Respite Care (Advantage)
Beginning January 1, 2014 Ohio’s five managed care plans, through the Ohio Department of Medicaid (ODM), began offering a Respite Care benefit to a limited group of members. Prior Authorization is required for all Respite Care Services. (See OAC Rule 5160-26-03 Section I)
What are Respite Services?
Respite services are services that provide short-term, temporary relief to the informal, unpaid caregiver of an individual under the age of 21 in order to support and preserve the primary caregiving relationship. The service provides general supervision of the child, meal preparation, and hands-on assistance with personal care that are incidental to supervision of the child during the period of service delivery. Respite services can be provided on a planned or emergency basis and shall only be furnished in the child's home. The provider must be awake during the provision of respite services and the services shall not be provided overnight.
Respite Benefit Eligibility Criteria
The Ohio Department of Medicaid established criteria for this benefit, which must be met in order for a member to receive the respite services. Criteria include:
- The member must reside with his or her informal, unpaid primary caregiver in a home or an apartment that is not owned, leased, or controlled by a provider of any health-related treatment or support services.
- The member must not be residing in foster care.
- The member must be under the age of 21
- The member must be enrolled in the MCP's care management program.
- The member must be determined by the MCP to meet an institutional level of care as set forth in rules 5160-3-08 and 5160-3-09 of the Ohio Administrative Code.
- The member must require skilled nursing or skilled rehabilitation services at least once per week.
- The member must have received at least 14 hours per week of home health aide services for at least two consecutive months immediately preceding the date respite services are requested.
- The MCP must have determined that the member's primary caregiver has a need for temporary relief from the care of the member as a result of the member's long-term service support needs, or in order to prevent an inpatient institutional or out-of-home stay.
- The member must have behavioral health needs as determined by the MCP through the use of a nationally recognized standardized functional assessment tool, and be diagnosed with serious emotional disturbance as described in the appendix to this rule resulting in a functional impairment, to not be exhibiting symptoms or behaviors that indicate eminent risk of harm to him or herself or others, and the MCP must have determined that the members primary care giver has a need for temporary relief from the care of the member as a result of the members behavioral health needs, either: to prevent an inpatient or institutional or out-of-home stay or because the member has a history of an inpatient, institutional or out-of-home stay.
Respite Benefit Coverage/Limitations
For more information about the updated respite benefit, contact Paramount’s Care Management Department at 419-887-2520 or toll free at 1-800-891-2520.