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Please read first: In February 2007, the Ohio Department of Developmental Disabilities (DODD) suggested to the county boards to put a "pause" on the waiver transition process for the Individuals Option (IO) waiver. This pause will allow DODD to review issues identified with the process, and to develop and propose changes to the federal government for the waiver reimbursement system. The proposed changes might affect the current ODDP process described in this booklet. If you are receiving services through the IO waiver and having problems with the ODDP and transition process, contact OLRS Intake at 1-800-282-9181.
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Ohio is in the middle of changing the way it decides the level of funding for services for persons who are served by the Individual Options (IO) waiver. This new reimbursement system is used for every new enrollee on the IO waiver and is being phased in for current enrollees on the IO waiver. It must be used in every county in the state.
The IO waiver is a Medicaid service, and like all Medicaid services it is funded in part by the federal government (approximately 59 percent) and in part by the state or local government (approximately 41 percent). The state or local money is often referred to as "match" because without state or local matching dollars you cannot get the federal dollars. The federal government (who must approve all waivers) has had concerns about Ohio's system of paying for IO waiver services, in part because it was not always consistent across the state.
Additional information: The "match" for a significant portion of the people served by the IO waiver comes from the county boards of developmental disabilities (DD). The county board either commits money that they would be receiving from the state to use as "match" or they may also use local levy money. Given that not all 88 county boards are funded equally, there have been differences (often significant) in the level of funding available for individuals receiving IO waiver services. The intent of the Ohio Developmental Disabilities Profile (ODDP) is to establish a baseline for a funding level that treats everyone the same regardless of where they reside in the state.
Additional information: This publication was developed by Ohio Legal Rights Service (OLRS), Ohio's protection and advocacy agency for people with disabilities, to respond to questions about the process that is being implemented and to identify some of your rights.
The Ohio Developmental Disabilities Profile (ODDP) is an assessment tool that is being used for all individuals on the IO waiver, and all new applicants for that waiver. The state developed the ODDP, and requires the county boards of DD to use it, in order to ensure that people on the IO waiver with similar needs receive similar funding for their services - regardless of where they live in Ohio. The score received on the ODDP determines a funding range for your annual waiver services. The ODDP does not determine the number of hours of waiver service that you require. The funding range provided by the ODDP is used together with the development of your Individual Service Plan (ISP) to decide what services you will receive.
A person from the county board of DD (or from a council of government acting on behalf of a county board) completes the ODDP. The person has been trained and certified by the Ohio Department of Developmental Disabilities to complete the assessment.
Right: The person who receives waiver services, or their guardian (if they have one), or their parent (if the waiver recipient is a child) has the right to take part in the assessment (or they can refuse to take part).
Right: You can identify the people who are most important to you to participate in the assessment.
The ODDP includes, but is not limited to, the following:
Additional information: The ODDP does not cover all variables that might impact your needs. For example, the ODDP does not include questions about your sleeping patterns. If there is a variable that you think is important, tell the person completing the ODDP and ask them to document it on the front of the ODDP. It will not change your funding range but may be helpful if you need to ask for higher funding later.
The person who completed the assessment will enter the information into a computer program that is maintained by the Ohio Department of Developmental Disabilities. That program will determine a score and provide a funding range for your waiver services.
Additional information: The computer program is designed to "weigh" the answers to the ODDP in order to provide the funding range. However, neither the person who gets waiver services, nor the county board of DD, knows how much weight is given to each answer on the ODDP.
Right: You have the right to a copy of the completed ODDP and the results.
There are individuals on the IO waiver who live with family members who are getting lower funding ranges under the ODDP. It is not yet clear why the ODDP is giving lower funding ranges in this situation. However, one thing that the ODDP considers is unpaid care that is available to you. There are questions on the ODDP about your living arrangement and about whether you live alone, with family members or with others. There is also a series of questions on the ODDP that asks about a "routine voluntary caregiver." The questions include whether your caregiver is able and willing to continue to provide services. Your caregiver is not required to provide a specific amount of voluntary care.
The questions also ask about the number of hours per week that your voluntary caregiver provides different kinds of care for you. Carefully consider the number of hours of assistance that your voluntary caregiver assists you in each of the areas of care. You can be conservative in your estimates of these hours. You do not need to include hours where your caregiver assists a paid staff person (for example, if your caregiver helps bathe you but cannot do it alone). Remember when you estimate these hours that this is "routine" care and does not include hours where your paid staff person is ill or does not show up to work.
Additional information: Make sure that the person who is completing the ODDP knows about a family member's ability and willingness to provide routine care. For example, if your voluntary caregiver has a bad back and should not be lifting you, or if your voluntary caregiver is your spouse and must work and take care of children, this will affect their ability to provide care and the need for assistance. Make sure this information is reflected in the answers to the ODDP.
If the ODDP gives you a funding range that will pay for the level of services you receive now, there will be no change to your waiver services. For many people the funding range determined by the ODDP will be the same as it has been. For some people it could result in a decrease, or even increase the amount of funding available under your waiver. The ODDP is only the first step in determining what waiver services you will receive.
You now need to meet with your team to develop a proposed Individual Service Plan (ISP), because this is the document that sets out the type of services and units of service that you need. The development of the ISP determines services you need - the ODDP does not. Do not consider the ODDP funding range when determining your needs. Do not sign your ISP yet. The county board will apply the reimbursement rates to those services to see if the services on the ISP fall within the funding range that was determined by the ODDP. If the services that you need cost more than the funding range, there is a process to ask for more funding.
Additional information: If the funding range fits your services, and you are otherwise satisfied with the ISP, and the county board is ready to transition you to the new funding system, then you can sign your ISP. If the services in your ISP cost more than your funding range, there are options you can consider, including a process that is set up to ask for more funding.
Additional information: Statewide rates have been developed for the first time for the IO waiver. County boards must apply the rates for their geographic area to the specific services you need (as developed in your proposed ISP).
If you were enrolled on the IO waiver on July 1, 2005 or later, the new waiver funding is already in effect. Prior authorization is required for higher funding (prior authorization is described starting with question 11). If you were enrolled on the IO waiver before July 1, 2005 your county board of DD has developed a transition plan for when it will transition individuals in that county. Some people have already transitioned to the new funding range. There may be some people who have had some reduction in services but are not yet within their funding range.
The new funding range does not have to take effect right away if the ODDP gives you less money to pay for your waiver services than what you currently receive. You can ask your county board about its plan for transitioning you.
Right: You should never have your services reduced without being given information about your right to appeal that decision.
If the services you need that are outlined in your ISP are more expensive than the funding range that you received from the ODDP, one option that you can consider is to share your waiver services with another person. Having a staff person work with two people in one setting costs less than providing services to only one person. You do not have to choose this option.
There will be people currently living by themselves and getting IO waiver services who will not be able to get the same level of services under the new reimbursement system. They may find this roommate option to be the best way to get the services that they need under the waiver.
There have been cases where it has been suggested that a person who lives with their family and receives waiver services should have another person who receives waiver services move in with the family. There is no obligation for a family to do this. If a person who lives with their family is given a significantly lower funding range than they have had, it may be that there is a flaw in how the computer program considers unpaid family support. Requesting more funding through the process described in the upcoming questions should be considered in this situation.
Additional information: The criteria used to approve or deny a request for higher funding will include a requirement that the additional services requested must be "the most efficient AND effective services that when combined with other non-waiver funded services ensure the health and safety of the individual." If you need to ask for higher funding rather than getting a roommate, consider how having a roommate would change the effectiveness of the waiver services.
Child: For a child under age 21 there are other alternatives through HealthChek, especially in the family home.
The first step is to make sure that the answers that were completed on your ODDP are accurate. Make sure that the people you wanted to provide input were able to and that their input is reflected in the answers.
Right: You can request at any time that any (or all) of the answers on the ODDP be revised if the answers do not adequately reflect your needs.
The second step, if step 1 does not result in the funding range that you think you need, is to work with the county board of DD to ask for services and supports that exceed that funding range. This is the beginning of a process called prior authorization, in which the state can approve services beyond the funding range allowed by the ODDP.
Right: You have the right to ask for higher funding.
Child: A child (under age 21) may have rights to expanded services under the HealthChek program.
This process is called "prior authorization" and is required to get services that exceed your funding range. The person (or their parent or guardian) requests prior authorization for higher funding. The county board of DD cannot request higher funding without the person's agreement. Prior authorization has to be requested in writing and submitted to the Ohio Department of Developmental Disabilities. The county board of DD is required to help you complete the request. If you send the request directly to the state, the county board will be notified of your request and will be asked for additional information. The following steps should be done before you submit a request for prior authorization.
Additional information: The rule that governs the Prior Authorization Process is Ohio Administrative Code 5101:3-41-12. You can ask your county board of DD for a copy.
Yes. There is a form, called a Prior Authorization form, that you can get from your Service and Support Administrator at the county board of DD, or you can get it online at Individual Request Form - Prior Authorization of Individual Options Waiver Services (PDF file) [http://odmrdd.state.oh.us/forms/9-05ReqPriorAuthWaiver.pdf].
Child: If the waiver recipient is a child under age 21, you may want to write the words "HealthChek/EPSDT" on the Prior Authorization form to alert the state that the child may be eligible for expanded services.
You still have the right to ask for the higher funding range. While it might be best to work with the county board to see if you can reach an agreement for requesting higher funding and additional services, the county board does not have the final say in the decision. If the county board is not going to support your request for more funding, then it is important that you provide more information to the Ohio Department of DD. The county board will specifically be asked about whether your request meets the four criteria that the state uses to decide your request (see Question 14).
Right: You have the right to ask for a higher funding range, with or without the agreement of the county board.
Additional information: Get documentation from your doctor, other professionals and from your provider that supports your request for more funding. Submit that material with your prior authorization request.
There are four criteria that you must meet to be eligible for prior authorization of a higher funding level. The services requested through prior authorization must be:
Child: Although the rules state that you must meet all four criteria to be approved for prior authorization, some of the criteria are more restrictive than what applies to a child under HealthChek. Make sure that the prior authorization form that you sign for your child under age 21 includes the words "EPSDT/Healthchek".
If you sent the request directly to the Ohio Department of DD they will contact your county board of DD to tell them and to request documents from the county board. The county board must send the needed documents within five days. The timeline for responding to the request is expected to be within 20 days, but failing to respond within the timeline does not mean that the request is approved. As of the date of this publication the Ohio Department of DD was running late on these requests.
The Ohio Department of DD can approve the request. If they approve the request they will notify you in writing. If they cannot approve the request they must send it on to the state Medicaid agency - the Ohio Department of Job and Family Services (ODJFS).
ODJFS can:
Right: You must be notified in writing of the decision and of your right to appeal the decision.
If the Ohio Department of Job and Family Services does not approve your request they must notify you in writing and provide you the opportunity to appeal their decision through the Medicaid fair hearing process. You can request a hearing where you can present information and testimony about why your request should be approved. If you file your request for a hearing within 15 days of notification, you will keep your current level of services during the appeal process.
Right: Since the IO waiver is a Medicaid service you can not have services reduced or terminated without being given the right to appeal that decision in what is called a Medicaid "Fair Hearing."
Learn more about Medicaid fair hearing rights through the following resources:
This is a summary of the ODDP process.
This publication was produced by the Ohio Legal Rights Service, 50 West Broad Street, Suite 1400, Columbus, Ohio 43215-5923. Telephone 614-466-7264/800-282-9181 TTY 614-728-2553/800-858-3542 Web site: http://olrs.ohio.gov
Ohio Legal Rights Service produced this publication with funding from the Protection & Advocacy for Individuals with Developmental Disabilities (PADD) program, administered by the Administration for Developmental Disabilities of the United States Department of Health and Human Services.
Funding for printing this publication was provided by the Ohio Developmental Disabilities Council under the Developmental Disabilities Assistance and Bill Of Rights Act.
Ohio Legal Rights Service does not discriminate in provision of service or employment because of race, color, religion, sex, sexual orientation, national origin, military service, disability, or age.