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HCBS Waivers

Home Care Waiver Services

Waiver Services

Medicaid waivers allow individuals with disabilities and chronic conditions to receive care in their homes and communities rather than in long-term care facilities, hospitals or intermediate care facilities. These waivers also allow individuals to have more control over their care and remain active in their community.

Individuals must require a specific level of care and meet the financial criteria in order to enroll on an Ohio home and community-based care waiver.

What is “Level of Care”?

A level of care is a non-financial eligibility component of the Medicaid long-term care programs. An individual who wants to be enrolled in a waiver must meet the specific level of care that is required for that waiver.

  • Nursing Facility (NF)-Based Level of Care: A Medicaid home and community-based services waiver that requires a nursing facility-based level of care provides services as an alternative to nursing facilities, hospitals or rehabilitation facilities. Individuals must exceed the requirements of a protective level of care, which includes a minimum of supervision of activities of daily living (such as mobility, dressing or eating) or medication administration and assistance with instrumental activities of daily living (such as shopping, meal preparation or accessing the community), amongst other requirements.

To meet a nursing facility-based level of care, individuals must meet either an “Intermediate Level of Care,” which includes several requirements such as assistance with activities of daily living, medication administration, and skilled nursing or rehabilitation; or a “Skilled Level of Care,” which indicates a higher need due to an unstable medical condition.

The Ohio Department of Medicaid and the Ohio Department of Aging administer the waivers that require a nursing facility level of care. They include the Ohio Home Care Waiver, PASSPORT Waiver, and Assisted Living Waiver.

The condition results in substantial functional limitations in three or more of the following areas of major life activities:self-care, receptive and expressive communication, learning, mobility, self-direction, capacity for independent living, or economic self-sufficiency.

  • Development Disabilities Level of Care: The developmental disabilities level of care is necessary for enrollment into a Medicaid home and community based services (HCBS) waiver as an alternative to an intermediate care facility for individuals with intellectual disabilities.

    The Ohio Department of Developmental Disabilities administers the waivers that require a developmental disabilities level of care. They include the Individual Options Waiver, Level 1 Waiver and SELF Waiver.

    To be eligible for a “Developmental Disabilities Level of Care,” an individual must meet the following criteria:

    • For individuals birth through age 9, inclusive, the criteria for a developmental disabilities level of care is met when the individual has a substantial developmental delay or specific congenital or acquired condition; and in the absence of individually planned supports, the individual has a high probability of having substantial functional limitations in at least three major life areas:
      • Self-care, receptive and expressive communication, learning, mobility,
      • Self-direction, capacity for independent living, or
      • Economic self-sufficiency later in life.
    • For individuals ages 10 and above, the criteria for developmental disabilities level of care is met when the individual meets all the following criteria:
      1. The individual has been diagnosed with a severe, chronic disability that is attributable to a mental or physical; impairment or combination of physical and mental impairments, other than an impairment caused solely by mental illness;
      2. Is manifested before the individual is age 22; and
      3. Is likely to continue indefinitely.

For individuals to be enrolled with the OhioRISE 1915(c) waiver (OhioRISE Waiver) enrollment, they need to meet a specific level of care (LOC) criteria, have a need for a service available only through the OhioRISE waiver, and be enrolled in Medicaid, as outlined in OAC rule 5160-59-04
 
Only OhioRISE Care Management Entities (CMEs) can assist ODM with the OhioRISE Waiver LOC assessments and waiver eligibility documentation, which include:

  1. An OhioRISE Waiver Ohio Children’s Initiative Child and Adolescent Needs and Strengths (CANS) assessment completed by the CME indicating the individual meets OhioRISE Waiver criteria; 
  2. The individual has a qualifying serious emotional disturbance diagnosis; 
  3. The individual has documented functional impairment and behaviors; and
  4. The individual has a need for at least one of the OhioRISE Waiver services, which include:
    • Out-of-Home Respite: A service provided to individuals unable to care for themselves that is furnished on a short-term basis because of the absence or need for relief of those persons who normally provide care for the individual.
    • Transitional Services and Supports (TSS): Shorter-term supports for individuals and their families to help them understand, mitigate, and provide connections to long-term solutions that address behavior challenges. 
    • Secondary Flex Funds: Services, equipment, or supplies not otherwise provided through the waiver or through Medicaid that address an identified need in the service plan, including improving and maintaining the individual’s opportunities for full participation in the community.
  5. The individual has waiver needs that are less than or equal to the waiver service cost limit of $15,000.

If an individual is not yet enrolled in Medicaid and the CME’s OhioRISE Waiver LOC assessment indicates the individual meets the OhioRISE Waiver LOC, the individual can apply for Medicaid. If the individual does not meet Modified Adjusted Gross Income (MAGI)-based Medicaid eligibility income limits (which considers the family’s income as a unit), the special income level (SIL) used for individuals with specified long-term care needs, including 1915(c) waivers, may be explored. The SIL considers only the individual’s income. If the individual meets both the OhioRISE Waiver LOC criteria and Ohio Medicaid eligibility criteria, the individual will be enrolled in the OhioRISE Waiver.
 
For Medicaid eligibility and how to apply, please see the following for a step-by-step process: https://medicaid.ohio.gov/families-and-individuals/coverage/01-how-to-apply 
 
For information about income limits related to Medicaid eligibility, please see the Medicaid Eligibility Procedure Letters (MEPL) on this page: https://medicaid.ohio.gov/resources-for-providers/policies-guidelines/medicaid-eligibility-procedure-letters/medicaid-eligibility-procedure-letters. For MAGI-based Medicaid eligibility income limits, look for the MEPL indicating the Federal Poverty Level Income Guidelines for the calendar year for which Medicaid eligibility is being explored (2022 is here). For SIL income limits, see the MEPL pertaining to the Social Security Cost of Living Adjustment (COLA) for the calendar year for which Medicaid eligibility is being explored (2022 is here). Please note that many factors are considered when determining Medicaid eligibility, so it is best to submit a Medicaid application for an accurate eligibility determination. 

Nursing Facility Level of Care Waivers:

Developmental Disabilities Level of Care Waivers:

Inpatient Psychiatric Services Level of Care Waivers: