Ohio Medicaid Waiver Guide

Cover Image for Ohio Medicaid Waiver Guide
By Juan O

What is the HCBS Waiver Program?

Home- and Community-Based Services (HCBS) waiver programs are special programs that allow individuals covered by Medicaid to receive care and support in their own homes or communities instead of institutional settings like nursing homes or hospitals.

Think of it like this: instead of moving into a long-term care facility to get the help you need, an HCBS waiver lets you get those same services—whether it is healthcare, personal care, or other support services—right where you live. This approach offers greater flexibility, independence, and a better quality of life because you can stay in a familiar environment.

Ohio’s HCBS waiver programs are made to meet the diverse needs of its residents, including older adults, people with disabilities, and young people with complex needs. Depending on your situation, there are different programs to help you live independently in your community.

Key Eligibility Criteria

Regardless of the specific waiver program, all participants must meet the following criteria:

  1. Medicaid Eligibility:

    • Be a U.S. citizen or meet Medicaid citizenship requirements.
    • Have or apply for a Social Security number.
    • Live in Ohio.
    • Meet financial requirements.

  2. Level of Care (LOC) Eligibility: The level of care you need depends on the program and will be one of these:

    • Nursing Facility (NF)-Based Level of Care.
    • Developmental Disability (DD)-Based Level of Care.
    • Mental Illness (MI).

  3. Service Needs:

    • Need and use at least one waiver service monthly.
    • Agree to participate in the person-centered planning process.

Waivers are generally aimed at three main groups: older adults, people with physical disabilities, and those with developmental disabilities. Each group has specific programs to meet their unique needs.

Waivers for Older Adults and Individuals with Physical Disabilities (Nursing Facility-Based Level of Care)

These waiver programs are administered by the Ohio Department of Medicaid (ODM) and the Ohio Department of Aging (ODA).

  1. Assisted Living Waiver

    • Audience: People aged 21 and older living in a licensed residential care facility certified by the Ohio Department of Aging.
    • Services Covered: Personal care, supportive services, nursing services, and case management.
    • Eligibility: Must be aged 21 or older and meet the nursing facility level of care.
    • Code Reference: Rule 5160-33-03

  2. MyCare Ohio Waiver

    • Audience: People aged 18 and older who meet a hospital or nursing level of care.
    • Services Covered: Both medical and long-term care services.
    • Eligibility: Must be aged 18 or older and live in specific counties that provide these services.
    • Code Reference: Rule 5160-58-02

  3. Ohio Home Care Waiver

    • Audience: People aged 0-59 with physical disabilities living at home.
    • Services Covered: Home health care, personal care services, and medical equipment.
    • Eligibility: Must be aged 0-59 with physical disabilities.
    • Code Reference: Rule 5160-46-02

  4. PASSPORT Waiver

    • Audience: People aged 65 and older and people with physical disabilities aged 60-64.
    • Services Covered: Home care and community-based services instead of nursing home care.
    • Eligibility: Must be aged 60-64 with physical disabilities or 65 and older.
    • Code Reference: Rule 5160-31-03

Waivers for Individuals with Developmental Disabilities (Developmental Disability-Based Level of Care)

These programs are run by the Ohio Department of Developmental Disabilities (DODD) and local County Boards of Developmental Disabilities (CBDD).

  1. Individual Options (IO) Waiver

    • Audience: People who require extensive support services.
    • Services Covered: Residential, day services, assistive technologies, and more.
    • Eligibility: Must meet the developmental disability-based level of care.
    • Code Reference: Rule 5160-40-01

  2. Level One Waiver

    • Audience: People who require limited paid support services.
    • Services Covered: Basic support services, emergency assistance, and monitoring.
    • Eligibility: Must meet the developmental disability-based level of care and need fewer services.
    • Code Reference: Rule 5160-42-01

  3. Self-Empowered Life Funding (SELF) Waiver

    • Audience: People who want to manage their own services.
    • Services Covered: Personal care assistance, supported employment, and community integration.
    • Eligibility: Must meet the developmental disability-based level of care and choose self-directed services.
    • Code Reference: Rule 5160-41-17

Waiver for Children and Youth with Complex Needs

OhioRISE (Resilience through Integrated Systems and Excellence) Waiver

  • Audience: This waiver is for children and youth aged 0-20 with complex behavioral health challenges and multi-system needs. This includes mental health issues, substance use challenges, autism, or other developmental disabilities. It also supports those involved with juvenile courts, child protective services, or those having difficulties in school or with family and friends.
  • Services Covered: OhioRISE offers a wide range of services, including Intensive Home-Based Treatment (IHBT), Psychiatric Residential Treatment Facilities (PRTF), Behavioral Health Respite, and Primary Flex Funds. These services provide functional intervention, care coordination, and specialized behavioral health support.
  • Eligibility:
    • Must be aged 0-20 at the time of enrollment.
    • Have a Serious Emotional Disturbance diagnosis.
    • Have documented functional limitations assessed by the Child and Adolescent Needs and Strengths tool.
  • Unique Aspects: The program works within a managed care system, ensuring that assessments and care coordination are done by OhioRISE Care Management Entities. Enrollment is required for eligible participants, and those not eligible receive a notice of denial along with hearing rights.
  • Code Reference: Authorized under 1915(b) and 1915(c) of the Social Security Act (SSA).

How to Begin the Enrollment Process

If you believe you qualify for any of the above waivers, you can begin the enrollment process or get more information through several methods:

  1. Request on the Medicaid Application: Indicate your interest in an HCBS waiver directly on your Medicaid application.
  2. Submit Form ODM 02399: Complete and submit the "Request for Medicaid Home and Community-Based Services (HCBS) Waiver" form to your County Department of Job and Family Services.
  3. Contact Ohio Medicaid: Make a verbal or written request to the administrative agency (Ohio Medicaid) or any approved long-term services and supports agency.

For local resources and support:

For additional support, your local County Department of Job and Family Services (CDJFS) can assist with applications and enrollment. Locate your local agency through the County Directory.