services that are funded with federal funds provided under 29 U.S.C. 730 or the "Individuals with Disabilities Education Act," 111 Stat. 37 (1997), 20 U.S.C. 1400, as amended.

(G) Safeguards shall be taken to protect the health and welfare of individuals receiving medicaid services under a component, including safeguards established in rules adopted under section 5166.02 of the Revised Code and safeguards established by licensing and certification requirements that are applicable to the providers of that component's medicaid services.

(H) No medicaid services may be provided under a component by a provider that is subject to standards that the "Social Security Act," section 1616(e)(1), 42 U.S.C. 1382e(e)(1), requires be established if the provider fails to comply with the standards applicable to the provider.

(I) Individuals determined to be eligible for a component, or such individuals' representatives, shall be informed of that component's medicaid services, including any choices that the individual or representative may make regarding the component's medicaid services, and given the choice of either receiving medicaid services under that component or, as appropriate, hospital services, nursing facility services, or ICF/IID services.

(J) No individual shall lose eligibility for services under a component, or have the services reduced or otherwise disrupted, on the basis that the individual also receives services under the medicaid buy-in for workers with disabilities program.

(K) No individual shall lose eligibility for services under a component, or have the services reduced or otherwise disrupted, on the basis that the individual's income or resources increase to an amount above the eligibility limit for the component if the individual is participating in the medicaid buy-in for workers with disabilities program and the amount of the individual's income or resources does not exceed the eligibility limit for the medicaid buy-in for workers with disabilities program.

(L) No individual receiving services under a component shall be required to pay any cost sharing expenses for the services for any period during which the individual also participates in the medicaid buy-in for workers with disabilities program.

Section 5166.041 | Provision of nursing services in a group visit under a home and community-based services medicaid waiver component.

• Effective: October 12, 2016
• Latest Legislation: House Bill 483 - 131st General Assembly

A medicaid provider of nursing services may provide nursing services in a group visit under a home and community-based services medicaid waiver component if the component covers the nursing services, the number of medicaid recipients who receive the nursing services during the group visit does not exceed four, and all of the following apply to all of those medicaid recipients:

(A) They are enrolled in the component;

(B) They are medically fragile children;

(C) They are siblings;

(D) They reside together in the home of their caretaker relative.

Section 5166.05 | Review of plans of care and individual service plans.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The department of medicaid may review and approve, modify, or deny written plans of care and individual service plans that section 5166.04 of the Revised Code requires be created for individuals determined eligible for a home and community-based services medicaid waiver component. If a state agency or political subdivision contracts with the department under section 5162.35 of the Revised Code to administer a home and community-based services medicaid waiver component and approves, modifies, or denies a written plan of care or individual service plan pursuant to the agency's or subdivision's administration of the component, the department may review the agency's or subdivision's approval, modification, or denial and order the agency or subdivision to reverse or modify the approval, modification, or denial. The state agency or political subdivision shall comply with the department's order.

The department of medicaid shall be granted full and immediate access to any records the department needs to implement its duties under this section.

Section 5166.06 | Agency records of costs of medicaid waiver components.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

Each administrative agency shall maintain, for a period of time the department of medicaid shall specify, financial records documenting the costs of medicaid services provided under the home and community-based services medicaid waiver components that the agency administers, including records of independent audits. The administrative agency shall make the financial records available on request to the United States secretary of health and human services, United States comptroller general, and their designees.

Section 5166.07 | Agency accountable for medicaid waiver components funds.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

Each administrative agency is financially accountable for funds expended for medicaid services covered by the home and community-based services medicaid waiver components that the agency administers.

Section 5166.08 | Agency contracting for medicaid waiver components; assurance of compliance.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

Each state agency and political subdivision that enters into a contract with the department of medicaid under section 5162.35 of the Revised Code to administer a home and community-based services medicaid waiver component, or one or more aspects of such a component, shall provide the department a written assurance that the agency or subdivision will not violate any of the requirements of sections 5166.01 to 5166.07 of the Revised Code.

Section 5166.09 | Reservation of participant capacity for individuals related to active duty military who were receiving services in another state.

• Effective: September 15, 2020
• Latest Legislation: House Bill 287 - 133rd General Assembly

Every home and community-based services medicaid waiver component shall reserve a portion of the participant capacity of the waiver for eligible individuals whose spouse or parent or legal guardian is an active duty military service member and, at the time of the service member's transfer to Ohio, the eligible individual was receiving home and community-based services in another state.

Section 5166.10 | Transfer of enrollee in one medicaid waiver component to another.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

To the extent necessary for the efficient and economical administration of medicaid waiver components, the department of medicaid may transfer an individual enrolled in a medicaid waiver component administered by the department to another medicaid waiver component the department administers if the individual is eligible for the medicaid waiver component and the transfer does not jeopardize the individual's health or safety.

Section 5166.11 | Creation of medicaid waiver components for home and community-based services programs.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) As used in this section, "Ohio home care program" means the program the department of medicaid administers that provides state plan services and medicaid waiver component services pursuant to rules adopted for the medicaid program and a medicaid waiver that went into effect July 1, 1998.

(B) The department of medicaid may create and administer two or more medicaid waiver components under which home and community-based services are provided to eligible individuals who need the level of care provided by a nursing facility or hospital. In administering the medicaid waiver components, the department may specify the following:

(1) The maximum number of individuals who may be enrolled in each of the medicaid waiver components;

(2) The maximum amount the medicaid program may expend each year for each individual enrolled in the medicaid waiver components;

(3) The maximum amount the medicaid program may expend each year for all individuals enrolled in the medicaid waiver components;

(4) Any other requirements the department selects for the medicaid waiver components.

(C)

(D) After the first of any of the medicaid waiver components that the department administers under this section begins to enroll eligible individuals, the department may cease to enroll additional individuals in a medicaid waiver component of the Ohio home care program.

Section 5166.121 | Home first component for the Ohio home care waiver program.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) Unless the Ohio home care waiver program is terminated pursuant to section 5165.12 of the Revised Code, the department of medicaid shall establish a home first component for the Ohio home care waiver program. An individual is eligible for the Ohio home care waiver program's home first component if the individual has been determined to be eligible for the Ohio home care waiver program and at least one of the following applies:

(1) If the individual is under twenty-one years of age, the individual received inpatient hospital services for at least fourteen consecutive days, or had at least three inpatient hospital stays during the twelve months, immediately preceding the date the individual applies for the Ohio home care waiver program.

(2) If the individual is at least twenty-one but less than sixty years of age, the individual received inpatient hospital services for at least fourteen consecutive days immediately preceding the date the individual applies for the Ohio home care waiver program.

(3) The individual received private duty nursing services under the medicaid program for at least twelve consecutive months immediately preceding the date the individual applies for the Ohio home care waiver program.

(4) The individual does not reside in a nursing facility or hospital long-term care unit at the time the individual applies for the Ohio home care waiver program but is at risk of imminent admission to a nursing facility or hospital long-term care unit due to a documented loss of a primary caregiver.

(5) The individual resides in a nursing facility at the time the individual applies for the Ohio home care waiver program.

(6) At the time the individual applies for the Ohio home care waiver program, the individual participates in the money follows the person demonstration project authorized by section 6071 of the "Deficit Reduction Act of 2005," Pub. L. No. 109-171, as amended, and either resides in a residential treatment facility or inpatient hospital setting.

(B) An individual determined to be eligible for the home first component of the Ohio home care waiver program shall be enrolled in the program in accordance with rules adopted under section 5166.02 of the Revised Code.

Section 5166.16 | Integrated care delivery system medicaid waiver.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) As used in this section and section 5166.161 of the Revised Code, "ODA or MCD medicaid waiver component" means all of the following:

(1) The medicaid-funded component of the PASSPORT program;

(2) The medicaid-funded component of the assisted living program;

(3) The Ohio home care waiver program.

(B) The medicaid director may create a home and community-based services medicaid waiver component as part of the integrated care delivery system. If the ICDS medicaid waiver component is created, both of the following apply:

(1) The department of medicaid shall administer it;

(2) When it begins to accept enrollments, no ICDS participant who is eligible for the ICDS medicaid waiver component shall be enrolled in an ODA or MCD medicaid waiver component regardless of whether the participant prefers to remain or be enrolled in an ODA or MCD medicaid waiver component.

(C) A dual eligible individual who is eligible for an ODA or MCD medicaid waiver component may enroll in the component before the individual becomes an ICDS participant. The dual eligible individual shall disenroll from the ODA or MCD medicaid waiver component and enroll in the ICDS medicaid waiver component once the individual becomes an ICDS participant and it is possible to enroll the individual in the ICDS medicaid waiver component. The disenrollment from the ODA or MCD medicaid waiver component and enrollment into the ICDS medicaid waiver component shall occur regardless of whether the individual prefers to remain enrolled in the ODA or MCD medicaid waiver component.

(D) An ICDS participant's disenrollment from an ODA or MCD medicaid waiver component and enrollment in the ICDS medicaid waiver component resulting from division (B)(2) or (C) of this section shall be accomplished without a disruption in the participant's services under the components.

Last updated October 6, 2023 at 10:37 AM

Section 5166.161 | Home and community-based services for Holocaust survivors.

• Effective: September 29, 2015
• Latest Legislation: House Bill 64 - 131st General Assembly

The department of medicaid shall ensure that each ICDS participant who is a survivor of the Holocaust that occurred in Europe during World War II receives, while enrolled in the ICDS medicaid waiver component, home and community-based services of the type and in at least the amount, duration, and scope that the participant is assessed to need and would have received if the participant were enrolled in an ODA or MCD medicaid waiver component.

Section 5166.20 | Additional Medicaid waiver components for home and community-based services.

• Effective: October 12, 2016
• Latest Legislation: House Bill 158 - 131st General Assembly

(A) The department of medicaid may create the following:

(1) One or more medicaid waiver components under which home and community-based services are provided to individuals with developmental disabilities as an alternative to placement in ICFs/IID;

(2) One or more medicaid waiver components under which home and community-based services are provided in the form of any of the following:

(a) Early intervention and supportive services for children under three years of age who have developmental delays or disabilities the department determines are significant;

(b) Therapeutic services for children who have autism;

(c) Specialized habilitative services for individuals who are eighteen years of age or older and have autism.

(B) No medicaid waiver component created pursuant to division (A)(2)(b) or (c) of this section shall provide services that are available under another medicaid waiver component. No medicaid waiver component created pursuant to division (A)(2)(b) of this section shall provide services to an individual that the individual is eligible to receive through an individualized education program as defined in section 3323.01 of the Revised Code.

(C) The director of developmental disabilities and director of health may request that the department of medicaid create one or more medicaid waiver components under this section.

(D) Before creating a medicaid waiver component under this section, the department of medicaid shall seek, accept, and consider public comments.

Section 5166.21 | Transitions developmental disabilities waiver.

• Effective: October 12, 2016
• Latest Legislation: House Bill 158 - 131st General Assembly

The department of medicaid shall enter into a contract with the department of developmental disabilities under section 5162.35 of the Revised Code with regard to one or more of the medicaid waiver components created by the department of medicaid under section 5166.20 of the Revised Code. The contract shall include the medicaid waiver component known as the transitions developmental disabilities waiver. The contract shall provide for the department of developmental disabilities to administer the components in accordance with the terms of the federal medicaid waivers authorizing the components. The contract shall include a schedule for the department of developmental disabilities to begin administering the transitions developmental disabilities waiver.

If the department of developmental disabilities or the department of medicaid denies an individual's application for home and community-based services provided under any of these medicaid components, the department that denied the services shall give timely notice to the individual that the individual may appeal pursuant to section 5160.31 of the Revised Code.

The departments of developmental disabilities and medicaid may approve, reduce, deny, or terminate a medicaid service included in the individual service plan developed for a medicaid recipient eligible for home and community-based services provided under any of these medicaid components. The departments shall consider the recommendations a county board of developmental disabilities makes under division (A)(1)(c) of section 5126.055 of the Revised Code. If either department approves, reduces, denies, or terminates a medicaid service, that department shall give timely notice to the medicaid recipient that the recipient may appeal pursuant to section 5160.31 of the Revised Code.

If supported living, as defined in section 5126.01 of the Revised Code, is to be provided as a medicaid service under any of these components, any person or government entity with a current, valid provider agreement and a current, valid certificate under section 5123.161 of the Revised Code may provide the medicaid service.

If a medicaid service is to be provided under any of these components by a residential facility, as defined in section 5123.19 of the Revised Code, any person or government entity with a current, valid provider agreement and a current, valid license under section 5123.19 of the Revised Code may provide the medicaid service.

Section 5166.22 | Allocating enrollment numbers to county board of developmental disabilities.

• Effective: October 17, 2019
• Latest Legislation: House Bill 166 - 133rd General Assembly

(A) Subject to division (B) of this section, when the department of developmental disabilities allocates enrollment numbers to a county board of developmental disabilities for home and community-based services specified in division (A)(1) of section 5166.20 of the Revised Code and provided under any of the medicaid waiver components that the department administers under section 5166.21 of the Revised Code, the department shall consider both of the following:

(1) The number of individuals with developmental disabilities placed on the county board's waiting list established for the services pursuant to section 5126.042 of the Revised Code;

(2) Anything else the department considers necessary to enable the county board to provide the services to individuals placed on the county board's waiting list established for the services pursuant to section 5126.042 of the Revised Code.

(B) Division (A) of this section applies to home and community-based services provided under the medicaid waiver component known as the transitions developmental disabilities waiver only to the extent, if any, provided by the contract required by section 5166.21 of the Revised Code regarding the component.

Section 5166.23 | Rules regarding payments for home and community-based services provided under medicaid component.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) Subject to division (D) of this section, the medicaid director shall adopt rules under section 5166.02 of the Revised Code establishing the payment amounts or the methods by which the payment amounts are to be determined for home and community-based services specified in division (A)(1) of section 5166.20 of the Revised Code and provided under the components of the medicaid program that the department of developmental disabilities administers under section 5166.21 of the Revised Code. With respect to these rules, all of the following apply:

(1) The rules shall establish procedures for the department of developmental disabilities to follow in arranging for the initial and ongoing collection of cost information from a comprehensive, statistically valid sample of persons and government entities providing the services at the time the information is obtained.

(2) The rules shall establish procedures for the collection of consumer-specific information through an assessment instrument the department of developmental disabilities shall provide to the department of medicaid.

(3) With the information collected pursuant to divisions (A)(1) and (2) of this section, an analysis of that information, and other information the director determines relevant, the rules shall establish payment standards that do all of the following:

(a) Assure that payment amounts are consistent with efficiency, economy, and quality of care;

(b) Consider the intensity of consumer resource need;

(c) Recognize variations in different geographic areas regarding the resources necessary to assure the health and welfare of consumers;

(d) Recognize variations in environmental supports available to consumers.

(B) As part of the process of adopting rules authorized by this section, the director shall consult with the director of developmental disabilities, representatives of county boards of developmental disabilities, persons who provide the home and community-based services, and other persons and government entities the director identifies.

(C) The medicaid director and director of developmental disabilities shall review the rules authorized by this section at times they determine are necessary to ensure that the payment amounts or the methods by which the payment amounts are to be determined continue to meet the payment standards established under division (A)(3) of this section.

(D) This section applies to home and community-based services provided under the medicaid waiver component known as the transitions developmental disabilities waiver only to the extent, if any, provided by the contract required by section 5166.21 of the Revised Code regarding the component.

Section 5166.30 | Coverage of home care attendant services.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) As used in sections 5166.30 to 5166.3010 of the Revised Code:

(1) "Adult" means an individual at least eighteen years of age.

(2) "Appropriate director" means the following:

(a) The medicaid director in the context of both of the following:

(i) The Ohio home care waiver program;

(ii) The integrated care delivery system medicaid waiver component authorized by section 5166.16 of the Revised Code.

(b) The director of aging in the context of the medicaid-funded component of the PASSPORT program.

(3) "Authorized representative" means the following:

(a) In the case of a consumer who is a minor, the consumer's parent, custodian, or guardian;

(b) In the case of a consumer who is an adult, an individual selected by the consumer pursuant to section 5166.3010 of the Revised Code to act on the consumer's behalf for purposes regarding home care attendant services.

(4) "Authorizing health care professional" means a health care professional who, pursuant to section 5166.307 of the Revised Code, authorizes a home care attendant to assist a consumer with self-administration of medication, nursing tasks, or both.

(5) "Consumer" means an individual to whom all of the following apply:

(a) The individual is enrolled in a participating medicaid waiver component.

(b) The individual has a medically determinable physical impairment to which both of the following apply:

(i) It is expected to last for a continuous period of not less than twelve months.

(ii) It causes the individual to require assistance with activities of daily living, self-care, and mobility, including either assistance with self-administration of medication or the performance of nursing tasks, or both.

(c) In the case of an individual who is an adult, the individual is mentally alert and is, or has an authorized representative who is, capable of selecting, directing the actions of, and dismissing a home care attendant.

(d) In the case of an individual who is a minor, the individual has an authorized representative who is capable of selecting, directing the actions of, and dismissing a home care attendant.

(6) "Controlled substance" has the same meaning as in section 3719.01 of the Revised Code.

(7) "Custodian" has the same meaning as in section 2151.011 of the Revised Code.

(8) "Gastrostomy tube" means a percutaneously inserted catheter that terminates in the stomach.

(9) "Guardian" has the same meaning as in section 2111.01 of the Revised Code.

(10) "Health care professional" means a physician or registered nurse.

(11) "Home care attendant" means an individual holding a valid provider agreement in accordance with section 5166.301 of the Revised Code that authorizes the individual to provide home care attendant services to consumers.

(12) "Home care attendant services" means all of the following as provided by a home care attendant:

(a) Personal care aide services;

(b) Assistance with the self-administration of medication;

(c) Assistance with nursing tasks.

(13) "Jejunostomy tube" means a percutaneously inserted catheter that terminates in the jejunum.

(14) "Medication" means a drug as defined in section 4729.01 of the Revised Code.

(15) "Minor" means an individual under eighteen years of age.

(16) "Participating medicaid waiver component" means all of the following:

(a) The medicaid-funded component of the PASSPORT program;

(b) The Ohio home care waiver program;

(c) The integrated care delivery system medicaid waiver component authorized by section 5166.16 of the Revised Code.

(17) "Physician" means an individual authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery.

(18) "Practice of nursing as a registered nurse," "practice of nursing as a licensed practical nurse," and "registered nurse" have the same meanings as in section 4723.01 of the Revised Code. "Registered nurse" includes an advanced practice registered nurse, as defined in section 4723.01 of the Revised Code.

(19) "Schedule II," "schedule III," "schedule IV," and "schedule V" have the same meanings as in section 3719.01 of the Revised Code.

(B) Participating medicaid waiver components may cover home care attendant services in accordance with sections 5166.30 to 5166.3010 of the Revised Code and rules adopted under section 5166.02 of the Revised Code.

Last updated October 6, 2023 at 10:39 AM

Section 5166.301 | Home care attendant services providers.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The medicaid director shall enter into a provider agreement with an individual to authorize the individual to provide home care attendant services to consumers if the individual does both of the following:

(A) Agrees to comply with the requirements of sections 5166.30 to 5166.3010 and rules adopted under section 5166.02 of the Revised Code;

(B) Provides the director evidence satisfactory to the director of all of the following:

(1) That the individual either meets the personnel qualifications specified in 42 C.F.R. 484.4 for home health aides or has successfully completed at least one of the following:

(a) A competency evaluation program or training and competency evaluation program approved or conducted by the director of health under section 3721.31 of the Revised Code;

(b) A training program approved by the appropriate director that includes training in at least all of the following and provides training equivalent to a training and competency evaluation program specified in division (B)(1)(a) of this section or meets the requirements of 42 C.F.R. 484.36(a):

(i) Basic home safety;

(ii) Universal precautions for the prevention of disease transmission, including hand-washing and proper disposal of bodily waste and medical instruments that are sharp or may produce sharp pieces if broken;

(iii) Personal care aide services;

(iv) The labeling, counting, and storage requirements for schedule II, III, IV, and V medications.

(2) That the individual has obtained a certificate of completion of a course in first aid from a first aid course to which all of the following apply:

(a) It is not provided solely through the internet.

(b) It includes hands-on training provided by a first aid instructor who is qualified to provide such training according to standards set in rules adopted under section 5166.02 of the Revised Code.

(c) It requires the individual to demonstrate successfully that the individual has learned the first aid taught in the course.

(3) That the individual meets any other requirements for the medicaid provider agreement specified in rules adopted under section 5166.02 of the Revised Code.

Section 5166.302 | Continuing education requirements for home care attendants.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

A home care attendant shall complete not less than twelve hours of in-service continuing education regarding home care attendant services each year and provide the appropriate director evidence satisfactory to the appropriate director that the attendant satisfied this requirement. The evidence shall be submitted to the appropriate director not later than the annual anniversary of the issuance of the home care attendant's initial provider agreement.

Section 5166.303 | Responsibilities of home care attendants.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

A home care attendant shall do all of the following:

(A) Maintain a clinical record for each consumer to whom the attendant provides home care attendant services in a manner that protects the consumer's privacy;

(B) Participate in a face-to-face visit every ninety days with all of the following to monitor the health and welfare of each of the consumers to whom the attendant provides home care attendant services:

(1) The consumer;

(2) The consumer's authorized representative, if any;

(3) A registered nurse who agrees to answer any questions that the attendant, consumer, or authorized representative has about consumer care needs, medications, and other issues.

(C) Document the activities of each visit required by division (B) of this section in the consumer's clinical record with the assistance of the registered nurse.

(D) The face-to-face visit requirement in division (B) of this section may be satisfied by telephone or electronically if permitted by rules adopted under section 5166.02 of the Revised Code.

Last updated September 14, 2023 at 9:42 AM

Section 5166.304 | Nursing assistance by home care attendants.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) A home care attendant may assist a consumer with nursing tasks or self-administration of medication only after the attendant does both of the following:

(1) Subject to division (B) of this section, completes consumer-specific training in how to provide the assistance that the authorizing health care professional authorizes the attendant to provide to the consumer;

(2) At the request of the consumer, consumer's authorized representative, or authorizing health care professional, successfully demonstrates that the attendant has learned how to provide the authorized assistance to the consumer.

(B) The training required by division (A)(1) of this section shall be provided by either of the following:

(1) The authorizing health care professional;

(2) The consumer or consumer's authorized representative in cooperation with the authorizing health care professional.

Section 5166.305 | Nursing assistance by home care attendants; consent and authorization.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

A home care attendant shall comply with both of the following when assisting a consumer with nursing tasks or self-administration of medication:

(A) The written consent of the consumer or consumer's authorized representative provided to the appropriate director under section 5166.306 of the Revised Code;

(B) The authorizing health care professional's written authorization provided to the appropriate director under section 5166.307 of the Revised Code.

Section 5166.306 | Nursing assistance by home care attendants; written statement providing consent.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

To consent to a home care attendant assisting a consumer with nursing tasks or self-administration of medication, the consumer or consumer's authorized representative shall provide the appropriate director a written statement signed by the consumer or authorized representative under which the consumer or authorized representative consents to both of the following:

(A) Having the attendant assist the consumer with nursing tasks or self-administration of medication;

(B) Assuming responsibility for directing the attendant when the attendant assists the consumer with nursing tasks or self-administration of medication.

Section 5166.307 | Nursing assistance by home care attendants; written statement of authorization.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

To authorize a home care attendant to assist a consumer with nursing tasks or self-administration of medication, a health care professional shall provide the appropriate director a written statement signed by the health care professional that includes all of the following:

(A) The consumer's name and address;

(B) A description of the nursing tasks or self-administration of medication with which the attendant is to assist the consumer, including, in the case of assistance with self-administration of medication, the name and dosage of the medication;

(C) The times or intervals when the attendant is to assist the consumer with the self-administration of each dosage of the medication or nursing tasks;

(D) The dates the attendant is to begin and cease providing the assistance;

(E) A list of severe adverse reactions the attendant must report to the health care professional should the consumer experience one or more of the reactions;

(F) At least one telephone number at which the attendant can reach the health care professional in an emergency;

(G) Instructions the attendant is to follow when assisting the consumer with nursing tasks or self-administration of medication, including instructions for maintaining sterile conditions and for storage of task-related equipment and supplies;

(H) The health care professional's attestation of both of the following:

(1) That the consumer or consumer's authorized representative has demonstrated to the health care professional the ability to direct the attendant;

(2) That the attendant has demonstrated to the health care professional the ability to provide the consumer assistance with nursing tasks or self-administration of medication that the health care professional has specifically authorized the attendant to provide and that the consumer or consumer's authorized representative has indicated to the health care professional that the consumer or authorized representative is satisfied with the attendant's demonstration.

Section 5166.308 | Nursing assistance by home care attendants; unauthorized actions.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

When authorizing a home care attendant to assist a consumer with nursing tasks or self-administration of medication, a health care professional may not authorize a home care attendant to do any of the following:

(A) Perform a task that is outside of the health care professional's scope of practice;

(B) Assist the consumer with the self-administration of a medication, including a schedule II, schedule III, schedule IV, or schedule V drug unless both of the following apply:

(1) The medication is administered orally, topically, or via a gastrostomy tube or jejunostomy tube, including through any of the following:

(a) In the case of an oral medication, a metered dose inhaler;

(b) In the case of a topical medication, including a transdermal medication, either of the following:

(i) An eye, ear, or nose drop or spray;

(ii) A vaginal or rectal suppository.

(c) In the case of a gastrostomy tube or jejunostomy tube, only through a pre-programmed pump.

(2) The medication is in its original container and the label attached to the container displays all of the following:

(a) The consumer's full name in print;

(b) The medication's dispensing date, which must not be more than twelve months before the date the attendant assists the consumer with self-administration of the medication;

(c) The exact dosage and means of administration that match the health care professional's authorization to the attendant.

(C) Assist the consumer with the self-administration of a schedule II, schedule III, schedule IV, or schedule V medication unless, in addition to meeting the requirements of division (B) of this section, all of the following apply:

(1) The medication has a warning label on its container.

(2) The attendant counts the medication in the consumer's or authorized representative's presence when the medication is administered to the consumer and records the count on a form used for the count as specified in rules adopted under section 5166.02 of the Revised Code.

(3) The attendant recounts the medication in the consumer's or authorized representative's presence at least monthly and reconciles the recount on a log located in the consumer's clinical record.

(4) The medication is stored separately from all other medications and is secured and locked at all times when not being administered to the consumer to prevent unauthorized access.

(D) Perform an intramuscular injection;

(E) Perform a subcutaneous injection unless it is for a routine dose of insulin;

(F) Program a pump used to deliver a medication unless the pump is used to deliver a routine dose of insulin;

(G) Insert, remove, or discontinue an intravenous access device;

(H) Engage in intravenous medication administration;

(I) Insert or initiate an infusion therapy;

(J) Perform a central line dressing change.

Section 5166.309 | Practice of nursing as registered nurse or licensed practical nurse not allowed by home care attendants.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

A home care attendant who provides home care attendant services to a consumer in accordance with the authorizing health care professional's authorization does not engage in the practice of nursing as a registered nurse or in the practice of nursing as a licensed practical nurse in violation of section 4723.03 of the Revised Code.

A consumer or the consumer's authorized representative shall report to the appropriate director if a home care attendant engages in the practice of nursing as a registered nurse or the practice of nursing as a licensed practical nurse beyond the authorizing health care professional's authorization. The appropriate director shall forward a copy of each report to the board of nursing.

Section 5166.3010 | Authorized representative.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

A consumer who is an adult may select an individual to act on the consumer's behalf for purposes regarding home care attendant services by submitting a written notice of the consumer's selection of an authorized representative to the appropriate director. The notice shall specifically identify the individual the consumer selects as authorized representative and may limit what the authorized representative may do on the consumer's behalf regarding home care attendant services. A consumer may not select the consumer's home care attendant to be the consumer's authorized representative.

Section 5166.32 | Medicaid waiver for individuals with cystic fibrosis.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

If the department of medicaid terminates the 209(b) option, the department shall establish a medicaid waiver component under which an individual who has cystic fibrosis and is enrolled in the program for children and youth with special health care needs by the department of health under section 3701.023 of the Revised Code or the program the department of health administers pursuant to division (G) of that section may qualify for medicaid under the same type of spenddown process that is part of the 209(b) option.

Last updated October 6, 2023 at 10:40 AM

Section 5166.37 | Medicaid waiver - additional eligibility requirements for members of expansion group.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) The medicaid director shall establish a medicaid waiver component under which an individual eligible for medicaid on the basis of being included in the expansion eligibility group must satisfy at least one of the following requirements to be able to enroll in medicaid as part of the expansion eligibility group:

(1) Be at least fifty-five years of age;

(2) Be employed;

(3) Be enrolled in school or an occupational training program;

(4) Be participating in an alcohol and drug addiction treatment program;

(5) Have intensive physical health care needs or serious mental illness.

(B) Not earlier than February 1, 2025, and not later than March 1, 2025, the director shall seek approval from the United States centers for medicare and medicaid services to implement the medicaid waiver component described in this section.

Last updated October 6, 2023 at 10:41 AM

Section 5166.40 | Definitions.

• Effective: September 29, 2017
• Latest Legislation: House Bill 49 - 132nd General Assembly

(A) As used in sections 5166.40 to 5166.409 of the Revised Code:

(1) "Adult" means an individual who is at least eighteen years of age.

(2) "Buckeye account" means a modified health savings account established under section 5166.402 of the Revised Code.

(3) "Contribution" means the amounts that an individual contributes to the individual's buckeye account and are contributed to the account on the individual's behalf under divisions (C) and (D) of section 5166.402 of the Revised Code. "Contribution" does not mean the portion of an individual's buckeye account that consists of medicaid funds deposited under division (B) of section 5166.402 of the Revised Code or section 5166.404 of the Revised Code.

(4) "Core portion" means the portion of a healthy Ohio program participant's buckeye account that consists of the following:

(a) The amount of contributions to the account;

(b) The amounts awarded to the account under divisions (C) and (D) of section 5166.404 of the Revised Code.

(5) "Eligible employer-sponsored health plan" has the same meaning as in section 5000A(f)(2) of the "Internal Revenue Code of 1986," 26 U.S.C. 5000A(f)(2).

(6) "Healthy Ohio program" means the medicaid waiver component established under sections 5166.40 to 5166.409 of the Revised Code under which medicaid recipients specified in division (B) of this section enroll in comprehensive health plans and contribute to buckeye accounts.

(7) "Healthy Ohio program debit swipe card" means a debit swipe card issued by a managed care organization to a healthy Ohio program participant under section 5166.403 of the Revised Code.

(8) "Not-for-profit organization" means an organization that is exempt from federal income taxation under section 501(a) and (c)(3) of the "Internal Revenue Code of 1986," 26 U.S.C. 501(a) and (c)(3).

(9) "Ward of the state" means an individual who is a ward, as defined in section 2111.01 of the Revised Code.

(10) "Workforce development activity" and "local board" have the same meanings as in section 6301.01 of the Revised Code.

(B) The medicaid director shall establish a medicaid waiver component to be known as the healthy Ohio program. Each adult medicaid recipient, other than a ward of the state, determined to be eligible for medicaid on the basis of either of the following shall participate in the healthy Ohio program:

(1) On the basis of being included in the category identified by the department of medicaid as covered families and children;

(2) On the basis of being included in the expansion eligibility group.

(C) Except as provided in section 5166.406 of the Revised Code, a healthy Ohio program participant shall not receive medicaid services under the fee-for-service component of medicaid or participate in the care management system.

Section 5166.401 | Enrolllment for healthy Ohio program participants.

• Effective: September 29, 2015
• Latest Legislation: House Bill 64 - 131st General Assembly

A healthy Ohio program participant shall enroll in a comprehensive health plan offered by a managed care organization under contract with the department of medicaid. All of the following apply to the health plan:

(A) It shall cover physician, hospital inpatient, hospital outpatient, pregnancy-related, mental health, pharmaceutical, laboratory, and other health care services the medicaid director determines necessary.

(B) It shall not begin to pay for any services it covers until the amount of the noncore portion of the participant's buckeye account is zero.

(C) It shall require copayments for services covered by the health plan, except that a participant's copayments shall be waived whenever the amount of the core portion of the participant's buckeye account is zero.

(D) It shall have the following payout limits:

(1) Three hundred thousand dollars per year;

(2) One million dollars for a participant's lifetime.

Section 5166.402 | Buckeye accounts for participants.

• Effective: September 29, 2015
• Latest Legislation: House Bill 64 - 131st General Assembly

(A)(1) A buckeye account shall be established for each healthy Ohio program participant. Subject to division (A)(2) of this section, a participant's buckeye account shall consist of both of the following:

(a) The medicaid funds deposited into the account under division (B) of this section and division (A) of section 5166.404 of the Revised Code;

(b) Contributions made by the participant and on the participant's behalf under divisions (C) and (D) of this section.

(2) A buckeye account shall not have more than ten thousand dollars in it at one time.

(B) Subject to division (A)(2) of this section, one thousand dollars of medicaid funds shall be deposited each year into the buckeye account of a healthy Ohio program participant. Except in the case of a participant who is not required to make contributions to the participant's buckeye account, the initial deposit of medicaid funds into a participant's buckeye account shall not occur until the initial contribution to the participant's account is made under division (C) or (D) of this section.

(C)(1) Subject to divisions (A)(2), (D), and (F) of this section, a healthy Ohio program participant shall contribute each year to the participant's buckeye account the lesser of the following:

(a) Two per cent of the participant's annual countable family income;

(b) Ninety-nine dollars.

(2) A participant's contributions to the participant's buckeye account may be made in monthly installments. A monthly installment payment shall be considered an initial contribution.

(D)(1) Subject to division (D)(2) of this section, the following may make contributions to a healthy Ohio program participant's buckeye account on the participant's behalf:

(a) The participant's employer, but only up to fifty per cent of the contributions the participant is required to make;

(b) A not-for-profit organization, but only up to seventy- five per cent of the contributions the participant is required to make;

(c) The managed care organization that offers the health plan in which the participant enrolls under the healthy Ohio program, but both of the following apply to such contributions:

(i) They shall be used only to pay the costs for the participant to participate in a health-related incentive available under the health plan, such as completion of a risk assessment or participation in a smoking cessation program.

(ii) They cannot reduce the amount the participant is required to contribute.

(2) Contributions made on a participant's behalf under divisions (D)(1)(a) and (b) of this section shall be coordinated in a manner so that the participant makes at least twenty-five per cent of the contributions the participant is required to make.

(E) Except in the case of a healthy Ohio program participant who is not required to make contributions to the participant's buckeye account, a participant shall not begin to receive benefits under the healthy Ohio program until the initial contribution to the participant's buckeye account is made under division (C) or (D) of this section.

(F)(1) The following portion of the amount that remains in a healthy Ohio program participant's buckeye account at the end of a year shall carry forward in the account for the next year:

(a) If the participant satisfies requirements regarding preventative health services established in rules authorized by section 5166.409 of the Revised Code, the entire amount;

(b) If division (F)(1)(a) of this section does not apply, the amount representing the contributions to the account.

(2) The amount of contributions that must be made to a participant's buckeye account for a year shall be reduced by the amount that is carried forward under division (F)(1) of this section. If the amount carried forward is at least the amount of contributions that division (C) of this section requires for that year, no contributions are required to be made for the participant that year.

(G) A buckeye account shall be used only for the following:

(1) To pay for the expenses for which a healthy Ohio program debit swipe card may be used as specified in division (A) of section 5166.403 of the Revised Code;

(2) Other purposes authorized by rules adopted under section 5166.409 of the Revised Code.

(H) The department of medicaid shall provide for a healthy Ohio program participant to receive monthly statements showing the current amount in the participant's buckeye account and the previous month's expenditures from the account. The statement shall specify how much of the amount in the participant's buckeye account is the core portion and how much is the noncore portion. The department may arrange for the statements to be provided in an electronic format.

Section 5166.403 | Debit swipe cards.

• Effective: September 29, 2015
• Latest Legislation: House Bill 64 - 131st General Assembly

(A) A managed care organization that offers the health plan in which a healthy Ohio program participant enrolls shall issue a debit swipe card to be used to pay only for the following:

(1) Until the amount of the noncore portion of the participant's buckeye account is zero, the costs of health care services that are covered by the health plan and provided to the participant by a provider participating in the health plan;

(2) The participant's copayments under division (C) of section 5166.401 of the Revised Code;

(3) Subject to rules authorized by section 5166.409 of the Revised Code, the costs of health care services that are medically necessary for the participant but not covered by the health plan.

(B)(1) A healthy Ohio program participant's debit swipe card shall be credited with one point for each of the following:

(a) Each dollar of medicaid funds deposited into the participant's buckeye account under division (B) of section 5166.402 of the Revised Code;

(b) Each dollar contributed to the participant's buckeye account under divisions (C) and (D) of section 5166.402 of the Revised Code;

(c) Each point awarded to the participant under section 5166.404 of the Revised Code.

(2) Each time a healthy Ohio program participant uses the participant's debit swipe card, the amount for which the card is used shall be deducted from the number of points on the card as follows:

(a) If the card is used for the purpose specified in division (A)(1) of this section, the deduction shall come from the points representing the noncore portion of the participant's buckeye account.

(b) If the card is used for the purpose specified in division (A)(2) or (3) of this section, the deduction shall come from the points representing the core portion of the participant's buckeye account.

(C) A healthy Ohio program participant's debit swipe card shall do all of the following:

(1) Verify the participant's eligibility for the healthy Ohio program;

(2) Determine whether the service the participant seeks is covered under the health plan;

(3) Determine whether the provider from which the participant seeks the service is a participating provider under the health plan;

(4) Be linked to the participant's buckeye account in a manner that enables the participant to know at the point of service what will be deducted from the noncore portion and core portion of the participant's buckeye account for the service and how much will remain in each portion of the account after the deduction.

Section 5166.404 | Points award system.

• Effective: September 29, 2015
• Latest Legislation: House Bill 64 - 131st General Assembly

(A) The medicaid director shall establish a system under which points are awarded in accordance with this section to healthy Ohio program debit swipe cards. One dollar of medicaid funds shall be deposited into a healthy Ohio program participant's buckeye account for each point awarded to the participant under this section.

(B) The director shall provide a one-time award of twenty points to a healthy Ohio program participant who provides for the participant's contributions under division (C) of section 5166.402 of the Revised Code to be made by electronic funds transfers from the participant's checking or savings account. Twenty points shall be deducted from the participant's card if the participant terminates the electronic funds transfers.

(C) The director may award up to two hundred points annually to a healthy Ohio program participant who achieves health care goals. The points shall be awarded in accordance with the rules authorized by section 5166.409 of the Revised Code. A participant shall not be awarded more than two hundred points per year under this division regardless of the number of health care goals the participant achieves that year.

(D) Up to one hundred points may be awarded annually to a healthy Ohio program participant by one or more primary care physicians who verify that the participant has satisfied health care benchmarks set by the physicians. A participant shall not be awarded more than one hundred points per year under this division regardless of how many primary care physicians award points to the participant that year and the number of points the primary care physicians award the participant that year.

Section 5166.405 | Cessation of participation.

• Effective: September 29, 2017
• Latest Legislation: House Bill 49 - 132nd General Assembly

(A) A healthy Ohio program participant's participation in the program shall cease if any of the following applies:

(1) Unless the participant is pregnant, a monthly installment payment to the participant's buckeye account is sixty days late.

(2) The participant fails to submit documentation needed for a redetermination of the participant's eligibility for medicaid before the sixty-first day after the documentation is requested.

(3) The participant becomes eligible for medicaid on a basis other than being included in the category identified by the department of medicaid as covered families and children or being included in the expansion eligibility group.

(4) The participant becomes a ward of the state.

(5) The participant ceases to be eligible for medicaid.

(6) The participant exhausts the annual or lifetime payout limit specified in division (D) of section 5166.401 of the Revised Code.

(7) The participant requests that the participant's participation be terminated.

(B) A healthy Ohio program participant who ceases to participate in the program under division (A)(1) or (2) of this section may not resume participation until the former participant pays the full amount of the monthly installment payment or submits the documentation needed for the former participant's medicaid eligibility redetermination. The former participant shall not be transferred to the fee-for-service component of medicaid or the care management system as a result of ceasing to participate in the healthy Ohio program under division (A)(1) or (2) of this section.

(C) Except as provided in section 5166.407 of the Revised Code, a healthy Ohio program participant who ceases to participate in the program shall be provided the contributions that are in the participant's buckeye account at the time the participant ceases participation.

Section 5166.406 | Exhaustion of payout limits.

• Effective: September 29, 2015
• Latest Legislation: House Bill 64 - 131st General Assembly

If a healthy Ohio program participant exhausts the annual or lifetime payout limits specified in division (D) of section 5166.401 of the Revised Code, the participant shall be transferred to the fee-for-service component of medicaid or the care management system. A participant who exhausts the annual payout limit for a year shall resume participation in the healthy Ohio program at the beginning of the immediately following year if division (B) of section 5166.40 of the Revised Code continues to apply to the participant.

Section 5166.407 | Disqualification for medicaid; disposition of remainder in buckeye account.

• Effective: September 29, 2015
• Latest Legislation: House Bill 64 - 131st General Assembly

(A) If a healthy Ohio program participant ceases to qualify for medicaid due to increased family countable income and purchases a health insurance policy or obtains health care coverage under an eligible employer-sponsored health plan, the amount remaining in the former participant's buckeye account shall be transferred to an account to be known as a bridge account. The amount so transferred may be used only to pay for the following:

(1) If the former participant has purchased a health insurance policy, the former participant's costs in purchasing the policy and paying for the former participant's out-of-pocket expenses under the policy for health care services and prescription drugs covered by the policy;

(2) If the former participant has obtained health care coverage under an eligible employer-sponsored health plan, the former participant's out-of-pocket expenses under the plan for health care services and prescription drugs covered by the plan.

(B) Only the amount remaining in a former healthy Ohio program participant's buckeye account at the time the former participant ceased to participate in the healthy Ohio program shall be deposited into the bridge account. The bridge account shall be closed once the amount transferred to it under division (A) of this section is exhausted.

(C) The medicaid director shall notify a former healthy Ohio program participant when a bridge account is established for the former participant under this section.

Section 5166.408 | Referral to workforce development agency.

• Effective: September 29, 2017
• Latest Legislation: House Bill 49 - 132nd General Assembly

Each county department of job and family services shall offer to refer to a local board each healthy Ohio program participant who resides in the county served by the county department and is either unemployed or employed for less than an average of twenty hours per week. The referral shall include information about the workforce development activities available from the local board. A participant may refuse to accept the referral and to participate in the workforce development activities without any affect on the participant's eligibility for, or participation in, the healthy Ohio program.

Section 5166.409 | Rules.

• Effective: September 29, 2015
• Latest Legislation: House Bill 64 - 131st General Assembly

The medicaid director shall adopt rules under section 5166.02 of the Revised Code to do all of the following:

(A) For the purpose of division (F)(1)(a) of section 5166.402 of the Revised Code, establish requirements regarding preventative health services for healthy Ohio program participants. The requirements may differ for participants of different ages and genders.

(B) For the purpose of division (G)(2) of section 5166.402 of the Revised Code, authorize additional uses of a buckeye account and establish the means for using the account for those purposes.

(C) For the purpose of division (A)(3) of section 5166.403 of the Revised Code, establish requirements for the use of a healthy Ohio program debit swipe card to pay for the costs of medically necessary health care services not covered by the health plan in which a healthy Ohio program participant enrolls.

(D) For the purpose of division (C) of section 5166.404 of the Revised Code, establish a system under which the director may award points to healthy Ohio program participants who achieve health care goals. The rules shall specify the goals that qualify for points and the number of points each goal is worth. The number of points may vary for different goals.

(E) For the purpose of section 5166.407 of the Revised Code, establish procedures and requirements for the transfer of the amounts remaining in former healthy Ohio program participants' buckeye accounts to bridge accounts.

Section 5166.45 | Medicaid enrollment for chidren through age three.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) As used in this section, "medical assistance program" and "refugee medical assistance program" have the same meanings as in section 5160.01 of the Revised Code.

(B) The medicaid director shall establish a medicaid waiver component to provide continuous medicaid enrollment for children from birth through three years of age. A child who is determined eligible for medical assistance under Title XIX of the "Social Security Act" or child health assistance under Title XXI of the "Social Security Act" shall remain eligible for those benefits until the earlier of:

(1) The end of a period, not to exceed forty-eight months, following the determination;

(2) The date when the individual exceeds four years of age.

(C) The waiver component described in division (B) of this section does not apply to a child who is eligible for a medical assistance program on the basis of being any of the following:

(1) Deemed presumptively eligible for medicaid pursuant to section 5163.101 of the Revised Code;

(2) Eligible for alien emergency medical assistance, as specified in section 1903(v)(2) of the "Social Security Act," 42 U.S.C. 1396b(v)(2);

(3) Eligible for the refugee medical assistance program administered pursuant to section 5160.50 of the Revised Code.

Last updated October 6, 2023 at 5:11 PM