10/04/2017

ODA and ODM Clarify Heightened Scrutiny Process

LeadingAge Ohio participated in a call on September 29 during which the Ohio Department of Aging (ODA) and Ohio Department of Medicaid (ODM) provided information and clarification on how the State plans to address new assisted living waiver properties that are co-located with a nursing facility, ICF or hospital.  Prior to recent guidance from CMS providing the State with the discretion on when and how the State offers heightened scrutiny not only for existing settings but also those constructed after 2014, ODA was not certifying new, co-located properties. Since this recent guidance from CMS, ODA and ODM have been engaged in several activities to provide an avenue and process by which newly constructed co-located communities can be submitted for consideration under the heightened scrutiny process.  

ODA and ODM are in the process of reviewing rules and creating a heightened scrutiny rule including how to handle Change of Provider (CHOPs), but in the mean time will be utilizing the current process for new provider certifications.  The process for new providers that are co-located with an institution is listed below:

• The provider will initiate the process to become an assisted living waiver provider by using the on-line application process in use today.
• Once all application materials are submitted, ODA will review and follow-up using the current process.
• Once ODA determines that all the necessary items are in place, the Passport Administrative Agency (PAA) or ODA will conduct a precertification review including a desk review/on-site review that will incorporate the HCBS setting rule review components.
• Following the review, the PAA will make a recommendation if the provider should be certified.
• ODA will review all the information supplied and HCBS compliance and make an assessment if additional documentation is needed for heightened scrutiny.
• If further information is needed, ODA will reach out to the provider to get added information to strengthen ODM’s package to help providers meet the settings rule.
• Per CMS requirements, the information is submitted under the heightened scrutiny package and goes live on the ODM website for public comment for 30 days.
• ODA then incorporates input from the public comment period and provides a summary of the disposition with a recommendation to ODM to submit to CMS. Please note:  ODM will be submitting packages on a quarterly basis.
• CMS reviews application package and applies heightened scrutiny to the identified setting and makes final determination.
• If CMS denies HCBS setting, then ODA will be unable to certify the provider.
• Please note: that during the application process a provider will not be able to accept waiver individuals because the provider will not be certified.

ODA and ODM are still discussing issues around appeals of ODA/ODM’s decision as well as issues surrounding hearing rights.  For those providers in the Ohio Home Care Waiver program, ODA/ODM will be using a similar process.  As consistently stated throughout this process, ODA and ODM remain committed to ensuring that individuals continue to have access to assisted living and adult day and continue to express the intent to work with providers to ensure compliance.  LeadingAge Ohio will continue to keep providers abreast of additional information as it unfolds.  Please direct questions to Nisha Hammel at nhammel@leadingageohio.org.