Ohio Adm.Code 5160 | Ohio Administrative Code 5160 — Ohio Department of Medicaid

Chapter 5160-1 General Provisions

Ohio Adm.Code 5160-1-01 Medicaid medical necessity: definitions and principles.

(A) Medical necessity for individuals covered by early and periodic screening, diagnosis and treatment (EPSDT) is criteria of coverage for procedures, items, or services that prevent, diagnose, evaluate, correct, ameliorate, or treat an adverse health condition such as an illness, injury, disease or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability.

(B) Medical necessity for individuals not covered by EPSDT is criteria of coverage for procedures, items, or services that prevent, diagnose, evaluate, or treat an adverse health condition such as an illness, injury, disease or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability and without which the person can be expected to suffer prolonged, increased or new morbidity; impairment of function; dysfunction of a body organ or part; or significant pain and discomfort.

(1) It meets generally accepted standards of medical practice;

(2) It is clinically appropriate in its type, frequency, extent, duration, and delivery setting;

(3) It is appropriate to the adverse health condition for which it is provided and is expected to produce the desired outcome;

(4) It is the lowest cost alternative that effectively addresses and treats the medical problem;

(5) It provides unique, essential, and appropriate information if it is used for diagnostic purposes; and

(6) It is not provided primarily for the economic benefit of the provider nor for the sole convenience of the provider or anyone else other than the recipient.

(D) The fact that a physician, dentist or other licensed practitioner renders, prescribes, orders, certifies, recommends, approves, or submits a claim for a procedure, item, or service does not, in and of itself make the procedure, item, or service medically necessary and does not guarantee payment.

(E) The definition and conditions of medical necessity articulated in this rule apply throughout the entire medicaid program. More specific criteria regarding the conditions of medical necessity for particular categories of service may be set forth within the Ohio department of medicaid (ODM) coverage policies or rules.

Last updated July 18, 2025 at 1:31 PM

History

Effective: February 24, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-02 General reimbursement principles.

This rule describes general principles regarding reimbursement of services by medicaid. Reimbursement may be subject to additional administrative criteria as described in agency 5160 of the Administrative Code.

(A) A medical service is reimbursable if:

(1) The service is determined medically necessary as defined in rule 5160-1-01 of the Administrative Code.

(2) The service is agreed to by the medicaid-covered individual or the medicaid-covered individual's authorized representative.

(3) The service is rendered to a medicaid-covered individual as defined in division 5160:1 of the Administrative Code.

(4) The service is provided within the limits of the medicaid-covered individual's medicaid benefit package.

(5) The service is provided within the scope of practice of the rendering provider as defined by applicable federal, state, and local laws and regulations.

(6) The service is rendered by a provider assigned to or selected by the medicaid-covered individual or medicaid-covered individual's authorized representative, with the exception of medicaid-covered individuals enrolled in the coordinated services program as defined in Chapter 5160-20 of the Administrative Code.

(7) The service is rendered by an eligible provider or panel provider for managed care plan participating provider.

(B) Special conditions regarding medicaid reimbursement.

(1) If a service is charged to medicaid at a rate greater than the provider's usual and customary charge to other patients for comparable services, the provider will be reimbursed at the provider's usual and customary charge or medicaid permitted reimbursement rate, whichever is lower.

(2) Inpatient and outpatient hospital services billed by hospitals reimbursed on a prospective payment basis, as defined in Chapter 5160-2 of the Administrative Code, will not be paid, in the aggregate, more than the provider's customary and prevailing charges for comparable services.

(3) Medicaid will not provide reimbursement for a provider-preventable condition as defined in 42 CFR 447.26 (as in effect on October 1, 2018). The prohibition on provider-preventable conditions shall not result in a loss of access to care or services for medicaid-covered individuals.

(1) Services delivered through the medicaid managed plans as described in Chapter 5160-26 of the Administrative Code.

(2) Habilitation services as defined in 42 USC 1396n(c)(5) (as in effect on October 1, 2018) and permitted in agency 5160 of the Administrative Code.

(D) Commingling is prohibited. For the purposes of this rule commingling occurs when the sharing of office space, staff (employed or contracted), supplies, equipment, or other resources with an on-site practice or provider organization owned or operated by the same provider, physician, or non-physician practitioners results in one or both of the following:

(1) Duplicate medicaid reimbursement for services performed; or

(2) A provider selectively choosing a higher reimbursement rate for the services performed.

Last updated September 4, 2026 at 8:30 AM

History

Effective: December 1, 2019
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-04 Employee access to confidential personal information.

(A) Definitions.

For the purposes of rules promulgated by this agency in accordance with section 1347.15 of the Revised Code effective April 9, 2009, the following definitions apply:

(1) "Access" as a noun means an instance of copying, viewing, or otherwise perceiving; whereas, "access" as a verb means to copy, view, or otherwise perceive.

(2) "Acquisition of a new computer system" means the purchase of a "computer system," as defined in this rule, that is not a computer system currently in place nor one for which the acquisition process has been initiated as of April 7, 2009.

(3) "Confidential personal information" (CPI) has the meaning as defined by division (A)(1) of section 1347.15 of the Revised Code. The appendix to this rule identifies, in accordance with division (B)(3) of section 1347.15 of the Revised Code, the federal statutes and regulations and state statutes and administrative rules that make personal information maintained by the agency confidential.

(4) "Employee of the state agency" means each employee of a state agency regardless of whether he or she holds an elected or appointed office or position within the state agency. "Employee of the state agency" is limited to the specific employing state agency.

(5) "Incidental contact" means contact with the information that is secondary or tangential to the primary purpose of the activity that resulted in the contact.

(6) "Individual" means a natural person and in the context used in division (C)(1)(b) of section 1347.15 of the Revised Code, and paragraph (E)(4)(b)(iv) of this rule, means the subject of the confidential personal information or the subject of the confidential personal information's authorized representative, legal counsel, legal custodian or legal guardian, and anyone as otherwise permitted under state or federal law acting on behalf of, or in furtherance of, the interests of the subject of the confidential personal information. "Individual" does not include an opposing party in litigation, or the opposing party's legal counsel, or an investigator, auditor or any other party who is not acting on behalf of, or in furtherance of the interests of, the subject of the confidential personal information, even if such individual has obtained a signed release from the subject of the confidential personal information.

(7) "Information owner" means the individual appointed in accordance with division (A) of section 1347.05 of the Revised Code to be directly responsible for a system.

(8) "Interconnection of Systems" Refers to a linking of systems that belong to more than one agency, or to an agency, and other organization, which linking of systems results in a system that permits each agency or organization involved in the linking to have unrestricted access to the systems of the other agencies and organizations.

(9) "Person" means a natural person.

(10) "Personal information" has the same meaning as defined in division (E) of section 1347.01 of the Revised Code.

(11) "Personal information system" means a "system" that "maintains" "personal information" as those terms are defined in section 1347.01 of the Revised Code. "System" includes manual and computer systems.

(12) "Research" means a methodical investigation into a subject.

(13) "Routine" means commonplace, regular, habitual, or ordinary.

(14) "Routine information that is maintained for the purpose of internal office administration, the use of which would not adversely affect a person" as that phrase is used in division (F) of section 1347.01 of the Revised Code means personal information relating to employees and maintained by the agency for internal administrative and human resource purposes.

(15) "System or Information System" As defined in section 1347.01 of the Revised Code, "system" means any collection or group of related records that are kept in an organized manner and that are maintained by a state or local agency, and from which personal information is retrieved using the person's name or by an identifying number, symbol, or other identifier assigned to the person. "System" includes both records that are manually stored and records that are stored using electronic data processing equipment.

(16) "Upgrade" means a substantial redesign of an existing computer system for the purpose of providing a substantial amount of new application functionality, or application modifications that would involve substantial administrative or fiscal resources to implement, but would not include maintenance, minor updates and patches, or modifications that entail a limited addition of functionality due to changes in business or legal requirements.

(B) Procedures for accessing confidential personal information.

(1) Criteria for accessing confidential personal information.

Personal information systems of the Ohio department of medicaid (ODM) are managed on a "need-to-know" basis whereby the information owner determines the level of access required for an employee of the agency to fulfill his or her job duties. The determination of access to confidential personal information shall be approved by the employee's supervisor, the information's owner, designee operating under guidlines approved by the information's owner before providing the employee with access to confidential personal information within a personal information system. The agency shall establish procedures for determining a revision to an employee's access to confidential personal information upon a change to that employee's job duties including, but not limited to, transfer or termination. Whenever an employee's job duties no longer require access to confidential personal information in a personal information system, the employee's access to confidential personal information shall be removed.

(2) Individual's request for a list of confidential personal information.

Based upon a request of any individual for a list of confidential personal information about the individual maintained by ODM, or its predecessor ODJFS, ODM shall do the following:

(a) Verify the identity of the individual by a method that provides safeguards commensurate with the risk associated with the confidential personal information.

(b) Provide to the individual the confidential personal information that does not relate to an investigation about the individual or is otherwise not excluded from being released under Chapter 1347. of the Revised Code, or other federal/state laws or regulations.

(c) If all information relates to an investigation about that individual, inform the individual that the agency has no confidential personal information about the individual that is responsive to the individual's request.

(d) Notifications made under this section shall be made in compliance with all applicable state and federal regulations.

(3) Notice of invalid access.

(a) Upon discovery or notification that confidential personal information of a person has been accessed by an employee for an invalid reason, the agency shall notify the person whose information was invalidly accessed as soon as practical and to the extent known at the time. However, the agency shall delay notification for a period of time necessary to ensure that the notification would not delay or impede an investigation or jeopardize homeland or national security. Additionally, the agency may delay the notification consistent with any measures necessary to determine the scope of the invalid access, including which individuals' confidential personal information was invalidly accessed, and to restore the reasonable integrity of the system. "Investigation" as used in this paragraph means the investigation of the circumstances and involvement of an employee surrounding the invalid access of the confidential personal information. Once the agency determines that notification would not delay or impede an investigation, the agency shall disclose the access to confidential personal information made for an invalid reason to the person.

(b) Notification provided by the agency shall inform the person of the type of confidential personal information accessed and the date or dates of the invalid access, if known.

(c) Notification may be made by any method reasonably designed to accurately inform the person of the invalid access, including written, electronic, or telephone notice.

(d) Notifications made under this section shall be made in compliance with all applicable state and federal regulations.

(4) Appointment of a data privacy point of contact and completion of a risk of harm assessment.

(a) The ODM director shall designate an employee of ODM to serve as the data privacy point of contact under the working title of "ODM HIPAA privacy official."

(b) The ODM HIPAA privacy official shall work with the state of Ohio chief privacy officer and the state of Ohio chief information security officer within the state of Ohio office of information technology to assist ODM with both the implementation of privacy protections for the confidential personal information that ODM maintains and compliance with section 1347.15 of the Revised Code and the rules adopted thereunder.

(c) The ODM HIPAA privacy official shall ensure the timely completion of the "privacy impact assessment" developed by the state of Ohio office of information technology.

Pursuant to the requirements of division (B)(2) of section 1347.15 of the Revised Code, this rule contains a list of valid reasons, directly related to the ODM exercise of its powers or duties, for which only employees of the agency may access confidential personal information regardless of whether the personal information system is a manual system or computer system.

Except as prohibited by federal and state law, performing the following functions constitute valid reasons for authorized employees of the agency to access confidential personal information:

(1) Responding to a public records request, which would require all appropriate redaction of any responsive records as required by law;

(2) Responding to a request from an individual for the list of the confidential personal information the agency maintains on that individual;

(3) Administering a constitutional provision or duty;

(4) Administering a statutory provision or duty;

(5) Administering an administrative rule provision or duty;

(6) Complying with any state or federal program requirements;

(7) Processing or payment of claims or otherwise administering a program with individual participants or beneficiaries;

(8) Auditing purposes;

(9) Licensure (or permit, eligibility, filing, etc.) processes;

(10) Investigation or law enforcement purposes;

(11) Administrative hearings;

(12) Litigation, complying with an order of the court, or subpoena;

(13) Human resource matters (for example, hiring, promotion, demotion, discharge, salary/compensation issues, leave requests/issues, time card approvals/issues);

(14) Complying with an executive order or policy;

(15) Complying with an agency policy or a state administrative policy issued by the department of administrative services, the office of budget and management, or other similar state agency;

(16) Complying with a collective bargaining agreement provision; or

(17) Research in the furtherance of agency specific programs in so far as allowed by statute.

(D) Confidentiality statutes and administrative rules.

The federal statutes and regulations and state statutes and administrative rules listed in the appendix to this rule make personal information maintained by the agency confidential and identify the confidential personal information that are subject to rules promulgated by this agency in accordance with section 1347.15 of the Revised Code.

(E) Restricting and logging access to confidential personal information systems.

For personal information systems that are computer systems and contain confidential personal information, ODM shall do the following:

(1) Access restrictions.

Access to confidential personal information that is kept electronically shall require a password or other sufficient authentication measure as determined by the ODM HIPAA privacy official in conjunction with the chief information security official will determine what constitutes sufficient authentitication measures.

(2) Acquisition of a new computer system.

When the agency acquires a new computer system that stores, manages, or contains confidential personal information, ODM shall include a mechanism for recording specific access by employees of ODM to confidential personal information in the system.

(3) Upgrading existing computer systems.

When ODM modifies an existing computer system that stores, manages, or contains confidential personal information, that results in over half of the lines of code associated with that system being modified, then that system must have an automated mechanism for recording specific access by employees of ODM to any confidential personal information that is accessed via that system.

(4) Logging requirements regarding confidential personal information in existing ODM computer systems.

(a) ODM shall require employees who access confidential personal information within ODM computer systems to maintain a log that records that access.

(b) Access to confidential information is not required to be entered into the log under the following circumstances:

(i) The ODM employee is accessing confidential personal information for official agency purposes including research, and the access is not specifically directed toward a specifically named individual or a group of specifically named individuals.

(ii) The ODM employee is accessing confidential personal information for routine office procedures and the access is not specifically directed toward a specifically named individual or a group of specifically named individuals.

(iii) The ODM employee comes into incidental contact with confidential personal information and the access of the information is not specifically directed toward a specifically named individual or a group of specifically named individuals.

(iv) The employee of the agency accesses confidential personal information about an individual based upon a request made under either of the following circumstances:

(a) The individual requests confidential personal information about himself or herself; or

(b) The individual makes a request that ODM take some action on that individual's behalf and accessing the confidential personal information is required in order to consider or process that request.

(v) ODM shall use a consistent electronic means for logging where reasonably possible. If the logging requirements are already being met through existing means, then no additional logging is required in those instances.

(5) Log management.

Each office within ODM shall use the log provided by the agency, currently identified as "CPI Log", or its successor system. Nothing in this rule limits the agency from requiring logging in any circumstance that it deems necessary.

View Appendix

History

Effective: August 1, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-05 Medicaid coordination of benefits with the medicare program (Title XVIII).

Paragraphs (A)(7) to (F)(4) of this rule do not apply to pharmacy services covered under the medicare part D program. Pharmacy services covered under the medicare part D program should be billed in accordance with rule 5160-9-06 of the Administrative Code.

(A) Definitions.

(1) "Medicare" is a federally financed program of hospital insurance (part A) and supplemental medical insurance (also called SMI or part B) for aged and disabled persons.

(2) "Medicare Benefits" means the health care services available to an individual through the medicare program where payment for the services is either completely the obligation of the medicare program or in part the obligation of the medicare program with the remaining payment obligations belonging to the individual, some other third party payer, or medicaid.

(3) "Traditional Medicare" is a health plan that pays for medicare benefits provided to individuals on a fee-for-service basis.

(4) "Medicare Advantage Plan (also known as medicare part C plan)" is a managed care delivery system that includes coverage for both hospital insurance and SMI, but the delivery of health care services are contracted to and provided by an approved medicare managed care plan, preferred provider organization, private fee-for-service plans, or medicare specialty plans.

(5) "Medicare Cost Sharing" for the purpose of this rule means the portion of a medicare crossover claim paid by medicaid.

(6) "Dual Eligibles or Dually Eligible Individuals" are individuals who are entitled to medicare hospital insurance and SMI and are eligible for medicaid to pay some form of medicare cost sharing. The following is a list of dual eligibles or dually eligible individuals that qualify to have medicaid pay all or part of the cost sharing portion of a paid medicare claim:

(a) "Qualified Medicare Beneficiaries without Other Medicaid (QMB Only)" are individuals entitled to medicare hospital insurance, have income of one hundred per cent of the federal poverty level (FPL) or less and resources that do not exceed the maximum amount of resources allowed under section 1905(p)(1) of the Social Security Act (as in effect on October 1, 2018), as adjusted annually according to the change in the consumer price index for urban areas (CPI-U), and are not otherwise eligible for full medicaid benefits.

(b) "QMBs with Full Medicaid (QMB Plus)" are individuals entitled to medicare hospital insurance, have incomes of one hundred per cent FPL or less and resources that do not exceed the maximum amount of resources allowed under section 1905(p)(1) of the Social Security Act (as in effect on October 1, 2018), as adjusted annually according to the change in the consumer price index for urban areas (CPI-U), and are eligible for full medicaid benefits.

(c) "Specified Low-Income Medicare Beneficiaries with Full Medicaid (SLMB Plus)" are individuals entitled to medicare hospital insurance, have income of greater than one hundred per cent FPL, but less than one hundred twenty per cent FPL and resources that do not exceed twice the limit for SSI eligibility, and are eligible for full medicaid benefits.

(d) "Medicaid Only Dual Eligibles (for example Non QMB)" are individuals entitled to medicare hospital insurance and SMI and are eligible for full medicaid benefits. They are not eligible for medicaid in any of the other dual eligible categories (for example QMB).

(7) "Medicare Crossover Claim" means any claim that has been submitted to the Ohio department of medicaid (ODM) for medicare cost sharing payments after the claim has been adjudicated and paid by the medicare central processor, medicare carrier/intermediary or the medicare managed care plan. Claims denied by the medicare carrier/intermediary or the medicare managed care plan are not considered medicare crossover claims. See paragraphs (E) and (F) of this rule for policy on services denied or not covered by medicare.

(a) "Automatic Crossover Claim" is a medicare claim submitted to ODM via the automatic medicare crossover process described in paragraph (B)(2)(a) of this rule.

(b) "Provider-Submitted Crossover Claim" means a medicare crossover claim submitted to ODM as described in paragraph (B)(2)(b) of this rule.

(B) Medicare crossover process.

(1) Medicare crossover claims must meet the claim submission guidelines in accordance with rule 5160-1-19 of the Administrative Code.

(2) The medicare program determines the portion of medicare cost sharing, if any, due to the provider based on medicare's business rules and submits the claim for payment to ODM using the automatic medicare crossover process.

(a) The "Automatic Medicare Crossover Process" is the coordination of benefit (COB) process whereby the provider bills medicare for services provided to a dual eligible or a dually eligible individual described in paragraph (A)(6) of this rule. Medicare adjudicates the claim, pays the provider and electronically submits the claim to ODM for the medicare cost sharing determination. Then, when appropriate, the provider is paid by medicaid within ninety days from the date of payment by medicare.

(b) When the automatic medicare crossover process does not work (i.e., the provider has received payment by medicare, has not received a payment from medicaid for the medicare cost sharing portion and at least ninety days has elapsed from the date of the receipt of the medicare payment), the provider must submit a medicare crossover claim directly to ODM. This is considered the "Provider-Submitted Crossover Claim Process."

(3) For a provider to receive reimbursement through the automatic medicare crossover process, all of the following criteria must be met:

(a) The provider must be recognized as both a medicare and medicaid provider;

(b) The provider must accept medicare assignment; and

(c) The individual must be receiving health care benefits under the traditional medicare part A and part B program (i.e., the individual is not enrolled in a medicare managed care plan). At this time ODM does not have payer-to-payer COB arrangements with medicare managed care plans.

(4) For medicare crossover claims, the total sum of the payments made by ODM, medicare and all other third party payers is considered payment in full and no additional payment may be requested from the individual with the exception of medicare co-payments as specified in paragraph (E)(5) of this rule. This is true whether or not the provider normally accepts assignment under medicare.

(a) When the provider's total reimbursement from medicare and all other third party payers equals or exceeds the medicare approved amount, no additional payment will be made by ODM.

(b) If payment (other than the cost sharing amounts) is inadvertently received from both medicare and medicaid for the same service, the provider must notify the ODM claims adjustment unit in accordance with the provisions set forth in rule 5160-1-19 of the Administrative Code.

(5) Provider submitted crossover claims must be submitted timely in accordance with rule 5160-1-19 of the Administrative Code.

(6) Crossover claims are not subject to medicaid co-payments in accordance with rule 5160-1-09 of the Administrative Code.

(C) When the individual receiving medicaid is covered by other third party payers, in addition to medicare, medicaid is the payer of last resort. Whether or not medicare is the primary payer, providers must bill all other third party payers prior to submitting a crossover claim to ODM in accordance with rule 5160-1-08 of the Administrative Code.

(D) ODM will not pay for services denied by medicare for lack of medical necessity, but may pay claims denied for reasons other than lack of medical necessity in accordance with paragraph (F) of this rule as long as the services are covered under the medicaid program. ODM will not pay for any service payable by, but not billed to, medicare.

(E) Reimbursement for medicare cost sharing on medicare crossover claims.

Reimbursement for medicare crossover claims is limited to the dual eligibles or dually eligible individuals listed in paragraph (A)(6) of this rule.

(1) The medicaid maximum reimbursement for the medicare cost sharing of hospital inpatient, outpatient or emergency room services is set forth in rule 5160-2-25 of the Administrative Code for individuals that elected to receive medicare benefits under traditional medicare.

(2) The medicaid maximum reimbursement for the medicare cost sharing of nursing facility services included in the nursing facility per diem is set forth in Chapter 5160-3 of the Administrative Code for individuals that elected to receive medicare benefits under traditional medicare.

(3) The medicaid maximum reimbursement for the medicare cost sharing of all other part B services not included in paragraph (E)(1) or paragraph (E)(2) of this rule is set forth in rule 5160-1-05.3 of the Administrative Code for individuals that elected to receive medicare benefits under traditional medicare.

(4) The medicaid maximum reimbursement for the medicare cost sharing of all advantage plan (part C) services is set forth in rule 5160-1-05.1 of the Administrative Code for individuals that elected to receive medicare benefits under a medicare advantage plan.

(5) Cost sharing for medicare part D services is not reimbursable by ODM in accordance with rule 5160-9-06 of the Administrative Code. Dual eligibles or dually eligible individuals may be required to pay medicare co-payments for prescription drugs that are covered by medicare part D.

(F) Services that are not covered by medicare must be submitted to ODM as a regular medicaid claim and should never be submitted as a medicare crossover claim.

With the exception of long term care nursing facilities, when the service is denied by medicare, and is also denied by medicaid with an error message indicating that the service is covered under medicare and the provider has documentation to support the service is not covered under medicare, the provider must do all of the following when requesting payment consideration from ODM:

(1) Submit the appropriate claim in accordance with rule 5160-1-19 of the Administrative Code;

(2) Attach the summary notice of medicare benefits that shows the denied medicare services, and the denial reason code with the denial reason code explanation from the medicare summary of benefits, the provider is requesting ODM to consider for payment;

(3) Attach a completed "ODM 06653 Medical Claim Review Request Form (rev. 7/2014 )" with supporting documentation; and

(4) Submit all forms together to the address indicated on the instruction page accompanying the ODM 06653 form.

(G) Long term care nursing facility providers must submit the appropriate claim in accordance with Chapter 5160-3 of the Administrative Code.

Last updated June 25, 2025 at 5:47 PM

History

Effective: September 16, 2019
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-05.1 Payment for "Medicare Part C" cost sharing.

(A) For qualified medicare beneficiaries and medicaid recipients enrolled in medicare part C managed health care plans (medicare advantage plans) the department will pay as cost sharing the lesser of the following amounts:

(1) The provider's billed charges for the service (except for hospital and nursing facility services); or

(2) The deductible, coinsurance and co-payment amount as provided by the medicare part C plan; or

(3) The difference between the medicare part C plan's payment to a provider for a service or services identified and the medicaid maximum allowable reimbursement rate for the same identified service or services; or

(4) The medicaid liability for the cost sharing if the service had been rendered under medicare part A or part B (calculated as twenty-five per cent of the medicare maximum allowed amount).

(B) The department will not make any additional payment to the provider, or will make a payment of zero dollars, when payment for part C cost sharing is made using the method described in paragraph (A)(3) of this rule, and the sum of the amounts paid by medicare and all other third party insurers exceeds the medicare or medicaid maximum allowed amount.

(C) The medicaid provider is ultimately responsible for accurate and valid reporting of medicaid claims and retention of relevant documents to support claims submitted for payment and any other business transactions in accordance with rule 5160-1-17.2 of the Administrative Code.

(D) Any costs beyond the medicare advantage plan's maximum out-of-pocket (MOOP) limit are not subject to cost sharing pursuant to 42 C.F.R. 422.100 (as in effect January 1, 2023).

Last updated June 25, 2025 at 5:47 PM

History

Effective: July 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-05.3 Payment for "Medicare Part B" cost sharing.

(A) The reimbursement methodology set forth in paragraph (B) of this rule is limited to medicare part B services that meet all of the following criteria:

(1) Are not hospital services defined in accordance with Chapter 5160-2 of the Administrative Code;

(2) Are not nursing facility services included in the nursing facility per diem as defined in accordance with Chapter 5160-3 of the Administrative Code;

(3) Are covered as supplemental medical insurance benefits under the medicare program; and

(4) Are provided to dual eligibles, defined in accordance with paragraph (A)(6) of rule 5160-1-05 of the Administrative Code, who elect to receive their medicare part B benefits through the original medicare program.

(B) The Ohio department of medicaid (ODM) will pay the lesser of the following calculations for part B cost sharing described in this rule:

(1) The sum of the deductible and coinsurance medicare specifies ODM is obligated to pay for crossover claims; or

(2) The difference between the medicare approved amount and the sum of the amount medicare paid and all other third party (insurance other than medicare or medicaid) payments; or

(3) The difference between the sum of the amount medicare paid and any third party payments, and the medicaid maximum allowable reimbursement rate for the same identified service or services.

(C) When payment for part B cost sharing is made using the method described in paragraph (B)(2) or (B)(3) of this rule and the sum of the amounts paid by medicare and all other third party insurers exceeds the medicare or medicaid approved amount, ODM will not make any additional payment to the provider, or will make a payment of zero dollars, and the service(s) are considered to be paid in full to the provider.

Last updated October 2, 2026 at 8:11 AM

History

Effective: January 1, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-06.1 Home and community-based service waivers: PASSPORT.

(A) The Ohio department of aging is responsible for the daily administration of the preadmission screening system providing options and resources today (PASSPORT) medicaid waiver program. Ohio department of aging will administer the waiver pursuant to an interagency agreement with the Ohio department of medicaid in accordance with section 5162.35 of the Revised Code.

(B) The PASSPORT waiver provides home and community based services (HCBS) to individuals enrolled in the waiver in accordance with rule 5160-31-03 of the Administrative Code.

(C) The PASSPORT HCBS waiver covered services and eligibility requirements are set forth in Chapter 5160-31 of the Administrative Code.

(D) The maximum allowable payment rates for PASSPORT HCBS waiver program services are listed in the appendix to this rule.

(E) PASSPORT HCBS payment will be provided in accordance with paragraphs (A) to (C) of rule 5160-1-60 of the Administrative Code.

View Appendix

Last updated April 17, 2026 at 8:02 AM

History

Effective: April 17, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-06.5 Home and community based services (HCBS) waivers: assisted living.

(A) The Ohio department of aging (ODA) is responsible for the daily administration of the assisted living HCBS waiver. ODA will administer this waiver pursuant to an interagency agreement with the Ohio department of medicaid (ODM), in accordance with section 5162.35 of the Revised Code.

(B) The assisted living HCBS waiver is an alternative to nursing facility placement for persons age twenty-one and over who require an intermediate level of care or a skilled level of care as set forth in rule 5160-3-08 of the Administrative Code and are enrolled in the waiver.

(1) The assisted living HCBS waiver's services and program eligibility criteria are set forth in Chapter 5160-33 of the Administrative Code.

(2) The maximum allowable reimbursement rates for assisted living HCBS waiver program services are listed in appendix A to this rule.

(3) Assisted living HCBS reimbursement are provided in accordance with rule 5160-1-60 of the Administrative Code.

(4) The billing maximum for the community transition service listed in appendix A to this rule represents the cumulative maximum for the items purchased or deposits made through the community transition service as set forth in rule 173-39-02.17 of the Administrative Code.

View Appendix

Last updated July 1, 2024 at 4:38 PM

History

Effective: July 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-08 Coordination of benefits.

(A) Definitions.

(1) "Coordination of benefits" (COB) means the process of determining which health plan or insurance policy will pay first or determining the payment obligations of each health plan, medical insurance policy, or third party resource when two or more health plans, insurance policies or third party resources cover the same benefits for a medicaid covered individual.

(2) "Coordination of benefits claim" (COB claim) means any claim that meets either the definition of third party claim as described in paragraph (A)(7) of this rule or the definition of medicare crossover claim as described in rule 5160-1-05 of the Administrative Code.

(3) "Explanation of benefits" (EOB) or "remittance advice" means the information sent to providers or plan beneficiaries (covered individuals) by any other third party payer, medicare, or medicaid to explain the adjudication of the claim.

(4) "Medicare benefits" has the same meaning as in rule 5160-1-05 of the Administrative Code.

(5) "Third party" (TP) has the same meaning as in section 5160.35 of the Revised Code.

(6) "Third party benefit" means any health care service available to individuals through any medical insurance policy or through some other resource that covers medical benefits and the payment for those services is either completely the obligation of the third party payer (TPP) or in part the obligation of the individual, the third party payer, or medicaid (examples of a third party benefit include private health or accidental insurance, medicare, CHAMPUS or worker's compensation).

(7) ) "Third party claim" means any claim submitted to the Ohio department of medicaid (ODM) for reimbursement after all TPPs have met their payment obligations. In addition, the following will be considered third party claims by ODM:

(a) Any claim received by ODM that shows no prior payment by a TPP, but, ODM's records indicate the medicaid covered individual has third party benefits.

(b) Any claim received by ODM that shows no prior payment by a TPP but the provider's records indicate the medicaid covered individual has third party benefits.

(8) "Third party liability" (TPL) means the payment obligations of the third party payer for health care services rendered to eligible medicaid covered individuals when the individual also has third party benefits as described in paragraph (A)(6) of this rule.

(9) "Third party payer" (TPP) means an entity, other than the medicaid or medicare programs, responsible for adjudicating and paying claims for third party benefits rendered to an eligible medicaid covered individual.

(B) If the existence of a third party benefit is known to ODM, a code number that represents the name of the third party payer covering the individual will be indicated on the individual's medicaid card. The provider shall obtain from the medicaid covered individual the name and address of the insurance company, and any other necessary information, and bill the insurance company prior to billing ODM.

(C) The provider must always review the individual's Ohio medicaid card for evidence of third party benefits. Whether there is or is not an indication of a TPP on the medicaid card, the provider must always request from the medicaid covered individual, or the individual's representative, information about any third party benefit(s). If the medicaid covered individual specifies no TP coverage and the medicaid card does not indicate TP coverage, the provider may submit a claim to medicaid (and the claim for the service is not considered a TP claim). If, as a result of this process, the provider or ODM determines that TP liability exists, the provider may only submit a claim for reimbursement if it first takes reasonable measures to obtain TP payments as set forth in paragraph (E) of this rule.

(D) The medicaid program must be the last payer to receive and adjudicate the claim except for the following:

(1) Medicaid pays after any TPL and medicare but before:

(a) The children with medical handicaps program under sections 3701.021 to 3701.0210 of the Revised Code.

(b) The state sponsored program awarding reparations to victims of crime under sections 2743.51 to 2743.72 of the Revised Code.

(2) Medicaid pays before any TPL and medicare for preventive pediatric services identified in 42 C.F.R. 433.139 (as in effect October 1, 2018).

(E) ODM reimburses for medically necessary covered services only after the provider takes reasonable measures to obtain all third party payments and file claims with all TPPs prior to billing ODM. Providers who have gone through reasonable measures to obtain all third party payments, but who have not received payment from a TPP, or have gone through reasonable measures and received partial payment, may use an appropriate code on the claim to obtain payment and submit a claim to ODM requesting reimbursement for the rendered service.

(1) Providers are considered by ODM to have taken reasonable measures to obtain all third party payments if they comply with one of the following requirements:

(a) The provider submits a claim first to the TPP and receives a remittance advice indicating that a valid reason for non-payment applies for the service as described in paragraph (E)(2) of this rule.

(b) The provider submits a claim first to the TPP for the rendered service no less than three times within a ninety-day period and does not receive a remittance advice or other communication from the TPP within ninety days of the last submission to the TPP. Providers must be able to document each claim submission and the date of the submission.

(c) The provider followed the process described in paragraph (C) of this rule for the billed service and meets the following requirements:

(i) The provider did not find a change in third party coverage;

(ii) The billed service was previously rendered to the medicaid covered individual by the provider within the last three hundred sixty-five days; and

(iii) The claim for the previously rendered service met the requirements of paragraph (E)(1)(a) or paragraph (E)(1)(d) of this rule.

(d) The provider did not send a claim to the TPP, but has received and retained at least one of the following types of documentation that indicates a valid reason for non-payment for the service(s) as set forth in paragraph (E)(2) of this rule:

(i) Written documentation from the TPP;

(ii) Written documentation from the TPP's automated eligibility and claim verification system;

(iii) Written documentation from the TPP's member benefits reference guide or manual; or

(iv) Any other reliable method for obtaining information or documentation from the TPP that there is no third party benefit coverage for the rendered service(s).

(e) The provider submits a claim first to the TPP and receives a partial payment along with a remittance advice documenting the allocation of the billed charges.

(2) Valid reasons for non-payment from a third party payer to the provider for a third party benefit claim include, but are not limited to, the following:

(a) The service is not covered under the medicaid covered individual's third party benefits.

(b) The medical expenses for the medicaid covered individual were incurred prior to the third party benefit's coverage dates.

(c) The medical expenses for the medicaid covered individual were incurred after the third party benefits coverage was terminated.

(d) The medicaid covered individual does not have third party benefits through the TPP for the date of service.

(e) All of the provider's billed charges or the TPP's approved rate was applied to the medicaid covered individual's third party benefit deductible amount.

(f) All of the provider's billed charges or the TPP's approved rate was applied in total across the medicaid covered individual's deductible, coinsurance, or co-payment for the third party benefit.

(g) The medicaid covered individual has not met eligibility requirements, out-of-pocket expenses, required waiting periods, or residency requirements for the third party benefits.

(h) The medicaid covered individual is a dependent of the individual with third party benefits, but the benefits do not cover the individual's dependents.

(i) The medicaid covered individual has reached the lifetime benefit maximum for the medical service being billed to the third party payer.

(j) The medicaid covered individual has reached the benefit maximum of the third party benefits.

(k) The TPP is disputing or contesting its liability to pay the claim or cover the service.

(l) The claim was submitted timely and with the correct information to the TPP but the claim was rejected by the TPP.

(F) Providers who have gone through reasonable measures as described in paragraph (E) of this rule to obtain all third party payments, but who have not received payment from a TPP, or received a partial payment, may submit a claim to ODM requesting reimbursement for the rendered service. If payment from the TPP is received after ODM has made payment, the provider is required to repay ODM any overpaid amount. The provider must not reimburse any overpaid amounts to the medicaid covered individual.

(G) Providers who have billed the TPP and the TPP submits payment directly to the medicaid covered individual should contact the individual to request the payment be remitted to the provider. If the individual is uncooperative with the request, the provider should contact the county department of job and family services (CDJFS).

(H) Third party claims must meet the claim submission guidelines in accordance with rule 5160-1-19 of the Administrative Code.

(I) Medicaid reimbursement for third party claims will not exceed the medicaid maximum payment for the service, determined in accordance with applicable rules for the service, less all third party payments for the service. If the result is less than or equal to zero dollars, there will be no further medicaid payment for the service.

(J) ODM will reject a TP claim when a third party claim indicates coverage by a TPP, or when the existence of third party benefits is known to ODM, and the submitted claim does not indicate collection of the third party payment or does not indicate compliance with paragraph (E) of this rule. Providers should complete their investigation of available third party benefits before submitting a TP claim to ODM for payment.

(K) The provider is prohibited from billing the medicaid covered individual any charges in accordance with rule 5160-1-60 of the Administrative Code.

(L) If the medicaid covered individual states his or her private health insurance has changed or been terminated, the provider should advise the individual to contact his or her county caseworker to correct the case record. If the individual is not cooperative in pursuing third party liability as required by rule 5160:1-2-10 of the Administrative Code, the provider should contact the CDJFS. Once the case record has been corrected, the provider may bill ODM directly.

(M) ODM has right of recovery pursuant to section 5160.37 of the Revised Code (medicaid, or any federal or state funded public health program) against the liability of a third party for the cost of medical services paid by ODM, or billable to ODM for payment at a later date. Section 5160.37 of the Revised Code requires that a medicaid covered individual provide notice to ODM prior to initiating any action against a liable third party. ODM will take steps to protect its rights of recovery if that notice is not provided. If any person, whether the medicaid covered individual or an individual acting on the behalf of a medicaid covered individual requests a financial statement from a medicaid provider for services paid by ODM or to be billed to ODM on behalf of the medicaid covered individual, the provider shall meet all of the following requirements:

(1) Require that the medicaid covered individual or the individual's representative make a request for access to financial statements in writing.

(2) Notify ODM immediately upon receipt of the medicaid covered individual's written request and forward a copy of the request to ODM, bureau of claims operations, coordination of benefits section.

(3) Release the financial statement to the medicaid covered individual or the individual's representative no later than thirty days after the date the request is received.

(4) Stamp or type on each page of the financial statement in bold font "SUBJECT TO RIGHT OF RECOVERY PURSUANT TO SECTION 5160.37 OF THE OHIO REVISED CODE. FAILURE TO COMPLY MAY RESULT IN PERSONAL LIABILITY."

(5) This rule applies to financial statements whether or not the provider has received reimbursement from ODM. This rule is not intended to prevent or restrict the provider from furnishing records of medical treatment and condition to the medicaid covered individual.

(N) Except as otherwise provided in paragraph (D)(2) of this rule, when the medicaid covered individual is covered by medicare, in addition to other third party payers, medicaid is the payer of last resort. Whether or not a TPP is the primary payer, providers must bill all other third party payers and medicare prior to submitting a claim to ODM in accordance with rule 5160-1-05 of the Administrative Code.

History

Effective: September 16, 2019
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-09 Co-payments.

This rule sets forth requirements regarding co-payments by individuals for medicaid-covered services.

(A) Certain medicaid services are subject to individual co-payments. Information regarding these services and co-payment amounts can be found in the following Administrative Code rules:

(1) Co-payments for dental services are described in rule 5160-5-01 of the Administrative Code.

(2) Co-payments for vision services are described in rule 5160-6-01 of the Administrative Code.

(3) Co-payments for non-emergency emergency department services are described in rule 5160-2-21.1 of the Administrative Code.

(4) Co-payments for pharmacy services are described in rule 5160-9-09 of the Administrative Code.

(5) Co-payment requirements for services provided through a medicaid managed care plan are described in Chapter 5160-26-12 of the Administrative Code.

(B) With regard to the application of individual payments, the following apply:

(1) No provider may deny services to an individual who is eligible for the services on account of the individual's inability to pay the medicaid co-payment. Individuals who are not able to pay their medicaid co-payment may declare their inability to pay for services or medication and receive their services or medication without paying their medicaid co-payment amount. With regard to an individual who is unable to pay a required medicaid co-payment in accordance with this paragraph, this does not:

(a) Relieve the individual from the obligation to pay a medicaid co-payment; or

(b) Prohibit the provider from attempting to collect an unpaid medicaid co-payment.

(2) No provider shall waive an individual's obligation to pay a provider a medicaid co-payment except when paragraph (A)(5) of this rule applies.

(3) No provider or drug manufacturer, including the manufacturer's representative, employee, independent contractor, or agent, shall pay any co-payment on behalf of an individual.

(4) If it is the routine business practice of the provider to refuse service to any individual who owes an outstanding debt to the provider, the provider may consider an unpaid medicaid co-payment as an outstanding debt and refuse service to an individual who owes the provider an outstanding debt. If the provider intends to refuse service to an individual who owes the provider an outstanding debt, the provider shall notify the individual of the provider's intent to refuse services. In determining outstanding debt of an individual, the following apply:

(a) A provider's decision to continue rendering services to an individual who has an unpaid co-payment shall not be considered an outstanding debt of an individual.

(b) Charges which are prohibited in accordance with paragraph (A) of rule 5160-1-60 of the Administrative Code may not be considered an outstanding debt of an individual.

(C) The following individuals are excluded from the co-payment requirement for dental, vision, non-emergency emergency department services and pharmacy services:

(1) Children and youth under the age of twenty-one.

(a) The provider may use the individual's date of birth to identify if this exclusion applies; or

(b) The provider may submit the claim to the Ohio department of medicaid (department). During adjudication of the claim, if the department identifies the individual as a child or youth under the age of twenty-one, the department will not reduce the medicaid payment by the co-payment amount.

(2) Pregnant women during pregnancy and women with post-partum coverage as defined in rule 5160-4-04 of the Administrative Code. The following also apply:

(a) Routine eye examinations and the dispensation of eyeglasses during an individual's pregnancy are subject to co-payment.

(b) For all other claims, the provider may accept the individual's self-declaration of her pregnancy if the pregnancy/ post-partum co-payment exclusion applies. If the provider reports this exclusion applies, the medicaid payment will not be reduced by the co-payment amount.

(3) Residents of a nursing facility (NF) or intermediate care facility for individuals with intellectual disabilities (ICF/IID).

(a) The provider may use the individual's address to validate whether the individual resides in a NF or ICF/IID; or

(b) The provider may submit the claim to the department. During the adjudication of the claim, if the department identifies the individual as a resident of a NF or ICF/IID, the department will not reduce the medicaid payment by the co-payment amount.

(4) Individuals receiving emergency services are excluded from co-payment when they are provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy;

(5) Individuals receiving family planning services defined as pregnancy/contraception management services in rule 5160-21-02 of the Administrative Code are excluded from co-payment when these services are provided to an individual of child-bearing age. The provider may determine on the basis of his or her professional judgment that the individual is receiving pregnancy prevention/ contraceptive services and the co-payment exclusion applies.

(6) Individuals receiving hospice services are excluded from co-payment obligations. The provider may accept the individual's self-declaration that he or she is enrolled in hospice. If the provider reports that the individual is enrolled in hospice, the medicaid payment will not be reduced by the co-payment amount.

(7) Individuals receiving medicaid because of the state's election to provide coverage under the breast and cervical cancer option pursuant to 42 CFR 447.56(a)(1)(xi).

(D) Medicare cross-over claims as defined in rule 5160-1-05 of the Administrative Code are not subject to medicaid co-payments.

Last updated September 12, 2022 at 8:13 AM

History

Effective: July 3, 2017
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-10 Limitations on elective obstetric deliveries.

(A) Payment for any cesarean section, labor induction, or any delivery following labor induction is subject to the following criteria:

(1) Gestational age of the fetus must be determined to be at least thirty-nine weeks; or

(2) If a delivery occurs prior to thirty-nine weeks gestation, maternal and/or fetal conditions must indicate medical necessity for the delivery.

(B) Cesarean sections, labor inductions, or any deliveries following labor induction that occur prior to thirty-nine weeks gestation that are not considered medically necessary are not eligible for payment.

History

Effective: May 1, 2015
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-11 Out-of-state coverage.

(A) Out-of-state providers:

(1) Should be licensed, accredited, or certified by their respective states to be considered eligible to receive reimbursement for services provided to Ohio medicaid covered individuals.

(2) Should meet any standards applicable to the provision of the service in the state in which the service is being furnished, as well as those standards set forth in the Ohio medicaid program and in the Administrative Code.

(3) Except as provided in paragraph (A)(4) of this rule, need to enroll as Ohio medicaid providers in order to obtain payment and follow appropriate billing procedures in accordance with Chapter 5160-1 of the Administrative Code and Chapter 5160-3 of the Administrative Code for long term care nursing facility services.

(4) Who are rendering services to medicaid covered individuals enrolled in a managed care plan (MCP) are not required to enroll with the Ohio department of medicaid (ODM) when:

(a) The out-of-state provider is not in the MCP's network and is providing services under a single case agreement; or

(b) The out-of-state provider is a pharmacy that is in-network with the MCP under a national contract.

(5) May have their out-of-state provider's enrollment application denied by ODM based on the denial, censure or revocation of their professional license by the applicable licensing board of any other state, or if the applicable licensing board in Ohio denies, censures or revokes a professional license even if another state's licensing board approves the respective provider.

(B) Ohio medicaid covered services will be reimbursed when rendered by out-of-state providers only under the following circumstances:

(1) The medically necessary services are not available within the state of Ohio, and the use of out-of-state providers to perform the services is authorized by the department or its designee, or authorized in accordance with rule 5160-1-31 of the Administrative Code; or

(2) The medical need arose as a result of an emergency, an accident, or an illness which occurred during a period of time the medicaid covered individual was temporarily absent from Ohio; or

(3) The individual's health would have been endangered if care was postponed until the individual returned to Ohio or attempted to return to Ohio; or

(4) The provider location for the medically necessary service is in a bordering state of Ohio, and it is the usual practice of residents in that community to utilize out-of-state providers, so long as the cost of the service does not exceed the cost of the service if provided by in-state providers; or

(5) The state determines on the basis of medical advice, that the needed medical services or necessary supplementary resources are more readily available in another state.

Last updated April 8, 2021 at 1:29 PM

History

Effective: April 4, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-13.1 Medicaid recipient liability.

(A) In accordance with 42 C.F.R. 447.15 (as in effect October 1, 2018), the medicaid payment for a covered service constitutes payment-in-full. It shall not be construed as a partial payment even when the payment amount is less than the provider's charge.

(1) The provider shall not collect nor bill a medicaid recipient for any difference between the medicaid payment and the provider's charge, nor shall the provider ask a medicaid recipient to share in the cost through a deductible, coinsurance, co-payment, missed appointment fee or other similar charge, other than medicaid co-payments as defined in rule 5160-1-09 of the Administrative Code and patient liability as described in Chapter 5160-3 and rule 5160:1-6-07 of the Administrative Code.

(2) The provider shall not charge a medicaid recipient a down payment, refundable or otherwise.

(3) Should the individual become eligible for medicaid after the date of service and the eligibility span includes the date of service, the individual may not be financially responsible.

(B) A medicaid recipient cannot be billed when a medicaid claim has been denied for any of the following reasons:

(1) Unacceptable or untimely submission of a claim;

(2) Failure to request a prior authorization; or

(3) A retroactive finding by a peer review organization (PRO) that a rendered service was not medically necessary.

(C) A provider may bill a medicaid recipient for a medicaid covered service in lieu of submitting a claim to the Ohio department of medicaid (ODM) only if all of the following conditions are met:

(1) The provider explains to the medicaid recipient that the service is a covered medicaid service and other medicaid providers may render the service at no cost to the individual;

(2) Prior to each date of service for the specific service rendered, the provider notifies the medicaid recipient in writing that the provider will not submit a claim to ODM for the service;

(3) The medicaid recipient agrees to be liable for payment of the service and signs a written statement to that effect before the service is rendered; and

(4) The medicaid covered service is not a prescription for a controlled substance as defined in section 3719.01 of the Revised Code.

(D) Services that are not covered by the medicaid program, including services requiring prior authorization that have been denied by ODM, may be billed to a medicaid recipient when the conditions in paragraphs (C)(2) to (C)(4) of this rule are met.

(E) Any individual not covered by medicaid on the date of service is financially responsible for those services unless the individual qualifies for the hospital care assurance program (HCAP) in accordance with section 5168.14 of the Revised Code.

History

Effective: January 1, 2020
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-14 Healthchek: early and periodic screening, diagnostic, and treatment (EPSDT) covered services.

(A) Definitions.

(1) "Healthchek" is Ohio's early and periodic screening, diagnostic, and treatment (EPSDT) benefit for all medicaid recipients younger than twenty-one years of age, described in 42 U.S.C. 1396d(r) (as in effect January 1,2025).

(2) "Bright futures guidelines" are the American academy of pediatrics bright futures guidelines for preventive health care, available at http://www.aap.org.

(3) "Medical necessity" and "medically necessary" have the same meaning as in rule 5160-1-01 of the Administrative Code.

(4) "Prior authorization" is one of two processes:

(a) For members of a medicaid managed care entity (MCE), it is the process established by the medicaid MCE in accordance with rule 5160-26-05.1 of the Administrative Code.

(b) For all other medicaid recipients, it is the process outlined in rule 5160-1-31 of the Administrative Code.

(B) Healthchek screening, diagnostic, and treatment services may be rendered by eligible providers in an appropriate discipline, acting within the scope of practice authorized under state law and as set forth in agency 5160 of the Administrative Code.

(C) For medicaid-eligible individuals younger than twenty-one years of age, healthchek covers the following services and items:

(1) Screening services conducted in accordance with 42 C.F.R. 441.56 (as in effect October 1, 2025).

(a) Healthchek screening services include, but are not limited to, all of the following procedures:

(i) A comprehensive health and developmental history, including assessment of both physical and mental health development, as well as substance use disorders;

(ii) A comprehensive unclothed physical exam, when appropriate;

(iii) Immunizations appropriate to age and health history;

(iv) Laboratory tests appropriate to age and risk factors, ;

(v) Nutritional status assessment; and

(vi) Health education, counseling, anticipatory guidance, and risk factor reduction intervention provided to an individual younger than twenty-one years of age and, as applicable, to another person responsible for the individual younger than twenty-one years of age.

(b) Healthchek screening services are covered at the following frequency:

(i) For immunizations, in accordance with the schedule regarding the appropriate periodicity, dosage, and contraindications applicable to pediatric vaccines established by the advisory committee on immunization practices of the centers for disease control and prevention, found at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html;

(ii) For other screening services, at ages and intervals in accordance with the bright futures guidelines; and

(iii) For all screening services, at such other intervals indicated as medically necessary to determine the existence of physical or mental illnesses or conditions.

(2) Vision services.

(a) Healthchek vision services include but are not limited to diagnosis and treatment for defects in vision, including eyeglasses.

(b) Healthchek vision services are covered at the following frequency:

(i) At intervals that meet reasonable standards of medical practice in accordance with the bright futures guidelines; and

(ii) At such other intervals indicated as medically necessary to determine the existence of a suspected illness or condition.

(3) Dental services.

(a) Healthchek dental services include but are not limited to relief of pain and infections, restoration of teeth, and maintenance of dental health.

(b) Healthchek dental services are covered at the following frequency:

(i) For individuals six years of age or younger, at intervals that meet reasonable standards of dental practice in accordance with the bright futures guidelines;

(ii) For individuals older than six and younger than twenty-one years of age, at least once every one hundred eighty days; and

(iii) For all individuals younger than twenty-one years of age, at such other intervals indicated as medically necessary to determine the existence of a suspected illness or condition.

(4) Hearing services.

(a) Healthchek hearing services include but are not limited to diagnosis and treatment for defects in hearing, including hearing aids.

(b) Healthchek hearing services are covered at the following frequency:

(i) At intervals that meet reasonable standards of medical practice in accordance with the bright futures guidelines; and

(ii) At such other intervals indicated as medically necessary to determine the existence of a suspected illness or condition.

(5) All medically necessary services and items set forth in agency 5160 of the Administrative Code.

(6) All medically necessary screenings, health care, diagnostic services, treatment, and other measures described in 42 C.F.R. 440.347 (as in effect October 1, 2025) to correct or ameliorate defects and physical and mental illnesses and conditions, regardless of whether such measures are addressed in agency 5160 of the Administrative Code.

(D) Additional provisions.

(1) Coverage limits that have been established may be exceeded, with prior authorization, for medically necessary services rendered to medicaid-eligible individuals younger than twenty-one years of age.

(2) Separate payment may be made for additional medically necessary services rendered during, as part of, or as a result of a screening visit. Payment may be made to a provider for necessary follow-up services rendered at the time of the screening visit if the provider is qualified to perform them.

(3) When a screening examination indicates the need for further evaluation of a child's health, the child must be appropriately referred without delay for diagnosis, necessary treatment, and follow-up.

(4) In accordance with section 5121 of the Consolidated Appropriations Act of 2023, 42 U.S.C. 1396a (as in effect January 1, 2025), screening and diagnostic services are covered for incarcerated individuals under the age of twenty-one in the thirty days prior to release from the carceral institution.

Last updated November 12, 2025 at 7:59 AM

History

Effective: November 10, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-16 Preventive services.

(A) "Preventive service" is a procedure, treatment, or other measure that is included in either of two groups:

(1) Services addressed in any of the following sources:

(a) "USPSTF A and B Recommendations" (January 2017), published by the United States preventive services task force and available at http://www.uspreventiveservicestaskforce.org;

(b) Immunization schedules for January 2017 published by the centers for disease control and prevention and available at http://www.cdc.gov;

(c) "Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, 4th Edition" (2017), published by the American academy of pediatrics and available at http://www.aap.org; or

(d) "Recommendations for Preventive Services for Women" (December 2016), published by the women's preventive services initiative and available at http://www.womenspreventivehealth.org; or

(2) Medically necessary procedures that meet the definition of "early and periodic screening, diagnostic, and treatment services" set forth in 42 U.S.C. 1396d(r) (as in effect in January 2017).

(B) Payment may be made for a preventive service and necessary related services (e.g., medications, procedures, devices, tests, education, and counseling) when both of the following conditions are met:

(1) A practitioner in an appropriate discipline, acting within the scope of practice authorized under state law, has determined, on the basis of at least one risk factor, that the preventive service is indicated for a particular individual; and

(2) The preventive service is provided in accordance with nationally recognized, evidence-based frequency schedules.

History

Effective: October 1, 2017
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-17 Eligible providers.

This rule sets forth eligibility requirements for practitioners, group practices, or organizational providers enrolling with, and seeking reimbursement from, the Ohio medicaid program.

(A) Eligible provider means any practitioner, group practice, or organization identified by the Ohio department of medicaid (ODM) as a type of provider eligible to enroll in the medicaid program that:

(1) Meets the applicable provider requirements and standards in agency 5160 of the Administrative Code that address applicable service categories and provider types covered under the Ohio medicaid program;

(2) Meets additional requirements and standards set forth in this rule;

(3) Meets provider screening requirements and, when applicable, pays the fee for enrollment as a provider in the medicaid program in accordance with rule 5160-1-17.8 of the Administrative Code; and

(4) Is approved for participation in the medicaid program by ODM as evidenced by the issuance of both a signed "provider agreement" and an Ohio medicaid provider number.

(B) Eligible practitioners licensed by an Ohio licensing board may enroll as a medicaid provider in accordance with their active licensure and scope of practice as determined by the licensing entity.

(C) A provider can be assigned a professional group provider type when organized for the purpose of providing professional services under Chapter 4715., 4723, 4725., 4730., 4731., 4732., 4734., 4753., 4755., 4757., 4759., or 4762. of the Revised Code, and meets the requirements in either paragraph (C)(1) or (C)(2) of this rule, and meets the additional requirements set forth in paragraphs (C)(3) to (C)(5) of this rule.

(1) A professional practice that is owned by an individual may be enrolled as a professional group practice if the practice is formed as an organizational structure listed in paragraph (C)(3) of this rule, and the owner or member of the practice possesses a valid license, certificate, or other legal authorization issued under Chapter 4715., 4723, 4725., 4730., 4731., 4732., 4734., 4753., 4755., 4757., 4759., or 4762. of the Revised Code, and also meets the requirements found in paragraph (A)(1) of this rule.

A provider enrolling with the medicaid program that does not meet the provisions listed in paragraph (C) of this rule may only be enrolled as an individual provider.

(2) Any group of two or more individuals may be enrolled as a professional group practice if the practice is formed as an organizational structure listed in paragraph (C)(3) of this rule. ODM recognizes two types of professional group practices, a professional medical group and a professional dental group.

(a) A professional medical group is a group that consists of individual practitioners recognized by ODM as eligible members. These eligible members include but are not limited to: physicians, osteopaths, advanced practice nurses, physician assistants, psychologists, podiatrists, optometrists, chiropractors, licensed independent social workers, licensed professional clinical counselors, independent marriage and family counselors, licensed independent chemical dependency counselors, occupational therapists, physical therapists, speech therapists, acupuncturists, audiologists, opticians, ocularists, licensed dietitians and registered dietitian nutritionists. With the exception of an incorporated individual in accordance with paragraph (C)(3)(b) of this rule, the professional medical practice must consist of two or more members, of like or different scopes of practice or licensure.

(b) A professional dental group is a group that consists only of dentists. With the exception of an incorporated individual in accordance with paragraph (C)(3)(b) of this rule, the practice must consist of two or more dentists.

(c) An out of state professional medical group must abide by the requirements stated in rule 5160-1-11 of the Administrative Code.

(3) For the purposes of the Ohio medicaid program, a professional group practice may be organized in accordance with one of the following organization structures:

(a) A corporation formed under Chapter 1701. of the Revised Code.

(b) A limited liability company formed under Chapter 1705. of the Revised Code.

(d) A professional association formed under Chapter 1785. of the Revised Code.

(e) A partnership formed under Chapters 1776. and 1782. of the Revised Code.

(4) With the exception of hospitals, long term care facilities, home health agencies, hospice programs, and intermediate care facilities, each practitioner employed by or under contract with a group practice or an organization, including, but not limited to professional group practices, clinics, federally qualified health centers, and behavioral health facilities, who also meet the respective requirements in paragraph (A) of the rule, must have an approved individual provider agreement with ODM.

(5) Each practitioner, employed or under contract with a group practice or an organization that is actively enrolled as a provider in the Ohio medicaid program, shall affiliate themselves with their respective group practices or organizational providers when applying for a provider agreement with ODM.

(D) Requirements for obtaining and using national provider identifiers (NPI).

(1) For the purposes of receiving reimbursement for services rendered to medicaid recipients, ODM shall require providers and practitioners enrolling in the medicaid program to obtain a NPI.

(2) Providers, and practitioners, whether practicing independently or employed or under contract with a group practice or organization, who are identified by the american medical association's national uniform claim committee with a provider taxonomy number shall obtain a NPI and shall divulge the NPI to ODM upon enrollment.

(3) The name and NPI of the practitioner who furnishes services to medicaid recipients shall be on claims submitted to ODM for reimbursement. Claims submitted without a NPI will be denied.

(4) An organization with components or subparts is responsible for determining if any components or subpart of its organization require a separate NPI and, if so, shall obtain it for that component or subpart.

(E) As part of the initial medicaid provider application, an applicant shall include a list of all geographical locations at which it renders services under its NPI. An existing provider shall submit to ODM any additions or deletions to the list of locations within thirty calendar days of the change. An enrolled provider must also notify ODM of any provider affiliation additions or deletions within thirty days of the change. Failure to follow the requirements of this paragraph may prevent an applicant from being enrolled as a medicaid provider or if enrolled, may result in the termination of a provider agreement as provided for in rule 5160-1-17.6 of the Administrative Code.

(F) ODM does not enroll providers located outside of the United States and its territories.

History

Effective: November 25, 2019
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-17.2 Provider agreement for providers.

Provisions of provider agreements for long term care nursing facilities are defined in Chapter 5160-3 of the Administrative Code. Provisions for provider agreements for medicaid contracting managed care plans are defined in Chapter 5160-26 of the Administrative Code.

A valid provider agreement with medicaid will act as a provider agreement for participation in the medicaid program. All medicaid provider applications must be submitted through the medicaid information technology system (MITS) web portal. Provider applications submitted in paper format will be returned to the provider unprocessed.

If a provider application requires additional supporting documentation by the department for the application process to be completed, the supporting documentation may be sent through the MITS web portal or sent to the department through regular mail service.

A provider agreement is a contract between the Ohio department of medicaid (ODM) and a provider of medicaid covered services. By signing this agreement the provider agrees to comply with the terms of the provider agreement, Revised Code, Administrative Code, and federal statutes and rules; and the provider certifies and agrees:

(A) To render medical services as medically necessary for the patient and only in the amount required by the patient without regard to race, creed, color, age, sex, national origin, source(s) of payment, or disability; submit claims only for services actually performed; and, bill ODM for no more than the usual and customary fee charged other patients for the same service.

(B) To ascertain and recoup any third-party resource(s) available to the consumer prior to billing ODM. ODM will then pay any unpaid balance up to the lesser of the provider's billed charge or the maximum allowable reimbursement as set forth in agency 5160 of the Administrative Code.

(C) To accept the allowable reimbursement for all covered services as payment-in-full, except as required in paragraph (B) of this rule. The provider will not seek reimbursement for that service, except as defined in rule 5160-1-09 of the Administrative Code, from the patient, any member of the family, or any other person.

(D) To maintain all records necessary and in such form so as to fully disclose the extent of services provided and significant business transactions. The provider will maintain such records for a period of six years from the date of receipt of payment or until any audit initiated within the required six year record maintenance period is completed.

(E) To furnish to ODM, the secretary of the department of health and human services, or the Ohio medicaid fraud control unit or their designees any information maintained under paragraph (D) of this rule for audit and review purposes. Audits may use statistical sampling. Failure to supply requested records within thirty days shall result in withholding of medicaid payments and may result in termination from the medicaid program.

(F) To inform ODM within thirty days of any changes including, but not limited to changes in licensure, certification, or registration status; ownership; specialty; additions, deletions, or replacements in group membership and hospital-based physician affiliations; and address, including all locations where services are rendered.

(G) To disclose ownership and control information, and to disclose the identity of any person who has been convicted of a criminal offense related to medicare, medicaid, or services provided under Title XX of the Social Security Act as in effect on November 15, 2018 (Title XX), as specified in rule 5160-1-17.3 of the Administrative Code.

(H) That neither the individual practitioner, nor the company, nor any owner, director, officer, or employee of the company, nor any independent contractor retained by the company, is currently subject to sanction under medicare, medicaid, or Title XX; or, is otherwise prohibited from providing services to medicare, medicaid, or Title XX beneficiaries.

(I) To provide to ODM, through the court of jurisdiction, notice of any bankruptcy action brought by the provider. Notice shall be mailed to: office of legal services, Ohio department of medicaid.

(J) To comply with the appropriate advance directives requirements for hospitals, providers of home health care, personal care services, and hospices as specified in Chapter 3701-83 of the Administrative Code.

(K) To comply with the confidentiality safeguards and the use and release of information regarding public assistance recipients as described in section 5101.27 of the Revised Code.

(L) To comply with section 121.36 of the Revised Code and rule 5160-1-39 of the Administrative Code when providing home care services.

Last updated September 1, 2023 at 12:55 PM

History

Effective: September 19, 2019
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-17.3 Provider disclosure requirements.

(A) For the purposes of this rule, the following definitions apply:

(1) "Affiliation" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023).

(2) "Agent" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023).

(3) "Disclosable event" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023).

(4) "Disclosing provider" means a medicaid provider, managed care entity, or fiscal agent under contract with the department of medicaid (department) in accordance with 42 C.F.R. 455.101 (as in effect on October 1, 2023).

(5) "Indirect ownership interest" means an ownership interest in an entity that has direct or indirect ownership in the disclosing provider.

(6) "Managing employee" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023).

(7) "Person with an ownership or control interest" means a person or corporation that meets any of the following:

(a) Has an ownership interest totaling five per cent or more in the disclosing provider;

(b) Has an indirect ownership interest equal to five per cent or more in the disclosing provider;

(c) Has a combination of direct and indirect ownership interest equal to five per cent or more in the disclosing provider;

(d) Owns an interest of five per cent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least five per cent of the value of the property or assets of the disclosing provider;

(e) Is an officer or director of the disclosing provider that is organized as a corporation or non-profit; or

(f) Is a partner in the disclosing provider that is organized as a partnership or limited liability company.

(8) "Significant business transaction" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023).

(B) Disclosing providers will disclose the following information to the department in accordance with 42 C.F.R. 455.104 to 42 C.F.R 455.106 (as in effect on October 1, 2023):

(1) The name and address of any person (individual or corporation) with an ownership or control interest in the disclosing provider.

(a) In the case of an individual, date of birth and social security number.

(b) In the case of a corporation, other tax identification number with an ownership or control interest in the disclosing provider or in any subcontractor in which the disclosing provider has a five per cent or more interest.

(2) Whether the person (individual or corporation) with an ownership or control interest in the disclosing provider is related to another person with ownership or control interest in the disclosing provider as a spouse, parent, child, or sibling.

(3) Whether the person (individual or corporation) with an ownership or control interest in any subcontractor in which the disclosing provider has a five per cent or more interest is related to another person with ownership or control interest in the disclosing provider as a spouse, parent, child, or sibling.

(4) The name of any disclosing provider in which an owner of the disclosing provider has an ownership or control interest.

(5) The name, address, date of birth, and social security number of any managing employee of the disclosing provider.

(6) The identity of any person who has ownership or control interest in the disclosing provider or is an agent or managing employee of the disclosing provider, and has been convicted of a criminal offense related to that person's involvement in any program under medicare, medicaid, or the title XX services program since the inception of those programs.

(7) The ownership of any subcontractor with whom the disclosing provider has had business transactions totaling more than twenty-five thousand dollars during the preceding twelve-month period ending on the date the disclosure is due.

(8) Any significant business transaction between the disclosing provider and any wholly owned supplier, or between the disclosing provider and any subcontractor, during the preceding five-year period ending on the date the disclosure is due.

(C) Disclosing providers, prior to initial enrollment or revalidation with the Ohio department of medicaid (department), who are not enrolled in medicare, will at the request of the department disclose when a managing employee, within the past five years, has an affiliation with a currently or formerly enrolled medicare, medicaid, or child health insurance program (CHIP) provider or supplier that has had a disclosable event in accordance with 42 C.F.R. 455.107 (as in effect on October 1, 2023).

(1) Applicable disclosing providers will disclose the following information about each affiliation:

(a) General identifying information including:

(i) Legal name of the provider as reported to either the internal revenue service (IRS) or social security administration (SSA);

(ii) Legal name of any managing employees as reported to either the IRS or SSA;

(iii) Tax identification number (TIN); and

(iv) National provider identifier (NPI);

(b) Length of the relationship;

(d) Degree or extent of affiliation; and

(e) If the affiliation has ended, the reason for the termination.

(2) The department, in consultation with the center for medicare and medicaid services (CMS), will decide, utilizing the factors found in 42 C.F.R 455.107 (as in effect on October 1, 2023), whether the affiliation poses an undue risk of fraud, waste, and abuse.

(a) If the department determines the provider's affiliation poses an undue risk, the provider's application will be denied or if enrolled, will result in the termination of the provider agreement.

(b) If enrollment is denied or the provider agreement terminated as a result of the department determining the provider's affiliation poses an undue risk of fraud, waste, and abuse, the provider may request a hearing pursuant to Chapter 119. of the Revised Code.

(D) Disclosures will be due at any of the following times in accordance with 42 C.F.R. 455.104 (as in effect on October 1, 2023):

(1) Prior to entering into a medicaid provider agreement or contract, during a procurement process or as part of a request for proposal.

(2) Prior to revalidating a medicaid provider agreement, or the renewal or extension of the contract.

(3) Within thirty-five days of any change in ownership.

(4) At any time within thirty-five days upon written request from the department.

(E) Failure by the disclosing provider to disclose information in accordance with this rule may result in the denial, suspension, or termination of the medicaid provider agreement or contract.

Last updated June 25, 2025 at 6:35 PM

History

Effective: July 15, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-17.4 Revalidation of provider agreements.

(A) Revalidation is the process that a provider is required to follow to renew and revalidate its provider agreement. Provider agreements must be revalidated no later than five years from the effective date of the original or the last revalidated provider agreement, whichever is applicable. In the event the center for medicare and medicaid services (CMS) waives or modifies the deadline, provider agreement revalidation may be delayed as authorized by the CMS waiver or modification. Provider agreements must also be revalidated whenever there is a change in risk pursuant to 42 C.F.R. 455.450 (as in effect October 1, 2020) The revalidation process is as follows:

(1) The Ohio department of medicaid (ODM) shall send a revalidation notice ninety days prior to the expiration date of the provider's time-limited agreement either to the provider's email or mailing address on file notifying the provider that it is required to revalidate its agreement.

(2) The revalidation notice shall instruct the provider what is required to complete the revalidation process. Providers are expected to meet all conditions for participation as an eligible provider that are in effect in Chapter 5160-1 of the Administrative Code at the time of revalidation.

(3) The provider shall submit all required information before the revalidation deadline date specified in the revalidation notice including the required fee as specified in rule 5160-1-17.8 of the Administrative Code.

(4) A provider shall not initiate revalidation prior to the receipt of the revalidation notification sent by ODM. This rule does not negate the requirement that a provider must properly disclose any changes to its provider agreement in accordance with rule 5160-1-17.3 of the Administrative Code. The reporting of changes does not constitute the initiation of revalidation and remains the provider's responsibility.

(5) When a provider fails to revalidate in the time and the manner required by ODM, as specified in this rule and in accordance with the revalidation notice referred to in paragraph (A)(1) of this rule, ODM shall deny an application for revalidation and terminate the time-limited provider agreement. The denial and termination will take effect thirty days after ODM mails a written notice to the provider by regular mail to the address on file notifying the provider of the decision. ODM shall specify in the notice the date on which the provider is required to cease operating under a terminated provider agreement.

(6) If a provider files an application for revalidation within the time and in the manner required, as specified in this rule, but the provider agreement expires before ODM acts on the application or before the effective date of the ODM decision on the application, the provider may continue operating under the terms of the expired agreement until the effective date of the ODM decision.

(7) If a provider files an application for revalidation within the time and in the manner required, as specified in this rule, but has not been able to obtain a renewal of its licensure, certification, accreditation, or registration the application may be accepted and processed by ODM as long as the granting official, board, commission, department, division, bureau, or other agency of state or federal government considers the provider in good standing and that its licensure, certification, accreditation, or registration is still active.

(B) The effective date of a new provider agreement is the date on which the provider signs the application and meets all of the federal and state requirements for participation in the medicaid program. The effective date of a new provider agreement may be made retroactive for up to twelve months prior to the date of application if the provider was properly licensed or certified.

(C) Pursuant to section 5164.38 of the Revised Code, ODM is not required to afford hearing rights, in accordance with Chapter 119. of the Revised Code when terminating a time-limited provider agreement due to the provider's failure to properly file an application for revalidation.

(D) In processing an application for revalidation, ODM reserves the right to conduct an on-site review at the provider's facility, place of business, or both, as ODM deems necessary to ensure program integrity.

Last updated September 16, 2026 at 8:28 PM

History

Effective: April 17, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-17.5 Suspension of medicaid provider agreements.

(A) Definitions:

(1) "Credible allegation of fraud" means an accusation of fraud as defined in section 5164.36 of the Revised Code.

(2) "Non-institutional provider" means any person or entity with a medicaid provider agreement other than a hospital, long-term care nursing facility, intermediate care facility for individuals with intellectual disabilities or medicaid contracting managed care plans.

(B) The Ohio department of medicaid (ODM) shall suspend a medicaid provider agreement when at least one of the following conditions apply:

(1) Upon determining there is a credible allegation of fraud for which an investigation is pending against a provider under the medicaid program, unless good cause to not suspend is found pursuant to 42 CFR 455.23(e) or (f), effective Feb. 2, 2011; or

(2) Upon receiving notice and copy of an indictment that charges a non-institutional provider, its owner or owners, officer, authorized agent, associate, manager, or employee with committing an offense as specified in division (E) of section 5164.37 of the Revised Code.

(1) If a provider is suspended pursuant to this rule, then any other provider agreements where the provider is an owner, officer, authorized agent, manager, or employee may also be suspended.

(2) A provider, its owner or owners, officer, authorized agent, associate, manager, or employee shall not own or provide services to any other medical provider or risk contractor or arrange for, render, or order services for medicaid recipients during the period of suspension.

(3) During the period of suspension, the provider owner or owners, officer, authorized agent, associate, manager, or employee shall not receive reimbursement in the form of direct payments from ODM or indirect payments of medicaid funds.

(4) The suspension shall continue until either of the following:

(a) The department or a prosecuting authority determines that there is insufficient evidence of fraud by the provider;

(b) The proceedings in any related criminal case are completed through dismissal of the indictment or through conviction, entry of a guilty plea, or finding of not guilty.

(5) If ODM commences a process to terminate the suspended provider agreement, the suspension shall continue in effect until the termination process is concluded.

(D) Reconsideration of suspension:

(1) A provider, owner, or owners subject to a suspension may request a reconsideration in accordance with section 5164.36 or 5164.37 of the Revised Code. A request for reconsideration is not subject to Chapter 119. of the Revised Code.

(2) The reconsideration shall be conducted by the ODM director or the director's designee in the office where the contestation arose provided that the designee was not involved in the original decision. Decisions made by the director or the director's designee are not appealable or subject to further reconsideration.

Last updated September 1, 2023 at 12:56 PM

History

Effective: March 22, 2015
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-17.6 Termination and denial of provider agreement.

(A) For purposes of this rule, the following definitions apply:

(1) "Ownership or control interest" means having at least five per cent ownership, or interest, either directly, indirectly, or in any combination.

(2) "Provider" has the same meaning as "eligible provider," as defined in rule 5160-1-17 of the Administrative Code.

(3) "Provider Agreement" means an agreement as defined in rule 5160-1-17.2 of the Administrative Code or any rule contained in agency 5160 of the Administrative Code.

(B) Termination for long term care nursing facilities and intermediate care facilities for individuals with intellectual disabilities is located in Chapters 5160-3 and 5123:2-7 of the Administrative Code.

(C) Termination for providers enrolled in a medicaid managed care plan is located in Chapter 5160-26 of the Administrative Code.

(D) A provider may voluntarily terminate a provider agreement upon written notice thirty days before the provider's chosen termination date. The Ohio department of medicaid (ODM) has the discretion to accept or deny a voluntary termination for a provider who is facing involuntary termination due to an ODM action. ODM may waive the thirty day requirement if appropriate.

(E) A provider is ineligible for payment for dates of service on or after the effective date of a denial, suspension, revocation, limitation, or failure to renew a license, permit, certifcate, or certification issued by an official, board, commission, department, bureau, or other agency of the state or federal government.

(F) A provider that was terminated because of a conviction that was a result of a suspension due to credible allegation of fraud is ineligible for all payments, regardless of the dates of service.

(G) ODM may propose termination or denial of a provider agreement at any time it is determined that continuation or assumption of provider status is not in the best interest of recipients or the state of Ohio. The phrase "not in the best interest" shall include, but not be limited to, the following circumstances or occurrences:

(1) The provider has not billed or otherwise submitted a medicaid claim to ODM for two years or longer.

(2) The provider, or any person having an ownership or controlling interest in the provider, or who is an agent or employee of the provider, has been indicted or granted immunity from prosecution for, or has pled guilty to, or has been convicted of, any criminal offense against the state of Ohio or any other state or territory, whether the offense occured prior to or during the period of ownership, employment, or agency.

(3) The provider has made false representations, by omission or commission, on the provider enrollment application or does not fully and accurately disclose to ODM information as required by the provider agreement, any rule contained in agency 5160 of the Administrative Code, or any provisions contained in 42 C.F.R., Part 455, Subpart B (October 1, 2014)..

(4) The provider has been determined liable for negligent performance of professional services to its clientele or patients.

(5) As determined by ODM, the provider has departed from or failed to conform to accepted standards of care of similar practitioners under the same or similar circumstances, whether or not actual injury to a patient is established.

(6) The provider has been formally reprimanded or censured, placed on probation, suspended or placed on practice limitations for unethical conduct or improper practices by a state licensure board or by an association of its peers.

(7) The provider fails to file cost reports as required.

(8) The provider makes false statements, provides false information, or alters records, documents, charts, or prescriptions, or fails to cooperate or provide records or documentation upon request during an audit or review of provider activity by staff or contracting entity of ODM, any county department of job and family services, the attorney general's office, the auditor of state, the department of health and human services, or any other state or federal agency which, by law, has authorized access to records or documents. An alteration of provider records does not include records for which there is a properly documented correction.

(9) The provider has not corrected deficiency(ies) after receiving a written notice of operational deficiency from ODM.

(10) The provider fails to abide by, meet the requirements of, or have the capacity to comply with the terms and conditions of the provider agreement, and/or rules and regulations promulgated by ODM.

(11) The provider has been suspended or terminated from participation in another government medical program other than a program that requires automatic termination.

(12) The provider is found in violation of section 504 of the Rehabilitation Act of 1973, as amended (January 1, 2015), or the Civil Rights Act of 1964, as amended (January 1, 2015), in relation to the employment of individuals, the provision of services or in the purchase of goods and services.

(13) The provider, by any act or omission, has negatively affected the health, safety, or welfare of the medicaid recipient or the fiscal or programmatic integrity of the medicaid program.

(14) The office of the attorney general, auditor of state, or any board, bureau, commission, or department has recommended that ODM terminate the provider agreement where the reason for the request bears a reasonable relationship to the administration of the medicaid program or the integrity of state and/or federal funds.

(15) As determined by ODM, the provider fails to use reasonable care or discretion in the storage, administration, dispensing, or prescribing of drugs, or fails to employ acceptable scientific methods in the selection of drugs or other modalities of treatment of disease.

(16) As determined by ODM, the provider sells, gives away, personally furnishes, prescribes, or administers drugs for other than legal and legitimate therapeutic purposes.

(17) The United States drug enforcement agency has suspended or revoked the provider's registration for any act or acts which would constitute a violation of paragraph (E)(5), (E)(15), or (E)(16) of this rule.

(18) The provider or the provider's staff misrepresents the type and/or units of service, inflates billing codes to increase payments, or bills for, or receives payments for services not rendered, or any other practice that is a violation of any rule contained in agency 5160 of the Administrative Code.

(19) As determined by ODM, the provider, or the provider's staff prescribes, authorizes, bills for, or receives payments for, services that are not medically necessary as defined in rule 5160-1-01 of the Administrative Code.

(20) The provider or the provider's staff lack the ability or legal authority to provide services for which the provider has billed, because of lack of equipment or material, or a failure to comply with minimal requirements under state and federal law.

(21) The provider consistently violates the prohibition against billing medicaid recipients or assigning provider claims to a factor, as found in rule 5160-1-13.1 of the Administrative Code or 42 CFR 447.10 (October 1, 2014).

(22) The provider fails to notify ODM within thirty days of any changes in licensure, certification, accreditation, or registration status, ownership, closure, specialty, additions, deletions, or replacements in group memberships, and address.

(23) The provider fails to repay an overpayment or recovery amount assessed as a result of a final adjudication order.

(24) The provider has a previous or current exclusion, suspension, termination or involuntary withdrawal from participation in any medicaid program, or any other public or private health insurance program.

(25) The provider has been convicted under federal or state law of a criminal offense relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct.

(26) The provider has not responded to two certified mail correspondences from ODM and the provider's business cannot otherwise be located.

(27) The provider signed a provider agreement and failed to revalidate the provider agreement in accordance with rule 5160-1-17.4 of the Administrative Code.

(28) Any reason permitted or required by federal law.

(H) For any reason permitted or required by federal law, ODM may deny or exclude from participation in the medicaid program any individual, provider of services or goods, or other entity that does not possess a medicaid provider agreement.

(I) ODM shall terminate or deny a provider agreement when any of the following apply:

(1) Any license, permit, or certification that is required in the provider agreement or department rule has been denied, suspended, revoked, not renewed or is otherwise limited and the provider has been afforded the opportunity for a hearing in accordance with the hearing process established by the official, board, commission, department, division, bureau, or other agency of state or federal government.

(2) The terms of a provider agreement require the provider to hold a license, permit, or certificate, or maintain certification, issued by an official, board, commission, department, division, bureau, or other agency of state or federal government, other than ODM, and the provider has not obtained the license, permit, certificate, or maintained the certification.

(3) An official, board, commission, department, division, bureau, or other agency of this state, other than ODM, has denied, terminated, or not renewed a license, permit, certificate or certification that is required for participation, notwithstanding the fact that the provider may hold a license, permit, certificate or certification from an official, board, commission, department, division, bureau, or other agency of another state.

(4) A judgment has been entered in either a criminal or civil action against a medicaid provider or its owner, officer, authorized agent, associate, manager, or employee in an action brought pursuant to section 109.85 of the Revised Code, except if the provider or owner can demonstrate to ODM that the provider or owner did not directly or indirectly sanction the action of its authorized agent, associate, manager, or employee which resulted in the conviction or entry of judgment.

(5) The provider is terminated, suspended, or excluded by the medicare program and/or by the federal department of health and human services and that action is binding on the provider's participation in the medicaid program or renders federal financial participation unavailable for that provider's participation in the medicaid program.

(6) The provider has been convicted of, or pled guilty to, any criminal activity materially related to either the medicare or medicaid program or has been convicted of one of the offenses that caused the provider agreement to be suspended in accordance with rule 5160-1-17.5 of the Administrative Code..

(7) The provider has failed to apply for revalidation within the time and in the manner specified for revalidation pursuant to section 5164.32 of the Revised Code.

(8) The provider fails to timely submit a required background check or when the background check reveals that the provider has been convicted of, or pled guilty to a disqualifying offense unless the provider meets specific circumstances provided in agency 5160 of the Administrative Code.

(9) ODM has determined that the provider facility has closed or is not providing medicaid covered services.

(J) Appeal rights for the termination or denial of a provider agreement provided in this rule are found in rule 5160-1-57 of the Administrative Code.

(K) In determining the length of termination, ODM shall consider the following:

(1) The number and nature of program violations and other related offenses and the degree to which the provider participated in the offense;

(2) The nature and extent of any adverse impact the violations have had on recipients, including but not limited to the health and safety of those recipients who are aged and/or at greater physical, mental and emotional risk;

(3) The amount of any damages incurred by the medicaid program;

(4) Whether there are any mitigating circumstances;

(5) Any other facts bearing on the nature and seriousness of the violations or related offenses;

(6) The current, pending and previous sanction record of the provider under the medicare, medicaid, or other health-related programs; and

(7) Whether the provider is pending any future state or federal litigation relating to the current or any similar offense.

(L) ODM reserves the right to deny twelve months retroactivity for the submission of claims to providers whose agreement is reinstated after termination for cause in accordance with this rule.

Last updated May 18, 2026 at 5:25 PM

History

Effective: April 9, 2015
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-17.7 Application by a former participating medicaid provider to resume participation in the Ohio medicaid program [except for medicaid contracting managed care plans (MCPs)].

(A) An individual or entity that at one time was a participating provider in the Ohio medicaid program and whose provider agreement was terminated either voluntarily or involuntarily in accordance with rule 5160-1-17.6 of the Administrative Code must complete a new application for enrollment if that individual or entity wants to resume participation in the Ohio medicaid program.

(B) In considering an application for participation in the Ohio medicaid program by a former medicaid provider described in paragraph (A) of this rule, and except as provided by paragraphs (C) and (D) of this rule, the Ohio department of medicaid (ODM) may grant the application only if it is reasonably certain that the types of actions that formed the basis for termination or exclusion have not recurred and will not recur. In making this determination, ODM will consider, in addition to any factors set forth in state law:

(1) The conduct of the former medicaid provider from the date the provider's previous provider agreement was terminated;

(2) Whether all fines, and all debts due and owing, including overpayments, to any federal, state or local government that relate to any of the state health care programs, have been paid, or satisfactory arrangements have been made, that fulfill these obligations; and

(3) Whether all requirements for participation are met at the time of the application filed pursuant to paragraph (A) of this rule, as evidenced by all appropriate and required documentation submitted with the application by the former medicaid provider.

(C) Notwithstanding paragraph (B) of this rule, ODM shall deny the application of a former medicaid provider whose provider agreement was terminated under paragraph (I)(4) or (I)(6) of rule 5160-1-17.6 of the Administrative Code.

(D) In the case of a former medicaid provider that allowed its provider agreement to lapse by failing to timely revalidate its provider agreement, and whose provider agreement has been inactive for at least sixty days, ODM may, without regard to the criteria set forth in paragraph (B) of this rule and at its discretion, grant an application that demonstrates through all appropriate and required documentation that the requirements to participate as a medicaid provider are met at the time the application is filed.

(E) If ODM approves an application filed under paragraph (A) of this rule, it must give written notice to the applicant specifying the date on which participation in the Ohio medicaid program may resume. The notice shall specify whether the applicant is assigned its former provider number or a new provider number, the determination of which shall be in the sole discretion of ODM.

(F) If ODM does not approve an application filed under paragraph (A) of this rule, it must give the applicant written notice of that decision. The notice will provide review rights in accordance with paragraph (D) of rule 5160-70-02 of the Administrative Code.

Last updated September 1, 2023 at 12:57 PM

History

Effective: January 13, 2017
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-17.8 Provider screening and application fee.

(A) In accordance with 42 C.F.R. 455.410 (as in effect October 1, 2019) and rule 5160-1-17 of the Administrative Code in order to become an eligible provider, a provider must meet the screening requirements described in this rule and in section 5164.34 of the Revised Code and pay an applicable application fee if required in the appendix to this rule. Provider screening and application fees are required at the time of enrollment and revalidation as defined in rule 5160-1-17.4 of the Administrative Code.

(1) Exemptions.

(a) If a provider is required to participate in the medicare program as a condition of enrollment in medicaid or elects to participate in the medicare program and has met the provider screening requirements and paid an applicable application fee to the centers for medicare and medicaid services (CMS) or its designee, the provider is exempt from the application fee requirements set forth in this rule.

(b) If a provider has met the provider screening requirements and paid an applicable application fee to another state medicaid agency or its designee, the provider is exempt from the application fee requirements set forth in this rule.

(c) A provider must provide documentation to support it meets the criteria for an exemption described in paragraphs (A)(1)(a) and (A)(1)(b) of this rule.

(d) When employed by or independently contracted with an entity certified by the Ohio department of mental health and addiction services, the following are exempt from the provisions of paragraphs (E)(2) to (E)(4) of this rule when providing services for the entity.

(i) Certified peer recovery supporters as defined in rule 5122-29-15.1 of the Administrative Code;

(ii) Practitioners licensed or certified under Chapter 4757. of the Revised Code;

(iii) Practitioners licensed or certified under Chapter 4758. of the Revised Code.

(2) The appendix to this rule sets forth:

(a) The screening risk level assigned to each provider type in accordance with paragraph (B) of this rule; and

(b) The provider types that must pay an application fee in accordance with paragraph (G) of this rule.

(B) The appropriate screening based on screening risk level must be given to all service locations of an enrolled provider. Providers must disclose all service locations at time of enrollment and notify the department of changes or additional service locations within thirty days of the change in order to be reimbursed for services delivered at that location.

(C) In accordance with 42 C.F.R. 455.452 (as in effect October 1, 2019), the Ohio department of medicaid (ODM) reserves the right to conduct additional screenings and background checks as determined necessary by ODM or its designee.

(D) Screening requirements differ by risk level. If more than one risk level could apply to a provider, the highest level of screening is required.

(1) Limited.

(a) Providers are subject to verification that they meet any applicable medicaid requirements as stated in agency 5160 of the Administrative Code for their provider type; and

(b) Providers are subject to license verifications, including state licensure verification in states other than Ohio; and

(c) Providers are subject to database checks on a pre- and post-enrollment basis to ensure that providers continue to meet the enrollment criteria for their provider type.

(i) Database checks must confirm the identity and exclusion status of providers and any person with a five per cent or greater ownership or control interest; or any person who is an agent or an individual (including a general manager, business manager, administrator, director, or consultant) who directly or indirectly manages, advises, or supervises any element of the practices, finances, or operations of the provider entity.

(ii) Databases to be checked include, but are not limited to, the social security administration's death master file, the national plan and provider enumeration systems (NPPES), the list of excluded individuals/entities maintained by the office of the inspector general, health and human services, the medicare exclusion database (MED), or the system for awards management (SAM), the list of providers terminated by another state's medicaid program, the nurse aid registry maintained by the Ohio department of health and the abuser registry maintained by the Ohio department of developmental disabilities.

(iii) A provider is disqualified from receiving a medicaid provider agreement during the time the provider is on one or more of the following registries or databases:

(a) The social security administration's death master file;

(b) The list of excluded individuals or entities maintained by the office of the inspector general, health and human services;

(d) The list of providers terminated by another state's medicaid program;

(e) The abuser registry maintained by the Ohio department of developmental disabilities;

(f) The system for awards management (SAM) list of individuals or entities with an exclusion;

(g) The nurse aid registry abuse listing maintained by the Ohio department of health.

(2) Moderate.

(a) Providers are subject to the requirements in paragraph (D)(1) of this rule; and

(b) Providers are subject to on-site visits.

(i) Pre- and post-enrollment site visits by ODM or its designee will verify that information provided to ODM or its designee is accurate and to determine compliance with medicaid enrollment requirements.

(ii) Once enrolled, providers must allow CMS or its agents or contractors, or ODM or its agents or contractors to conduct unannounced on-site inspections of any and all provider locations.

(3) High.

(a) Providers are subject to the requirements in paragraphs (D)(1) and (D)(2)(b) of this rule; and

(b) Each person with a five per cent or greater ownership or control interest with the provider is subject to a criminal background check and is required to submit to a fingerprint-based background check within thirty days of submission of the application in a form and manner determined by ODM, or its designee.

(E) The following sets forth the exclusionary offenses and exclusion time periods from participation in the medicaid program:

(1) Tier I. Permanent exclusion.

(a) Individuals who have been convicted of or pleaded guilty to, an offense in any of the following sections of the Revised Code are permanently excluded from participation in the medicaid program:

(i) 2903.01 (aggravated murder);

(ii) 2903.02 (murder);

(iii) 2903.03 (voluntary manslaughter);

(iv) 2903.11 (felonious assault);

(v) 2903.15 (permitting child abuse);

(vi) 2903.16 (failing to provide for a functionally-impaired person);

(vii) 2903.34 (patient abuse or neglect);

(viii) 2903.341 (patient endangerment);

(ix) 2905.01 (kidnapping);

(x) 2905.02 (abduction);

(xi) 2905.32 (human trafficking);

(xii) 2905.33 (unlawful conduct with respect to documents);

(xiii) 2907.02 (rape);

(xiv) 2907.03 (sexual battery);

(xv) 2907.04 (unlawful sexual conduct with a minor, formerly corruption of a minor);

(xvi) 2907.05 (gross sexual imposition);

(xvii) 2907.06 (sexual imposition);

(xviii) 2907.07 (importuning);

(xix) 2907.08 (voyeurism);

(xx) 2907.12 (felonious sexual penetration, as that offense existed prior to September 3, 1996);

(xxi) 2907.31 (disseminating matter harmful to juveniles);

(xxii) 2907.32 (pandering obscenity);

(xxiii) 2907.321 (pandering obscenity involving a minor);

(xxiv) 2907.322 (pandering sexually-oriented matter involving a minor);

(xxv) 2907.323 (illegal use of a minor in nudity-oriented material or performance);

(xxvi) 2909.22 (soliciting or providing support for act of terrorism);

(xxvii) 2909.23 (making terroristic threats);

(xxviii) 2909.24 (terrorism);

(xxix) 2913.40 (medicaid fraud);

(xxx) If related to another offense under paragraph (E)(1)(a) of this rule, 2923.01 (conspiracy), 2923.02 (attempt), or 2923.03 (complicity); or

(b) A conviction related to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct involving a federal or state-funded program, excluding the disqualifying offenses set forth in section 2913.46 of the Revised Code (illegal use of supplemental nutrition assistance program (SNAP) or women, infants, and children (WIC) program benefits) and paragraph (E)(2)(a)(xiii) of this rule; or

(c) A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations described in paragraph (E)(1)(a) or (E)(1)(b) of this rule.

(2) Tier II. Ten-year exclusionary period.

(a) Individuals who have been convicted of or pleaded guilty to, an offense in any of the following sections of the Revised Code are excluded from participation in the medicaid program for a period of ten years from the date the individual was fully discharged from all imprisonment, probation or parole:

(i) 2903.04 (involuntary manslaughter);

(ii) 2903.041 (reckless homicide);

(iii) 2905.04 (child stealing, as that offense existed prior to July 1, 1996);

(iv) 2905.05 (child enticement);

(v) 2905.11 (extortion);

(vi) 2907.21 (compelling prostitution);

(vii) 2907.22 (promoting prostitution);

(viii) 2907.23 (enticement or solicitation to patronize a prostitute; procurement of a prostitute for another);

(ix) 2909.02 (aggravated arson);

(x) 2909.03 (arson);

(xi) 2911.01 (aggravated robbery);

(xii) 2911.11 (aggravated burglary);

(xiii) 2913.46 (illegal use of SNAP or WIC program benefits);

(xiv) 2913.48 (worker's compensation fraud);

(xv) 2913.49 (identity fraud);

(xvi) 2917.02 (aggravated riot);

(xvii) 2923.12 (carrying concealed weapons);

(xviii) 2923.122 (illegal conveyance or possession of deadly weapon or dangerous ordnance in a school safety zone, illegal possession of an object indistinguishable from a firearm in a school safety zone);

(xix) 2923.123 (illegal conveyance, possession, or control of deadly weapon or ordnance into courthouse);

(xx) 2923.13 (having weapons while under a disability);

(xxi) 2923.161 (improperly discharging a firearm at or into a habitation or school);

(xxii) 2923.162 (discharge of firearm on or near prohibited premises);

(xxiii) 2923.21 (improperly furnishing firearms to minor);

(xxiv) 2923.32 (engaging in a pattern of corrupt activity);

(xxv) 2923.42 (participating in a criminal gang);

(xxvi) 2925.02 (corrupting another with drugs);

(xxvii) 2925.03 (trafficking in drugs);

(xxviii) 2925.04 (illegal manufacture of drugs or cultivation of marijuana);

(xxix) 2925.041 (illegal assembly or possession of chemicals for the manufacture of drugs);

(xxx) 3716.11 (placing harmful or hazardous objects in food or confection); or

(xxxi) If related to an offense under paragraph (E)(2)(a) of this rule, 2923.01 (conspiracy), 2923.02 (attempt), or 2923.03 (complicity); or

(b) A violation of an existing or former municipal ordinance or law of this state, any other state or the United States that is substantially equivalent to any of the offenses or violations described under paragraph (E)(2)(a) of this rule.

(c) If the individual has been convicted of multiple disqualifying offenses, including an offense listed in paragraph (E)(2)(a) or (E)(2)(b) of this rule, and another offense or offenses listed in paragraph (E)(2)(a), (E)(3)(a), (E)(3)(b), (E)(4)(a), or (E)(4)(b) of this rule, the individual is subject to a fifteen-year exclusionary period beginning on the date the individual was fully discharged from all imprisonment, probation or parole for the most recent offense.

(3) Tier III. Seven-year exclusionary period.

(a) Individuals who have been convicted of or pleaded guilty to, an offense in any of the following sections of the Revised Code are excluded from participation in the medicaid program for a period of seven years from the date the individual was fully discharged from all imprisonment, probation or parole:

(i) 959.13 (cruelty to animals);

(ii) 959.131 (prohibitions concerning companion animals);

(iii) 2903.12 (aggravated assault);

(iv) 2903.21 (aggravated menacing);

(v) 2903.211 (menacing by stalking);

(vi) 2905.12 (coercion);

(vii) 2909.04 (disrupting public services);

(viii) 2911.02 (robbery);

(ix) 2911.12 (burglary);

(x) 2913.47 (insurance fraud);

(xi) 2917.01 (inciting to violence);

(xii) 2917.03 (riot);

(xiii) 2917.31 (inducing panic);

(xiv) 2919.22 (endangering children):

(xv) 2919.25 (domestic violence);

(xvi) 2921.03 (intimidation);

(xvii) 2921.11 (perjury);

(xviii) 2921.13 (falsification, falsification in a theft offense, falsification to purchase a firearm, or falsification to obtain a concealed handgun license);

(xix) 2921.34 (escape);

(xx) 2921.35 (aiding escape or resistance to lawful authority);

(xxi) 2921.36 (illegal conveyance of weapons, drugs or other prohibited items onto the grounds of a detention facility or institution);

(xxii) 2925.05 (funding drug trafficking);

(xxiii) 2925.06 (illegal administration or distribution of anabolic steroids);

(xxiv) 2925.24 (tampering with drugs);

(xxv) 2927.12 (ethnic intimidation); or

(xxvi) If related to an offense under paragraph (E)(3)(a) of this rule, 2923.01 (conspiracy), 2923.02 (attempt), or 2923.03 (complicity); or

(c) If an individual has been convicted of multiple disqualifying offenses, including an offense listed in paragraph (E)(3)(a) or (E)(3)(b) of this rule, and another offense or offenses listed in paragraph (E)(3)(a), (E)(3)(b), (E)(4)(a), or (E)(4)(b) of this rule, the individual is subject to a ten-year exclusionary period beginning on the date the individual was fully discharged from all imprisonment, probation or parole for the most recent offense.

(4) Tier IV. Five-year exclusionary period.

(a) Individuals who have been convicted of or pleaded guilty to, an offense in any of the following sections of the Revised Code are excluded from participation in the medicaid program for a period of five years from the date the individual was fully discharged from all imprisonment, probation or parole:

(i) 2903.13 (assault);

(ii) 2903.22 (menacing);

(iii) 2907.09 (public indecency);

(iv) 2907.24 (soliciting);

(v) 2907.25 (prostitution);

(vi) 2907.33 (deception to obtain matter harmful to juveniles);

(vii) 2911.13 (breaking and entering);

(viii) 2913.02 (theft);

(ix) 2913.03 (unauthorized use of a vehicle);

(x) 2913.04 (unauthorized use of computer, cable or telecommunication property);

(xi) 2913.05 (telecommunication fraud);

(xii) 2913.11 (passing bad checks);

(xiii) 2913.21 (misuse of credit cards);

(xiv) 2913.31 (forgery - forging identification cards or selling or distributing forged identification cards);

(xv) 2913.32 (criminal simulation);

(xvi) 2913.41 (defrauding a rental agency or hostelry);

(xvii) 2913.42 (tampering with records);

(xviii) 2913.43 (securing writings by deception);

(xix) 2913.44 (personating an officer);

(xx) 2913.441 (unlawful display of law enforcement emblem);

(xxi) 2913.45 (defrauding creditors);

(xxii) 2913.51 (receiving stolen property);

(xxiii) 2919.12 (unlawful abortion);

(xxiv) 2919.121 (unlawful abortion upon minor);

(xxv) 2919.123 (unlawful distribution of an abortion-inducing drug);

(xxvi) 2919.23 (interference with custody);

(xxvii) 2919.24 (contributing to the unruliness or delinquency of a child);

(xxviii) 2921.12 (tampering with evidence);

(xxix) 2921.21 (compounding a crime);

(xxx) 2921.24 (disclosure of confidential information);

(xxxi) 2921.32 (obstructing justice);

(xxxii) 2921.321 (assaulting or harassing a police dog, horse, or service animal);

(xxxiii) 2921.51 (impersonation of peace officer);

(xxxiv) 2925.09 (illegal administration, dispensing, distribution, manufacture, possession, selling, or using of any dangerous veterinary drug);

(xxxv) 2925.11 (drug possession, other than a minor drug possession offense);

(xxxvi) 2925.13 (permitting drug abuse);

(xxxvii) 2925.22 (deception to obtain a dangerous drug);

(xxxviii) 2925.23 (illegal processing of drug documents);

(xxxix) 2925.36 (illegal dispensing of drug samples);

(xl) 2925.55 (unlawful purchase of pseudoephedrine product);

(xli) 2925.56 (unlawful sale of pseudoephedrine product);

(xlii) If related to an offense under paragraph (E)(4)(a) of this rule, 2923.01 (conspiracy), 2923.02 (attempt), or 2923.03 (complicity); or

(c) If an individual has been convicted of multiple disqualifying offenses listed in paragraph (E)(4)(a) or (E)(4)(b) of this rule, the individual is subject to a seven-year exclusionary period beginning on the date the individual was fully discharged from all imprisonment, probation or parole for the most recent offense.

(5) Tier V. No exclusionary period.

(a) Individuals who have been convicted of or pleaded guilty to, an offense in any of the following sections of the Revised Code are not subject to an exclusionary period and may participate in the medicaid program:

(i) 2919.21 (non-support/contributing to non-support of dependents);

(ii) 2925.11 (drug possession that is a minor drug possession offense); or

(iii) 2925.14 (drug paraphernalia); or

(iv) 2925.141 (illegal use or possession of marijuana drug paraphernalia); or

(F) Pardons and certificates. A conviction of, or a plea of guilty to, an exclusionary offense as set forth in paragraph (E) of this rule shall not prevent a provider from enrollment if any of the following circumstances apply:

(1) The provider has been granted an unconditional pardon for the offense pursuant to Chapter 2967. of the Revised Code;

(2) The provider has been granted an unconditional pardon for the offense pursuant to an existing or former law of the state of Ohio, any other state, or the United States, if the law is substantially equivalent to Chapter 2967. of the Revised Code;

(3) The provider has been granted a conditional pardon for the offense pursuant to Chapter 2967. of the Revised Code, and the condition(s) under which the pardon was granted have been satisfied;

(4) The provider's conviction or guilty plea has been set aside pursuant to law; or

(5) A certificate of qualification for employment has been issued by an Ohio court of common pleas pursuant to section 2953.25 of the Revised Code, or an equivalent certification has been issued by an out of state or federal jurisdiction.

(6) Provider applications that include a certificate of qualification for employment or an equivalent certification associated with a permanent exclusion offense as stated in paragraph (E)(1) of this rule, will be reviewed by ODM and a decision will be rendered by ODM on a case-by-case basis as to whether a provider agreement will be approved or not in accordance with section 2953.25 of the Revised Code.

(G) Application fee.

(1) Provider types identified as subject to an application fee in the appendix to this rule must submit the fee in a form and manner determined by ODM at the time of application for enrollment or revalidation as a medicaid provider. If proof of fee payment is not submitted with the provider's application, the application will be rejected as incomplete.

(2) Individual physicians and non-physician practitioners are exempt from paying an application fee in accordance with 42 C.F.R. 455.460, (October 1, 2019).

(3) ODM may waive an application fee if:

(a) ODM determines that imposing the fee would have an adverse impact on beneficiary access to services; and

(b) ODM has requested and CMS has approved a waiver of the fee.

(4) If ODM receives approval from CMS to waive a medicaid application fee, providers are still subject to the screening requirements set forth in this rule.

(5) The application fee is equal to the amount established by CMS and includes an annual adjustment for inflation in accordance with 42 U.S.C. 1395cc(j)(2)(C)(i) (January 1, 2020).

(6) The application fee will not be refunded if:

(a) Enrollment is denied as a result of failure to meet the provider screening requirements described in this rule;

(b) If enrollment is denied based on the results of the provider screening.; or

(H) If enrollment is denied as a result of failure to meet the provider screening requirements or failure to pay any associated application fee, the provider may request a hearing pursuant to Chapter 119. of the Revised Code.

View Appendix

Last updated June 25, 2025 at 5:56 PM

History

Effective: January 31, 2020
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-17.9 Ordering or referring providers.

(A) Definitions for purposes of this rule only:

(1) A "participating provider" is an active provider who bills the medicaid program for rendered services, or who is an active provider who orders, prescribes, refers, or certifies but does not bill the medicaid program.

(2) An "ordering or referring only provider" is a provider who orders, prescribes, refers, or certifies an item or service reported on a claim, and is not a billing provider in the medicaid program. For example: a provider orders items or services for the medicaid consumer, such as prescription drugs, durable medical equipment, prosthetics, orthotics, and supplies, clinical laboratory services, or imaging services, and may certify home health services for a medicaid consumer.

(3) "Physician" or "supervising physician" means an individual authorized to practice medicine in Ohio or another state.

(4) "Other professional" means those providers, other than physicians, who order, prescribe, refer, or certify an item or service reported on a claim. Examples include but are not limited to: physician assistant, clinical nurse specialist, nurse practitioner, clinical psychologist, certified nurse midwife, clinical social worker, and interns, residents, and fellows.

(B) A physician or other professional who is an ordering or referring only provider of medicaid services must be enrolled as a participating provider with the medicaid program.

(C) An ordering or referring only provider shall be considered limited risk for purposes of screening, as defined in rule 5101:3-1-17.8 of the Administrative Code.

(D) Ordering and referring only providers who are enrolled with the office shall revalidate in accordance with rule 5101:3-1-17.4 of the Administrative Code.

(E) Claims for services that require an order, prescription, referral, or certification will be denied if they do not include the following:

(1) A valid national provider identifier (NPI) and the legal name of the ordering, prescribing, referring, or certifying provider; or,

(2) If the ordering, prescribing, referring, or certifying provider is not a provider type eligible to participate in Ohio medicaid, a valid NPI and the legal name of the physician or other professional supervising the ordering or referring provider.

(F) This rule does not apply to services delivered through medicaid managed care plans.

Last updated October 2, 2026 at 8:33 PM

History

Effective: January 1, 2014
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-17.12 Qualified entity requirements and responsibilities for determining presumptive eligibility.

The Ohio department of medicaid (ODM) authorizes qualified entities (QEs) to determine presumptive eligibility (PE) based on self-attested information to grant immediate medicaid coverage to certain individuals seeking medicaid covered services. This rule sets forth eligibility requirements and responsibilities to maintain designation as a QE.

(A) For the purposes of this rule, the following definitions apply:

(1) "Qualified Entity" has the same meaning as defined in rule 5160:1-1-01 of the Administrative Code.

(2) "Unauthorized Use" means any access or activity that exceeds granted access or is performed without ODM approval, including misuse, credential sharing, or using the system for personal gain.

(B) To become a QE, the eligible entity must:

(1) Be an eligible provider as defined in rule 5160-1-17 of the Administrative Code;

(2) Read the presumptive eligibility training guide found on the ODM website, medicaid.ohio.gov; and

(3) Attest that it will meet the terms and conditions as a QE by reading, signing, and sending ODM form 10252 "Acknowledgement of Terms and Conditions Governing the Presumptive Eligibility Determinations Authority Granted by the Ohio Department of Medicaid to a Qualified Entity," found on the ODM website, medicaid.ohio.gov.

(1) Remain in good standing as an Ohio medicaid provider;

(2) Determine presumptive eligibility in accordance with rule 5160:1-2-13 of the Administrative Code and all other applicable federal and state laws;

(3) Verify the individual is not already enrolled in another category of medicaid;

(4) Without compensation, agree to perform all of the administrative functions associated with PE including, but not limited to:

(a) Provide to ODM a list of names and titles of all employees given responsibility to determine PE and request appropriate access to the PE portal;

(b) Ensure that employees given responsibility to determine PE have read the presumptive eligibility training guide, understand the criteria for all medicaid eligibility categories and have been trained on how to use the presumptive eligibility portal;

(c) Ensure those employees who have responsibility to submit claims to the medicaid program for reimbursement of medicaid services are not also employees responsible for determining presumptive eligibility; and

(d) Agree to retain all records related to presumptive eligibility determinations in accordance with rule 5160-1-27 of the Administrative Code and provide such records to ODM, its designee, or to any authorized state or federal agency upon request.

(5) Agree that it may be held responsible for the willful conduct of its employees. Any employee who knowingly files a claim containing false, incomplete, or misleading essential information to create eligibility for medicaid or receive payment from medicaid may be punishable under section 2913.40 or 2913.401 of the Revised Code;

(6) If the QE is a hospital, agree to provide thirty-six hours worth of medically necessary medications to any person enrolled presumptively by the QE at time of determination;

(7) If the QE is a federally qualified health center (FQHC) and is able to do so, provide thirty-six hours worth of medically necessary medications to any person enrolled presumptively by the QE at the time of determination if such needs are determined during a medical visit;

(8) Ensure that for all persons enrolled presumptively by the QE, a completed application for full medicaid benefits is submitted no later than the last day of the month following the month in which the QE makes the PE determination; and

(9) Ensure that at least 92.5 per cent of individuals determined presumptively eligible are subsequently awarded full medicaid eligibility.

(D) Monitoring.

(1) ODM will monitor performance standards in paragraphs (C)(8) and (C)(9) of this rule monthly for all PE determinations. A comprehensive PE training will be mandatory for all employees designated to make PE determinations for each period during which the QE fails to meet these performance standards, in accordance with section 5163.103 of the Revised Code.

(2) ODM will request a corrective action plan (CAP) from each QE for each period wherein performance standards set forth in this rule are not met in accordance with section 5163.103 of the Revised Code. Improvement will be monitored and reviewed annually to determine whether revocation of the QE designation in these instances is appropriate.

(3) A QE on an approved CAP will be monitored until successful completion of the CAP or revocation of the QE designation. Any QE exhibiting repeated instances of noncompliance with performance standards outlined in this rule or remaining on a CAP for more than one year may have its QE designation revoked.

(E) Revocation. ODM may terminate authority granted under this rule with or without written notice, for any reason supported by evidence of acts or omissions adversely affecting the medicaid program. An entity reapplying for QE designation after a revocation will need to follow the process outlined in paragraph (B) of this rule. QE designation revocation will occur in the following circumstances:

(1) Administrative revocation. ODM may revoke QE designation for the following reasons without subjecting the QE to a QE designation exclusion period:

(a) Suspension or termination of the QE's Ohio medicaid provider agreement;

(b) Unauthorized use of the PE portal by the QE;

(d) The QE does not perform at least fifty PE determinations in a twelve month period.

(2) Noncompliant revocation. ODM may revoke QE designation for failure to comply with performance standards outlined in paragraph (C)(8) or (C)(9) of this rule. Revocation resulting from noncompliance will subject the QE to the following periods of exclusion from QE designation:

(a) First revocation: one year exclusion from QE designation;

(b) Second revocation: three year exclusion from QE designation; and

Last updated October 1, 2026 at 10:11 AM

History

Effective: October 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-18 Telehealth.

(A) For the purposes of this rule, the following definitions apply:

(1) "Patient site" is the physical location of the patient at the time a health care service is provided through the use of telehealth.

(2) "Practitioner site" is the physical location of the treating practitioner at the time a health care service is provided through the use of telehealth.

(3) "Telehealth" is the direct delivery of health care services to a patient related to diagnosis, treatment, and management of a condition.

(a) Telehealth is the interaction with a patient via synchronous, interactive, real-time electronic communication comprising both audio and video elements; or

(b) The following activities that are asynchronous or do not have both audio and video elements:

(i) Telephone calls;

(ii) Remote patient monitoring; and

(iii) Communication with a patient through secure electronic mail or a secure patient portal.

(c) For services rendered by behavioral health providers as defined in rule 5160-27-01 of the Administrative Code, telehealth is defined in rule 5122-29-31 of the Administrative Code.

(d) Conversations or electronic communication between practitioners regarding a patient without the patient present is not considered telehealth unless the service would allow billing for practitioner to practitioner communication in a non-telehealth setting.

(B) Eligible providers.

(1) The following practitioners are eligible to render services through the use of telehealth:

(a) Physicians as defined in Chapter 4731. of the Revised Code.

(b) Psychologists as defined in Chapter 4732. of the Revised Code.

(d) Clinical nurse specialists, certified nurse-midwives, or certified nurse practitioners as defined in Chapter 4723. of the Revised Code.

(e) Licensed independent social workers, licensed independent marriage and family therapists, or licensed professional clinical counselors as defined in Chapter 4757. of the Revised Code.

(f) Licensed independent chemical dependency counselors as defined in Chapter 4758. of the Revised Code.

(g) Supervised practitioners, trainees, residents, and interns as defined in rules 5160-4-02 and 5160-8-05 of the Administrative Code.

(h) Audiologists, speech-language pathologists, speech-language pathology aides, audiology aides, and individuals holding a conditional license as defined in Chapter 4753. of the Revised Code.

(i) Occupational and physical therapists and occupational and physical therapist assistants as defined in Chapter 4755. of the Revised Code.

(j) Home health aides.

(k) Private duty registered nurses or licensed practical nurses in a home health setting.

(l) Dentists as defined in Chapter 4715. of the Revised Code.

(m) Medicaid school program (MSP) practitioners as described in Chapter 5160-35 of the Administrative Code.

(n) Dietitians as defined in Chapter 4759. of the Revised Code.

(o) Behavioral health practitioners as defined in rule 5160-27-01 of the Administrative Code.

(p) Optometrists as defined in Chapter 4725. of the Revised Code.

(q) Pharmacists as defined in Chapter 4729. of the Revised Code.

(r) Doulas as defined in rule 5160-8-43 of the Administrative Code.

(s) International board-certified lactation consultants (IBCLCs) as defined in rule 5160-8-42 of the Adminsitrative Code.

(t) Other practitioners if specifically authorized in rule promulgated under agency 5160 of the Administrative Code.

(2) The following provider types are eligible to bill for services rendered through the use of telehealth.

(a) Practitioners identified in paragraph (B)(1) of this rule, except for the following dependent practitioners:

(i) Supervised practitioners, trainees, residents, and interns as defined in rules 5160-4-02 and 5160-8-05 of the Administrative Code, except as provided in rule 5160-4-02.3 of the Administrative Code;

(ii) Occupational therapist assistants as defined in section 4755.04 of the Revised Code;

(iii) Physical therapist assistants as defined in section 4755.40 of the Revised Code;

(iv) Speech-language pathology aides, audiology aides, and individuals holding a conditional license as defined in Chapter 4753. of the Revised Code.

(b) A professional medical group.

(d) A federally qualified health center (FQHC) or rural health clinic (RHC) as defined in Chapter 5160-28 of the Administrative Code.

(e) Ambulatory health care clinics (AHCC) as defined in Chapter 5160-13 of the Administrative Code.

(f) Outpatient hospitals on behalf of licensed psychologists and independent practitioners not eligible to separately bill when practicing in an outpatient hospital setting.

(g) MSP providers as defined in Chapter 5160-35 of the Administrative Code.

(h) Private duty nurses.

(i) Home health and hospice agencies.

(j) Behavioral health providers as defined in paragraphs (A)(1) and (A)(2) of rule 5160-27-01 of the Administrative Code.

(k) Doulas as defined in rule 5160-8-43 of the Adminsitrative Code.

(l) International board-certified lactation consultants (IBCLCs) as defined in rule 5160-8-42 of the Adminsitrative Code.

(1) It is the responsibility of the practitioner to deliver telehealth services in accordance with all state and federal laws including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and any HIPAA related directives from the office for civil rights (OCR) at the department of health and human services (HHS) and 42 C.F.R. part 2 (January 1, 2020).

(2) It is the responsibility of the practitioner to deliver telehealth services in accordance with rules set forth by their respective licensing board and accepted standards of clinical practice.

(3) The practitioner site is responsible for maintaining documentation in accordance with paragraph (C)(1) of this rule for the health care service delivered through the use of telehealth and to document the specific telehealth modality used.

(4) For practitioners who render services to an individual through telehealth for a period longer than twelve consecutive months, the telehealth practice or practitioner is expected to conduct at least one in-person annual visit or refer the individual to a practitioner or their usual source of clinical care that is not an emergency department for an in-person annual visit.

(D) Payment may be made only for the following medically necessary health care services identified in appendix A to this rule when delivered through the use of telehealth from the practitioner site:

(1) When provided by a patient centered medical home as defined in rule 5160-19-01 of the Administrative Code or behavioral health provider as defined in rule 5160-27-01 of the Administrative Code, evaluation and management of a new patient described as "office or other outpatient visit" with medical decision making not to exceed moderate complexity.

(2) Evaluation and management of an established patient described as "office or other outpatient visit" with medical decision making not to exceed moderate complexity.

(3) Inpatient or office consultation for a new or established patient when providing the same quality and timeliness of care to the patient other than by telehealth is not possible, as documented in the medical record.

(4) Mental health or substance use disorder services described as "psychiatric diagnostic evaluation" or "psychotherapy."

(5) Remote evaluation of recorded video or images submitted by an established patient.

(6) Virtual check-in by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient.

(7) Online digital evaluation and management service for an established patient.

(8) Remote patient monitoring.

(9) Audiology, speech-language pathology, physical therapy, and occupational therapy services, including services provided in the home health setting.

(10) Medical nutrition services.

(11) Lactation consultation services.

(12) Psychological and neuropsychological testing.

(13) Smoking and tobacco use cessation counseling.

(14) Developmental test administration.

(15) Limited or periodic oral evaluation.

(16) Private duty nursing services.

(17) State plan home health services.

(18) Dialysis related services.

(19) Services under the specialized recovery services (SRS) program as defined in rule 5160-43-01 of the Administrative Code.

(20) Notwithstanding paragraph (D)(2) of this rule, behavioral health services covered under Chapter 5160-27 of the Administrative Code.

(21) Optometry services.

(22) Group prenatal care services.

(23) Diabetic self-management training (DSMT) services.

(24) Doula services as defined in rule 5160-8-43 of the Administrative Code.

(25) Nurse home visiting services as defined in rule 5160-21-05 of the Adminsitrative Code.

(26) Report of pregnancy submitted on either form ODM 10257, "Report of Pregnancy (ROP)" or its web-based equivalent.

(27) Pregnancy risk assessment submitted on either form ODM 10207, "Pregnancy Risk Assessment Form" or its web-based equivalent.

(28) Enhanced ambulatory patient group (EAPG) covered telehealth-eligible codes as identified on the ODM Website: www.medicaid.ohio.gov.

(29) Individual counseling for pre-exposure prophylaxis (PrEP).

(30) Services that have a code description including a telehealth component and are covered in an ODM fee schedule.

(31) Other services if specifically authorized in rule promulgated under agency 5160 of the Administrative Code.

(E) Submission and payment of telehealth claims.

(1) The practitioner site may submit either a professional or institutional claim for health care services delivered through the use of telehealth. For any professional claim submitted for health care services utilizing telehealth to be paid, it is the responsibility of the provider to follow ODM billing guidelines found on the ODM website: www.medicaid.ohio.gov.

(2) An institutional (facility) claim may be submitted by an outpatient hospital for telehealth services provided by licensed psychologists and independent practitioners not eligible to separately bill when practicing in an outpatient hospital setting. Other telehealth services provided in a hospital setting may be billed in accordance with rule 5160-2-02 of the Administrative Code.

(3) Medicaid-covered services may be provided through telehealth, as appropriate, if otherwise payable under the medicaid school program as defined in Chapter 5160-35 of the Administrative Code.

(4) Except for services billed by behavioral health providers as defined in paragraphs (A)(1) and (A)(2) of rule 5160-27-01 of the Administrative Code and FQHC and RHC services defined in rule 5160-28-03 of the Administrative Code, the payment amount for a health care service delivered through the use of telehealth is the lesser of the submitted charge or the maximum amount shown in appendix DD to rule 5160-1-60 of the Administrative Code for the date of service.

(5) For a covered telehealth service that is also an FQHC or RHC service, the face-to-face requirement is waived and payment is made in accordance with Chapter 5160-28 of the Administrative Code.

(6) Individuals who meet the definition of inmate in a penal facility or a public institution, with the exception of "eligible juvenile," as defined in rule 5160:1-1-03 of the Administrative Code are not eligible for telehealth services under this rule.

(7) For telehealth services billed by behavioral health providers as defined in paragraphs (A)(1) and (A)(2) of rule 5160-27-01 of the Administrative Code, payment is made in accordance with Chapter 5160-27 of the Administrative Code.

(8) Unless stated otherwise in the billing guidelines, professional claims submitted for health care services provided through the use of telehealth have to include:

(a) A "GT" modifier;

(b) A place of service code that reflects the physical location of the treating practitioner at the time a health care service is provided through the use of telehealth.

(d) A modifier as identified in appendix B to this rule if the physical location of the patient is one of the following locations:

(i) The patient's home (including homeless shelter, assisted living facility, group home, and temporary lodging);

(ii) School;

(iii) Inpatient hospital;

(iv) Outpatient hospital;

(v) Nursing facility;

(vi) Intermediate care facility for individuals with an intellectual disability.

View AppendixView Appendix

Last updated March 13, 2026 at 8:58 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-19 Submission of medicaid claims.

(A) Unless otherwise directed by the Ohio department of medicaid (ODM), paper claims will not be accepted. Except as otherwise provided in section 5164.46 of the Revised Code or a state agency's interagency agreement, claims are to be submitted directly to ODM through one of the following formats:

(1) Electronic data interchange (EDI), in accordance with rule 5160-1-20 of the Administrative Code.

(2) The ODM provider web portal; or

(3) Pharmacy point-of-sale.

(B) Claims should be submitted pursuant to the national correct coding initiative and according to the coding standards set forth in the following guides:

(1) The healthcare common procedure coding system;

(2) The current procedural terminology codebook;

(3) The current dental terminology codebook; or

(4) The international classification of diseases handbooks.

(C) Claims for items and services that necessitate a rendering or supervising provider, order, prescription, referral, or certification will be denied if:

(1) They do not include the national provider identifier (NPI) and the legal name of the rendering, supervising, ordering, prescribing, referring, or certifying provider; and

(2) The provider does not have an active medicaid provider agreement.

(D) Timely filing:

(1) Claims are timely if received by ODM within:

(a) Three hundred sixty-five days of the actual date the service was provided.

(b) Three hundred sixty-five days from the date of discharge for inpatient hospital claims.

(c) Three hundred sixty-five days from the date of service or inpatient hospital discharge, as applicable, for denied claims that are re-submitted for payment.

(2) Provider-reported underpaid claims should be adjusted within three hundred sixty-five days from the date of service or inpatient hospital discharge, as applicable.

(E) Exceptions to timely filing are:

(1) Claims submitted via the "automatic medicare crossover process" (the automatic process of medicare electronically submitting a claim to ODM following medicare adjudication and payment of a claim for a dually eligible individual) are not subject to timely filing provisions in this rule.

(2) Claims for wraparound payment for a federally qualified health center (FQHC) or rural health center (RHC) are timely if submitted to ODM within one hundred eighty days from the date the claim was paid.

(3) Claims submitted to ODM after three hundred sixty-five days of the date of service or discharge, as applicable, due to a delay in eligibility determination or a state hearing decision regarding eligibility are timely if received by ODM within one hundred eighty days of the notice of eligibility determination or state hearing decision to be considered for payment.

(4) Claims submitted to ODM after three hundred sixty-five days of the date of service or discharge, as applicable, due to a reversal of payment by a third party payer are timely if the adjusted claim is received within one hundred eighty days of the recovery of funds to be considered for payment.

(5) Any claim delayed in submission to, or adjudicated by ODM, due to an action or decision by ODM, at the discretion of ODM, may be reimbursed after three hundred sixty-five days from the date of service or inpatient hospital discharge.

(F) In instances of conflict of claim payment between two providers, ODM may adjust or void a claim as appropriate after notification to the providers.

(G) Overpaid claims.

(1) When a provider identifies an overpayment, the provider will submit an electronic adjustment to ODM within sixty days of discovery to return the overpayment.

(2) When ODM identifies an overpayment, ODM will notify the provider of the overpayment. The provider has sixty days to correct the overpayment. If the provider fails to correct an identified overpayment within sixty days, ODM will make the adjustment from subsequent payments to the provider or void the claim as appropriate. If an ODM adjustment is not possible, ODM will issue an invoice to the provider for the overpaid amount. The provider has sixty days from the date of the invoice to seek reconsideration or remit payment to ODM. If the provider fails to remit the full payment due the unpaid balance will be certified to the Ohio attorney general for collection.

(3) ODM will pursue collections by invoice for overpayments that result in a credit balance owed to ODM that remain outstanding for more than forty-five days.

(4) Appeal rights may be exercised in accordance with Chapter 5160-70 of the Administrative Code. All ODM recoverable amounts are subject to the application of interest in accordance with rule 5160-1-25 of the Administrative Code.

(H) ODM forms that are necessary for a claim to be processed should only be submitted through the ODM provider web portal unless otherwise permitted by ODM.

(I) Claim adjustments should only be submitted through EDI or the ODM provider web portal.

(J) ODM will only process refund checks from providers for an invoice for a claim overpayment, a letter of collection of an outstanding overpayment, audit, or review, or other circumstance deemed appropriate by ODM.

Last updated June 26, 2025 at 4:09 AM

History

Effective: February 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-20 Electronic data interchange (EDI) trading partner enrollment and testing.

(A) For purposes of this rule, the following definitions apply:

(1) "Covered entity" has the same meaning as in 45 C.F.R. 160.103 (as in effect on October 1, 2021).

(2) "Electronic data interchange (EDI) transactions" are transactions developed by standards development organizations recognized by the federal centers for medicare and medicaid services (CMS) and adopted by the Ohio department of medicaid (ODM). The different EDI transactions are as follows:

(a) "American national standards institute (ANSI) X12 270 eligibility, coverage, or benefit inquiry" is a transaction used to inquire about the eligibility, benefits or coverage under a subscriber's health care policy.

(b) "ANSI X12 271 eligibility, coverage, or benefit information response" is a transaction used to communicate information about, or changes to, eligibility, benefits, or coverage.

(c) "ANSI X12 274 provider information" is a transaction used to exchange demographic and educational or professional qualifications about health care providers between providers, provider networks, or any other entity that maintains or verifies health care provider information.

(d) "ANSI X12 275 patient information" is a transaction used to communicate individual patient information requests and patient information (either solicited or unsolicited) between separate care entities in a variety of settings.

(e) "ANSI X12 276 health care claim status request" is a transaction used to request the status of a health care claim.

(f) "ANSI X12 277 health care claim status notification" is a transaction used to respond to a request regarding the status of a health care claim.

(g) "ANSI X12 278 health care services review information request and response" is a transaction used to transmit health care service information for the purpose of referral, certification, authorization, notification, or reporting the outcome of a health care services review.

(h) "ANSI X12 820 premium payment" is a transaction used to make a payment or send a remittance advice.

(i) "ANSI X12 834 monthly member roster or enrollment and disenrollment in a health plan" is a transaction used to establish communication between the sponsor of the insurance product and the payer.

(j) "ANSI X12 835 health care claims payment and remittance advice" or "835 remittance advice" is a transaction used to make a payment or send an explanation of benefits remittance advice.

(k) "ANSI X12 837 health care claim" is a transaction used to submit health care claim billing or encounter information, or both, from providers (institutional, professional, or dental) of health care services to payers, either directly or via clearinghouses.

(3) "Trading partner" is a covered entity as defined in 42 C.F.R. 160.103 (as in effect October 1, 2021) that submits, receives, routes, or translates EDI transactions directly related to the administration or provision of medical assistance provided under a public assistance program.

(B) Responsibilities of trading partners.

(1) To enroll as an EDI trading partner with ODM under the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and be issued a trading partner number, a covered entity completes and submits to ODM the following:

(a) The electronic trading partner form available at https://medicaid.ohio.gov.

(b) The ODM form 06306 "Designation of an 835 or 834-820 Trading Partner" (rev. 4/2017). This form is submitted only if the trading partner will be receiving the 835 remittance advice on behalf of its clients.

(c) A trading partner agreement. Trading partner agreements are to be signed by an authorized representative of the trading partner.

(2) Once the medicaid trading partner number is assigned, the trading partner submits EDI transactions for the testing process in accordance with paragraph (C) of this rule.

(1) All trading partners are to abide by all ODM testing criteria as outlined in paragraph (C)(2) of this rule and in the trading partner enrollment and testing information guide available at www.medicaid.ohio.gov.

(2) The testing criteria to be met is as follows:

(a) Trading partners are to submit three files per the following transaction types and pass testing: 837 (professional, institutional, dental), 270 (eligibility), and 276 (claim status inquiry).

(b) Trading partners are to test the transaction types they will be submitting in production.

(c) For batch transactions, each file is to contain a minimum of fifty claims, claim status inquiries, or eligibility inquiries.

(d) For real-time transactions of types 270 and 276, provide at least three real-time submissions for each transaction type.

(e) All EDI files are to completely pass X12 integrity testing, HIPAA syntax, and HIPAA situation testing. Trading partners are expected to modify their EDI files in accordance with new federally mandated HIPAA standards.

(f) During testing, trading partners may submit one claim file per day, per 837 transaction (one professional, one institutional, and one dental), one eligibility inquiry, and one claim status inquiry per day. Multiple tests per day are accepted for real-time transactions of types 270 and 276.

(D) Passing criteria for transactions tested.

(1) Files containing the 270 eligibility transaction are considered passing when a successful 271 response is received without error codes 73 (invalid or missing subscriber) or 75 (subscriber not found).

(2) Files containing the 275 patient information transaction are considered passing when a successful 999 response is received.

(3) Files containing the 276 claim status transaction are considered passing when a valid 277 response is received with the requested claim information.

(4) Files containing the 278 service request transaction are considered passing when a valid 278 response is received without error codes 04 (authorized quantity exceeded) or 79 (invalid participant identification).

(5) Files containing the 837 health care claim transaction are considered passing when at least ninety per cent of the claims are in paid status after test adjudication.

(E) Trading partners that are not actively submitting and receiving 837 health care claim transaction sets but who are actively submitting and receiving 270/271 and 276/277 transaction sets are to provide, in a manner specified by ODM, a report of all providers by national provider identifier (NPI) that the trading partner represents. The first report is due at the time of initiating a trading partner agreement with ODM. Subsequent reports are due quarterly based on the calendar year, no later than January first, April first, July first and October first. If the necessary reports are not submitted, the trading partner agreement will be denied or terminated, as applicable.

(F) If a trading partner does not submit or receive EDI transactions for a period of two years or longer, ODM may terminate the trading partner agreement without notice.

(G) Trading partners are responsible for any breach of information and will be held fully liable for any and all costs related to such a breach.

Last updated December 1, 2022 at 10:40 AM

History

Effective: December 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-25 Interest on overpayments made to medicaid providers.

(A) Except for medicaid contracting managed care plans (MCPs), and nursing facilities and intermediate care facilities for individuals with intellectual disabilities (ICF/IID) rate recalculations performed in accordance with sections 5165.41 and 5124.41 of the Revised Code, any provider of services or goods contracting with the Ohio department of medicaid (ODM) pursuant to Title XIX of the Social Security Act who, without intent, obtains payment from the medicaid program in excess of the amount to which the provider is entitled becomes liable for payment of interest charged in accordance with this rule on the amount of the overpayment. The interest rate charged is the average bank prime rate in effect on the first day of the calendar quarter during which the provider receives notice of the excess payment, as determined in accordance with section 5164.60 of the Revised Code. Interest payments shall be calculated on the basis of simple interest.

(B) Interest payments shall be charged on a daily basis for the period from the date the payment was made to the date upon which repayment is received by the state.

(1) For any reasonable cost basis, prospective payment basis, or other cost-related rate final settlement issued by ODM, the "date payment was made" shall be ten days from the date the final settlement is received by the provider as shown by the U.S. postal service return receipt slip, with a notice of rights to appeal pursuant to Chapter 119. of the Revised Code.

(2) For audits conducted in accordance with rule 5160-1-27 of the Administrative Code, the "date payment was made" shall be the latest date a warrant or electronic funds transfer (EFT) was issued to pay an item included in the random sample.

(3) For post-payment reviews conducted in accordance with rule 5160-1-27 of the Administrative Code, the "date payment was made" shall be the latest date a warrant or EFT was issued in payment of a claim that is included in the review.

(D) The "date upon which repayment is received by the state" shall mean the following:

(1) In the case of repayment by check or EFT, the "date upon which repayment is received by the state" shall be the date the repayment is date-stamped by ODM, the date the repayment is deposited as certified mail with the U.S. postal service, or the date the EFT is deposited in the state's account.

(2) In the case of repayment by one or more offsets implemented by the ODM claims adjustment unit against future claims payments owed to the provider, the "date upon which repayment is received by the state" shall be the date on which the total amount of the overpayment is fully recovered.

(E) ODM may waive interest when voluntary repayment is made by a provider before any notification by ODM that an overpayment has occurred.

History

Effective: September 4, 2014
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-27 Review of provider records.

(A) As specified in Chapter 5160-1 of the Administrative Code, all medicaid providers are required to keep such records as are necessary to establish that conditions of payment for medicaid covered services have been met, and to fully disclose the basis for the type, frequency, extent, duration, and delivery setting of services provided to medicaid recipients, and to document significant business transactions. Medicaid providers are required to provide such records and documentation to the Ohio department of medicaid (ODM) or its designee, the secretary of the federal department of health and human services, or the state medicaid fraud control unit upon request.

(B) For purposes of this rule, the following definitions apply:

(1) "Audit" means a postpayment examination, made in consideration of generally accepted auditing standards, of a medicaid provider's records and documentation to determine program compliance, the extent and validity of services paid for under the medicaid program and to identify any inappropriate payments. The department shall have the authority to use statistical methods to conduct audits and to determine the amount of overpayment. An audit may result in a final adjudication order by the department.

(2) "Hold and Review" means a process of prepayment review of a medicaid provider's claims, including client records, medical records, or other supporting documentation, for determination of appropriate claims payment or reimbursement.

(a) Hold and review administered by ODM will be done in accordance with rule 5160-1-27.1 of the Administrative Code.

(b) Hold and review administered by state agencies other than ODM will be done in accordance with rule 5160-1-27.2 of the Administrative Code.

(3) "Review" means a post-payment examination of a medicaid provider's paid claims to determine program compliance, validity of payments and identification of recovery of overpayments under the medicaid program. Review also means special projects or analysis to determine quality of care, compliance with accepted standards of care, and general program compliance. A review may result in an educational letter, a request for a corrective action plan subject to department approval, and/or recovery of inappropriate paid claims due to non-program compliance.

(4) "Notice of operational deficiency" means a written notice issued by the department that identifies provider conduct, treatment or practices that are determined by the department not to be in the best interests of the consumer or the medicaid program and/or are noncompliant with the regulations governing the medicaid program and that must be corrected. The notice states the nature of the deficiency, the time period that the provider has to correct the deficiency and the person within the department the provider is to contact to verify that the deficiency has been corrected.

(C) Records, documentation and information must be available regarding any services for which payment has been or will be claimed to determine that payment has been or will be made in accordance with applicable federal and state requirements. For the purposes of this rule, an invoice constitutes a business transaction but does not constitute a record which is documentation of a medical service.

(D) Various methods of audit and review will be utilized in all cases of suspected fraud, waste and abuse, in accordance with rule 5160-1-29 of the Administrative Code. If fraud, waste and abuse are apparent, the department will take action to gain compliance and recoup inappropriate payments.

(E) The provider must maintain all records as stipulated in this rule and rule 5160-1-17.2 or Chapter 5160-3 of the Administrative Code, as applicable.

(F) All records, documentation and/or information requested in accordance with paragraph (B) of this rule shall be submitted to the department or its designee, in an appropriate manner as determined by the department. Records subject to audit and review must be produced at no cost to the department.

(1) Records subject to audit and review must be made available for examination in the time period described in rule 5160-1-17.2 of the Administrative Code, or as determined by the department or its designee. Failure to supply requested records, documentation and/or information as indicated in this rule will result in no payment for outstanding services.

(2) In all situations, the department has the authority to conduct an on-site visit with the provider at the provider's location for the examination or collection of records, and/or for compliance verification. Upon such occasions, as deemed necessary by the department or its designee, a member of the provider's staff is to be assigned to assist in collecting the information. Upon request from the department, the provider will photocopy or make the applicable records available for photocopying.

(3) Services billed to and reimbursed by the department, which are not validated in the recipients' records, are subject to recoupment through the audit and review process described in this rule.

History

Effective: September 3, 2015
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-27.1 Hold and review process.

(A) "Hold and Review" is defined in accordance with rule 5160-1-27 of the Administrative Code.

(1) Hold and review without prior notification.

(a) The Ohio department of medicaid (ODM) may place a medicaid provider's claim(s) payment on hold and review, in whole or in part, without first notifying the provider for the following reasons:

(i) In response to allegations of fraud or other willful misrepresentation of claims submission; or

(ii) When a provider has been indicted for a criminal offense.

(b) ODM shall notify the provider in writing within ten business days that the provider's claims have been, and will continue to be, subject to hold and review.

(2) Hold and review with prior notification.

(a) ODM may place a medicaid provider's claim(s) payment on hold and review, in whole or in part, with prior notice to the provider under the following circumstances:

(i) When the information is used to complement or follow up a provider certification or other quality review process;

(ii) Upon request from the office of the attorney general, the office of inspector general or the auditor of state;

(iii) A medicaid provider's agreement has been proposed for termination for reasons other than those stated in paragraph (A) of this rule; or

(iv) For reasons otherwise necessary to assure the basic integrity of claims submission and payment.

(b) ODM will notify the provider in writing within ten business days before the effective start date of the hold and review.

(B) Review of the medicaid provider's claims and documentation for the hold and review process is subject to the provisions of rule 5160-1-27 of the Administrative Code.

(D) Failure by ODM to notify a provider of a hold and review shall not impede the agency from taking actions under this rule.

(E) The notice from ODM shall:

(1) State the general reasons for the withholding of the medicaid provider's claims payments, but need not disclose any specific information concerning an ongoing investigation involving alleged fraud and/or willful misrepresentation;

(2) State the effective date ODM implements the hold and review process;

(3) State the types of services and claims, in whole or in part, that will be subject to the hold and review process;

(4) Identify the documentation required to be submitted to ODM by the provider:

(5) Inform the provider of the right to submit evidence for consideration to ODM;

(6) State the contact at ODM for questions regarding the hold and review process.

(F) Except for medicaid providers required to submit medical claims to ODM electronically, all claims from providers placed on hold and review must be submitted in non-electronic (paper) format.

(G) Providers who must submit medical claims electronically must submit paper documentation supporting each claim submitted electronically. These claims will not be processed until both the claim and the supporting documentation are reviewed by ODM.

(H) ODM may, if appropriate, send copies of the notice to local, state and federal entities that are involved in the review or that need to be aware of the review in order to assure the integrity of claims submission and payment.

(I) ODM has one hundred twenty days from the date each claim for payment is received to review the claim and make a determination whether or not to do one of the following:

(1) Forward the claim for adjudication;

(2) Forward the claim for denial; or

(3) Issue a "Notice of Operation Deficiency."

(J) The hold and review process is not subject to Chapter 119. of the Revised Code or any other appeal.

History

Effective: September 3, 2015
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-27.2 Medicaid hold and review process for medicaid claims paid through state agencies other than the Ohio department of medicaid.

(A) "Medicaid administrative agency" means a state agency other than the Ohio department of medicaid that:

(1) Administers a component of the medicaid program under the terms of a contract with ODM under section 5162.35 of the Revised Code; and

(2) Pays claims for medicaid services or reimburses local entities for claims paid for medicaid services.

(B) "Hold and Review" is defined in accordance with rule 5160-1-27 of the Administrative Code.

(1) When the information is used to complement or follow-up a provider or certification or other quality review process;

(2) In response to allegations of fraud or willful misrepresentation of claims submission;

(3) Upon the request of the office of the attorney general, the office of inspector general, or the auditor of state;

(4) When a provider's medicaid provider agreement is subject to termination;

(5) When a provider has been indicted for a criminal offense; or

(6) For reasons otherwise necessary to assure the basic integrity of claims submission and payment.

(D) The hold and review may be applied without regard to date of service.

(E) Hold and review initiated by medicaid administrative agencies.

(1) The medicaid administrative agency shall have formal written approval from ODM to initiate a hold and review process.

(2) The medicaid administrative agency may recruit the assistance of local governmental entities to review records subject to hold and review.

(3) The medicaid administrative agency may initiate hold and review without prior notification to the provider when the medicaid administrative agency receives a request to initiate hold and review from the office of the attorney general, the office of inspector general, the auditor of state, or ODM.

(4) When the medicaid administrative agency initiates hold and review without prior notification to the provider, the medicaid administrative agency shall provide written notice to the provider, including a copy of ODM written approval within ten business days of initiating a hold and review.

(5) The medicaid administrative agency may initiate hold and review with prior notification to the provider for any purpose contained in paragraph (C) of this rule. The medicaid administrative agency shall notify the provider at least ten business days prior to subjecting the provider's claims to hold and review.

(6) For claims payment that the medicaid administrative agency pays directly to the medicaid provider, the medicaid administrative agency may subject the medicaid provider's claim(s) payment, in part or in whole, to hold and review.

(7) For reimbursements the medicaid administrative agency makes to local entities for claims that the local entity pays to the medicaid provider directly, the medicaid administrative agency:

(a) May require the local entity to hold the medicaid provider's claim(s) payment for claims subject to hold and review;

(b) May deny reimbursement to the local entity for the claims on which the hold and review was requested after allowing the local entity a reasonable time to comply; and

(8) A failure by the medicaid administrative agency to notify a provider of a hold and review process shall not impede the agency from taking actions under this rule.

(9) Review of the medicaid provider's claims and documentation for hold and review is subject to the provisions of rule 5160-1-27 of the Administrative Code.

(10) The notice from the medicaid administrative agency shall:

(a) State the general reasons for subjecting the medicaid provider's claims to hold and review, but need not disclose any specific information concerning an ongoing investigation involving alleged fraud and/or willful misrepresentation;

(b) State the date the medicaid administrative agency implements the hold and review;

(d) Identify the documentation required to submit to the medicaid administrative agency;

(e) Inform the provider of the right to submit evidence for consideration to the medicaid administrative agency; and

(f) State the contact at the medicaid administrative agency for questions regarding the hold and review and where to send the requested documentation.

(11) The medicaid administrative agency shall send copies of the notice to all local, state, and federal entities that are involved in the review or that need to be aware of the review in order to assure the integrity of claims submission and payment.

(12) Providers who submit medical claims electronically may be required under this rule to submit paper documentation supporting each claim submitted electronically. These claims will not be processed until both the claim and the supporting documentation are reviewed by the medicaid administrative agency.

(13) The medicaid administrative agency has one hundred twenty days from the date each claim for payment is received to review the claim and make a determination whether or not to do one of the following:

(a) Forward the claim for adjudication;

(b) Forward the claim for denial; or

(F) Hold and review process initiated by ODM.

(1) ODM may require a medicaid administrative agency to initiate a hold and review described in this rule or to cooperate in a hold and review initiated by ODM under rule 5160-1-27.1 of the Administrative Code.

(2) In cooperating with a request from ODM to initiate a hold and review, medicaid administrative agencies shall:

(a) Comply with the provider notification requirements of this rule; and

(b) Suspend payment or reimbursement of the claims that are subject to hold and review; and

(d) Obtain provider records, including client records, medical records, and other supporting documentation that ODM requests as part of the review from local entities and providers; and

(e) Participate in the review of records and other supporting documentation when requested by ODM; and

(f) Provide any other information requested by ODM in order to assure accurate tracking and timely resolution of the claims subject to hold and review.

(3) For claims associated with alcohol and drug addiction services, ODM shall rely on the Ohio department mental health and addiction services to obtain and review provider records, including client records and medical records, as necessary to assure the special confidentiality of these records required by 42 C.F.R., part 2 as amended through October 1, 2006.

(4) After requesting a hold and review and allowing the medicaid administrative agency a reasonable time to comply, ODM may stop drawing from the centers for medicare and medicaid services, and passing to the other agency, the federal match associated with the claims that are subject to the review. ODM will not withhold federal match for claims that other agencies or local entities paid prior to the ODM request.

(G) For purposes of determining whether time limits for the submission of claims have been met for claims subjected to hold and review, the date of claims submission shall be the date that the medicaid administrative agency received the original claim from the provider.

(H) The hold and review process is not subject to Chapter 119. of the Revised Code or any other appeal.

History

Effective: September 3, 2015
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-29 Medicaid fraud, waste, and abuse.

(A) For purposes of this rule, the following definitions apply:

(1) "Abuse" has the same meaning as in 42 C.F.R. 455.2 (as in effect on October 1, 2023).

(2) "Fraud" has the same meaning as in 42 C.F.R. 455.2 (as in effect on October 1, 2023).

(3) "Waste" means any preventable act such as inappropriate utilization of services or misuse of resources that results in unnecessary expenditures to the medicaid program.

(B) The Ohio department of medicaid (ODM) will have in effect a program to prevent and detect fraud, waste, and abuse in the medicaid program. Where cases of suspected fraud to obtain payment from the medicaid program are detected, providers will be subject to a review by ODM and the case will be referred to the attorney general's medicaid fraud control unit or the appropriate enforcement officials. If waste and abuse are suspected or apparent, ODM, the office of the attorney general, or both will take action to gain compliance and recoup inappropriate or excess payments in accordance with rule 5160-1-27 or 5160-26-06 of the Administrative Code.

(1) A pattern of duplicate billing by a provider to obtain reimbursement to which the provider is not entitled.

(2) Misrepresentation as to services provided, quantity provided, date of service, who performed the service or to whom services were provided.

(3) Billing for services not provided.

(4) A pattern of billing, certifying, prescribing, or ordering services that are not medically necessary or reimbursable in accordance with rule 5160-1-01 of the Administrative Code, not clinically proven and effective, and not consistent with medicaid program rules and regulations.

(5) Differing charges for the same services to medicaid versus non-medicaid recipients. For inpatient hospital services billed by hospitals reimbursed on a prospective payment basis, ODM will not pay, in the aggregate, more than the provider's customary and prevailing charges for comparable services.

(6) Violation of a provider agreement by requesting or obtaining additional payment for covered medicaid services from the recipient or the recipient's family, other than medicaid co-payments as designated in rule 5160-1-09 of the Administrative Code, or from other providers.

(7) Collusive activities involving the medicaid program between a medicaid provider and any person or business entity.

(8) Misrepresentation of cost report data so as to maximize reimbursement or misrepresent gains or losses.

(9) Billing for services that are outside the current license limitations, scope of practice, or specific practice parameters of the person supplying the service.

(10) Misrepresenting by commission or omission any information on the provider enrollment and revalidation application, provider agreement, or any documentation supplied by the provider to ODM.

(11) Ordering excessive quantities of medical supplies, drugs and biologicals, or other services.

(12) Any action which would constitute a violation of the False Claims Act (October 1, 2023), 31 U.S.C. 3729-3733.

(13) Non-compliance with the service definitions, activities, coverage, and limitations as listed in the applicable provisions in agency 5160 of the Administrative Code.

(D) ODM will not pay for services prescribed, ordered, or rendered by a provider, when those services were prescribed, ordered, or rendered by that provider after the date the provider was terminated under the medicaid program in accordance with rule 5160-1-17.6 of the Administrative Code.

(E) In instances when a provider suspects that there may be fraud, waste, or abuse by a recipient, the provider should contact the local county department of job and family services (CDJFS). Cases of recipient fraud, waste, and abuse may include, but are not limited to:

(1) Alteration, sale, or lending of the medicaid card to others for securing medical services, or other related criminal activities.

(2) Receiving excessive medical visits and services.

(3) Obtaining services not personally needed and used by the recipient.

(4) Any action to falsely obtain medicaid eligibility as described in section 2913.401 of the Revised Code.

(F) Providers will assume responsibility for the business practices of employees. In accordance with rule 5160-1-17.2 of the Administrative Code, the Ohio medicaid provider agreement states that each provider will comply with the terms of the provider agreement, Revised Code, Administrative Code, and federal statutes and rules. Providers will take the necessary time to thoroughly acquaint themselves and their employees with all rules relative to their participation in the medicaid program. Ignorance of medicaid program rules will not be an acceptable justification for violation of the provider agreement, relevant statutes, or rules.

Last updated October 2, 2026 at 8:01 AM

History

Effective: July 18, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-31 Prior authorization.

(A) Reimbursement for certain items or services covered under the medicaid program is dependent on obtaining prior authorization from the Ohio department of medicaid (ODM), its designee, or a medicaid managed care entity (MCE). Prior authorization requests have to be approved by ODM, its designee, or MCE before the services are rendered or the items are delivered unless the services or items meet the provisions stated in section 5160.34 of the Revised Code or paragraph (D) of this rule.

(B) Except as authorized under section 5160.34 of the Revised Code, prior authorization requests submitted via paper cannot be processed. All other prior authorization requests should be submitted pursuant to the instructions located at www.medicaid.ohio.gov.

(C) For services or items requiring prior authorization, only those approved in the prior authorization determination will be eligible for reimbursement.

(D) The following exceptions to prior authorization apply:

(1) In situations where the provider considers a delay in providing services or an item requiring prior authorization to be detrimental to the health of the medicaid recipient, the services or item may be rendered or delivered and approval for reimbursement sought after the fact.

(2) In cases of emergency, for prescribed drugs requiring prior authorization, the prescribed drug may be rendered without prior authorization in accordance with rule 5160-9-03 of the Administrative Code.

(3) In the discretion of and as instructed by ODM, a retroactive prior authorization may be sought.

(E) A medicaid provider may request a reconsideration of an adverse prior authorization determination in accordance with section 5160.34 of the Revised Code. A reconsideration of an adverse prior authorization determination rendered by an MCE or transplant consortium should be submitted and addressed in accordance with their respective processes for reconsideration. A reconsideration of an adverse prior authorization determination rendered by ODM or its designee should be submitted and addressed in the following manner:

(1) The request for reconsideration has to be received by ODM or its designee within sixty calendar days of the notification to the provider of an adverse determination. A valid request for reconsideration should be submitted pursuant to the instructions located at www.medicaid.ohio.gov and include the following:

(a) Medicaid recipient's name and medicaid number;

(b) Name of requested service or item and billing code;

(d) Clinical documentation supporting medical necessity for the service or item;

(e) A reference to any relevant federal or state law or regulation, if applicable;

(f) An explanation outlining the reason for reconsideration, including supportive information not previously submitted as necessary; and

(g) If applicable, an indication of whether the service or item qualifies as "urgent care services" as defined in section 5160.34 of the Revised Code.

(2) ODM or its designee will make a standard reconsideration determination within ten calendar days of receipt. If an expedited review is requested because the service or item qualifies as urgent care services, the reconsideration determination will be made no later than forty-eight hours after receipt.

(3) The review of the reconsideration will be conducted by a clinical peer appointed or contracted by ODM or its designee.

(4) The provider reconsideration process afforded under this rule does not interfere with the medicaid recipient's right to appeal in accordance with division 5101:6 of the Administrative Code.

Last updated July 2, 2024 at 9:38 AM

History

Effective: June 30, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-32 Medicaid: safeguarding and releasing information.

(A) "Safeguarded information" includes but is not limited to the following types of information about individual medicaid applicants, enrollees, or former recipients:

(1) Names and addresses;

(2) Social security numbers;

(3) Medical services provided;

(4) Social and economic conditions or circumstances;

(5) Agency evaluation of personal information;

(6) Medical data, including diagnosis and past history of disease or disability;

(7) Any information received in connection with the identification of third party coverage; and

(8) Any information received for verifying income eligibility and amount of medical assistance payments. Income information received from the social security administration (SSA) or the internal revenue service (IRS) should be safeguarded according to the regulations of the agency that furnished the data.

(B) For the purpose of this rule, "administrative agency" means the Ohio department of medicaid (ODM) or an agent of ODM to determine eligibility or maintain records for a medical assistance program. The administrative agency has the following responsibilities:

(1) Implementing administrative, physical and technical safeguards in accordance with 45 C.F.R. 164.308, 45 C.F.R. 164.310, and 45 C.F.R. 164.312 (as in effect on October 1, 2023).

(2) Following the safeguarding guidelines for protecting federal tax information (FTI) described in the most current version of IRS publication 1075 (rev. 11/2021).

(3) Safeguarding information received or maintained about an individual connected with the administration of the medicaid program in accordance with section 1902(a)(7) of the Social Security Act (as in effect on October 1, 2023).

(4) Publicizing provisions governing the confidential nature of information about individuals, including the legal sanctions imposed for improper disclosure and use, in accordance with 42 C.F.R. 431.304 (as in effect October 1, 2023).

(5) Providing copies of the publicized provisions to individuals and to other persons and agencies to whom information is disclosed, in accordance with 42 C.F.R. 431.304 (as in effect October 1, 2023).

(6) Protecting the types of safeguarded information referenced in 42 C.F.R. 431.305 (as in effect October 1, 2023).

(7) Maintaining confidentiality and safeguarding psychiatric hospitalization records, mental health or addiction treatment records, rehabilitation and correction records, or other sensitive records in accordance with section 5122.31 of the Revised Code.

(8) Refraining from publishing names of individuals in accordance with 42 C.F.R. 431.306(c) (as in effect October 1, 2023).

(1) Obtaining permission from an individual or authorized representative before releasing information, unless that information is used to verify income or eligibility, in accordance with 42 C.F.R. 431.306(d) (as in effect on October 1, 2023).

(2) Applying policies to all requests for information from outside sources, including governmental bodies, courts of law, or law enforcement officials, except as provided in sections 5160.45 to 5160.48 of the Revised Code.

(3) Establishing criteria specifying the conditions for release and use of information about individuals. The information has to be restricted to persons or agency representatives who are subject to standards of confidentiality that are comparable to those of the agency in accordance with 42 C.F.R. 431.306(a) and (b) (as in effect on October 1, 2023).

(4) Limiting disclosures of protected health information (PHI) for individuals applying for, or participating in, a medical assistance program to purposes related to payment, treatment, or health care operations. For any other purposes, disclosures of information about the health care of an individual, health care provided to an individual, or payment for the provision of health care for an individual has to include an authorization or waiver of authorization from an institutional review board or privacy board compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) in accordance with 45 C.F.R. 164.508 and 45 C.F.R. 164.512(i) (as in effect October 1, 2023).

(5) Releasing information as permitted by and in accordance with section 5160.45 of the Revised Code.

Last updated June 25, 2025 at 6:45 PM

History

Effective: November 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-32.1 Standard authorization form.

In accordance with section 3798.10 of the Revised Code, a standardized authorization form that meets all requirements specified in 45 C.F.R. 164.508 and, where applicable, 42 C.F.R. Part 2 as in effect on October 1, 2025, for the use and disclosure of protected health information are found in the appendix of this rule.

View Appendix

Last updated February 17, 2026 at 8:04 AM

History

Effective: February 16, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-33 Medicaid: authorized representatives.

(A) Designation of an authorized representative.

(1) ) An individual may designate any person or organization to serve as that individual's authorized representative. Any person serving as an authorized representative must be at least eighteen years or older.

(2) Authority for a person or organization to act on behalf of the individual accorded under state law, including but not limited to, a court order establishing legal guardianship, must be treated as a written designation by the individual of authorized representation.

(3) The designation of an authorized representative must be in writing, and must identify what duties the individual is authorizing the representative to perform.

(4) If the designated authorized representative is unwilling or unable to accept the responsibility of being an authorized representative, the authorized representative must inform the administrative agency and the individual of the refusal or withdrawal.

(B) The authorized representative:

(1) Must present proper identification, if requested by the administrative agency, prior to the disclosure of medicaid information to the authorized representative.

(2) Must agree to maintain or be legally bound to maintain the confidentiality of any information regarding the individual provided by the administrative agency.

(3) Will receive copies of notices and correspondence sent to the individual by the administrative agency.

(4) Stands in the place of the individual. Any responsibility of the individual is a responsibility of the authorized representative. Any action taken by the authorized representative or failure to act will be accepted as the action or lack of action of the individual.

(5) Shares all responsibilities set out in rule 5160:1-2-08 of the Administrative Code.

(C) The administrative agency may contact the individual to clarify or verify information provided by an authorized representative if the authorized representative provides information that seems contradictory, unclear, or unrealistic.

(D) The administrative agency may choose not to contact the authorized representative if the administrative agency believes that the authorized representative might endanger the individual in a situation of domestic violence, abuse, or neglect in accordance with 45 C.F.R. 164.502(g)(5) (as in effect October 1, 2015).

(E) If the authorized representative is a provider or staff member or volunteer of an organization, the authorized representative must affirm that he or she will adhere to the regulations in 42 C.F.R. Part 431 Subpart F (as in effect October 1, 2015), 42 C.F.R. 447.10 (as in effect October 1, 2015), 45 C.F.R. 155.260(f) (as in effect October 1, 2015), as well as other relevant state and federal laws concerning conflicts of interest and confidentiality of information.

(F) The power to act as authorized representative is valid until the individual notifies the administrative agency that the authorized representative is no longer authorized to act on his or her behalf, or the authorized representative informs the administrative agency the he or she no longer is acting in such capacity, or there is a change in the legal authority upon which the authorized representative's authority was based. Such notice should include the applicant or authorized representative's signature as appropriate.

(G) Assistance from persons or organizations who are not authorized representatives.

(1) A person or organization may accompany and assist an individual with portions of the application, verification, or redetermination process without being an individual's authorized representative.

(2) The administrative agency must not reveal confidential information or send notices or correspondence to a person or organization who is assisting an individual, unless the person or organization is designated as an authorized representative.

(3) A person or organization who is assisting an individual must provide accurate information to the administrative agency, to the best of his or her knowledge, regardless of whether the person or organization is an authorized representative.

History

Effective: January 13, 2017
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-39 Verification of home care service provision to home care dependent adults.

(A) Home care service providers, as defined in this paragraph, must have a system as follows.

(1) Definitions.

(a) "Home care dependent adult" means a consumer who:

(i) Resides in a private home or other non-institutional, unlicensed living arrangement without a parent or guardian present;

(ii) Requires, due to health and safety needs, regularly scheduled home care services to remain in the home or other living arrangement; and,

(iii) Is sixty years of age or older, or is at least twenty-one years of age but less than sixty years of age, and has a physical disability or mental impairment.

(b) "Home care service provider" is:

(i) A medicare certified home health agency or other accredited agency in accordance with Chapter 5160-12 of the Administrative Code that provides service in the home to the home care dependent adult; or

(ii) A medicare certified hospice provider in accordance with Chapter 5160-56 of the Administrative Code that provides services to the terminally ill.

(c) "Life-threatening condition" means a health condition that will place the consumer at risk of permanent impairment if the home care service is not provided.

(d) "Mental impairment" means a consumer has a diminished capacity of judgment such that if the consumer were left alone, it would place the consumer at risk of permanent impairment.

(e) "Physical disability" means a consumer's physical condition of severe functional limitations.

(2) A home care service provider, who provides home care services to a home care dependent adult, must have a system which effectively monitors the delivery of services by its employee(s). The system must include:

(a) A mechanism to verify whether their employees are present (e.g., at the beginning and end of a visit) at the location and time where services are to be provided for home care dependent adults who have a mental impairment or life-threatening condition;

(b) Verification of whether the provider's employees have provided the services at the proper location and time at the end of each working day for all other home care dependent adults not addressed in paragraph (A)(2)(a) of this rule. (e.g., adults age sixty or older, or adults that are at least twenty-one years of age but less than sixty years of age and have a physical disability); and,

(c) Implementation of a protocol for scheduling substitute employees when the monitoring system identifies that an employee has failed to provide home care services at the proper location and time. The protocol must include a standard for determining the length of time that may elapse without jeopardizing the health and safety of the home care dependent adult.

(3) For the information obtained through the monitoring system in accordance with paragraph (A)(2) of this rule, the home care service provider must have procedures in place to:

(a) Maintain records;

(b) Compile annual reports which must include the rate at which home care services were provided at the proper location and time;

(c) Conduct random checks of the accuracy of the monitoring system. For purposes of conducting these checks, a random check is considered to be a check of not more than five per cent or less than one per cent of the home care visits the provider's employees make to different home care dependent adults within a particular work shift; and,

(d) Retain records in accordance with rule 5160-1-17.2 of the Administrative Code.

(B) Home care service providers, as defined in paragraph (A) of this rule and as defined by the department of developmental disabilities or department of aging, shall demonstrate their verification system of home care service provision in accordance with section 121.36 of the Revised Code and paragraph (A) of this rule by:

(1) Participating in periodic compliance reviews; and/or,

(2) Furnishing upon request to Ohio department of medicaid (ODM), its designee or the medicaid fraud control unit any records related to the provisions outlined in section 121.36 of the Revised Code.

History

Effective: July 3, 2015
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-42 Provider credentialing.

In accordance with the federal credentialing standards found in 42 CFR 422.204, "provider selection and credentialing" (as in effect on October 1, 2021), this rule details the credentialing and recredentialing process for medicaid providers.

(A) For purposes of this rule, the following definitions apply.

(1) "Council for affordable quality healthcare (CAQH)" is a non-profit organization which created a process allowing ODM to use a single, uniform application for credentialing. This end-to-end process simplifies data collection, primary source verification, and sanctions monitoring, to support ODM's credentialing needs.

(2) "Credentialing" means an evaluation of the qualifications of health care providers that seek contracts or participation agreements with ODM.

(3) "Credentialing committee" means the group of individuals appointed by ODM for provider and facility review, as well as reconsidering providers and facilities initially denied by credentialing as described in paragraph (K) of this rule.

(4) "Delegate" means a hospital group or physician hospital organization formed by a hospital and group of physicians granted the authority by ODM to credential its health care providers who require credentialing.

(5) "Delegation" means the act of ODM granting another health care entity the authority to credential its health care providers who require credentialing.

(6) "Designee" means a third party with whom ODM has contracted to complete certain credentialing related administrative tasks and information gathering tasks required to fulfill credentialing and re-credentialing for those providers whose credentialing is not completed through the process of delegation; and

(7) "Eligible provider" has the same meaning as a person or entity who is an eligible provider as defined in rule 5160-1-17 of the Administrative Code who is enrolled with ODM.

(B) Credentialing by ODM is mandatory for the following practitioners:

(1) Physicians as defined in Chapter 4731. of the Revised Code;

(2) Psychologists as defined in Chapter 4732. of the Revised Code;

(3) Physician assistant as defined in Chapter 4730. of the Revised Code;

(4) Dentists as defined in Chapter 4715. of the Revised Code;

(5) Optometrists as defined in Chapter 4725. of the Revised Code;

(6) Pharmacists as defined in Chapter 4729. of the Revised Code;

(7) Chiropractors as defined in Chapter 4734. of the Revised Code;

(8) Acupuncturists as defined in Chapter 4762. of the Revised Code;

(9) Clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner as defined in Chapter 4723. of the Revised Code;

(10) Licensed independent social worker, licensed independent marriage and family therapist, or licensed professional clinical counselor as defined in Chapter 4757. of the Revised Code;

(11) Licensed independent chemical dependency counselor as defined in Chapter 4758. of the Revised Code;

(12) Certified Ohio behavior analysts as defined in Chapter 4783. of the Revised Code;

(13) Audiologists as defined in Chapter 4753. of the Revised Code;

(14) Occupational therapist as defined in Chapter 4755. of the Revised Code;

(15) Physical therapist as defined in Chapter 4755. of the Revised Code;

(16) Speech-language pathologist as defined in Chapter 4753. of the Revised Code; and

(17) Dietitians as defined in Chapter 4759. of the Revised Code.

(1) Nursing facilities as defined in Chapter 5165. of the Revised Code;

(2) Hospitals as defined in Chapter 3727. of the Revised Code;

(3) Hospice as defined in Chapter 3721. of the Revised Code;

(4) Home health agencies as defined in rule 3701-60-01 of the Administrative Code;

(5) Ambulatory surgical facilities as defined in section 3702.30 of the Revised Code;

(6) Community mental health services providers as defined in Chapter 5119. of the Revised Code;

(7) Community addiction services providers as defined in Chapter 5119. of the Revised Code;

(8) End stage renal disease (ESRD) treatment centers as described in rule 3701-83-23.1 of the Administrative Code;

(9) Radiology centers as described in rule 3701-83-51 of the Administrative Code; and

(10) Residential facility as defined in Chapter 5119. of the Revised Code.

(D) Credentialing by ODM is not mandatory for the following practitioners:

(1) Health care professionals who are permitted to provide services only under the direct supervision of an independently enrolled practitioner as defined in rule 5160-4-02 of the Administrative Code;

(2) Hospital-based health care professionals who provide services "incidental-to" a hospital service and are not independently enrolled;

(3) Health care professionals who are designated as current residents, interns, or fellows as defined in Chapter 5160-4 of the Administrative Code; and

(4) Moonlighting residents as defined in 42 CFR 415.208 (as in effect on October 1, 2021).

(E) Those providers listed in paragraph (B) of this rule will provide ODM or ODM's credentialing designee the following information for initial credentialing verification:

(1) Access to the standard provider credentialing application form used by the council for affordable quality healthcare (CAQH) in accordance with section 3963.05 of the Revised Code within one-hundred-eighty days prior to credentialing date;

(2) Active provider licensing information;

(3) Board certification, if applicable;

(4) Education;

(5) Clinical privileges, if applicable;

(6) Medical malpractice insurance;

(7) Drug enforcement administration (DEA) certification, if applicable;

(8) National practitioner data bank information regarding malpractice and clinical privilege actions;

(9) Sanctions or limitations on licensure;

(10) Eligibility for participation in medicare and medicaid, if applicable; and

(11) Minimum five-year work history. The five-year timeframe begins with date of initial licensure. If the provider has been licensed for less than five years, available work history should be provided.

(F) The facilities listed in paragraph (C) of this rule will provide ODM or ODM's credentialing designee access to the following information for initial credentialing verification:

(1) The Ohio department of insurance (ODI) form INS5036, revision date February of 2021, found at https://insurance.ohio.gov/static/Forms/Documents/INS5036.pdf;

(2) Active provider licensing information;

(3) Certification through an accrediting body or a site visit completed by a state designated agency;

(4) Eligibility for participation in medicare and medicaid, if applicable;

(5) Verification of good standing with applicable state and federal bodies; and

(6) Active malpractice insurance.

(G) Prerequisites for becoming a delegate as defined in paragraph (A)(4) of this rule are the following:

(1) Maintain an active, valid delegation contract approved by the credentialing committee;

(2) The delegate has to complete a pre-delegation audit prior to their becoming an active delegate;

(3) The delegate has to adhere to the standards set forth in the delegated contract, including the time frames and content for reporting, duties assigned, necessary processes and procedures, and collaborating of a yearly audit;

(4) The delegate has to have their own credentialing committee, with decision making capabilities, and delegation contract monitoring;

(5) The delegate has to report any additions, changes, and terminations in a timely manner including both credentialed and non-credentialed practitioners and facilities;

(6) Delegates will be audited by ODM every twelve months; and

(7) Practitioners with a delegated group understand they are still expected to update their information in the provider data system, and to revalidate according to their ODM determined schedule.

(H) Every thirty-six months, those providers listed in paragraph (B) of this rule will provide ODM or ODM's credentialing designee information listed in paragraphs (E)(1) to (E)(10) of this rule for recredentialing.

(I) Every thirty-six months, facilities listed in paragraph (C) of this rule will provide ODM or ODM's credentialing designee the information listed in paragraphs (F)(1) to (F)(6) of this rule for recredentialing verification.

(J) The following information may be requested by the state or its designee from providers or facilities as listed in paragraph (B) or (C) of this rule at any time during the credentialing or recredentialing process:

(1) Demographic information;

(2) Information missing in CAQH;

(3) Verification of certifying board names;

(4) Explanation for work history gaps;

(5) Updates regarding expired information;

(6) Verification of specialty information;

(7) Information regarding previous sanctions or affirmative responses to CAQH disclosure questions; and

(8) Continuing education (CE) prerequisites as required by the provider's state licensing board.

(K) ODM will establish and utilize a credentialing committee for provider and facility review and appeals when the credentialing prerequisites specified in paragraph (K)(1) of this rule are under review. The credentialing committee will follow the process described in this paragraph when a provider or facility is found to be non-compliant with the credentialing prerequisites.

(1) Providers or facilities that fail to meet the following prerequisites, have a discrepancy, or negative findings with the information provided in paragraph (E) or (F) of this rule, are subject to review by the state established credentialing committee. Prerequisites are the following:

(a) Previous licensing board sanctions;

(b) Previous clinical actions taken by a medical group or hospital;

(i) To your knowledge, has information pertaining to you ever been reported to the national practitioner data bank (NPDB) or healthcare integrity and protection data bank (HIPDB)?

(ii) Have you had any professional liability actions (pending, settled, arbitrated, mediated or litigated) within the past ten years? And if yes, provide information for each case.

(d) Excessive malpractice claims within the past ten years, as defined by the credentialing committee;

(e) Inappropriate training or education for disclosed provider specialty;

(f) Previous medicare or medicaid disbarments or actions;

(g) Site visit non-compliance;

(h) Previous DEA actions;

(i) Material misrepresentation or omission concerning professional credentials; and

(j) Prior criminal history in accordance with rule 5160-1-17.8 of the Administrative Code.

(2) The following individuals will participate in the ODM credentialing committee as determined by ODM. Voting members are expected to attend no less than seventy-five per cent of all meetings held to maintain voting rights, and sign non-discrimination and conflict of interest forms.

(a) Committee chair;

(b) Community-based peers of providers requiring credentialing as defined in paragraph (B) of this rule;

(d) Medical directors; and

(e) Staff from ODM and ODM's designee.

(3) The credentialing committee members will carry out the following responsibilities:

(a) Review the credentials of practitioners;

(b) Review and approve sanctions monitoring;

(d) Review and approve credentialing reports from ODM and ODM's designee.

(4) When a provider or facility is denied by the credentialing committee, the following process will occur.

(a) The provider or facility is sent a denial letter by ODM outlining the unmet credentialing prerequisites or negative findings under review, and their appeal rights and instructions for proceeding;

(b) The provider or facility will have no more than thirty calendar days to appeal to the credentialing committee;

(c) The appellant provides the credentialing committee with supplemental information which supports its appeal of the decision;

(d) Appeal decision is rendered by the credentialing committee; and

(e) Credentialing committee decisions on appeals are final, and those providers and facilities denied by the credentialing committee are not subject to reconsideration as found in paragraph (D) of rule 5160-70-02 of the Administrative Code. The practitioners denied by the credentialing committee are denied ODM enrollment.

(L) Providers and facilities who do not have any negative findings regarding the information needed for initial credentialing verification or recredentialing listed in paragraph (E) or (F) of this rule and meet the prerequisites listed in paragraph (K)(1) of this rule are considered to have a clean file and have met the requirements for credentialing with ODM. Providers and facilities with clean files and no negative findings will not meet with the credentialing committee unless otherwise determined by ODM and ODM's designee. Clean files for initial credentialing and recredentialing will have a final review by ODM's medical director.

Last updated May 18, 2026 at 5:25 PM

History

Effective: October 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-42.1 Delegated credentialing.

(A) The Ohio department of medicaid (ODM) authorizes eligible provider delegates to perform credentialing activities on behalf of individual providers in accordance with rule 5160-1-42 of the Administrative Code.

(B) "Delegate" and "Delegation" have the same meaning as in rule 5160-1-42 of the Administrative Code.

(C) Entities seeking delegation will be expected to meet the following criteria to become an authorized delegate and to maintain delegate status:

(1) Be an eligible provider as defined in rule 5160-1-17 of the Administrative Code:

(2) Participate with home-state agency that administers titles XIX (medicaid), XXI (children's health insurance program - CHIP), or XVIII (medicare) of the Social Security Act;

(3) Be based in Ohio or a contiguous state;

(4) Have at least fifty Ohio medicaid enrolled and active affiliated individual providers;

(5) Submit to the credentialing department a request in writing; and

(6) Complete a pre-delegation audit conducted by ODM to include review of the following information maintained by the delegate:

(a) Credentialing policies and procedures;

(b) Sample of practitioner credentialing files;

(d) Ongoing sanctions monitoring.

(D) ODM has the right to deny or terminate delegation status. Denial or termination of delegation status does not afford hearing rights.

(E) Delegated credentialing of facilities is not permissible under the ODM delegated credentialing agreement.

Last updated May 18, 2026 at 5:25 PM

History

Effective: January 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-60 Medicaid payment.

(A) The medicaid payment for a covered procedure, service, or supply constitutes payment in full and may not be construed as a partial payment when the payment amount is less than the provider's submitted charge. A provider may not collect from a medicaid recipient nor bill a medicaid recipient for any difference between the medicaid payment and the provider's submitted charge, nor may a provider ask a medicaid recipient to share in the cost through a deductible, coinsurance, copayment, or other similar charge other than medicaid copayments as defined in rule 5160-1-09 of the Administrative Code. Nothing in agency 5160 of the Administrative Code, however, precludes a provider from requesting payment, collecting, or waiving the collection of medicare copayments from a medicaid recipient for medicare part D services. Medicaid recipient liability provisions set forth in rule 5160-1-13.1 of the Administrative Code do not apply to medicare part D services.

(B) Providers are expected to submit their usual and customary charge (the amount charged to the general public) on all claims. The medicaid payment amount for a covered service, procedure, or supply is the lesser of the submitted charge or the established medicaid maximum. Medicaid maximum payment amounts for many existing services, procedures, and supplies, particularly services rendered by practitioners of the healing arts, are set forth in the appendix to this rule. The initial maximum payment amount for a covered procedure, service, or supply represented by a new procedure code that takes effect at the beginning of a calendar year is established in accordance with paragraph (J) of this rule. Specific payment amounts or payment formulas set forth in other rules in agency 5160 of the Administrative Code supersede corresponding entries in the appendix to this rule.

(C) Pursuant to rule 5160-1-08 of the Administrative Code, providers are expected to take reasonable measures to determine any third-party resource available to a medicaid recipient and to file a claim with that third party when required to do so under rule 5160-1-08 of the Administrative Code. When there is a third-party payer, medicaid payment for a covered procedure, service, or supply is the lesser of two amounts:

(1) The provider's submitted charge; or

(2) The medicaid maximum payment amount less the sum of all third-party payments and any applicable medicaid copayment (unless the difference is zero or less, in which case medicaid will make no further payment).

(D) For services that are subject to a copayment pursuant to rule 5160-1-09 of the Administrative Code, the total medicaid maximum payment amount is reduced by the total medicaid copayment. The provider may collect from the medicaid recipient or bill the medicaid recipient for the total medicaid copayment, which is determined in accordance with the relevant rule of the Administrative Code.

(E) For dates of service on or after August 1, 2017, the rates for the facility services provided by an ASC are addressed in rule 5160-22-01 of the Administrative Code.

(F) Except as otherwise permitted by federal statute or regulation, the medicaid maximum payment amounts described in this rule must not exceed the established maximum medicare allowed amounts for the same procedures, services, or supplies.

(G) Medicaid payment is not allowed for non-covered procedures, services, and supplies nor for covered procedures, services, or supplies that are denied by the department as a result of a prepayment review, utilization review, or prior authorization process. (Chapter 5160-2 of the Administrative Code describes how these provisions are applied to inpatient and outpatient hospital services.)

(H) Every submitted claim must include the most appropriate code representing each procedure, service, or supply provided.

(I) "Site differential" is a difference in medicaid payment based on the place in which the service is provided. When a covered service is subject to a site differential, the payment amount is the lesser of the provider's submitted charge or the applicable maximum facility payment amount or maximum non-facility payment amount.

(1) The maximum facility payment amount applies to a service provided at one of the following sites:

(a) A hospital (inpatient hospital, outpatient hospital, emergency department, or inpatient psychiatric facility);

(b) A skilled nursing facility; or

(2) The maximum non-facility payment amount applies to a service provided at any other site.

(J) Additional information about the coverage of and payment for certain procedures is shown in the 'prof/tech split' and 'PC/TC indicator' columns of the appendix to this rule.

(1) A 'prof/tech split' entry indicates that the procedure is made up of both a professional and a technical component for the time period shown. The indicator denotes the relative proportions of the medicaid maximum payment amount allocated to the professional and technical components. For example, the indicator C means that the medicaid maximum payment amounts for the professional component and for the technical component are, respectively, forty per cent and sixty per cent of the medicaid maximum payment amount for the total procedure. There are thirteen such indicators:

(a) C: Forty per cent / sixty per cent;

(b) D: Eighty per cent / twenty per cent;

(d) G: Twenty per cent / eighty per cent;

(e) H: Twenty-five per cent / seventy-five per cent;

(f) I: Thirty per cent / seventy per cent;

(g) J: Thirty-five per cent / sixty-five per cent;

(h) K: Fifty per cent / fifty per cent;

(i) L: Sixty per cent / forty per cent;

(j) M: Seventy per cent / thirty per cent;

(k) O: One hundred per cent / zero per cent;

(l) P: Seventy-five per cent / twenty-five per cent; and

(m) Q: Ninety per cent / ten per cent.

(2) A numeric 'PC/TC indicator' entry shows the degree to which a procedure is professional or technical in nature or has a professional or technical component; these numeric values are defined by the centers for medicare and medicaid services (CMS), http://www.cms.gov. A lowercase alphabetic 'PC/TC indicator' entry indicates a medicaid payment restriction based on the location in which the procedure is performed (a place-of-service restriction). Meanings of these numeric and alphabetic indicators are summarized in the appendix to this rule.

(K) The department may set payment limits based on the characteristics of an individual procedure, service, or supply or the relationships between procedures, services, or supplies. For example, payment may be disallowed for a procedure if it is incompatible with another procedure or another procedure makes it redundant. In configuring its claim-processing system, the department may define its own limits, adopt limits established by an authoritative source, or modify limits established by an authoritative source. The maximum payment amounts for specimen collection and diagnostic testing for COVID-19 are set at the Ohio medicare rate.

(L) The "Healthcare Common Procedure Coding System (HCPCS)" is a numeric and alphanumeric code set maintained and distributed by CMS for the uniform designation of certain medical procedures and related services. Level one of HCPCS consists of "Current Procedural Terminology (CPT)," a comprehensive listing of medical terms and codes published by the American medical association (AMA), http://www.ama-assn.org, for the uniform designation of diagnostic and therapeutic procedures in surgery, medicine, and the medical specialties. When the department initially establishes coverage for a procedure, service, or supply the initial maximum payment amount is set at eighty per cent of the medicare allowed amount. If no medicare allowed amount is available the initial medicaid maximum payment amount is set at the unweighted average of the current maximum payment amounts for comparable procedures, services, or supplies. For convenience, a list of such initial maximum payment amounts is posted on the department's web site, http://medicaid.ohio.gov.

View Appendix

Last updated September 11, 2026 at 12:01 PM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-60.2 Direct reimbursement for out-of-pocket expenses incurred for medicaid covered services during approved eligibility periods.

(A) For purposes of this rule:

(1) "Applicant for reimbursement" is:

(a) An individual who has been determined eligible for a retroactive eligibility period in accordance with rule 5160:1-2-01 of the Administrative Code, and who is seeking reimbursement for medical expenses for which the individual paid for during this approved time period; or

(b) An individual who, as a result of an eligibility determination or state hearing decision, now has effective dates of eligibility and is seeking reimbursement for medical expenses for which the individual paid during this approved time period; or

(c) An individual who has been erroneously charged a medicaid co-pay for services eligible for a co-pay in accordance with rule 5160-1-09 of the Administrative Code, and who is seeking reimbursement of the co-pay amount incurred during the time period when the individual should not have been subject to a co-pay and for which the individual paid; or

(d) A person not legally obligated to pay for an individual's medical bills, but who does, in fact, contribute payment toward the individual's medical bills incurred during the approved eligibility period.

(2) "Effective dates of eligibility" means the period described in rule 5160:1-2-01 of the Administrative Code.

(3) "Medicaid covered service" is a service or product that meets all the following criteria:

(a) Medically necessary in accordance with rule 5160-1-01 of the Administrative Code;

(b) Delivered by an eligible provider who qualifies for one of the following:

(i) A medicaid provider agreement as described in rule 5160-1-17.12 of the Administrative Code; or

(ii) An approved contract or single case agreement with a medicaid managed care entity (MCE);

(d) A physician service as defined in Chapter 5160-4 of the Administrative Code, or a dental service as defined in Chapter 5160-5 of the Administrative Code.

(4) "Payer" is the Ohio department of medicaid (ODM), an MCE contracted with ODM, or any entity ODM designates with the authority to issue direct reimbursements.

(5) "Retroactive eligibility period" means the period described in rule 5160:1-2-01 of the Administrative Code.

(B) For any application for reimbursement, the payer will make direct reimbursement, including applicable co-pays, in accordance with 42 C.F.R. 447.25 only if all of the following are met:

(1) The individual has an eligibility period as defined in paragraph (A)(2) or (A)(5) of this rule and the date on which the individual received the medicaid covered service was within the period of eligibility;

(2) The service was a medicaid covered service, and the service was not a nursing facility service included in the nursing facility's per diem rate;

(3) The applicant for reimbursement contacts the provider and requests reimbursement, and the provider either does not agree to reimburse the applicant or does agree to reimburse the applicant but does not do so within ninety days;

(4) Within ninety days from the date the provider does not agree or fails to reimburse the applicant, the applicant requests direct reimbursement from the appropriate payer;

(5) Within ninety days from the date the applicant asks the payer for direct reimbursement described in paragraph (B)(4) of this rule, the applicant provides the following documentation to the payer:

(a) Written verification of a bill from the provider which specifies the medicaid covered services provided;

(b) Written verification that the individual paid the provider;

(c) Any other documentation that may be requested by the payer, including proof that the provider did not agree to reimburse the applicant, or did agree to reimburse the applicant but did not do so within ninety days of the request, as specified in paragraph (B)(4) of this rule;

(d) The name, address, and phone number of the provider who rendered the medicaid covered services to the individual and the name of the billing provider; and

(e) The name, address and phone number of any third party that paid or was liable to pay for any portion of the medicaid covered service.

(6) Requests for direct reimbursement will qualify for reimbursement consideration only if submitted to the payer within three hundred sixty-five days of the date of service or hospital discharge, or within one hundred eighty days of the notice of state hearing decision or eligibility determination;

(7) Reimbursement from a third party as defined in section 5160.35 of the Revised Code is not available;

(8) The request is not for reimbursement of medicare part A out-of-pocket expenses.

(C) Within ninety days of meeting the conditions specified in paragraph (B) of this rule, the payer will process the request for reimbursement. Applicants for reimbursement who receive an approval for reimbursement will be reimbursed either the amount of their out-of-pocket medical expenses or the co-pay charges, whichever is applicable, but in no event will the reimbursement exceed the medicaid maximum allowed amount identified in rule 5160-1-60 of the Administrative Code.

(D) The bills identified as satisfying a person's spenddown obligation or paid to the county to meet medicaid eligibility are not reimbursable by the medicaid program.

(E) All notice and hearing provisions set forth in division 5101:6 of the Administrative Code apply to determinations made under this rule.

Last updated September 11, 2026 at 12:01 PM

History

Effective: July 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-60.4 By-report procedures, services, and supplies.

(A) The term "by-report" identifies a covered procedure, service, or supply for which no single maximum payment amount has been established and for which payment is not determined by prior authorization. Claims for by-report procedures, services, and supplies are reviewed manually by the department or its designee. The purpose of the review is to determine whether the procedure code for the by-report procedure, service, or supply reported on the claim is the most appropriate and, if so, to establish a maximum payment amount for the procedure, service, or supply on a case-by-case basis. Information must be submitted on or with the claim (e.g., supporting documents such as operative reports, clinical assessments, or other medical records) to identify the particular by-report procedure, service, or supply.

(B) By-report procedures, services, and supplies are so indicated in the relevant rule in agency 5160 of the Administrative Code or in its associated payment schedule.

(C) A non-covered procedure, service, or supply that is reported on a claim with a by-report procedure code is non-covered.

(D) A claim for a by-report procedure, service, or supply will not be reviewed further and may be denied under either of the following conditions:

(1) Information submitted on or with the claim does not sufficiently identify the by-report procedure, service, or supply, and additional documentation requested by the reviewer is not supplied; or

(2) The procedure, service, or supply can be reported appropriately with a different procedure code for which a specific maximum payment amount has been established.

(E) When a claim has been denied because a different procedure code adequately describes a procedure, service, or supply, the provider may submit a new claim with the appropriate code. The new claim will not be submitted for by-report consideration.

Last updated September 11, 2026 at 12:01 PM

History

Effective: October 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-61 Non-covered services.

(A) The following services are entirely excluded from coverage:

(1) A service that is experimental in nature and is not performed in accordance with standards of medical practice;

(2) A service that is related to forensic studies;

(3) An autopsy service;

(4) A service for the treatment of infertility;

(5) An abortion that does not meet the criteria for coverage set forth in rule 5160-17-01 of the Administrative Code;

(6) A service that does not meet the criteria for coverage set forth in any other rule in agency 5160 of the Administrative Code;

(7) A service pertaining to a pregnancy that is a result of a contract for surrogacy services, under which a woman agrees to become pregnant for the purpose of carrying and giving birth to a child she will not raise but instead will relinquish to the other contracting party; and

(8) Assisted suicide and other measures taken actively with the specific intent of causing or hastening death.

(B) In accordance with Division CC, Title II, Section 210 of the Consolidated Appropriations Act, 2021 (Pub. L. No. 116-260), payment may be made for routine patient costs associated with participation in a qualifying clinical trial involving an experimental procedure.

(C) Neither the withholding or withdrawing of treatment nor the provision of palliative care constitutes assisted suicide, even if the measure may increase the likelihood of death, so long as the measure is not taken for the specific purpose of causing death.

Last updated March 22, 2024 at 10:32 AM

History

Effective: July 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-70 Relocated provisions concerning episode based payments.

Provisions concerning episode based payments are set forth in rule 5160-19-04 of the Administrative Code.

History

Effective: December 31, 2020
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-71 Relocated provisions concerning patient centered medical homes (PCMH) and eligible providers.

Provisions concerning patient centered medical homes (PCMH) and eligible providers are set forth in rule 5160-19-01 of the Administrative Code. The PCMH rules implement the Ohio department of medicaid's comprehensive primary care (CPC) program and CPC for kids programs.

History

Effective: October 17, 2020
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-72 Relocated provisions concerning patient centered medical homes (PCMH) and payments.

Provisions concerning patient centered medical homes (PCMH) and payments are set forth in rule 5160-19-02 of the Administrative Code. The PCMH rules implement the Ohio department of medicaid's comprehensive primary care (CPC) program and CPC for kids programs.

History

Effective: October 17, 2020
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-73 Behavioral health care coordination.

(A) For the purpose of this rule, the following definitions apply.

(1) "Attributed individual" is the Ohio medicaid covered individual for whom a qualified behavioral health entity eligible under this rule has accountability for providing behavioral health care coordination.

(2) "Attribution" is the process through which medicaid covered individuals are assigned to a specific qualified behavioral health entity. The Ohio department of medicaid (ODM) is responsible for attributing eligible individuals.

(3) "Behavioral health care coordination" (BHCC) is an evidence-based comprehensive care coordination model that connects qualified behavioral health entities with an assigned panel of eligible members with high-need behavioral health conditions.

(4) "Comprehensive primary care initiative" (CPC) is the ODM implementation of a patient-centered medical home (PCMH) model as established through rules 5160-1-71 and 5160-1-72 of the Administrative Code.

(5) "Consolidated clinical document architecture" (C-CDA) is an implementation guide developed and maintained by "Health Level Seven International" (HL7) which specifies a library of templates and prescribes their use for a set of specific document types for the purpose of electronic exchange of health care information.

(6) "Eligible member" is the medicaid covered individual who meets the diagnosis and service utilization criteria that enables them to receive BHCC from a qualified behavioral health entity to which they have been attributed.

(7) "Fast healthcare interoperability resources" (FHIR) is a standard developed by HL7 for exchanging healthcare information electronically.

(8) "Healthcare effectiveness data and information set" (HEDIS) is a tool developed by the national center for quality care (NCQA) to measure performance on dimensions of care and service.

(9) "Medication-assisted treatment" (MAT) is the combined provision of behavioral therapy and medications for the treatment of substance use disorders. All medications must be approved by the United States food and drug administration (FDA) for the treatment of a substance use disorder.

(10) "National quality forum" (NQF) refers to the performance measures endorsed by the national quality forum.

(11) "Performance and quality improvement" (PQI) refers to the standards developed by the council on accreditation (COA) that measure effective quality improvement plans.

(12) "Primary care practice" (PCP) is a practice led by primary care practitioners who comprehensively manage the health needs of individuals.

(13) "Qualified behavioral health entity" (QBHE) is the participating entity which has attributed individuals and is responsible for the BHCC activities.

(B) A QBHE must:

(1) Meet the certification requirements set forth in paragraph (A)(1) of rule 5160-27-01 of the Administrative Code and in calendar year 2017 or later have provided both mental health and substance use disorder treatment services under the same ownership; or

(2) Meet the requirements stated in paragraph (G)(2)(a) of rule 5160-2-75 of the Administrative Code if an outpatient hospital provider; and

(3) Within ninety calendar days of approval to participate as a QBHE, have an active provider contract with each medicaid managed care plan (MCP);

(4) Submit an application to become a QBHE. ODM reserves the right to deny any QBHE enrollment application it determines is not in compliance with the requirements of this rule. A QBHE may seek reconsideration pursuant to rule 5160-70-02 of the Administrative Code to challenge a decision by ODM to deny a QBHE enrollment application;

(5) At the time of submitting an enrollment application to become a QBHE, have at least one practitioner from each of the following categories affiliated with the entity:

(a) A practitioner with prescribing authority in the state of Ohio;

(b) A registered nurse or licensed practical nurse; and

(6) For the practitioner types defined in paragraph (B)(5) of this rule, continue to have such practitioners affiliated with the participating QBHE at all times to maintain eligibility as a QBHE.

(7) Demonstrate an organizational commitment to integration of physical and behavioral health care at the date of application to become a QBHE. The entity must meet one of the following:

(a) Have an ownership or membership interest in a primary care organization where primary care services are fully integrated and embedded;

(b) Enter into a written integrated care agreement such as a contract or memorandum of understanding with a primary care provider; or

(c) Achieve implementation of primary physical health care standards by a national accrediting entity as an integrated primary care-behavioral health provider, primary care medical home or behavioral health home.

(1) That it has the ability to share, receive, and use electronic data from a variety of sources with other health care providers, ODM, and the MCPs;

(2) That it uses consent forms containing elements necessary to support the full exchange of health information in compliance with all applicable state and federal laws.

(3) That it has the ability to submit prescriptions electronically;

(4) That it implements and actively uses an electronic health record (EHR) in clinical services; and

(5) If QBHE enrolled in the BHCC program prior to July 1, 2019, QBHE will have the ability, within six months of July 1, 2019 service start (January 2020), to send, receive, and use continuity of care records through the use of standard electronic formats such as FHIR and C-CDA. If QBHE enrolled in the BHCC program after July 1, 2019, QBHE will have the standard electronic formats prepared at the time of application.

(D) Eligible individual requirements.

(1) Except for the following populations, all medicaid covered individuals who meet the diagnostic and utilization criteria set forth in this rule will be attributed to a QBHE:

(a) Individuals who have been receiving inpatient care at a hospital or residing in a nursing facility for more than ninety days.

(b) Individuals who are currently receiving another care coordination service that substantially duplicates those activities provided through BHCC.

(2) Eligible individuals who meet the criteria in one of the following groups are eligible for BHCC and will be attributed to a QBHE:

(a) Group 1. Claims utilization in the twelve months preceding attribution identifies at least one of the following diagnostic criteria or diagnoses as identified in appendix A to this rule:

(i) A primary diagnosis of schizophrenia;

(ii) A primary diagnosis of bipolar disorder with psychosis;

(iii) A primary diagnosis of major depression with psychosis;

(iv) A primary diagnosis indicating attempted suicide or self-injury;

(v) A reported condition of homicidal ideation;

(vi) A reported condition of suicidal ideation;

(vii) A primary diagnosis of substance use with pregnancy or one year postpartum; or

(viii) Receipt of an injectable antipsychotic.

(b) Group 2. Claims utilization in the twelve months preceding attribution identifies a combination of the following diagnostic and utilization criteria:

(i) One or more of the following services, service locations or medications for a behavioral-health related condition:

(a) Inpatient hospital visit;

(b) Crisis unit visit;

(d) A rehabilitation facility visit;

(e) A medication as identified in appendix B to this rule that was administered as a component of MAT for treatment of a substance use disorder; or

(f) For individuals under the age of twenty-two, a therapeutic behavioral group service per diem; and

(ii) One or more of the following primary diagnoses as identified in appendix C to this rule:

(a) Bipolar disorder without psychosis;

(b) Major depression without psychosis;

(d) Substance use disorder;

(e) Conduct disorder;

(f) Personality disorder;

(g) Psychosis;

(h) Oppositional defiance disorder;

(i) Eating disorder; or

(j) Other depression.

(3) For medicaid covered individuals who do not have sufficient claims history to substantiate the eligibility criteria for BHCC, any provider may make a referral to the MCP to request enrollment in BHCC and attribution to a QBHE. The provider must provide sufficient documentation to demonstrate the individual meets the BHCC eligibility criteria as defined in this rule. Each referral is subject to review and approval by the MCP.

(4) Eligible members who are in foster care and meet the eligibility criteria in paragraph (D)(2) of this rule will be attributed to a QBHE only after the guardian is notified of eligibility by ODM or its designee, and the guardian provides consent for the individual in foster care to receive BHCC.

(5) For eligible members who are also receiving substance use disorder (SUD) residential treatment, the following applies:

(a) The eligible member will be attributed to or maintain attribution with a QBHE during the SUD residential treatment period.

(b) The QBHE will not be eligible for BHCC payments during the eligible member's SUD residential treatment period because BHCC is duplicative of the care coordination responsibilities of the SUD residential treatment program.

(c) The QBHE will immediately re-engage the eligible member for BHCC upon discharge from the SUD residential treatment period.

(6) For eligible members who also meet criteria for assertive community treatment (ACT) or intensive home based treatment (IHBT) as defined in Chapter 5160-27 of the Administrative Code, the following applies:

(a) The eligible member will be attributed to or maintain attribution with a QBHE.

(b) If the QBHE is certified to deliver ACT or IHBT, it shall provide ACT or IHBT in lieu of BHCC as long as ACT or IHBT is medically necessary. When the ACT or IHBT service is no longer medically necessary, the eligible member shall be transitioned to BHCC.

(c) If the QBHE is not an eligible provider of ACT or IHBT, the eligible member may choose to either receive BHCC from the QBHE or opt-out and receive ACT or IHBT from a provider eligible to deliver ACT or IHBT.

(E) Attribution.

(1) At any time, the eligible member may choose a specific QBHE or request to be re-attributed to a different QBHE by submitting a request to the member's MCP.

(2) If no choice has been identified by the eligible member, attribution will be completed using claims utilization data and the member's visit history, provider specialty, and geographic proximity between the member and provider.

(3) Eligible individuals may opt-out of receiving BHCC and may opt-in at any time by making a request to the MCP.

(F) A participating QBHE must perform the following activities as needed for their attributed individuals:

(1) "Outreach and engagement" activities which includes:

(a) Conducting initial outreach and engagement with attributed individuals upon enrollment in the BHCC program;

(b) Leading initial outreach with the attributed individual's PCP to share information regarding the BHCC program participation and care plan development;

(c) Building trust-based relationships to understand the preferences and goals of the attributed individual and begin engaging with the individual's family or social support system;

(d) Leading development of the outreach plan that ensures alignment with the individual's PCP and the MCP to establish a process for information exchange and to identify each stakeholder's role in coordinating care;

(e) Establishing relationships and collaborations with a full spectrum of providers and payers as appropriate; and

(f) Educating other providers and payers about the BHCC program and the value of collaborating to deliver medically necessary services.

(2) "Comprehensive care plan" activities in which the QBHE must:

(a) Within thirty days of the first BHCC activity conducted, begin developing a comprehensive care plan that addresses the individual's behavioral and physical health needs;

(b) Act as the lead for creating and maintaining the comprehensive care plan, including leading outreach to the PCP to incorporate inputs for physical health components in the comprehensive care plan; and

(G) "Ongoing maintenance" activities must be performed by the QBHE including, but not limited to, the following:

(1) Relationship maintenance activities in which the QBHE must, as a primary contact for communication about behavioral health and physical health needs of the attributed individual, conduct regular check-ins, educational activities and additional intensive support as needed which include the following:

(a) Directing individual and family education on behavioral health, including self-care and adherence to the comprehensive care plan; and

(b) Conducting follow ups with the individual on behavioral health care and updating, as appropriate, the comprehensive care plan, CPC practice, or PCP.

(2) "Individual engagement and access to appropriate care" activities in which the QBHE must:

(a) Improve access to appropriate care by addressing barriers such as assistance with scheduling appointments or connecting the attributed individual to transportation;

(b) Lead scheduling with guidance from the CPC practice or PCP and work with the attributed individual to reduce barriers to attendance for appointments;

(c) Lead follow-ups with the CPC practice or PCP to understand implications from ambulatory or acute encounters such as treatment adherence;

(d) Engage directly with the attributed individual's health care providers as well as community resources to support care and make necessary updates to the comprehensive care plan;

(e) Be accountable for referral decision support and scheduling for behavioral health care in both inpatient and outpatient settings; and

(f) Stabilize crises by gathering information from the attributed individual, CPC practice or PCP, social support systems, and other medical providers and formulating a response for immediate intervention or stabilization.

(3) "Engaging supportive services" activities in which the QBHE must facilitate access to needed community services such as housing or vocational services.

(4) "Population health management" activities in which the QBHE must use appropriate data to identify high-risk individuals and utilize the appropriate resources to deliver specialized interventions.

(5) "Individual transition" activities in which the QBHE must:

(a) Ensure the attributed individual's successful transition between providers or sites of care including triaging the individual to medically necessary services not available at the attributed QBHE;

(b) Lead outreach to the CPC practice or PCP after major behavioral health events such as an inpatient stay and discuss implications for physical healthcare;

(c) Follow up with the CPC practice or PCP following major physical health related events and discuss implications for behavioral health care as well as transition needs of the attributed individual such as transportation and medications; and

(d) Monitor the attributed individual's admission and discharges related to behavioral health treatment by establishing relationships with hospitals and hospital emergency departments.

(H) An enrolled QBHE will be evaluated based upon its population of attributed individuals meeting the identified thresholds for the following HEDIS, NQF, and PQI measures, as applicable, quarterly and at the end of each calendar year by ODM or the MCP. More detailed information regarding these requirements can be found on the ODM website, www.medicaid.ohio.gov.

(1) Adult body mass index (BMI) assessment;

(2) Controlling high blood pressure;

(3) Comprehensive diabetes care; eye exam (retinal) performed;

(4) Comprehensive diabetes care; HbA1c poor control (greater than nine per cent);

(5) Comprehensive diabetes care; HbA1c testing;

(6) Tobacco use; screening and cessation;

(7) Follow-up within seven days after hospitalization for mental illness;

(8) Follow-up within seven days after an emergency department visit for mental illness;

(9) Follow-up within seven days after an emergency department visit for alcohol or other drug dependence;

(10) Antidepressant medication management;

(11) Initiation and engagement of alcohol and other drug dependence treatment;

(12) Adherence to antipsychotic medications for individuals with schizophrenia;

(13) Metabolic monitoring for children and adolescents on antipsychotics;

(14) Use of multiple concurrent antipsychotics in children and adolescents;

(15) Emergency department visits;

(16) Behavioral health-related inpatient admissions;

(17) Inpatient discharges;

(18) All-cause readmissions;

(19) Adolescent well-care visits;

(20) Weight assessment and counseling for nutrition and physical activity for children and adolescents including BMI documentation;

(21) Per cent of live births weighing less than two thousand five hundred grams;

(22) Prenatal care including timeliness of care;

(23) Postpartum care;

(24) Use of opioids at high dosage (greater than eighty morphine equivalent dose per day); and

(25) Rate of opioid-related emergency department visits per one-thousand member months.

(I) Additional requirements for enrolled QBHEs.

(1) The QBHE must assign at least one individual who serves as the point of contact for the MCP and ODM or its designee to discuss performance of BHCC quality measures.

(2) The QBHE must identify a care team that includes the following roles:

(a) Case manager to lead the care coordination relationship and serve as the primary point of contact for the individual and their family.

(b) Registered nurse or licensed practical nurse to consult and coordinate with the eligible member's other medical providers.

(c) Program administrative contact to act as the single point of contact to fulfill records requests and perform other administrative activities.

(3) The QBHE must maintain records that meet the requirements set forth in rule 5160-1-17.2 of the Administrative Code.

(4) For eligible members or attributed individuals who opt-out of the BHCC program, the QBHE must document in the medical record the circumstances regarding the individual's decision and notify the member's MCP of this decision by no later than the end of the following business day.

(5) If a participating QBHE chooses to terminate its designation as a QBHE, it must provide notice to ODM and the MCPs in accordance with rule 5160-26-05 of the Administrative Code.

(J) Reimbursement.

(1) QBHEs are authorized under this rule to provide the identified BHCC activities on a monthly basis to attributed individuals and obtain a monthly payment rate as found in appendix D to this rule for each calendar month the BHCC specific activities are performed.

(2) To be eligible for payment under this rule, BHCC activities must be separate and distinct from other medicaid-covered services provided within the same calendar month.

(3) If the member is attributed prior to July 1, 2019, the QBHE may begin submitting claims for BHCC for dates of service in July 2019 no earlier than August 1, 2019. If the member is attributed after July 1, 2019 for the first program year, the QBHE may begin submitting claims for BHCC in the calendar month following the month in which the eligible member was attributed to the QBHE. QBHEs will not be reimbursed for BHCC services prior to July 1, 2019.

(4) The BHCC activities performed must be identified on claims for BHCC using the procedure codes and modifiers identified in appendix D to this rule.

(5) The QBHE may bill for BHCC once per calendar month per attributed individual when the following requirements are met:

(a) For the initial payment, the QBHE may submit a claim for the BHCC service if it has completed, at a minimum, the activity requirements set forth in paragraphs (F)(1)(a) to (F)(1)(c) of this rule and begin developing the comprehensive care plan as specified in paragraph (F)(2) of this rule.

(b) For ongoing payment, the QBHE may submit a claim for BHCC if it has completed in the same calendar month, at least one of the activity requirements set forth in paragraph (F) or (G) of this rule. Other activities stated in paragraphs (F) and (G) of this rule must be provided as needed.

(6) For attributed individuals in the BHCC program, payments for community psychiatric supportive treatment (CPST) and targeted case management as described in Chapter 5160-27 of the Administrative Code will not be made as these are considered duplicative of the BHCC program activities.

(K) Penalties.

(1) The QBHE must continue to meet all requirements as defined in this rule. If these requirements are not met upon evaluation, payment under this rule is subject to termination.

(2) A QBHE may seek reconsideration pursuant to rule 5160-70-02 of the Administrative Code to challenge decisions by ODM to terminate payments described in this rule.

View AppendixView AppendixView AppendixView Appendix

History

Effective: January 10, 2019
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-80 Substitute practitioners (locum tenens).

(A) Definitions.

(1) "Practitioner," for purposes of this rule, is a collective term for the following professionals:

(a) Doctor of medicine or osteopathy;

(b) Advanced practice registered nurse;

(d) Optometrist;

(e) Podiatrist; or

(f) Chiropractor.

(2) "Regular practitioner" is a practitioner enrolled in the Ohio medicaid program who regularly takes care of an individual's health care needs.

(3) "Substitute practitioner" is a practitioner who generally does not maintain an individual practice and who works in place of a regular practitioner when the regular practitioner is absent;

(B) Coverage and limitations. Payment may be made for services rendered by a substitute practitioner only when the following conditions are met:

(1) Both the regular practitioner and the substitute practitioner are professionals listed in paragraph (A)(1) of this rule;

(2) The regular practitioner is expected to be absent for a period of not longer than sixty days unless there are extenuating circumstances (e.g., active duty in the armed forces, pregnancy, extended illness);

(3) The substitute practitioner has the status of an independent contractor rather than of an employee;

(4) The substitute practitioner meets the applicable provider screening requirements described in rule 5160-1-17.8 of the Administrative Code;

(5) The substitute practitioner has not been sanctioned under medicare, medicaid, or Title XX and is not otherwise prohibited from providing services to medicare, medicaid, or Title XX beneficiaries; and

(6) The substitute practitioner receives payment from the regular practitioner as a fixed amount per diem or on a similar fee-for-time basis.

Last updated October 2, 2023 at 8:23 AM

History

Effective: October 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-97 One-time medicaid provider relief payments.

The department of medicaid (ODM) will make relief payments available to Ohio medicaid hospitals defined in paragraph (A) of this rule, as authorized under Section 270.15 of Amended Substitute House Bill 45 of the 134th General Assembly:

(A) ODM will make available a one-time lump sum payment to the following hospital types:

(1) "Critical access hospitals," as defined in rule 5160-2-05 of the Administrative Code.

(2) "Rural hospitals," as defined in rule 5160-2-05 of the Administrative Code.

(B) The payment will be established in the following manner:

(1) The total sum to be made available to all eligible Ohio medicaid hospitals as defined in paragraph (A) of this rule is sixty-two million dollars less the amount described in paragraph (B)(2) of this rule.

(2) Any hospital located in a county in the Northwest region as defined in the appendix of rule 5160-2-05 of the Administrative Code with a population of less than forty-two thousand residents and less than three hundred square land miles according to the United States census bureau (July 1, 2021) will qualify for an additional payment of two million one hundred thousand dollars.

(3) No individual hospital will receive a total calculated payment that exceeds three million dollars.

(4) For each hospital, the value of the final one-time payment will be calculated as follows:

(a) Base payment data to be utilized for establishing provider payment amounts are fee-for-service (FFS) payments for state fiscal year 2022 and reflected in the ODM management information technology system (MITS) on January 31, 2023.

(b) Each payment is the product of the ratio of each hospital's total FFS payments to the total FFS payments for all eligible hospitals as defined in paragraph (A) of this rule, multiplied by the amount listed in paragraph (B)(1) of this rule.

(c) For each hospital, if the total calculated payment in paragraph (B)(4)(b) of this rule exceeds the amount described in paragraph (B)(3) of this rule, the hospital's payment amount is limited to the amount defined in (B)(3) of this rule.

(d) For hospitals with a payment amount limited as described in paragraph (B)(4)(c) of this rule:

(i) Subtract the amount calculated in paragraph (B)(4)(c) of this rule from the amount determined in paragraph (B)(4)(b) of this rule then sum these amounts for these hospitals.

(ii) Distribute the sum of the amounts determined in paragraph (B)(4)(d)(i) of this rule, to all hospitals that have not exceeded the payment amount calculated in paragraph (B)(3) of this rule, using the same methodology described in paragraph (B)(4)(b) of this rule until all remaining funds from the amount calculated in paragraph (B)(4)(d)(i) of this rule are expended.

(5) If a hospital's calculated payment amount in paragraph (B)(4)(b) of this rule is less than four thousand dollars, no payment will be made to that hospital.

Last updated May 30, 2023 at 8:24 AM

History

Effective: May 27, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-1-98 Deposits to the health care/medicaid support and recoveries fund for program support.

(A) The Ohio department of medicaid (ODM) will deposit a portion of the intergovernmental transfers (IGT) that are paid under any state directed payment (SDP) program as authorized under 42 CFR 438.6(c) effective as of July 9, 2024.

(B) On or after the effective date of this rule and for each year thereafter:

(1) Pursuant to paragraph (A) of this rule, each provider eligible to receive a directed SDP program payment will submit to ODM an additional IGT which is to be four per cent of the provider's computed IGT amount.

(2) In subsequent SDP program years, ODM may establish a rate higher or lower than the rate described in paragraph (B)(1) of this rule as approved by the medicaid director.

Last updated December 12, 2024 at 8:13 AM

History

Effective: December 12, 2024
Promulgated Under: 119.03

Chapter 5160-2 Hospital Services

Ohio Adm.Code 5160-2-01 Eligible providers.

(A) All hospitals, except those excluded in paragraph (A)(2) of this rule, that meet medicare (Title XVIII) conditions of participation as described in 42 C.F.R. 482 effective as of October 1, 2025, are eligible to participate in the Ohio medicaid (Title XIX) program upon execution of a provider agreement.

(1) The following hospitals are also considered to be eligible:

(a) Hospitals that are currently determined to meet the established criteria for Title XVIII participation and have in effect a hospital utilization review plan applicable to all patients who receive medical assistance under Title XIX;

(b) Rural emergency hospitals that operate pursuant to the provisions of 42 C.F.R. 485 subpart E, effective October 1, 2025; and

(c) Critical access hospitals that operate pursuant to the provisions of 42 C.F.R. 485 subpart F, effective October 1, 2025.

(2) The following hospitals are excluded from participation:

(a) Tuberculosis hospitals; and

(b) Hospitals that have fifty per cent or more of their beds registered pursuant to Chapter 3701-59 of the Administrative Code as alcohol or drug abuse rehabilitation beds, and have no beds licensed as psychiatric beds pursuant to Chapter 5122-14 of the Administrative Code.

(B) Freestanding psychiatric hospitals with more than sixteen beds may provide inpatient psychiatric services as follows:

(1) For individuals aged sixty-five or older, hospitals will operate pursuant to the provisions of 42 C.F.R. 441 subpart C, effective as of October 1, 2025.

(2) For individuals under age twenty-one, hospitals will operate pursuant to the provisions of 42 C.F.R. 441 subpart D, effective as of October 1, 2025.

(3) For individuals aged twenty-one or older, but under age sixty-five, hospitals will operate pursuant to the provisions of 42 C.F.R. 482 subpart E, effective as of October 1, 2025.

(4) In the case of an individual under age twenty-two, the hospital will provide services before the individual reaches age twenty-one or, if the individual was receiving services immediately before they reached age twenty-one, then before the earlier of the following:

(a) The date the individual no longer needs the services; or

(b) The date the individual reaches age twenty-two.

(C) Ohio medicaid will not reimburse freestanding psychiatric hospitals with more than sixteen beds for inpatient psychiatric services rendered to individuals aged twenty-one or older, but under age sixty-five, except in accordance with the provisions of 42 C.F.R. 438.6(e), effective as of October 1, 2025.

(D) Freestanding psychiatric hospitals with sixteen or fewer beds may provide inpatient psychiatric services to individuals of any age and will operate pursuant to the provisions of 42 C.F.R. 482 subpart E, effective as of October 1, 2025.

Last updated February 9, 2026 at 7:46 AM

History

Effective: February 9, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-02 General provisions: hospital services.

For purposes of Chapter 5160-2 of the Administrative Code, the following definitions apply, unless the context clearly indicates otherwise:

(A) "Diagnosis related groups (DRGs)" is a patient classification system that reflects clinically cohesive groupings of services that consume similar amounts of hospital resources in an inpatient setting. The groupings used to assign cases to a DRG for claim payment and the grouping logic used to develop relative weights for DRG's are described in rule 5160-2-65 of the Administrative Code.

(B) "Discharged" means a patient who:

(1) Is formally released from a hospital;

(2) Dies while hospitalized;

(3) Is discharged within the same hospital from an acute care bed and admitted to a bed in an inpatient psychiatric facility, or is discharged within the same hospital from a bed in an inpatient psychiatric facility to an acute care bed. Rule 5160-2-65 of the Administrative Code explains the payment methodology for these types of discharges; or

(4) Signs himself or herself out against medical advice.

(C) "Enhanced Ambulatory Patient Groups (EAPGs)" is a group of outpatient procedures, encounters, or ancillary services, that reflect similar patient characteristics and resource utilization and incorporate the use of "International Classification of Diseases" diagnosis codes, current procedural terminology (CPT) code set, and healthcare common procedure coding system (HCPCS) procedure codes.

(D) "Hospital" has the same meaning as in rule 5160-2-01 of the Administrative Code.

(E) "Inpatient" is a patient who is admitted to a hospital based upon the written orders of a practitioner in accordance with section 3727.06 of the Revised Code and whose inpatient stay continues beyond midnight of the day of admission.

(F) "Inpatient psychiatric facility" or "distinct part psychiatric unit" means a hospital or unit of a hospital that focuses on the treatment of the behavioral health needs of a patient and is excluded from the medicare inpatient prospective payment system in accordance with 42 C.F.R. 412.25 effective as of October 1, 2025.

(G) "Inpatient services" means services that are ordinarily furnished in a hospital for the care and treatment of patients. Inpatient services include all covered services provided to patients during their inpatient stay, whether furnished directly by the hospital or under arrangement, except for direct-care services provided by a practitioner of physician services as defined in paragraph (L) of this rule. Emergency room services are covered as an inpatient service when a patient is admitted from the emergency room.

Outpatient services provided within three calendar days prior to the date of admission in hospitals will be covered as inpatient services. This provision applies when the patient receives all the services, including emergency room and observation services, at the same hospital. The following exceptions apply:

(1) When a patient's medicaid coverage changes payer sources (fee-for-service or managed care) on the date of the inpatient admission, all outpatient services provided within three calendar days prior to the inpatient admission will be submitted to the payer source responsible for those dates of service. The inpatient claim will be submitted to the payer source in effect on the date of admission.

(2) When a patient is admitted under the inpatient hospital services program (IHSP) benefit plan, all outpatient services provided by either the same hospital or a different hospital prior to the inpatient admission will not be included on the inpatient claim, with the exception of any outpatient services provided on the date of admission, which will be included on the inpatient hospital claim if provided at the same facility as the inpatient admission.

(H) "Medically necessary services" means services as defined in rule 5160-1-01 of the Administrative Code.

(I) "Observation services" means services furnished in an outpatient hospital setting, including the use of a bed and periodic monitoring by a hospital's nursing or other staff, which are reasonable and necessary to evaluate a patient's condition or determine the need for possible admission to the hospital as an inpatient.

(J) "Outpatient" is a patient who is not admitted as an inpatient and who receives outpatient services at a hospital or at a hospital's off-site unit that has been extended accreditation by the "Joint Commission," the "American Osteopathic Association," or is certified under medicare. Outpatient includes a patient admitted as an inpatient whose inpatient stay does not extend beyond midnight of the day of admission except in instances when, on the day of admission, a patient dies or is transferred to an inpatient psychiatric facility within the same hospital, to another hospital, or to a state psychiatric facility.

(K) "Outpatient services" means diagnostic, therapeutic, rehabilitative, or palliative treatment or services furnished by or under the direction of a practitioner of physician services to a patient by a hospital. Outpatient services do not include direct-care services provided by a practitioner of physician services as defined in paragraph (L) of this rule.

(L) "Practitioner of physician services" is a physician, podiatrist, dentist, clinical nurse specialist, certified nurse-midwife, certified nurse practitioner, physician assistant, pharmacist, or clinical psychologist.

(M) "Principal diagnosis" means the diagnosis established after study to be chiefly responsible for causing the patient's admission to the hospital.

(N) "Readmission" means an admission to the same institution within thirty days of discharge for hospitals paid under the Ohio department of medicaid's prospective payment system, as described in rule 5160-2-65 of the Administrative Code.

(O) "Transfer" is a patient who:

(1) Is moved from one eligible hospital's inpatient or outpatient department to another eligible hospital's inpatient or outpatient department, including state psychiatric facilities;

(2) Is moved from an eligible hospital to the same hospital's inpatient psychiatric facility; or

(3) Is moved to an eligible hospital from the same hospital's inpatient psychiatric facility.

Last updated January 12, 2026 at 10:23 AM

History

Effective: January 10, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-03 Conditions and limitations.

(A) Conditions and limitations applicable to both inpatient and outpatient hospital services.

(1) Coverage of provider-based physician services reimbursable as an inpatient or outpatient hospital service is limited to those services reimbursable under medicare, part A, except as provided in rule 5160-4-01 of the Administrative Code.

(2) The following inpatient or outpatient services related to the provision of the services described in this rule are not covered:

(a) Abortions other than those that meet the criteria for coverage set forth in rule 5160-17-01 of the Administrative Code.

(b) Sterilizations and hysterectomies other than those that meet the criteria for coverage set forth in Chapter 5160-21 of the Administrative Code.

(d) Plastic or cosmetic surgery when the surgery is performed for aesthetic purposes; for example, rhinoplasty, ear piercing, mammary augmentation or reduction, tattoo removal, excision of keloids, facioplasty, osteoplasty (prognathism and micrognathism), dermabrasion, skin grafts, and lipectomy.

(e) Gender transformation.

(f) Acupuncture, with the exception of conditions described in rule 5160-8-51 of the Administrative Code.

(g) Services of a research nature or services that are experimental and not in accordance with customary standards of medical practice or are not commonly used.

(h) Dental procedures unless:

(i) The nature of the surgery or the condition of the patient precludes performing the procedure in the dentist's office or other non hospital outpatient setting and the inpatient or outpatient service is a medicaid covered service.

(ii) The service was an emergency dental procedure performed in the emergency room.

(i) Patient convenience items.

(j) Pregnancy related services pertaining to a pregnancy that is a result of a contract for surrogacy services. For the purposes of this rule, "surrogacy services" means a woman agrees to become pregnant for the purpose of gestating and giving birth to a child she will not raise, but hand over to a contracted party.

(3) Blood and blood components--The department encourages the use of replacement blood donated on behalf of the recipient. However, the medicaid program will cover the cost of all blood administered, equivalent quantities of packed red blood cells or plasma when not available to the recipient from other sources, and the administering of replacement blood.

(4) Services related to covered organ donations are reimbursable when the recipient of a transplant is medicaid eligible.

(B) Conditions and limitations applicable to inpatient services only.

(1) Accommodations--The medicaid program covers semiprivate accommodations.

(a) Private rooms are covered only when the patient's condition necessitates isolation to protect the patient's health or the health of others.

(b) When no semiprivate rooms are available, the private room will be reimbursed as semiprivate rooms.

(c) For hospitals paid on a DRG prospective payment basis as identified in rule 5160-2-65 of the Administrative Code, private rooms will be excluded for purposes of determining outliers.

(d) For hospitals paid on a non-DRG prospective payment basis as identified in rule 5160-2-05 of the Administrative Code, private rooms are not covered and, accordingly, will not be reimbursed.

(2) Covered days --In general, medicaid covers only those days of care that are medically necessary or otherwise within certain limits as follows.

(a) The number of days of care charged by a hospital are to be reported in units of full days.

(i) The day of admission counts as a full day.

(ii) The day of discharge is not counted as a covered day, but charges for any covered services other than those described in revenue center codes 0100-0219 are covered for the days on which the services were rendered, not for the days the charges were posted.

(b) Late discharge--The medicaid program will not pay for a patient's continued stay beyond the checkout time because of personal reasons on the part of the patient or because of physician negligence.

(c) Leave of absence--The day on which a patient begins a leave of absence cannot be counted as a covered day unless the patient returns to the hospital prior to midnight of the same day.

(d) Days waiting for placement and custodial care--Coverage is not available for hospital inpatients for whom acute short-term hospital care is no longer necessary. This includes days waiting for transfer to a long-term care facility, days of inpatient care due to unnecessary delays in applying for court-ordered commitment, grace periods, administrative days, and custodial care. For purposes of this rule, "custodial care" is defined as maintenance, rather than curative care, on an indefinite basis, while grace periods and administrative days relate to days of care while waiting for placement elsewhere. This exclusion also applies to days spent as an inpatient at a transferring hospital on or after the effective date of a court commitment to another facility and inpatient days resulting from a hospital's failure to timely request or perform necessary diagnostic studies, medical-surgical procedures, or consultations.

(e) Reimbursement for medicaid inpatient hospital services for the treatment of persons whose principal diagnosis is a mental health disorder, will only be made to facilities that are licensed by the department of mental health and addiction services in accordance with Chapter 5122-14 of the Administrative Code.

(f) For hospitals paid on a DRG prospective payment basis as identified in rule 5160-2-65 of the Administrative Code, the non covered days of inpatient stay described in paragraphs (B)(2)(a) to (B)(2)(e) of this rule will be excluded for purposes of determining outliers in accordance with rule 5160-2-65 of the Administrative Code.

(g) For hospitals paid on a non-DRG prospective payment basis as identified in rule 5160-2-05 of the Administrative Code, the non covered days of inpatient stay described in paragraphs (B)(2)(a) to (B)(2)(e) of this rule, including associated inpatient services, are not covered and, accordingly, are not reimbursable.

(3) Surgical treatment for obesity is covered when prior authorized.

(C) Coverage conditions and limitations applicable to hospitals eligible to provide services pursuant to paragraphs (B) and (D) of rule 5160-2-01 of the Administrative Code.

(1) Coverage of inpatient services provided in hospitals to eligible recipients will be provided in accordance with Chapter 5122-14 of the Administrative Code or section 5119.33 of the Revised Code.

(2) Outpatient services provided in hospitals to eligible recipients will be provided in accordance with rule 5160-2-76 of the Administrative Code.

Last updated March 1, 2022 at 8:31 AM

History

Effective: March 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-04 Coverage of hospital-provided pharmaceutical, dental, vision care, medical supply and equipment, and medically-related transportation services.

(A) Drugs.

(1) Drugs are classified as: administered inpatient (drugs administered to a patient while an inpatient); administered outpatient (drugs administered to a patient at the hospital in connection with outpatient services); take-home (drugs dispensed on an outpatient basis for use away from the hospital).

(2) Administered inpatient drugs are considered inpatient services and are reimbursed as an inpatient service. Administered outpatient drugs are considered outpatient services and are reimbursed as an outpatient hospital service in accordance with rule 5160-2-75 of the Administrative Code. Take-home drugs will be billed and reimbursed in accordance with provisions in Chapter 5160-9 of the Administrative Code.

(B) Medical supplies and equipment.

(1) Inpatient coverage:

(a) Supplies and equipment are covered for the care and treatment of the recipient during an inpatient stay and include:

(i) Implants and devices that are part of a surgical, immediate post surgical, or early fitting procedure (e.g., pacemakers, halos, and prosthetic devices);

(ii) Appliances that are generally applied prior to discharge (e.g., initial prostheses); and

(iii) Other items that are medically necessary as described in rule 5160-1-01 of the Administrative Code to permit or facilitate the patient's discharge from the hospital until such time as the recipient can obtain a permanent item or supply.

(b) Covered items should be included in the hospital's inpatient billing.

(c) Medical supplies and equipment provided to a medicaid recipient for use outside the hospital are reimbursed in accordance with Chapter 5160-10 of the Administrative Code.

(2) Outpatient coverage:

(a) Chapter 5160-10 of the Administrative Code describes the coverage and reimbursement of medical supplies provided during the provision of an outpatient visit

(b) Medical supplies and equipment provided to the medicaid recipient for use outside the hospital are reimbursed in accordance with Chapter 5160-10 of the Administrative Code.

(C) Dental services: Except for dental services described in rule 5160-2-03 of the Administrative Code and emergency dental services provided in the emergency room, all dental services are covered and reimbursed as dental services under the provisions set forth in Chapter 5160-5 of the Administrative Code.

(D) Vision care services: All vision care services are covered and reimbursed as inpatient or outpatient hospital services. All vision care materials are covered and reimbursed in accordance with the provisions of Chapter 5160-6 of the Administrative Code.

(E) Medically-related transportation services: The services of hospital staff as attendants during transportation are covered and reimbursed as an inpatient or outpatient hospital service. Transportation to or from a hospital, including inter hospital transfer, that is provided in accordance with Chapter 5160-15 of the Administrative Code is not a hospital service and is reimbursed as described in Chapter 5160-15 of the Administrative Code..

Last updated March 1, 2022 at 8:32 AM

History

Effective: March 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-05 Classification of hospitals.

(A) Definitions in Chapter 5160-2 of the Administrative Code.

(1) "Cancer hospitals" are hospitals recognized by medicare that primarily treat neoplastic disease in accordance with 42 C.F.R. 412.23(f), effective October 1, 2025.

(2) "Children's hospitals" are hospitals that primarily serve patients eighteen years of age and younger, have at least seventy-five beds, and are excluded from medicare prospective payment in accordance with 42 C.F.R. 412.23(d), effective October 1, 2025, or are licensed with the Ohio department of health in accordance with Chapter 3722. of the Revised Code.

Medicare-defined children's hospitals that do not meet this definition are grouped into their natural rural or urban hospital peer groups as described in paragraph (A)(8) or (A)(9) of this rule for the purposes of setting base rates but receive pricing considerations or differentials as if they were in the children's hospital peer group.

(3) "Critical access hospitals" (CAH) are hospitals that are certified as a critical access hospitals by the centers for medicare and medicaid services (CMS) and excluded from medicare prospective payment in accordance with 42 C.F.R.485 subpart F, effective October 1, 2025.

(4) "Freestanding long-term acute care hospitals" are hospitals that the department of health and human services has determined to be excluded from medicare prospective payment in accordance with 42 C.F.R. 412.23(e), effective October 1, 2025.

(5) "Freestanding psychiatric hospitals" are hospitals that are eligible to provide medicaid services as described in rule 5160-2-01 of the Administrative Code and are grouped into their natural peer group as described in paragraphs (A)(2), (A)(3), (A)(8), (A)(9), and (A)(10) of this rule.

(6) Freestanding rehabilitation hospitals" are those hospitals in which the department of health and human services has determined to be excluded from medicare prospective payment in accordance with 42 C.F.R. 412.23(b), effective October 1, 2025.

(7) "Hospital peer groups" are how hospitals are classified into mutually exclusive groups for the purpose of setting rates and making payments under the "All Patient Refined-Diagnosis Related Group" (APR-DRG) inpatient prospective payment system, the "Enhanced Ambulatory Patient Grouping" (EAPG) outpatient prospective payment system, and for the hospitals excluded from the prospective payment systems. The peer groups are:

(a) Critical access hospitals;

(b) Rural hospitals;

(d) Teaching hospitals;

(e) Urban hospitals.

(8) "Rural hospitals" are hospitals located in Ohio counties that are not classified into core based statistical areas (CBSA) as designated in the inpatient prospective payment system (IPPS) case-mix and wage index table as published by CMS for the federal fiscal year beginning in the calendar year immediately preceding the effective date of the hospital rates.

(a) Rural hospitals include hospitals certified as rural emergency hospitals by CMS as described in C.F.R. 485 subpart E, effective October 1, 2025.

(b) A copy of the medicare IPPS case-mix and wage index table by CMS certification number (CCN) is available on the department's website at medicaid.ohio.gov.

(9) "Teaching hospitals" are hospitals with a major teaching emphasis that have at least two hundred beds and have an intern- and resident-to-bed ratio of at least .35. Only non-Ohio hospitals classified by the Ohio department of medicaid (ODM) as teaching hospitals as of June 30, 2016, will be considered non-Ohio teaching hospitals.

(10) "Urban hospitals" are hospitals located in Ohio counties that are classified into CBSAs, as described in paragraph (A)(8) of this rule. Urban hospitals are grouped based on geographical regions listed in the appendix to this rule and are not otherwise defined in paragraphs (A)(2), (A)(3), (A)(7), (A)(8), and (A)(9) of this rule.

(11) For the purposes of this rule, the "number of beds" is the total number of beds reported on the hospital's state fiscal year (SFY) 2014 Ohio medicaid hospital cost report (ODM 02930, rev. 06/14).

(12) For the purposes of this rule, "interns and residents" is the net number of interns and residents reported on the hospital's SFY 2014 Ohio medicaid hospital cost report (ODM 02930, rev. 06/14).

(B) Ohio hospital prospective payment peer groups.

(1) The following hospitals will be paid on a prospective payment basis for inpatient services as described in rule 5160-2-65 of the Administrative Code

(a) Critical access hospitals;

(b) Rural hospitals, excluding rural emergency hospitals;

(d) Teaching hospitals;

(e) ) Urban hospitals.

(2) The following hospitals will be paid on a prospective payment basis for outpatient services, as described in rule 5160-2-75 of the Administrative Code:

(a) Critical access hospitals;

(b) Rural hospitals, including rural emergency hospitals;

(d) Teaching hospitals;

(e) Urban hospitals.

(3) The following hospitals will be paid in accordance with rule 5160-2-22 of the Administrative Code:

(a) Cancer hospitals;

(b) Rehabilitation hospitals;

On January first of each year, peer group classification will be reassigned for any hospital geographically located in an Ohio county that has been newly included or excluded from a CBSA, as described in paragraph (A)(8) of this rule. Affected hospitals will be classified into either the rural peer group or the urban peer group based on the geographic location of the hospital. The hospital's new base rate will be the average cost per discharge of the new peer group without any consideration of hospital-specific risk provisions described in rules 5160-2-65 and 5160-2-75 of the Administrative Code, of either the new or previous peer group.

(D) Rates for new, acquired, replacement, and merged hospitals.

(1) Hospitals new to medicaid.

(a) Hospitals described in paragraph (B)(1) of this rule that are newly enrolled with medicaid, will be classified into mutually exclusive peer groups as defined in paragraph (A) of this rule. Until data is available to calculate hospital-specific rates, the hospital will receive:

(i) The base rate of the peer group into which they are classified without any consideration for hospital-specific risk provisions as described in rule 5160-2-65 of the Administrative Code for inpatient services;

(ii) The statewide average for capital allowance in accordance with rule 5160-2-66 of the Administrative Code; and

(iii) The statewide average for the inpatient cost-to-charge ratio as described in paragraph (B)(2) of rule 5160-2-22 of the Administrative Code.

(b) Hospitals described in paragraph (B)(2) of this rule that are newly enrolled with medicaid, will be classified into mutually exclusive peer groups, as defined in paragraph (A) of this rule. Until data is available to calculate hospital-specific rates, the hospital will receive:

(i) The base rate of the peer group into which they are classified without any consideration for the hospital-specific risk provisions, as described in rule 5160-2-75 of the Administrative Code for outpatient services; and

(ii) The statewide average for outpatient cost-to-charge ratio, as described in paragraph (B)(2) of the rule 5160-2-22 of the Administrative Code.

(c) Hospitals described in paragraph (B)(3) of this rule that are newly enrolled with medicaid, will receive ninety per cent of the calculated rates described in paragraph (D)(1)(a)(iii) of this rule until data is available to calculate hospital-specific rates in accordance with rule 5160-2-22 of the Administrative Code.

(2) Acquired hospitals.

Hospitals that have a change of ownership will receive the prior owner's rates for reimbursement until a cost report is filed by the new owner in accordance with rule 5160-2-23 of the Administrative Code and rates are calculated in accordance with rule 5160-2-22 of the Administrative Code.

(3) Replacement hospitals.

If a new hospital facility is opened for the purpose of replacing an existing (original) hospital facility identifiable to a unique medicaid provider number and the original facility closes, the rates from the original facility will be used for reimbursement, if the conditions of paragraphs (C)(4)(a) to (C)(4)(c) of rule 5160-2-09 of the Administrative Code are met, and until a cost report is filed by the new owner in accordance with rule 5160-2-23 of the Administrative Code and rates are calculated in accordance with rule 5160-2-22 of the Administrative Code.

(4) Hospital mergers.

When hospitals identifiable by a unique medicaid provider number are involved in a merger, the rates for the surviving medicaid provider number will be used for reimbursement until a cost report is filed in accordance with rule 5160-2-23 of the Administrative Code and rates are calculated in accordance with rule 5160-2-22 of the Administrative Code.

View Appendix

Last updated February 9, 2026 at 7:46 AM

History

Effective: February 9, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-08 Data policies for disproportionate share and indigent care adjustments for hospital services.

This rule sets forth the data used to determine assessments and adjustments, and the data policies that are applicable for each program year for all providers of hospital services included in the definition of "hospital" as described under section 5168.01 of the Revised Code.

(A) Definitions.

(1) "Disproportionate share hospital" means a hospital that meets the requirements for disproportionate share status as defined in rule 5160-2-09 of the Administrative Code.

(2) "Governmental hospital" means a county hospital with more than five hundred beds or a state-owned and -operated hospital with more than five hundred beds.

(3) "Hospital" means a hospital that is described under section 5168.01 of the Revised Code.

(4) "Hospital care assurance program fund" means the fund described under section 5168.11 of the Revised Code.

(5) "Hospital care assurance match fund" means the fund described under section 5168.11 of the Revised Code.

(6) "Intergovernmental transfer" means any transfer of money by a governmental hospital.

(7) "Health care services administration fund" means the fund described under section 5162.54 of the Revised Code.

(8) "Program year" means the twelve-month period beginning on the first day of October and ending on the thirtieth day of September.

(9) "Total facility costs" for each hospital means the amount from the ODM 02930, "Ohio Medicaid Hospital Cost Report," for the applicable state fiscal year, schedule B, column 3, line 202. For non-medicaid participating hospitals, total facility costs shall be determined from the medicare cost report.

(10) "Total skilled nursing facility costs" for each hospital means the amount on the ODM 02930, schedule B, column 3, line 44. For non-medicaid participating hospitals, total skilled nursing facility costs shall be determined from the medicare cost report.

(11) "Total home health facility costs" for each hospital means the amount on the ODM 02930, schedule B, column 3, line 98. For non-medicaid participating hospitals, total home health facility costs shall be determined from the medicare cost report.

(12) "Total hospice facility costs" for each hospital means the amount on ODM 02930, schedule B, column 3, line 99. For non-medicaid participating hospitals, total hospice facility costs shall be determined from the medicare cost report.

(13) "Total ambulance costs" for each hospital means the amount on ODM 02930, schedule B, column 3, line 95. For non-medicaid participating hospitals, total ambulance costs shall be determined from the medicare cost report.

(14) "Total Durable Medical Equipment (DME) rental costs" for each hospital means the amount on ODM 02930, schedule B, column 3, line 96. For non-medicaid participating hospitals, total DME rental costs shall be determined from the medicare cost report.

(15) "Total DME sold costs" for each hospital means the amount on ODM 02930, schedule B, column 3, line 97. For non-medicaid participating hospitals, total DME sold costs shall be determined from the medicare cost report.

(16) "Other non-hospital costs" for each hospital means separately identifiable non-hospital operating costs found on worksheet B, Part I of the medicare cost report, as determined by the department upon the request of the hospital, that are permitted to be excluded from the provider tax in compliance with section 1903(w) of the Social Security Act.

(17) "Adjusted total facility costs" means the result of subtracting the sum of the amounts defined in paragraphs (A)(10), (A)(11), (A)(12), (A)(13), (A)(14) and (A)(15) of this rule from the amount defined in paragraph (A)(9) of this rule.

(B) Source data for calculations.

(1) The calculations described in this rule for each program year will be based on cost-reporting data described in rule 5160-2-23 of the Administrative Code that reflects the completed interim settled medicaid cost report (ODM 02930) for each hospital's cost reporting period ending in the state fiscal year that ends in the federal fiscal year preceding each program year. For non-medicaid participating hospitals, the calculations will be based on the medicare cost report for the same time period.

(a) For new hospitals, the first available cost report filed with the department in accordance with rule 5160-2-23 of the Administrative Code will be used until a cost report that meets the requirements of this paragraph is available. If, for a new hospital, there is no available or valid cost report filed with the department, the hospital will be excluded until valid data is available.

(b) Data for hospitals that have changed ownership shall be treated as described in paragraphs (B)(1)(b)(i) to (B)(1)(b)(ii) of this rule.

(i) For a change of ownership that occurs during the program year, the cost reporting data filed by the previous owner that reflects that hospital's most recent completed interim settled medicaid cost report shall be annualized to reflect one full year of operation. The data will be allocated to each owner based on the number of days in the program year the hospital was owned.

(ii) For a change of ownership that occurred in the previous program year, the cost reporting data filed by the previous owner that reflects that hospital's most recent completed interim settled medicaid cost report and the cost reporting data filed by the new owner that reflects that hospital's most recent completed interim settled medicaid cost report, will be combined and annualized by the department to reflect one full year of operation. If there is no available or valid cost report from the previous owner, the department shall annualize the cost report from the new owner to reflect one full year of operation.

(c) For hospitals involved in mergers during the program year that result in the hospitals using one provider number, the cost reports from the merged providers will be combined and annualized by the department to reflect one full year of operation.

Cost report data used in the calculations described in this rule will be the cost report data described in this paragraph and are subject to any adjustments made upon departmental review that is completed each year and subject to the provisions of paragraph (D) of this rule.

(2) Closed hospitals with unique medicaid provider numbers.

For a hospital facility, identifiable to a unique medicaid provider number, that closes during the current program year as defined in paragraph (A) of this rule, the cost report data shall be adjusted to reflect the portion of the year that the hospital was open during the current program year. That partial year data shall be used to determine the assessment owed by that closed hospital.

Hospitals identifiable to a unique medicaid provider number that closed during the immediate prior program year will not owe an assessment for the current program year.

(3) Replacement hospital facilities.

(a) If a new hospital facility is opened for the purpose of replacing an existing (original) hospital facility identifiable to a unique medicaid provider number and the original facility closes during the program year defined in paragraph (A) of this rule, the cost report data from the original facility shall be used to determine the assessment for the new replacement facility if the following conditions are met:

(i) Both facilities have the same ownership,

(ii) There is appropriate evidence to indicate that the new facility was constructed to replace the original facility,

(iii) The new replacement facility is so located as to serve essentially the same population as the original facility, and

(iv) The new replacement facility has not filed a cost report for the current program year.

(b) For a replacement hospital facility that opened in the immediate prior program year, the assessment for that facility will be based on the cost report data for that facility and the cost report data for the original facility, combined and annualized by the department to reflect one full year of operation.

From the first installment of assessments paid under rule 5160-2-08.1 of the Administrative Code and intergovernmental transfers made under rule 5160-2-08.1 of the Administrative Code during each program year, the department shall deposit into the state treasury to the credit of the health care services administration fund, a total amount equal to the amount allocated by the appropriations act from assessments paid under section 5168.06 of the Revised Code and intergovernmental transfers made under section 5168.07 of the Revised Code during each program year.

(D) Finalization of data used for disproportionate share and indigent care adjustments.

During each program year, the department may provide any data the department may choose to use for disproportionate share and indigent care adjustments, described in rule 5160-2-09 of the Administrative Code, to each hospital. The department may mail the data or may make the data available on the medicaid provider portal. The department will notify each hospital of the availability of the data via regular or electronic mail (e-mail). Not later than thirty days after the department mails or e-mails the notification, any hospital may submit to the department a written request to correct data. Any documents, data, or other information that supports the hospital's request to correct data must be submitted with the request. On the basis of the information submitted to the department, the department may adjust the data.

(1) For each program year, thirty-days after the expiration of all hospitals' thirty-day data correction periods, the department shall consider the data correction period closed and all data final, subject to review and acceptance by the department.

(2) Any hospital that requests to correct data after the expiration of its thirty-day correction period but before the data correction period is closed for all hospitals as described in paragraph (D)(1) of this rule, shall be subject to an administrative fee. The administrative late fee shall be 0.03 per cent of the hospital's adjusted total facility cost as calculated in paragraph (A)(17) of this rule. The hospital shall include payment of the administrative late fee with the written request to correct data.

(3) All amounts received by the department under this paragraph shall be deposited into the state treasury to the credit of the health care services administration fund, described under paragraph (A)(7) of this rule.

(4) The department shall accept at any time, data from any hospital that has misstated its reported data used to make disproportionate share and indigent care adjustments and that resulted in a disproportionate share and indigent care payment that was greater than the payment would have been with the corrected data.

(E) Confidentiality.

Except as specifically required by the provisions of this rule and rule 5160-2-24 of the Administrative Code, information filed shall not include any patient-identifying material. Information including patient-identifying information is not a public record under section 149.43 of the Revised Code and no patient-identifying material shall be released publicly by the department of medicaid or by any person under contract with the department who has access to such information.

History

Effective: June 13, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-08.1 Assessment rates.

(A) Applicability.

The requirements of this rule apply as long as the United States centers for medicare and medicaid services (CMS) determines that the assessment imposed under section 5168.06 of the Revised Code is a permissible health care related tax. Whenever the department of medicaid is informed that the assessment is an impermissible health care-related tax, the department shall promptly refund to each hospital the amount of money currently in the hospital care assurance match fund that has been paid by the hospital, plus any investment earnings on that amount.

(B) Definitions

(1) "Program year" - The period beginning the first day of October of a calendar year and ending on the thirtieth day of September of the following calendar year.

(2) "Current program year" - The program year beginning the first day of October of the most recent calendar year and ending on the thirtieth day of September the following calendar year.

(3) "Past program year" - Any program year beginning the first day of October in a calendar year preceding the current program year and ending the thirtieth day of September the following calendar year.

(C) The program years to which this rule applies are identified in paragraphs (C)(1) to (C)(3) of this rule. When the department is notified by the CMS that an additional disproportionate share allotment is available for a past program year, the department may amend the assessment rates for the past program year.

(1) The assessment rates applicable to the current program year are specified in paragraph (D) of this rule.

(2) The assessment rates applicable to the past program year when federal allotment is increased are specified in paragraph (E)(1) of this rule.

(3) The revised assessment rates applicable to the past program year when federal allotment is decreased are specified in paragraph (E)(2) of this rule.

(D) Calculation of assessment amounts.

The calculations described in this rule will be based on the cost-reporting data described in rule 5160-2-23 of the Administrative Code that reflect the most recently completed interim settled medicaid cost report for all hospitals. For non-medicaid participating hospitals, the calculations shall be based on the most recent as-filed medicare cost report.

The assessment is calculated as follows:

(1) Determine each hospital's adjusted total facility costs as the amount calculated in paragraph (A)(17) of rule 5160-2-08 of the Administrative Code.

(2) For hospitals with adjusted total facility costs, as described in paragraph (D)(1) of this rule, that are less than or equal to $216,372,500, multiply the hospital's adjusted total facility costs as described in paragraph (D)(1) of this rule by one and one half per cent. The product will be each hospital's assessment amount. For hospitals with adjusted total facility costs, as described in paragraph (D)(1) of this rule, that are greater than $216,372,500, multiply a factor of one and one half per cent times the hospital's adjusted total facility costs as described in paragraph (D)(1) of this rule, up to $216,372,500. Multiply a factor of one per cent times the hospital's adjusted total facility costs as described in paragraph (D)(1) of this rule, that are in excess of $216,372,500. The sum of the two products will be each hospital's assessment amount.

(3) The assessment amounts calculated in paragraph (D)(2) of this rule are subject to adjustment under the provisions of paragraph (G) of this rule.

(4) The department may establish a rate lower than the rates described in paragraph (D)(2) of this rule based on the assessment necessary to maximize the disproportionate share allotment for the current program year.

(E) Federal allotment adjustment.

(1) For past program years in which the federal disproportionate share allotment has increased, the department shall recalculate the assessment rate for that program year and notify each hospital via rate letter of the additional amount to be paid by the hospital to collect the state share necessary to expend the additional allotment. The adjusted assessment rate described in this paragraph will be calculated in accordance with paragraph (D) of this rule. The assessment collected will then be matched with federal funds and distributed to hospitals based upon the distribution model for the applicable past program year. Notwithstanding paragraph (D)(3) of this rule, the provisions outlined in paragraph (G)(2) of this rule are not applicable to any past program year.

(2) When the department is notified by the CMS of a decrease in the federal disproportionate share allotment for a past program year, the department shall recalculate the distribution for that program year and notify each hospital via recoupment letter of the amount to be recouped. Of the total amount recouped, the portion that was funded with federal funding shall be returned to the CMS. The portion of the recoupment that is state funds shall be applied toward the required assessment for a future program year. Notwithstanding paragraph (D)(3) of this rule, the provisions outlined in paragraph (G)(2) of this rule are not applicable to any past program year.

(F) Determination of intergovernmental transfer amounts.

The department may require governmental hospitals, as described in paragraph (A)(2) of rule 5160-2-08 of the Administrative Code, to make intergovernmental transfers each program year.

The department shall notify each governmental hospital of the amount of the intergovernmental transfer it is required to make during the program year.

Each governmental hospital shall make intergovernmental transfers in periodic installments, executed by electronic funds transfer.

(G) Notification and reconsideration procedures.

(1) The department shall mail by certified mail, return receipt requested, the results of the determinations made under paragraphs (D) and (E) of this rule to each hospital. If no hospital submits a request for reconsideration as described in paragraph (G)(2) of this rule, the preliminary determinations constitute the final reconciliation of the amounts that each hospital must pay under this rule.

(2) Not later than fourteen days after the department mails the preliminary determinations as described in paragraphs (D) and (E) of this rule, any hospital may submit to the department a written request for reconsideration of the preliminary determination made under paragraphs (D) and (E) of this rule. The request must be accompanied by written materials setting forth the basis for the reconsideration.

If one or more hospitals submit such a request, the department shall hold a public hearing in Columbus, Ohio not later than thirty days after the preliminary determinations have been mailed by the department for the purpose of reconsidering its preliminary determinations. The department shall mail written notice of the date, time, and place of the hearing to every hospital at least ten days before the date of the hearing.

On the basis of the evidence submitted to the department or presented at the public hearing, the department shall reconsider and may adjust the preliminary determinations. The result of the reconsideration is the final reconciliation of the amounts that each hospital must pay under the provisions of this rule.

(3) The department shall mail each hospital written notice of the amount it must pay under the final reconciliation as soon as practical. Any hospital may appeal the amount it must pay to the court of common pleas of Franklin county.

(4) In the course of any program year, the department may adjust the assessment rate defined in paragraphs (D) and (E) of this rule or adjust the amount of the intergovernmental transfers required under paragraph (F) of this rule, and, as a result of the adjustment, adjust each hospital's assessment and intergovernmental transfer, to reflect refinements made by the CMS during that program year.

History

Effective: November 11, 2018
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-09 Payment policies for disproportionate share and indigent care adjustments for hospital services.

This rule is applicable for each program year for all medicaid-participating providers of hospital services included in the definition of "hospital" as described under section 5168.01 of the Revised Code.

(A) Definitions.

(1) "Total fee for service (FFS) medicaid costs" for each hospital means the sum of inpatient program costs reported on ODM 02930, schedule H, section I, columns 1 and 3, line 1 and outpatient medicaid program costs as reported on ODM 02930, "Ohio Medicaid Hospital Cost Report," section II, column 1, line 10 for the applicable state fiscal year.

(2) "Total medicaid managed care plan (MCP) inpatient costs" for each hospital means the amount on ODM 02930 schedule I, column 3, line 202.

(3) "Total medicaid MCP outpatient costs" for each hospital means the amount on ODM 02930 schedule I, column 5, line 202.

(4) "Total Title V costs" for each hospital means the sum of the inpatient and outpatient program costs as reported on ODM 02930, schedule H, section I, column 2, line 1 and section II, column 2, line 10.

(5) "Total inpatient uncompensated care costs for people without insurance" for each hospital means the sum of the inpatient uncompensated care costs below the poverty level and inpatient uncompensated care costs above the poverty level amounts as totaled on ODM 02930, schedule F, column 5.

(6) "Total inpatient uncompensated care costs under one hundred per cent" for each hospital means the sum of the inpatient uncompensated care costs under one hundred per cent for patients with and without insurance as reported on the ODM 02930, schedule F, columns 4 and 5.

(7) "Total inpatient uncompensated care costs above one hundred per cent without insurance" for each hospital means the sum of the inpatient uncompensated care costs over one hundred per cent for patients without insurance as reported on the ODM 02930, schedule F, column 5.

(8) "Total outpatient uncompensated care costs under one hundred per cent" for each hospital means the sum of the outpatient care costs under one hundred per cent for patients with and without insurance as on the ODM 02930, schedule F, columns 4 and 5.

(9) "Total outpatient uncompensated care costs above one hundred per cent without insurance" for each hospital means the sum of the outpatient uncompensated care costs above one hundred per cent for patients without insurance as reported on the ODM 02930, schedule F, column 5.

(10) "Total uncompensated care costs under one hundred per cent" for each hospital means the sum of total inpatient uncompensated care costs under one hundred per cent as described in paragraph (A)(6) of this rule, and total outpatient uncompensated care costs under one hundred per cent as described in paragraph (A)(8) of this rule.

(11) "Total uncompensated care costs above one hundred per cent without insurance" for each hospital means the sum of total inpatient uncompensated care costs above one hundred per cent without insurance as described in paragraph (A)(7) of this rule, and total outpatient uncompensated care costs above one hundred per cent without insurance as described in paragraph (A)(9) of this rule.

(12) "Total outpatient uncompensated care costs for people without insurance" for each hospital means the sum of the outpatient uncompensated care costs below the poverty level and outpatient uncompensated care costs above the poverty level as represented on the ODM 02930, schedule F.

(13) "Total uncompensated care costs for patients without insurance" for each hospital means the sum of the total inpatient uncompensated care costs for people without insurance in paragraph (A)(5) of this rule and the total outpatient uncompensated care costs for people without insurance in paragraph (A)(12) of this rule.

(14) "Total FFS medicaid days" means, for each hospital, the amount on the ODM 02930, schedule C, column 6, line 49.

(15) "MCP days" mean for each hospital, the amount on the ODM 02930, schedule I, column 2, line 204.

(16) "Total medicaid days" for each hospital means the sum of total medicaid FFS days as defined in paragraph (A)(14) of this rule and MCP days as defined in (A)(15) of this rule.

(17) "High federal disproportionate share hospital" means a hospital with a ratio of total medicaid days as defined in paragraph (A)(16) of this rule to total facility days as defined in paragraph (A)(19) of this rule greater than the statewide mean ratio of the sum of total medicaid days to the sum of total facility days plus one standard deviation.

(18) "Total medicaid FFS payments" for each hospital means the sum of the total medicaid inpatient payments, total medicaid outpatient payments, and the medicaid settlement amounts as reported on the ODM 02930, schedule H, column 1, lines 7, 15, and 26.

(19) "Total facility days" means for each hospital the amount reported on the ODM 02930, schedule C, column 4, line 49.

(20) "Medicaid utilization rate" for each hospital means the rate calculated by dividing the sum of total medicaid days as defined in paragraph (A)(16) of this rule by the total facility days as defined in paragraph (A)(19) of this rule.

(21) "Total medicaid MCP costs" for each hospital means the actual cost to the hospital of care rendered to medical assistance recipients enrolled in a MCP that has entered into a contract with the department of medicaid and is the amount on ODM 02930, schedule I, column 3, line 202 and column 5, line 202.

(22) "Medicaid MCP inpatient payments" for each hospital means the amount on ODM 02930 schedule I, column 2, line 208.

(23) "Medicaid MCP outpatient payments" for each hospital means the amount on ODM 02930 schedule I, column 4, line 208.

(24) "Total medicaid MCP payments" for each hospital is the sum of the amount calculated in paragraph (A)(22) of this rule, and the amount calculated in paragraph (A)(23) of this rule.

(25) "Adjusted total facility costs" for each hospital means the amount described in paragraph (A) of rule 5160-2-08 of the Administrative Code.

(26) "Rural Hospital (RH)" means a hospital geographically located in an Ohio county that is not classified into a core based statistical area (CBSA) as designated in the inpatient prospective payment system (IPPS) case-mix and wage index table as published October first of each program year by the centers for medicare and medicaid services (CMS).

(27) "Critical Access Hospital (CAH)" means a hospital that is certified as a critical access hospital by CMS and that has notified the Ohio department of health and the Ohio department of medicaid of such certification. The Ohio department of medicaid must receive notification of critical access hospital certification by the first day of October, the start of the program year, in order for the hospital to be considered a critical access hospital for disproportionate share payment purposes. Hospitals shall notify the Ohio department of medicaid of any change in their critical access hospital status, including continued CAH designations, immediately following notification from CMS.

(28) "Hospital-specific disproportionate share limit" for each hospital means the limit on disproportionate share and indigent care payments made to a specific hospital as defined in paragraph (J)(2) of this rule.

(29) "Children's hospitals" are those hospitals that meet the definition in paragraph (A)(3) of rule 5160-2-05 of the Administrative Code.

(30) "Inpatient upper limit payment" for each hospital means the amount reported on ODM 02930, schedule H, section I, column 1, line 5.

(31) "Outpatient upper limit payment" for each hospital means the amount reported on ODM 02930, schedule H, section II, column 1, line 14.

(32) "Total program amount" means the sum of the amounts in paragraphs (K)(2) and (K)(3) of this rule.

(33) "Obstetric services requirements (OSR)" means for each hospital that satisfies the federal statute of having at least two obstetricians who have staff privileges at the hospital that agreed to provide obstetric services to medicaid eligible individuals during the cost-reporting year as defined in paragraph (B) of rule 5160-2-08 of the Administrative Code. For rural hospitals as defined in paragraph (A))(26) of this rule, this requirement includes any physician with staff privileges at the hospital to perform non-emergency obstetric procedures. This requirement shall not apply to a hospital whose inpatients are predominantly individuals under eighteen years of age or a hospital which did not offer non-emergency obstetric services to the general population as of December 22, 1987, the date the federal statute was enacted.

(B) Applicability.

The requirements of this rule apply as long as CMS determines that the assessment imposed under section 5168.06 of the Revised Code is a permissible health care related tax. Whenever the department of medicaid is informed that the assessment is an impermissible health care-related tax, the department shall promptly refund to each hospital the amount of money currently in the hospital care assurance program fund that has been paid by the hospital, plus any investment earnings on that amount.

(1) The calculations described in this rule will be based on cost-reporting data described in paragraph (B)(1) of rule 5160-2-08 of the Administrative Code.

(2) For new hospitals, the first available cost report filed with the department in accordance with rule 5160-2-23 of the Administrative Code will be used until a cost report that meets the requirements of this paragraph is available. If, for a new hospital, there is no available or valid cost report filed with the department, the hospital will be excluded until valid data is available.

Cost reports for hospitals involved in mergers during the program year that result in the hospitals using one provider number will be combined and annualized by the department to reflect one full year of operation.

(3) Closed hospitals with unique medicaid provider numbers.

For a hospital facility, identifiable to a unique medicaid provider number, that closes during the program year defined in paragraph (A) of rule 5160-2-08 of the Administrative Code, the cost report data used shall be adjusted to reflect the portion of the year the hospital was open during the current program year. That partial year data shall be used to determine the distribution to that closed hospital. The difference between the closed hospital's distribution based on the full year cost report and the partial year cost report shall be redistributed to the remaining hospitals in accordance with paragraph (G) of this rule.

For a hospital facility identifiable to a unique medicaid provider number that closed during the immediate prior program year, the cost report data shall be used to determine the distribution that would have been made to that closed hospital. This amount shall be redistributed to the remaining hospitals in accordance with paragraph (G) of this rule.

(4) Replacement hospital facilities.

If a new hospital facility is opened for the purpose of replacing an existing (original) hospital facility identifiable to a unique medicaid provider number and the original facility closes during the program year defined in paragraph (A) of rule 5160-2-08 of the Administrative Code, the cost report data from the original facility shall be used to determine the distribution to the new replacement facility if the following conditions are met:

(a) Both facilities have the same ownership,

(b) There is appropriate evidence to indicate that the new facility was constructed to replace the original facility,

(d) The new replacement facility has not filed a cost report for the current program year.

For a replacement hospital facility that opened in the immediate prior program year, the distribution for that facility will be based on the cost report data for that facility and the cost report data for the original facility, combined and annualized by the department to reflect one full year of operation.

(5) Hospitals that have changed ownership.

For a change of ownership that occurs during the program year, the cost reporting data filed by the previous owner that reflects that hospital's most recent completed interim settled medicaid cost report shall be annualized to reflect one full year of operation. The data will be allocated to each owner based on the number of days in the program year the hospital was owned.

For a change of ownership that occurred in the previous program year, the cost reporting data filed by the previous owner that reflects that hospital's most recent completed interim settled medicaid cost report and the cost reporting data filed by the new owner that reflects that hospital's most recent completed interim settled medicaid cost report, will be combined and annualized by the department to reflect one full year of operation. If there is no available or valid cost report from the previous owner, the department shall annualize the cost report from the new owner to reflect one full year of operation.

(6) Cost report data used in the calculations described in this rule will be the cost report data described in this paragraph subject to any adjustments made upon departmental review prior to final determination that is completed each year and subject to the provisions of rule 5160-2-08 of the Administrative Code.

(D) Determination of indigent care pool.

(1) The "indigent care pool" means the sum of the following:

(a) The total assessments paid by all hospitals less the assessment deposited into the health care services administration fund described in rule 5160-2-08 of the Administrative Code.

(b) The total amount of intergovernmental transfers required to be made by governmental hospitals less the amount of the transfer deposited into the health care services administration fund described in rule 5160-2-08 of the Administrative Code.

(c) The total amount of federal matching funds that will be made available to general acute care hospitals in the same program year as a result of the state's disproportionate share limit payment allotment determined by the CMS for that program year.

(2) The funds available in the indigent care pool shall be distributed through policy payment pools in accordance with paragraphs (E) to (I) of this rule. Policy payment pools shall be allocated a percentage of the indigent care pool as described in paragraphs (D)(2)(a) to (D)(2)(e) of this rule.

(a) High federal disproportionate share hospital pool: 12.00 per cent.

(b) Medicaid indigent care pool: 77.26 per cent.

(d) Critical access and rural hospitals: 8.76 per cent.

(e) Children's hospitals: 1.98 per cent.

(E) Distribution of funds through the indigent care payment pools.

The funds are distributed among the hospitals according to indigent care payment pools described in paragraphs (E)(1) to (E)(3) of this rule.

(1) Hospitals meeting the high federal disproportionate share hospital definition described in paragraph (A)(17) of this rule shall receive funds from the high federal disproportionate share indigent care payment pool.

(a) For each hospital that meets the high federal disproportionate share definition, calculate the ratio of the hospital's total FFS medicaid costs and total medicaid MCP costs to the sum of total FFS medicaid costs and total medicaid MCP costs for all hospitals that meet the high federal disproportionate share definition.

(b) For each hospital that meets the high federal disproportionate share definition, multiply the ratio calculated in paragraph (E)(1)(a) of this rule by the amount allocated in paragraph (D)(2)(a) of this rule to determine each hospital's high federal disproportionate share hospital payment amount, subject to the following limitations:

(i) If the hospital's payment amount calculated in paragraph (E)(1)(b) of this rule is greater than or equal to its hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule, the hospital's high federal disproportionate share hospital payment is the amount defined in paragraph (A)(28).

(ii) If the hospital's payment amount calculated in (E)(1)(b) of this rule is less than its hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule, the hospital's high federal disproportionate share hospital payment is equal to the amount in paragraph (E)(1)(b) of this rule and any additional amount provided by paragraph (E)(1)(b)(iv) of this rule.

(iii) If the hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule is equal to or less than zero, the hospital's high federal disproportionate share hospital payment is equal to zero.

(iv) For hospitals whose high federal disproportionate share hospital payment is set at the disproportionate share limit defined in paragraph (A)(28) of this rule, calculate each hospital's limited payment by subtracting the amount defined in paragraph (A)(28) of this rule from the amount determined in paragraph (E)(1)(b) of this rule and sum these amounts for all limited hospital(s). Subtract the sum of the limited payments from the amount allocated in paragraph (D)(2)(a) of this rule and repeat the distribution described in paragraph (E)(1) of this rule until all remaining funds for this pool are expended.

(2) Hospitals shall receive funds from the medicaid indigent care payment pool.

(a) For each hospital, subtract the amount distributed in paragraph (E)(1) of this rule from the hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule.

(b) For all hospitals, sum the amounts calculated in paragraph (E)(2)(a) of this rule.

(c) For each hospital, calculate the ratio of the amount in paragraph (E)(2)(a) of this rule to the amount in paragraph (E)(2)(b) of this rule.

(d) For each hospital, multiply the ratio calculated in paragraph (E)(2)(c) of this rule by the amount allocated in paragraph (D)(2)(b) of this rule to determine each hospital's medicaid indigent care payment amount subject to the following limitations:

(i) If the sum of a hospital's payment amounts calculated in paragraph (E)(1) of this rule is greater than or equal to its hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule, the hospital's medicaid indigent care payment pool amount is equal to zero.

(ii) If the sum of a hospital's payment amounts calculated in paragraphs (E)(1) and (E)(2)(d) of this rule is less than its hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule, then the payment is equal to the amount in paragraph (E)(2)(d) of this rule and any amount provided by paragraph (E)(2)(d)(iv) of this rule.

(iii) If the sum of a hospital's payment amounts calculated in paragraphs (E)(1) and (E)(2)(d) of this rule is greater than its hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule, then the payment is equal to the difference between the hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule and the amount calculated in paragraph (E)(1) of this rule.

(iv) If any hospital is limited as described in paragraph (E)(2)(d)(iii) of this rule, calculate each hospital's limited payment by subtracting the amount defined in paragraph (A)(28) of this rule from the amount determined in paragraph (E)(2)(d) of this rule and sum these amounts for all limited hospital(s). Subtract the sum of the limited payments from the amount allocated in paragraph (D)(2)(b) of this rule and repeat the distribution described in paragraph (E)(2) of this rule until all remaining funds for this pool are expended.

(v) For all hospitals, sum the amounts calculated in paragraph (E)(2)(d) of this rule. This amount is the hospital's medicaid indigent payment amount.

(3) Hospitals shall receive funds from the uncompensated care indigent care payment pool.

(a) For each hospital, sum total inpatient uncompensated care costs under one hundred per cent defined in paragraph (A)(6) of this rule and total outpatient uncompensated care costs under one hundred per cent defined in paragraph (A)(8) of this rule. For hospitals with total negative uncompensated care costs, the resulting sum is equal to zero.

(b) For all hospitals, sum the amounts calculated in paragraph (E)(3)(a) of this rule.

(c) For each hospital, calculate the ratio of the amount in paragraph (E)(3)(a) of the rule to the amount in paragraph (E)(3)(b) of this rule.

(d) For each hospital, multiply the ratio calculated in paragraph (E)(3)(c) of this rule by the amount allocated in paragraph (D)(2)(c) of this rule to determine each hospital's uncompensated care under one hundred per cent payment, subject to the following limitations:

(i) If the sum of a hospital's payment amounts calculated in paragraphs (E)(1) and (E)(2) of this rule is greater than or equal to its hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule, the hospital's uncompensated care under one hundred per cent payment amount is equal to zero.

(ii) If the sum of a hospital's payment amount calculated in paragraphs (E)(1) and (E)(2) of this rule and the amount calculated in paragraph (E)(3)(d) of this rule is less than its hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule, the hospital's uncompensated care under one hundred per cent payment amount is equal to the amount calculated in paragraph (E)(3)(d) of this rule and any amount provided by paragraph (E)(3)(d)(iv) of this rule.

(iii) If a hospital does not meet the condition described in paragraph (E)(3)(d)(i) of this rule, and the sum of its payment amounts calculated in paragraphs (E)(1) and (E)(2) of this rule and the amount calculated in paragraph (E)(3)(d) of this rule is greater than its hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule, the hospital's uncompensated care under one hundred per cent payment amount is equal to the difference between the hospital's disproportionate share limit and the sum of the payment amounts calculated in paragraphs (E)(1) and (E)(2) of this rule.

(iv) If any hospital is limited as described in paragraph (E)(3)(d)(iii) of this rule, calculate each hospital's limited payment by subtracting the amount defined in paragraph (A)(28) of this rule from the amount determined in paragraph (E)(3)(d) of this rule and sum these amounts for all limited hospital(s). Subtract the sum of the limited payments from the amount allocated in paragraph (D)(2)(c) of this rule and repeat the distribution described in paragraph (E)(3) of this rule until all funds for this pool are expended.

(e) For each hospital, sum the amount calculated in paragraph (E)(3)(d) of this rule. This amount is the hospital's uncompensated care indigent care payment amount.

(F) Distribution of funds through the rural and critical access payment pools.

The funds are distributed among the hospitals according to rural and critical access payment pools described in paragraphs (F)(1) to (F)(2) of this rule.

(1) Hospitals meeting the definition described in paragraph (A)(27) of this rule, shall receive funds from the critical access hospital (CAH) payment pool.

(a) For each hospital with CAH certification, calculate the remaining hospital-specific disproportionate share limit by subtracting the amounts calculated in paragraphs (E)(1), (E)(2) and (E)(3) of this rule from the amount described in paragraph (A)(28) of this rule.

(b) For each hospital with CAH certification:

(i) Calculate the ratio of each CAH hospital's remaining hospital-specific disproportionate share limit as described in paragraph (F)(1)(a) of this rule to the total remaining hospital-specific disproportionate share limit for all CAH hospitals.

(ii) For each CAH hospital, multiply the ratio calculated in paragraph (F)(1)(b)(i) of this rule by 38.81 per cent of the amount allocated in paragraph (D)(2)(d) of this rule to determine each hospital's CAH payment amount.

(d) For each hospital with CAH certification, if the amount described in paragraph (F)(1)(a) of this rule is equal to zero, the hospital shall be included in the RH payment pool described in paragraph (F)(2)(a) of this rule.

(2) Hospitals meeting the definition described in paragraph (A)(26) of this rule but do not meet the definition described in paragraph (A)(27) of this rule, shall receive funds from the rural hospital RH payment pool.

(a) For each hospital with RH classification, as qualified by paragraphs (F)(2) and (F)(1)(d) of this rule, sum the hospital's total payments allocated in paragraphs (E)(1)(b), (E)(2)(d), and (E)(3)(e) of this rule.

(b) For each hospital with RH classification, as qualified by paragraphs (F)(2) and (F)(1)(d) of this rule subtract the amount calculated in paragraph (F)(2)(a) of this rule, from the amount calculated in paragraph (A)(28) of this rule. If this difference for the hospital is negative, then for the purpose of this calculation set the difference equal to zero.

(c) For all hospitals with RH classification, as qualified by paragraphs (F)(2) and (F)(1)(d) of this rule, sum the amounts calculated in paragraph (F)(2)(b) of this rule.

(d) For each hospital with RH classification, as qualified by paragraphs (F)(2) and (F)(1)(d) of this rule, determine the ratio of the amounts in paragraphs (F)(2)(b) and (F)(2)(c) of this rule.

(e) Subtract the amount calculated in paragraph (F)(1)(c) of this rule from the amount allocated in paragraph (D)(2)(d) of this rule.

(f) For each hospital with RH classification, as qualified by paragraphs (F)(2) and (F)(1)(d) of this rule, multiply the ratio calculated in paragraph (F)(2)(d) of this rule, by the amount calculated in paragraph (F)(2)(e) of this rule, to determine each hospital's rural hospital payment pool amount.

(g) For each hospital, sum the amount calculated in paragraph (F)(1)(b) of this rule, and the amount calculated in paragraph (F)(2)(f) of this rule. This amount is the hospital's rural and critical access payment amount.

(G) Distribution of funds through the county redistribution of closed hospitals payment pools.

If funds are available in accordance with paragraph (C) of this rule, the funds are distributed among the hospitals according to the county redistribution of closed hospitals payment pools described in paragraphs (G)(1) to (G)(3) of this rule.

(1) If a hospital facility that is identifiable to a unique medicaid provider number closes during the current program year, the payments that would have been made to that hospital under paragraphs (E), (F), (H), and (I) of this rule for the portion of the year it was closed, less any amounts that would have been paid by the closed hospital under provisions of rules 5160-2-08 and 5160-2-08.1 of the Administrative Code for the portion of the year it was closed, shall be distributed to the remaining hospitals in the county where the closed hospital is located. If another hospital does not exist in such a county, the funds shall be distributed to hospitals in bordering counties within the state.

For each hospital identifiable to a unique medicaid provider number that closed during the immediate prior program year, the payments that would have been made to that hospital under paragraphs (E), (F), (H), and (I) of this rule, less any amounts that would have been paid by the closed hospital under provisions of rules 5160-2-08 and 5160-2-08.1 of the Administrative Code, shall be distributed to the remaining hospitals in the county where the closed hospital was located. If another hospital does not exist in such a county, the funds shall be distributed to hospitals in bordering counties within the state.

If the closed hospital's payments under paragraphs (E), (F), (H), and (I), of this rule does not result in a net gain, nothing shall be redistributed under paragraphs (G)(2) and (G)(3) of this rule.

(2) Redistribution of closed hospital funds within the county of closure.

(a) For each hospital within a county with a closed hospital as described in paragraph (G)(1) of this rule, sum the amount calculated in paragraph (E)(3)(a) of this rule, if the sum of a hospital's total payments calculated in paragraphs (E)(1), (E)(2), (E)(3), (F)(1), and (F)(2) of this rule does not exceed the hospital's disproportionate share limit defined in paragraph (A)(28) of this rule.

(b) For all hospitals within a county with a closed hospital, sum the amounts calculated in paragraph (G)(2)(a) of this rule.

(c) For each hospital within a county with a closed hospital, determine the ratio of the amounts in paragraphs (G)(2)(a) and (G)(2)(b) of this rule.

(d) For each hospital within a county with a closed hospital, multiply the ratio calculated in paragraph (G)(2)(c) of this rule, by the amount calculated in paragraph (G)(1) of this rule, to determine each hospital's county redistribution of closed hospitals payment amount, subject to the following limitation:

If the sum of a hospital's payment amounts calculated in paragraphs (E)(1), (E)(2), (E)(3), (F)(1), and (F)(2) of this rule is less than the hospital's disproportionate share limit defined in paragraph (A)(28) of this rule, then the hospital's redistribution of closed hospital funds amount is equal to the amount in paragraph (G)(2)(d) of this rule, not to exceed the amount defined in paragraph (A)(28) of this rule.

(3) Redistribution of closed hospital funds to hospitals in a bordering county.

(a) For each hospital within a county that borders a county with a closed hospital where another hospital does not exist, as described in paragraph (G)(1) of this rule, sum the amount calculated in paragraph (E)(3)(a) of this rule, if the sum of a hospital's total payments calculated in paragraphs (E)(1), (E)(2), (E)(3), (F)(1) and (F)(2) of this rule does not exceed the hospital's disproportionate share limit defined in paragraph (A)(28) of this rule.

(b) For all hospitals within counties that border a county with a closed hospital where another hospital does not exist, sum the amounts calculated in paragraph (G)(3)(a) of this rule.

(c) For each hospital within a county that borders a county with a closed hospital where another hospital does not exist, determine the ratio of the amounts in paragraphs (G)(3)(a) and (G)(3)(b) of this rule.

(d) For each hospital within a county that borders a county with a closed hospital where another hospital does not exist, multiply the ratio calculated in paragraph (G)(3)(c) of this rule, by the amount calculated in paragraph (G)(1) of this rule, to determine each hospital's county redistribution of closed hospitals payment amount subject to the following limitation:

If the sum of a hospital's payment amounts calculated in paragraphs (E)(1), (E)(2), (E)(3), (F)(1), and (F)(2) of this rule is less than the hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule, the hospital's redistribution of closed hospital funds amount is the amount defined in paragraph (G)(3)(d) of this rule, not to exceed the amount defined in paragraph (A)(28) of this rule.

(H) Distribution of funds through the children's hospital pool.

(1) For each hospital meeting the children's hospital definition described in paragraph (A)(29) of this rule, sum the payment amounts as calculated in paragraphs (E), (F), and (G) of this rule. This is the hospital's calculated payment amount.

(2) For each hospital meeting the children's hospital definition described in paragraph (A)(29) of this rule, with a calculated payment amount that is not greater than the disproportionate share limit, as described in paragraph (A)(28) of this rule, subtract the amount in paragraph (H)(1) of this rule from the disproportionate share limit, as described in paragraph (A)(28) of this rule.

(3) For hospitals meeting the children's hospital definition described in paragraph (A)(29) of this rule, with calculated payment amounts that are not greater than the disproportionate share limit, as described in paragraph (A)(28) of this rule, sum the amounts calculated in paragraph (H)(2) of this rule.

(4) For each hospital meeting the children's hospital definition described in paragraph (A)(29) of this rule, with a calculated payment amount that is not greater than the disproportionate share limit, as described in paragraph (A)(28) of this rule, determine the ratio of the amounts in paragraphs (H)(2) and (H)(3) of this rule.

(5) For each hospital meeting the children's hospital definition described in paragraph (A)(29) of this rule, with a calculated payment that is not greater than the disproportionate share limit, as described in paragraph (A)(28) of this rule, multiply the ratio calculated in paragraph (H)(4) of this rule by the amount allocated in paragraph (D)(2)(e) of this rule. This amount is the children's hospital payment pool payment amount, subject to the following limitation.

If the sum of the hospital's payment amounts calculated in paragraphs (E)(1), (E)(2), (E)(3), (F)(1), (F)(2), and (G) of this rule is less than the hospital's disproportionate share limit defined in paragraph (A)(28) of this rule, then the hospital's children's hospital pool payment amount is equal to the amount calculated in paragraph (H)(5) of this rule, not to exceed the amount defined in paragraph (A)(28) of this rule.

If any hospital is limited as described in paragraph (H)(5) of this rule, calculate each hospital's limited payment by subtracting the amount defined in paragraph (A)(28) of this rule from the amount determined in paragraph (H)(5) of this rule and sum these amounts for all limited hospital(s). Subtract the sum of the limited payments from the amount in paragraph (D)(2)(e) of this rule and repeat the distribution described in paragraph (H) of this rule until all funds for this pool are expended.

(I) Distribution model adjustments and limitations through the statewide residual pool.

(1) For each hospital, sum the payment amounts as calculated in paragraphs (E), (F), (G), and (H), of this rule. This is the hospital's calculated payment amount.

(2) For each hospital, calculate the hospital's specific disproportionate share limit as defined in paragraph (A)(28) of this rule.

(3) For each hospital, subtract the hospital's disproportionate share limit as calculated in paragraph (I)(2) of this rule from the payment amount as calculated in paragraph (I)(1) of this rule to determine if a hospital's calculated payment amount is greater than its disproportionate share limit. If the hospital's calculated payment amount as calculated in paragraph (I)(1) of this rule is greater than the hospital's disproportionate share limit calculated in paragraph (I)(2) of this rule, then the difference is the hospital's residual payment funds.

(4) If a hospital's calculated payment amount, as calculated in paragraph (I)(1) of this rule, is greater than its disproportionate share limit defined in paragraph (I)(2) of this rule, then the hospital's payment is equal to the hospital's disproportionate share limit.

(a) The hospital's residual payment funds as calculated in paragraph (I)(3) of this rule is subtracted from the hospital's calculated payment amount as calculated in paragraph (I)(1) of this rule and is applied to and distributed as the statewide residual payment pool as described in paragraph (I)(5) of this rule.

(b) The total amount distributed through the statewide residual pool will be the sum of the hospital care assurance fund described in paragraph (K)(4) minus the sum of the lessor of each hospital's calculated payment amount calculated in paragraph (I)(1) of this rule or the hospital's disproportionate share limit calculated in paragraph (I)(2) of this rule.

(5) Redistribution of residual payment funds in the statewide residual payment pool.

(a) For each hospital with a calculated payment amount that is not greater than the disproportionate share limit, as described in paragraph (I)(4) of this rule, subtract the amount in paragraph (I)(1) of this rule from the amount in paragraph (I)(2) of this rule.

(b) For hospitals with calculated payment amounts that are not greater than the disproportionate share limit, sum the amounts calculated in paragraph (I)(5)(a) of this rule.

(c) For each hospital with a calculated payment amount that is not greater than the disproportionate share limit, determine the ratio of the amounts in paragraphs (I)(5)(a) and (I)(5)(b) of this rule.

(d) For each hospital with a calculated payment amount that is not greater than the disproportionate share limit, multiply the ratio calculated in paragraph (I)(5)(c) of this rule by the total amount distributed through the statewide residual pool described in paragraph (I)(4)(b) of this rule. This amount is the hospital's statewide residual payment pool payment amount subject to the following limitation:

If the sum of the hospital's payment amounts calculated in paragraphs (E), (F), (G), and (H) of this rule is less than the amount of the hospital's disproportionate share limit defined in paragraph (A)(28) of this rule, then hospital's residual pool payment amount is equal to the amount defined in paragraph (I)(5)(d) of this rule, not to exceed the amount defined in paragraph (A)(28) of this rule.

(J) Disproportionate share adjustment.

(1) Determination of disproportionate share qualification.

(a) For each hospital, calculate the medicaid utilization rate as defined in paragraph (A)(20) of this rule.

(b) Each hospital with a medicaid utilization rate greater than or equal to one per cent and meets the obstetric services requirements as defined in paragraph (A)(33) of this rule qualifies as a disproportionate share hospital for the purposes of this rule.

(c) Each hospital with a medicaid utilization rate less than one per cent or does not meet the obstetric services requirements as defined in paragraph (A)(33) of this rule qualifies as a nondisproportionate share hospital for the purposes of this rule.

(2) Limitations on disproportionate share and indigent care payments made to hospitals.

(a) For each hospital, calculate medicaid fee for service (FFS) shortfall by subtracting from total medicaid FFS costs, as defined in paragraph (A)(1) of this rule, total medicaid FFS payments, as described in paragraph (A)(18) of this rule.

(b) For each hospital, calculate medicaid MCP shortfall by subtracting from total medicaid MCP costs, as defined in paragraph (A)(21) of this rule, the total medicaid MCP payments, as described in paragraph (A)(24) of this rule.

(c) For each hospital, calculate the total medicaid shortfall by adding the medicaid FFS shortfall as defined in paragraph (J)(2)(a) of this rule to the medicaid MCP shortfall as defined in paragraph (J)(2)(b) of this rule.

(d) For each hospital, determine the total cost of uncompensated care for people without insurance by taking the sum of the amounts described in paragraphs (A)(5) and (A)(12) of this rule.

(e) For each hospital, determine the amount received under section 1011 - federal reimbursement of emergency health services furnished to undocumented aliens from the ODM 02930, schedule E, line 7b.

(f) For each hospital, calculate the hospital disproportionate share limit by adding the total medicaid shortfall as described in paragraph (J)(2)(c) of this rule and total uncompensated care costs for people without insurance as described in paragraph (J)(2)(d) of this rule and subtracting section 1011 payments as described in paragraph (J)(2)(e) of this rule.

(g) The hospital will receive the lesser of the disproportionate share limit as described in paragraph (J)(2)(f) of this rule or the sum of disproportionate share and indigent care payments as calculated in paragraphs (E) to (I) of this rule.

(K) Payments and adjustments.

(1) Every hospital that must make payments of assessments and/or intergovernmental transfers to the department of medicaid under the provisions of rule 5160-2-08.1 of the Administrative Code shall make the payments in accordance with the payment schedule as described in this rule. If the final determination that the hospital must make payments was made by the department, the hospitals shall meet the payment schedule developed by the department after consultation with the hospitals or a designated representative thereof.

If the final determination that the hospital must make payments was made by the court of common pleas of Franklin county, the hospital shall meet the payment schedule developed by the department after consultation with the hospital or a designated representative thereof. Delayed payment schedules for hospitals that are unable to make timely payments under this paragraph due to financial difficulties will be developed by the department.

The delayed payments shall include interest at the rate of ten per cent per year on the amount payable from the date the payment would have been due had the delay not been granted until the date of payment.

(2) Except for the provisions of paragraphs (E) and (F) of rule 5160-2-08.1 of the Administrative Code, all payments of assessments and intergovernmental transfers, when applicable, from hospitals under rule 5160-2-08 of the Administrative Code shall be deposited to the credit of the hospital care assurance program fund. All investment earnings of the fund shall be credited to the fund. The department shall maintain records that show the amount of money in the fund at any time that has been paid by each hospital and the amount of any investment earnings on that amount. All moneys credited to the hospital care assurance program fund shall be used solely to make payments to hospitals under the provisions of this rule.

(3) All federal matching funds received as a result of hospital payments of assessments and intergovernmental transfers the department makes to hospitals under paragraph (K)(4) of this rule shall be credited to the hospital care assurance match fund. All investment earnings of the fund shall be credited to the fund. All money credited to the hospital care assurance match fund shall be used solely to make payments to hospitals under the provisions of this rule.

(4) The department shall make payments to each medicaid participating hospital meeting the definition of hospital as described under section 5168.01 of the Revised Code. The payments shall be based on amounts that reflect the sum of amounts in the hospital care assurance program fund described in paragraph (K)(2) of this rule and the hospital care assurance match fund described in paragraph (K)(3) of this rule. Payments to each hospital shall be calculated as described in paragraphs (E), (F), (G), (H), and (I) of this rule. For purposes of this paragraph, the value of the hospital care assurance match fund is calculated as:

Sum of hospital care assurance program fund/{1-(federal medical assistance percentage/100)}

The payments shall be made solely from the hospital care assurance program fund and the hospital care assurance match fund. If amounts in the funds are insufficient to make the total amount of payments for which hospitals are eligible, the department shall reduce the amount of each payment by the percentage by which the amounts are insufficient. Any amounts not paid at the time they were due shall be paid to hospitals as soon as moneys are available in the funds.

(5) All payments to hospitals under the provisions of this rule are conditional on:

(a) Expiration of the time for appeals under the provisions of rule 5160-2-08.1 of the Administrative Code without the filing of an appeal, or on court determinations, in the event of appeals, that the hospital is entitled to the payments;

(b) The availability of sufficient moneys in the hospital care assurance program fund and the hospital care assurance match fund to make payments after the final determination of any appeals;

(d) The payment made to hospitals does not exceed the hospital's disproportionate share limit as calculated in paragraph (J)(2) of this rule.

(6) If an audit conducted by the department of the amounts of payments made and received by hospitals under the provisions of this rule identifies amounts that, due to errors by the department, a hospital should not have been required to pay but did pay, should have been required to pay but did not pay, should not have received but did receive, or should have received but did not receive, the department shall:

(a) Make payments to any hospital that the audit reveals paid amounts it should not have been required to pay but did pay or did not receive amounts it should have received; and

(b) Take action to recover from a hospital any amounts that the audit reveals it should have been required to pay but did not pay or that it should not have received but did receive.

(7) Payments made under paragraph (K)(6)(a) of this rule shall be made from the hospital care assurance program fund. Amounts recovered under paragraph (K)(6)(b) of this rule shall be deposited to the credit of the hospital care assurance program fund. Any hospital may appeal the amount the hospital is to be paid under paragraph (K)(6)(a) of this rule or the amount to be recovered from the hospital under paragraph (K)(6)(b) of this rule to the court of common pleas of Franklin county.

(L) Confidentiality.

(M) Penalties for failure to report or make payment.

(1) Any hospital that fails to report the information required under this rule and under paragraph (A) of rule 5160-2-23 of the Administrative Code on or before the dates specified in this rule and in rule 5160-2-23 of the Administrative Code shall be fined one thousand dollars for each day after the due date that the information is not reported.

(2) In addition to any other remedy available to the department under law to collect unpaid assessments and transfers, any hospital that fails to make payments of the assessments and intergovernmental transfers to the department of medicaid on or before the dates specified in this rule or under any schedule for delayed payments established under paragraph (K)(1) of this rule shall be fined one thousand dollars for each day after the due date.

(3) The director of medicaid shall waive the penalties provided for in paragraphs (M)(1) and (M)(2) of this rule for good cause shown by the hospital.

(N) Payment schedule.

The assessments, intergovernmental transfers and payments made under the provisions of this rule will be made in installments.

(1) On or before the fourteenth day after the department mails the final determination as described in rule 5160-2-08.1 of the Administrative Code, the hospital must submit its first assessment to the department.

All subsequent assessments and intergovernmental transfers, when applicable, must be made on or before the fifth working day after the date on the warrant or electronic funds transfer (EFT) issued as payment by the department as described in paragraph (N)(2) of this rule.

Each hospital shall submit its assessment amount to the Ohio department of medicaid via EFT.

(2) On or before the tenth working day after the department's deadline for receiving assessments and intergovernmental transfers, the department must make a payment to each hospital. However, the department shall make no payment to any hospital that has not paid assessments or made intergovernmental transfers that are due until the assessments and transfers are paid in full or a final determination regarding amounts to be paid is made under any request for reconsideration or appeal.

(3) If a hospital closes after the date of the public hearing held in accordance with rule 5160-2-08.1 of the Administrative Code, and before the last payment is made, as described in this paragraph, the payments to the remaining hospitals will be adjusted in accordance with paragraphs (E) to (K)(7) of this rule.

History

Effective: November 11, 2018
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-10 Payment policies for disproportionate share and indigent care adjustments for psychiatric hospitals.

This rule is applicable for each program year for all medicaid-participating psychiatric hospitals as described in paragraphs (B) to (D) of rule 5160-2-01 of the Administrative Code.

(A) Definitions for each psychiatric hospital.

(1) "Cash subsidies for inpatient services received directly from state and local governments" is the amount of cash subsidies each psychiatric hospital has received from state and local governments for inpatient services for the applicable state fiscal year. In accordance with paragraph (C) of this rule, each psychiatric hospital reports cash subsidies received from state and local government on "Ohio Medicaid Hospital Cost Report" ODM 02930, for the applicable state fiscal year, schedule F, section II, column 4.

(2) "Charges for charity care" is the total charges for inpatient services provided to indigent patients, which includes charges for services provided to individuals who do not possess health insurance for the service provided. Charity care does not include bad debts, contractual allowances, or uncompensated care costs rendered to patients with insurance as described in paragraph (A)(13) of this rule. Each psychiatric hospital reports charges for charity care on ODM 02930, schedule F, section II, column 3.

(3) "Inpatient days" is the sum of the number of inpatient fee for service (FFS) hospital days as reported on ODM 02930, schedule C, section I, column 4 and the number of inpatient managed care plan (MCP) hospital days as reported on ODM 02930, schedule C, section III, column 2.

(4) "Insurance revenues" are the revenues received in the same twelve months of the hospital's cost-reporting period for inpatient services provided to, billed to, and received from all sources other than medicaid or self-pay revenues as described in paragraph (A)(6) of this rule. Each psychiatric hospital reports insurance revenues on ODM 02930, schedule F, section II, column 1.

(5) "Medicaid inpatient utilization rate" is the ratio of the psychiatric hospital's number of inpatient days attributable to patients who were medicaid eligible as described in paragraph (A)(10) of this rule divided by the psychiatric hospital's total number of inpatient days as described in paragraph (A)(3) of this rule.

(6) "Self-pay revenues" are the revenues received in the same twelve months of the hospital's cost-reporting period for inpatient services provided to, billed to, and received from either the person that received inpatient services or the family of the person that received inpatient services. Each psychiatric hospital reports self-pay revenues on ODM 02930, schedule F, section II, column 2.

(7) "Total charges for inpatient services" for each psychiatric hospital, except for free-standing, state-owned psychiatric hospitals, is the sum of the amounts reported for inpatient hospital services on ODM 02930, schedule B, column 6. For free-standing, state-owned psychiatric hospitals, "total charges for inpatient services" equals "total inpatient allowable costs" as defined in paragraph (A)(9) of this rule.

(8) "Total facility inpatient revenues" is the sum of the hospital's insurance revenues as described in paragraph (A)(4) of this rule, self-pay revenues as described in paragraph (A)(6) of this rule, and total medicaid revenues as described in paragraph (A)(11) of this rule.

(9) "Total inpatient allowable costs" is the sum of the general service and capital related costs for inpatient hospital services. Each psychiatric hospital reports total inpatient allowable costs on ODM 02930 schedule B, column 7.

(10) "Total medicaid days" is the sum of the amounts that each psychiatric hospital reports on ODM 02930, schedule F, section II, columns 6 to 8.

(11) "Total medicaid revenues" are the revenues received in the same twelve months of the hospital's cost-reporting period for inpatient services provided to, billed to, and received from all sources other than insurance revenues as described in paragraph (A)(4) of this rule or self-pay revenues as described in paragraph (A)(6) of this rule. Each psychiatric hospital reports total FFS medicaid revenues on ODM 02930, schedule H, section I, column 1 and total MCP medicaid revenues on ODM 02930, schedule I, column 2.

(12) "Uncompensated care costs" is the amount calculated by subtracting the sum of the total facility inpatient revenue as described in paragraph (A)(8) of this rule and the uncompensated care costs rendered to patients with insurance as described in paragraph (A)(13) of this rule from the total inpatient allowable costs as described in paragraph (A)(9) of this rule. For hospitals with negative uncompensated care costs, the result is equal to zero.

(13) "Uncompensated care costs rendered to patients with insurance" is the costs for an individual that has insurance coverage for the service provided, but the full cost of the service was not reimbursed because of per diem caps or coverage limitations. Each psychiatric hospital reports uncompensated care costs rendered to patients with insurance on ODM 02930, schedule F, section II, column 5.

(B) Applicability.

The requirements of this rule are limited pursuant to section 1923 of the Social Security Act, 42 USC 1396r-4 (effective October, 11, 2020).

The calculations described in this rule will be based on cost-reporting data described in paragraph (B)(1) of rule 5160-2-08 of the Administrative Code.

(D) Determination of disproportionate share qualifications for psychiatric hospitals.

Psychiatric hospitals will be determined to be disproportionate share if based on data described in paragraph (C) of this rule, they meet the obstetric services requirements as described in paragraph (A)(33) of rule 5160-2-09 of the Administrative Code, and they meet both qualifications described in paragraphs (D)(1) and (D)(2) of this rule.

(1) The hospital's medicaid inpatient utilization rate, as described in paragraph (A)(5) of this rule, is greater than or equal to one per cent; and

(2) The hospital's uncompensated care costs, as described in paragraph (A)(12) of this rule is at least sixty per cent of the hospital's total inpatient allowable costs as described in paragraph (A)(9) of this rule.

(E) Distribution of funds.

The funds available to each psychiatric hospital qualifying as a disproportionate share hospital as described in paragraph (D) of this rule are distributed among the hospitals based on data described in paragraph (C) of this rule and according to the payment formulas as follows:

(1) For each hospital, calculate the uncompensated care costs as described in paragraph (A)(12) of this rule;

(2) For all hospitals, sum all hospitals' uncompensated care costs as described in paragraph (A)(12) of this rule;

(3) For each hospital, calculate the ratio of the amount described in paragraph (E)(1) of this rule to the amount described in paragraph (E)(2) of this rule;

(4) Multiply the ratio for each hospital calculated in paragraph (E)(3) of this rule by the disproportionate share funds available to psychiatric hospitals as described in paragraph (G) of this rule to determine each hospital's disproportionate share payment amount.

(5) Each hospital will be distributed a payment amount based on the lesser of;

(a) Uncompensated care costs as determined in paragraph (A)(12) of this rule; or

(b) The hospital's disproportionate share payment as determined in paragraph (E)(4) of this rule.

(F) Payments.

The department will make payments in accordance with paragraph (E) of this rule to qualifying hospitals in accordance with paragraph (D) of this rule.

(G) Disproportionate share funds.

The maximum amount of disproportionate share funds available for distribution to psychiatric hospitals will be determined by subtracting the funds distributed in accordance with rule 5160-2-09 of the Administrative Code from the state's disproportionate share limit payment allotment determined by the centers for medicare and medicaid services (CMS) for that program year.

Last updated January 12, 2024 at 7:49 AM

History

Effective: January 12, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-12 Appeals and reconsideration of departmental determinations regarding hospital inpatient and outpatient services.

(A) Appeals.

Pursuant to Chapter 5160-70 of the Administrative Code, final settlements that are based upon final audits by the department may be appealed by hospitals under Chapter 119. of the Revised Code. Rule 5160-2-24 of the Administrative Code describes final fiscal audits and final settlements performed by the department. Rules 5160-1-27 and 5160-1-29 of the Administrative Code describe the audits performed by the department which may be appealable under Chapter 119. of the Revised Code. Since the scope and substance of these two types of audits differ, in no instance will the conduct and implementation of one type of audit preclude the conduct and implementation of the other.

(B) Utilization review reconsideration.

Pursuant to rule 5160-2-13 of the Administrative Code, the department or a medical review entity under contract with the department may make determinations regarding utilization review. These determinations are subject to the reconsideration process described in rule 5160-70-02 of the Administrative Code as follows:

(1) A written request for a reconsideration should be submitted to the department or the medical review entity, whichever made the initial determination as indicated by the denial letter, within sixty calendar days of the date of the determination. The department or the medical review entity has thirty business days from receipt of the request for reconsideration to issue a final and binding decision accepting, modifying, or rejecting its previous determination. The request for reconsideration must include:

(a) A copy of the written determination;

(b) A copy of the patient's medical record (if not already submitted to the review entity); and

(2) If the submitted request for a reconsideration is incomplete, the department or the medical review entity will notify the provider of missing documentation. The notice will give the provider two business days to submit the missing documentation.

(3) The department will conduct an administrative review of the reconsideration decision if the provider submits its request within thirty calendar days of that decision. The department has thirty business days from receipt of the request for review to issue a final and binding decision. A request for an administrative review must include:

(a) A letter requesting a review of the reconsideration;

(b) A statement as to why the provider believes that the reconsideration decision was in error; and

(4) The department may extend time frames described in paragraphs (B)(1) and (B)(3) of this rule, where adherence to time frames causes exceptional hardships to a large number of hospitals or where adherence to time frames as described in paragraphs (B)(1) and (B)(3) of this rule causes exceptional hardship to a hospital because potential determinations constitute a large portion of that hospital's total medicaid business.

(1) Except when the department's determination is based on a finding made by medicare, the proper application of rules 5160-2-65, 5160-2-75 and 5160-2-76 of the Administrative Code and the proper calculation of amounts (including source data used to calculate the amounts) determined in accordance with rules 5160-2-66 and 5160-2-67 of the Administrative Code are subject to the reconsideration process described in rule 5160-70-02 of the Administrative Code as follows:

(a) Requests for reconsideration authorized by paragraph (C)(1) of this rule should be submitted to the department in writing. If the request for reconsideration involves a rate component or determination made at the beginning of the rate year, the request should be submitted within ninety calendar days of the beginning of the rate year. If the request involves an adjustment or a determination made by the department after the beginning of the rate year, the request should be submitted within thirty calendar days of the date the adjustment or determination was implemented. The request should include a statement as to why the provider believes that the rate component or determination was incorrect as well as all documentation supporting the provider's position.

(b) The department has thirty business days from receipt of the request for reconsideration to issue a final and binding decision.

(2) When a medicare audit finding was used by the department in establishing a rate component and the finding is subsequently overturned on appeal, the provider may request reconsideration of the affected rate component. Such requests should be submitted to the department in writing prior to final settlement as described in rule 5160-2-24 of the Administrative Code and within thirty calendar days of the date the hospital receives notification from medicare of the appeal decision. The request for reconsideration of a medicare audit finding that has been overturned on appeal should include all documentation that explain the appeal decision. The department has thirty business days in which to notify the provider of its final and binding decision regarding the medicare audit finding.

(D) State hearings for medicaid recipients whose claim for hospital services is denied.

Any recipient whose claim for hospital services is denied may request a state hearing in accordance with division 5101:6 of the Administrative Code. The determination of whether outlier payments will be made or the amounts of outlier payments as described in rule 5160-2-65 of the Administrative Code is not a denial of a claim for inpatient hospital services. Similarly, the determination of amounts payable for inpatient hospital services involving readmissions or transfers is not a denial of a claim for inpatient hospital services.

(E) The following items are not subject to the department's reconsideration process:

(1) The use of the diagnosis related groups (DRG) classification system and the method of classification of discharges within DRGs.

(2) The assignment of DRGs and severity of illness (SOI).

(3) The assignment of relative weights to DRGs based on the methodology set forth in rule 5160-2-65 of the Administrative Code.

(4) The establishment of peer groups as set forth in rule 5160-2-65 of the Administrative Code.

(5) The methodology used to determine prospective payment rates as described in rule 5160-2-65 of the Administrative Code.

(6) The methodology used to identify cost thresholds for services that may qualify for outlier payments as described in rule 5160-2-65 of the Administrative Code.

(7) The formulas used to determine rates of payment for outliers, certain transfers and readmissions, and services subject to pre-certification, as described, respectively, in rules 5160-2-65 and 5160-2-40 of the Administrative Code.

(8) The peer group average cost per discharge for all hospitals except when the conditions detailed in rule 5160-2-65 of the Administrative Code are met.

(9) Statewide calculations of the direct and indirect medical education threshold for allowable costs per intern and resident as described in rule 5160-2-67 of the Administrative Code.

(10) The threshold for establishing which hospitals will be recognized as providing a disproportionate share of indigent care as described in rule 5160-2-09 of the Administrative Code.

(11) The use of the Enhanced Ambulatory Patient Groups (EAPG) classification system and the method of classification of claim details within EAPGs.

(12) The assignment of EAPGs.

(13) The assignment of relative weights to EAPGs based on the methodology set forth in rule 5160-2-75 of the Administrative Code.

(14) The establishment of peer groups as set forth in rule 5160-2-75 of the Administrative Code.

(15) The methodology used to determine prospective payment rates as described in rule 5160-2-75 of the Administrative Code.

(16) The peer group average cost per detail for all hospitals except when the conditions detailed in rule 5160-2-75 of the Administrative Code are met.

(17) Technical denials, which are the result of failure to submit medical records within thirty calendar days of the original request in accordance with rule 5160-2-13 and 5160-1-17.2 of the Administrative Code.

Last updated October 24, 2025 at 2:14 AM

History

Effective: June 12, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-13 Utilization review.

(A) The Ohio department of medicaid (ODM) will perform or contract with a medical review entity to perform utilization review for medicaid inpatient services regardless of the payment methodology used for reimbursement of those services. For the purposes of this rule, "ODM" means ODM or its contracted medical review entity. During the course of its analyses, ODM may request information or records from the hospital and may conduct on-site medical record reviews.

(B) ODM will review a statistical sample of all admissions retrospectively.

(1) While the nature of the review will vary depending on the category of admission, all admissions selected will be reviewed to determine whether care was medically necessary on an inpatient hospital basis; to determine if the care was medically necessary as defined in rule 5160-1-01 of the Administrative Code; to determine whether the discharge occurred at a medically appropriate time; to assess the quality of care rendered as mandated in 42 C.F.R. 456.3(b), in effect as of October 1, 2021; and to assess compliance with agency 5160 of the Administrative Code.

(2) If any of the cases reviewed for a hospital do not meet the conditions described in paragraph (B)(1) of this rule, then ODM may deny payment or recoup payment beginning with the first inappropriate admission or discharge. Any negative determinations should be made by a physician.

(3) If the diagnostic or procedural information on the claim is found to be inconsistent with that found in the medical records in conjunction with the physician attestation, then changes may be made in the coding and payment may be adjusted as described in paragraph (D)(3) of this rule.

(4) ODM may determine upon retrospective review, in accordance with this rule, that the location of services was not medically necessary, but that the services rendered were medically necessary. In such instances:

(a) The hospital may bill the department on an outpatient basis for those medically necessary services that were rendered on the date of admission in accordance with rule 5160-2-75 of the Administrative Code.

(b) Only laboratory and diagnostic radiology services rendered during the remainder of the medically unnecessary admission may be billed in accordance with rule 5160-2-75 of the Administrative Code.

(c) The outpatient bill will be submitted with a copy of the reconsideration affirming the original decision or the administrative decision issued in accordance with rule 5160-2-12 of the Administrative Code.

(d) The outpatient bill with attachments will be submitted to the department within sixty calendar days from the date on the remittance advice recouping the DRG payment for the medically unnecessary admission.

(C) ODM may include in its retrospective review sample the categories of admissions described in paragraphs (C)(1) to (D)(3) of this rule.

(1) ODM may review transfers as defined in rule 5160-2-02 of the Administrative Code. The purpose of the transfer review will be to examine the documented reasons for and appropriateness of the transfer. ODM considers a transfer appropriate if the transfer is necessary because the individual needs some treatment or care that is unavailable at the transferring hospital or if there are other exceptional circumstances that justify transfer.

Cases will be individually considered by ODM based on the merits of each case. If any of the hospital's transfer cases reviewed are found to be inappropriate transfers, then ODM may intensify the review, including the addition of prepayment review and pretransfer certification. ODM may deny payment to or recoup payment from a provider who has transferred patients inappropriately.

(2) ODM may review readmissions to determine if the readmission as defined in rule 5160-2-02 of the Administrative Code is appropriate.

(a) If the readmission is related to the first hospitalization, ODM will determine if the readmission resulted from complications or other circumstances that arose because of an early discharge or other treatment errors.

(b) If the readmission is unrelated, ODM will determine if the treatment or care provided during the readmission should have been provided during the first hospitalization.

(c) If it is determined the readmission was the result of circumstances as described in paragraph (2)(a) or (2)(b) of this rule, then any payment made for the separate admissions will be recouped. A new payment amount will be determined by collapsing any affected admissions into one payment.

(3) ODM may review claims for which outlier payments are made to determine if days or services were covered and were medically necessary. For outliers, review will be made to determine that all services were medically necessary, appropriately billed based on services rendered, ordered by a practitioner of physician services and not duplicatively billed. If it is determined that services were inappropriately billed or if days or services are determined to be noncovered or not medically necessary as described in rules 5160-1-01 and 5160-2-03 of the Administrative Code, recoupment of any overpayments will occur. Overpayments will be determined by calculating the difference between the amount paid and the amount that would be paid if the nonallowable or noncovered days or services were excluded from the claim.

(4) ODM may review admissions with short lengths of stay. Reviews in this category will be concentrated on any admission with a length of stay greater than two standard deviations below the mean length of stay for the DRG (diagnosis related groups) of that admission. This is based on the distribution, by DRG, of lengths of stay of admissions in Ohio medicaid inpatient claims. Reviews will be conducted to determine if the inpatient stay was medically necessary to provide services or if the services rendered could have been provided in an outpatient setting using observation codes as described in rule 5160-2-75 of the Administrative Code.

(5) ODM may review cases in which a denial letter has been issued by the hospital. In addition, ODM will review all cases in which the the attending practitioner of physician services or recipient (or family member) disagrees with the hospital's decision and requests a review of the case. The hospital will send a copy of each denial letter to ODM's medical review entity.

(D) ODM may review medical records to validate DRG assignment for any admission.

(1) The physician attestation process is to be completed for the medicaid program by following the medicare procedure for attestation as delineated in 42 C.F.R. 412.46, in effect as of October 1, 2021.

(2) DRG validation will be done on the basis of a review of medical records by verifying that the diagnostic and procedural coding used by the hospital is substantiated in these records.

(3) If the diagnostic and procedural information on the claim form is found to be inconsistent with that found in the medical records in conjunction with the physician attestation, the provider will submit a corrected claim reflecting this information.

(E) Pre-certification review as detailed in rule 5160-2-40 of the Administrative Code will be conducted in addition to the utilization review activities described in this rule.

(F) Outpatient hospital services may also be reviewed by ODM to determine whether the care or services were medically necessary as defined in rule 5160-1-01 of the Administrative Code, to determine whether the services were appropriately billed, and to assess the quality of care rendered as mandated in 42 C.F.R. 456.3(b), in effect as of October 1, 2021.

(G) Intensified reviews may result whenever ODM identifies inappropriate admission or billing practices during reviews conducted in accordance with this rule. These reviews may periodically necessitate that hospitals produce evidence of invoice costs supporting amounts billed for take-home drugs.

(H) Medical records will be maintained in accordance with 42 C.F.R. 482.24, in effect as of October 1, 2021. Records requested by ODM for review will be supplied within thirty calendar days of the request as described in rule 5160-1-17.2 of the Administrative Code. Failure to produce records within thirty days will result in withholding or recoupment of medicaid payments.

(I) With the exception of paragraph (H) of this rule, decisions made by ODM as described in this rule are appealable to ODM and are subject to the reconsideration process described in rule 5160-2-12 of the Administrative Code.

(J) Over or under payments resulting from a utilization review will be settled in accordance with section 5164.57 of the Revised Code.

(K) Recovery of payments for professional services.

Payments made in accordance with appendix DD to rule 5160-1-60 of the Administrative Code for professional services that are associated with a recouped hospital payment that is not eligible for resubmission due to the results of a utilization review, will be recovered by ODM.

Last updated June 13, 2022 at 12:26 PM

History

Effective: June 12, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-17 Provision of basic, medically necessary hospital-level services.

(A) In accordance with section 5168.14 of the Revised Code, each hospital that receives payment under the provisions of Chapter 5168. of the Revised Code, will provide, without charge to the individual, basic, medically necessary hospital-level services to the individual who is a resident of this state, is not a recipient of the medicaid program, and whose income is at or below the federal poverty line. Residence is established by a person who is living in Ohio voluntarily and who is not receiving public assistance in another state.

(B) For purposes of this rule, the following definitions apply:

(1) "Basic, medically necessary hospital level services" are all inpatient and outpatient services covered under the medicaid program in Chapter 5160-2 of the Administrative Code with the exception of transplantation services and services associated with transplantation. These covered services are to be ordered by a practitioner of physician services and delivered at a hospital where the provider has clinical privileges, and where such services are permissible to be provided by the hospital under its certificate of authority granted under Chapters 3711., 3727., and 5119. of the Revised Code. Hospitals will be responsible for providing basic, medically necessary hospital-level services to those persons described in paragraph (C) of this rule.

(2) "Family" includes the patient, the patient's spouse (regardless of whether they live in the home), and all of the patient's children, natural or adoptive, under the age of eighteen who live in the home. If the patient is under the age of eighteen, the "family" will include the patient, the patient's natural or adoptive parent(s) (regardless of whether they live in the home), and the parent(s)' children, natural or adoptive, under the age of eighteen who live in the home. If the patient is the child of a minor parent who still resides in the home of the patient's grandparents, the "family" includes only the parent(s) and any of the parent(s)' children, natural or adoptive, who reside in the home.

(3) "Income" is defined as total salaries, wages, and cash receipts before taxes; cash receipts that reflect reasonable deductions for business expenses will be counted for both farm and non-farm self-employment.

(4) "Third-party payer" means any private or public entity or program that may be liable by law or contract to make payment to or on behalf of an individual for health care services. Third-party payer does not include a hospital.

(1) A person is eligible for basic, medically necessary hospital-level services under the provisions of this rule if the person's individual or family income is at or below the current poverty guideline issued by the department of health and human services, as published at http://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines/ and effective on the date they were published in the Federal Register. The current poverty guideline that applies to the individual or family is calculated using either of the methods described in paragraphs (C)(2)(a) and (C)(2)(b) of this rule on the date of inpatient admission or outpatient service.

(2) If the income of a spouse or parent who does not live in the home cannot be obtained, or the absent spouse or parent does not contribute income to the family, determination of eligibility will proceed with the available income information. Income will be calculated by:

(a) Multiplying the person's or family's income by four, as applicable, for the three months preceding the date hospital services were provided;

(b) Using the person's or family's income, as applicable, for the twelve months preceding the date hospital services were provided.

(3) For outpatient hospital services, a hospital may consider an eligibility determination to be effective for ninety days from the initial service date, during which a new eligibility determination need not be completed. Eligibility for inpatient hospital services is determined separately for each admission, unless the patient is readmitted within forty-five days of discharge for the same underlying condition.

(4) A complete application for the hospital care assurance program is necessary prior to determination of eligibility. Each hospital will develop an application that, at a minimum, documents income, family size and eligibility for the medicaid program. The patient or a legal representative will need to sign the application. An unsigned application can be deemed acceptable if the patient is physically unable to sign the application or does not live in the vicinity of the hospital and is unable to return a signed application by mail. In these situations, the hospital representative should complete all questions on the application, sign the application, and document why the patient is unable to sign the application. A hospital may create policies, in accordance with paragraph (F) of this rule, that allow for the completion and signature of an application electronically provided there is reasonable assurance that it is the patient or the patient's legal representative who signs the application.

(5) A hospital system may create policies, in accordance with paragraph (F) of this rule, that allow for all hospitals in the system to use a single approved application provided that the provisions of paragraph (C)(3) of this rule are maintained.

(6) The hospital will accept application for services without charge until three years from the date of the follow-up notice, as described in paragraphs (D)(2) and (D)(3) of this rule, has elapsed.

(7) Applicants will cooperate in supplying information about health insurance or medical benefits available so a hospital may determine any potential third-party resources that may be available.

(8) Nothing in this rule will be construed to prevent a hospital from assisting or requiring an individual to apply for medicaid before the hospital processes an application under this rule.

(D) Billing of claims.

(1) Claims should be billed in accordance with section 5168.14 of the Revised Code and this rule.

(2) If the written statement as described in division (B)(2) of section 5168.14 of the Revised Code is printed on the back of the hospital's bill or data-mailer, the hospital will reference the statement on the front of the bill or data-mailer.

(E) Notices.

(1) Each hospital that receives payment under Chapter 5168. of the Revised Code will post notices in appropriate areas of their facility, including but not limited to the admissions areas, the business office, and the emergency room. The posted notices will specify the rights of persons with incomes at or below the federal poverty line to receive, without charge to the individual, basic, medically necessary hospital-level services at the hospital.

Posted notices will include all of the following in order to comply with the criteria as described in this paragraph:

(a) At a minimum, the rights of individuals to receive without charge, basic, medically necessary hospital-level services;

(b) Clear wording in simple terms understandable by the population serviced;

(d) Print that is clearly readable at a distance of twenty feet or the expected vantage point of the patrons.

(2) The facility will make reasonable efforts to communicate the contents of the posted notice to persons it has reason to believe cannot read the notice.

(F) Documentation.

Each hospital will establish and maintain a written policy outlining its internal policy for administration of the hospital care assurance program in compliance with this rule and with rule 5160-2-23 of the Administrative Code. Each hospital may change its written policy as needed, but policy changes cannot be implemented retroactively. The written policy will include, but is not limited to, the following:

(1) Procedure for taking applications and a copy of the current application in use as described in paragraph (C) of this rule; and

(2) Procedure for eligibility determination including the determination of family size and determination of income. If the hospital needs verification of income other than the application, the written policy should describe what constitutes acceptable income documentation.

(G) Reporting.

(1) Information regarding the number and identity of individuals served pursuant to this rule should be reported on the ODM 02930, schedules F and J, which is submitted annually along with a certification of the accuracy of this reported data as described by rule 5160-2-23 of the Administrative Code. The ODM 02930 and instructions for completion are available on the department's website.

(2) The use of estimation methods to determine amounts for charges related to non-hospital level services or to determine the health insurance status of patient charges on patient accounts is not permitted.

(3) Each hospital will maintain, make available for review, and provide to the department or the department's disproportionate share hospital auditor on request, any records necessary to document its compliance with the provisions of this rule, including:

(a) Any documents, including medical records of the population served, from which the information to be reported on the ODM 02930 was obtained;

(b) Accounts that clearly segregate the services rendered under the provisions of this rule from other accounts; and

(4) Hospitals will retain these records for a period of six years from the date of receipt of payment based upon those records or until any audit initiated within the six-year period is completed.

(H) This rule in no way alters the scope or limits the obligation of any governmental entity or program, including the program awarding reparations to victims of crime under sections 2743.51 to 2743.72 of the Revised Code and the program for medically handicapped children established under section 3701.023 of the Revised Code, to pay for hospital services in accordance with state or local law.

Last updated July 28, 2022 at 9:01 AM

History

Effective: July 28, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-22 Non-DRG prospective payment for hospital services.

This rule applies to all hospital services excluded from the inpatient hospital and outpatient hospital prospective payment systems.

(A) Applicability.

(1) Cost-related reimbursement, where payments are made for services to approximate cost based on a historical cost-to-charge ratio, and where no subsequent reconciliation occurs, applies to:

(a) All outpatient hospital services provided by hospitals excluded from outpatient prospective payment as set forth in rule 5160-2-05 of the Administrative Code.

(b) All inpatient hospital services provided by hospitals excluded from inpatient prospective payment as set forth in rule 5160-2-05 of the Administrative Code.

(B) Payments under non-DRG prospective payment.

(1) Payments for services subject to non-DRG prospective payment are made by applying a historic cost-to-charge ratio to hospital allowed charges.

(a) For outpatient services, the ratio used is medicaid outpatient costs as reported on ODM 02930, schedule H, section II divided by medicaid outpatient charges as reported on ODM 02930, schedule H, section II. For inpatient hospital services, the ratio used is medicaid inpatient costs, as reported on the ODM 02930, schedule H, section I, divided by medicaid inpatient charges as reported on the ODM 02930, schedule H, section I.

(b) For those hospitals which do not file the ODM 02930 cost-report, the ratio used is the statewide average. For outpatient services, the ratio used is the sum of medicaid outpatient costs as reported on ODM 02930, schedule H, section II for all Ohio hospitals, divided by the sum of medicaid outpatient charges as reported on ODM 02930, schedule H, section II for all Ohio hospitals. For inpatient hospitals services, the ratio used is the sum of medicaid inpatient costs as reported on the ODM 02930, schedule H, section I for all Ohio hospitals, divided by the sum of medicaid inpatient charges as reported on the ODM 02930, schedule H, section I for all Ohio hospitals.

(c) The ratio used for a claim payment will be the ratio that is operational in the claims processing system on the date the claim is paid and effective on the date of admission. The ratios which are operational during a prospective rate year in the claims processing system reflect data from each hospital's cost-report filed with the department during the calendar year proceeding the year during which the prospective rate year begins.

(2) For hospitals subject to non-DRG prospective payment, the historical cost-to-charge ratio described in paragraph (B)(1) of this rule shall be either:

(a) Ninety per cent of the calculated cost-to-charge ratio for freestanding rehabilitation hospitals and freestanding long-term acute care hospitals, as defined in rule 5160-2-05 of the Administrative Code; or

(b) Ninety-one and seven tenths per cent of the calculated cost-to-charge ratio for cancer hospitals, as defined in rule 5160-2-05 of the Administrative Code.

(C) In general, reasonable cost reimbursement recognizes costs that are reasonable and allowable under Title XVIII standards and principles described in 42 C.F.R 413.1 to 413.40 effective as of October 1, 2018, except as otherwise provided in this paragraph. These Title XVIII standards and principles are applicable to those covered inpatient and outpatient hospital services as identified in Chapter 5160-2 of the Administrative Code which are subject to cost-related reimbursement as described in this rule.

(1) The costs identified in paragraphs (C)(1)(a) to (C)(1)(f) of this rule are nonallowable.

(a) Cost of goods or services furnished free, by the hospital, or at less than fair market value. For example, the cost of office space or hospital employee time used to prepare physician invoices for physicians who invoice the department on a fee-for-service basis.

(b) Cost of services not reimbursable due to not having been billed timely as defined in rule 5160-1-19 of the Administrative Code.

(c) Cost of services which would be or are covered by a third-party payer as described in rule 5160-1-08 of the Administrative Code.

(d) The amount of any interest expense for money borrowed to alleviate cash flow problems resulting from rate reductions imposed for delinquent filing of cost reports as provided in rule 5160-2-23 of the Administrative Code.

(e) The amount of any interest on overpayments and any interest expense for money borrowed to alleviate cash flow problems resulting from an interest assessment as defined in rule 5160-1-25 of the Administrative Code.

(f) Costs which exceed limits described in 42 C.F.R. 413.30 effective as of October 1, 2018 except that the department may exempt certain facilities from these limits as described in 42 C.F.R. 413.30. The determinations to exempt facilities according to 42 C.F.R. 413.30 will be made during the final settlement process.

(2) Provisions of Title XVIII related to prospective payment for inpatient hospital services as described in 42 C.F.R. 412.1 to 412.125 effective as of October 1, 2018 are not applicable to hospital services reimbursed under the provisions of this rule. Hospital services described in this rule are reimbursed under the provisions described in paragraphs (C) to (C)(1)(f) of this rule except in instances when those regulations have been altered to accommodate the Title XVIII prospective payment system.

Last updated September 4, 2026 at 8:43 AM

History

Effective: December 5, 2019
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-23 Cost reports.

(A) For cost-reporting purposes, each eligible provider, as defined in rule 5160-2-01 of the Administrative Code, is to submit periodic reports that generally cover a consecutive twelve-month period of the provider's operations. Failure to submit all necessary items and schedules will delay processing and may result in a reduction of payment or termination as a provider as described in paragraph (A)(7) of this rule.

Any hospital that fails to submit cost reports on or before the dates specified by the department of medicaid (ODM) will be fined one thousand dollars for each day after the due date that the information is not reported.

The hospital is to complete and submit the ODM 02930 "Ohio Medicaid Hospital Cost Report" that is applicable to the state fiscal year in which the hospital's cost reporting period ends. The hospital's cost report is to:

(1) Be prepared in accordance with medicare principles governing reasonable cost reimbursement set forth in the providers' reimbursement manual "CMS Publications, 15-1 and 15-2", as applicable to the hospital's reporting period.

(2) Include all information necessary for the proper determination of costs payable under medicaid, including financial records and statistical data.

(3) Be submitted in accordance with the cost report instructions and include an electronic copy of the medicare cost report, which is to be identical in all respects to the cost report submitted to the medicare fiscal intermediary.

(4) Include the cost report certification executed by an officer of the hospital attesting to the accuracy of the cost report and to the accuracy of the Omnibus Budget Reconciliation Act (OBRA) survey. In addition, all subsequent revisions to the cost report are to include an executed certification.

(5) The executed certification is to include an acknowledgement by the officer of the hospital that an independent, certified public accountant has successfully verified the data reported on "Schedule F" of the cost report in accordance with the procedures included in the cost report instructions. In addition, all subsequent revisions to "Schedule F" are also to be successfully verified by an independent, certified public accountant in accordance with the recertification procedures included in the cost report instructions.

(6) For hospital reporting periods ending between January first and June thirtieth the cost report is to be postmarked on or before December thirty-first of the same calendar year. For hospital reporting periods ending between July first and December thirty-first, the cost report is to be postmarked on or before June thirtieth of the following calendar year.

(a) Extensions may be granted as specified in the cost report instructions.

(b) The department may grant a blanket extension that affects one or both of the due dates described in paragraph (A)(6) of this rule. When the department grants a blanket extension, hospitals may still request an extension as specified in paragraph (A)(6)(a) of this rule.

(7) Hospitals that fail to submit cost reports timely as described in paragraph (A) of this rule will receive a delinquency letter from ODM and are subject to notification that thirty days following the date on which the cost report was due, payments for hospital services will be suspended. Suspension of payments will be terminated on the fifth working day following receipt of the delinquent cost report. At the beginning of the third month following the month in which the hospital cost report became overdue, if the cost report has not yet been submitted, termination of the provider from the program will be proposed in accordance with Chapter 5160-1 of the Administrative Code.

(8) Hospitals are to separately report all supplemental payments received for services provided during the cost report period, including;

(a) "Medicaid Managed Care Incentive Payments," as established by Section 309.30.33 of Amended Substitute House Bill 153 of the 129th General Assembly, and continued as a baseline program, and

(b) "Hospital Additional Payments," as established by Section 16 of Amended Substitute Senate Bill 310 of the 133rd General Assembly and continued in Section 333.45 of Amended Substitute House Bill 110 of the 134th General Assembly.

(B) Hospitals having a distinct part psychiatric or rehabilitation unit recognized by medicare in accordance with the provisions of 42 C.F.R. 412.25 effective as of October 1, 2022, 42 C.F.R. 412.27 effective as of October 1, 2022, and 42 C.F.R. 412.29 effective as of October 1, 2022, are to identify distinct part unit costs separately within the cost report as described in paragraph (A) of this rule.

(C) Ohio hospitals performing ambulatory surgery within the hospital outpatient setting are to identify ambulatory surgery costs and charges separately within the cost report as described in paragraph (A) of this rule.

(D) Ohio hospitals providing services to medicaid managed care entities (MCE) enrollees are to identify MCE costs, charges and payments separately within the cost report as described in paragraph (A) of this rule.

(E) It is not necessary for the hospital to wait for the medicare (Title XVIII) audit in order to file the initial cost report for the stated time period. The interim cost report filing can be audited by ODM prior to any applicable final adjustment and settlement. If an amount is due ODM as a result of the filing, payment is to be forwarded, in accordance with the cost report instructions, at the time the cost report is submitted for it to be considered a complete filing. Any revised interim cost report is to be received within thirty days of the mailing of the interim cost settlement. A desk audit will be performed by the hospital cost report review and audit section on all as filed and interim cost reports. An interim cost settlement by ODM does not preclude the finding of additional cost exceptions in a final settlement for the same cost-reporting period.

(1) If an amended medicare cost report is filed with the medicare fiscal intermediary, a copy of the amended medicare cost report is to be filed with the hospital audit section. Information contained in the amended medicare cost report will be incorporated into the interim cost report, as originally filed, if received prior to interim settlement; otherwise, it is subject to the provisions of paragraph (E) of this rule.

(2) Adjustments may be made to the interim cost report as described in rule 5160-2-24 of the Administrative Code.

(F) Out-of-state hospitals that are paid on a non-diagnostic related groups (DRG) prospective payment basis as described in rule 5160-2-22 of the Administrative Code and provide either inpatient or outpatient services, or both, to eligible Ohio medicaid recipients will be assigned a cost-to-charge ratio as described in rule 5160-2-22 of the Administrative Code.

Last updated October 24, 2025 at 2:14 AM

History

Effective: February 19, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-24 Audits.

(A) General provisions.

(1) Audits will be conducted by the Ohio department of medicaid for services rendered by the hospital under the medicaid program. The examination of hospital costs and charges will be made in consideration with generally accepted auditing standards necessary to fulfill the scope of the audit. To facilitate this examination, providers will make available all records and source documents necessary to fully disclose the extent of services provided to program recipients, the corresponding costs and charges made and payments received for such services, for the period corresponding to the cost-reporting period. The principle objective of the audit is to enable the department to determine that payment has been, or will be made, in accordance with federal, state, and department standards. Based on the audit, adjustments in payments to the provider will be made as necessary by provisions of this rule. Records necessary to fully disclose the extent of services provided will be maintained for a period of six years or, if an audit has been initiated, until the audit is completed and every exception is resolved. Said records will be made available, upon request, to the department for audit purposes. No payment for outstanding medical services can be made if a request for audit is refused.

(2) Additionally, audits will be performed to verify hospital costs and charges utilized in the determination of the hospital's contribution to and reimbursement from the hospital care assurance fund and disproportionate share fund as described in rules 5160-2-08, 5160-2-08.1, 5160-2-09 and 5160-2-10 of the Administrative Code.

(3) All audit activities described in this rule may be undertaken during any rate year for the purpose of assuring accuracy of data maintained by the department.

(B) Scope of audits for hospital services reimbursed on a non-diagnostic related groups (DRG) prospective payment basis.

(1) For hospital services reimbursed on a non-DRG prospective payment basis as identified in rule 5160-2-22 of the Administrative Code, audits are performed to determine whether:

(a) Services billed were provided;

(b) Services were provided to persons eligible as medicaid recipients on the date(s) services were rendered;

(d) Costs reported to the department represent actual incurred, reasonable, and allowable costs in accordance with the provisions of rule 5160-2-22 of the Administrative Code;

(e) Payments made to the hospital for services rendered during the cost period being audited were sufficient or insufficient in relation to audit findings;

(f) Payments made under medicaid are, in the aggregate on a statewide basis, equal to or less than amounts that would have been recognized under Title XVIII (medicare) of the Social Security Act in accordance with 42 C.F.R. 447.272 effective as of October 1, 2022 for comparable services and on a hospital-specific basis equal to or less than the provider's customary and prevailing charges for comparable services in accordance with 42 C.F.R. 447.253 effective as of October 1, 2022;

(g) Amounts of third-party payments reported to the department as described in rules 5160-1-08 and 5160-2-25 of the Administrative Code reflect the actual amounts received;

(h) For the purpose of updating interim payment rates that are subject to cost settlement, desk audit procedures will take into consideration the relationship between the prior year's reported costs and audited costs; and

(i) Amounts paid by the hospital and payments made by the department related to the indigent care adjustments described in rules 5160-2-09 and 5160-2-10 of the Administrative Code were based upon data described in rules 5160-2-09 and 5160-2-10 of the Administrative Code.

(2) Underpayments or overpayments determined as a result of findings made under the provisions of paragraphs (B)(1)(a) to (B)(1)(h) of this rule will be reconciled at the time of final settlement as described in paragraph (D)(2) of this rule taking into account any adjustments made during interim settlements as provided in rule 5160-2-23 of the Administrative Code.

(1) For hospitals services subject to prospective payment, audit activities are undertaken for several purposes. For each cost-reporting period, cost reports are audited, following the criteria outlined in paragraphs (C)(1)(a) to (C)(1)(e) of this rule for the purpose of reaching interim and final settlement with a hospital. For determination of amounts related to indigent care adjustment provisions described in rules 5160-2-09 and 5160-2-10 of the Administrative Code, audit steps will be performed following the criteria outlined in paragraph (C)(1)(h) of this rule. During years in which prospective payments are being rebased, additional activities such as those described in paragraphs (C)(1)(f) and (C)(1)(g) of this rule are undertaken to establish program costs used for the calculations described in rules 5160-2-65 and 5160-2-75 of the Administrative Code. For hospital services subject to prospective payment, desk or field audits of interim cost reports are performed to determine whether:

(a) Services billed were provided.

(b) Services billed were provided to persons eligible as medicaid recipients on the date(s) services were rendered.

(d) Payments made under medicaid are, in the aggregate on a statewide basis, equal to or less than amounts that would have been recognized under Title XVIII (medicare) of the Social Security Act in accordance with 42 C.F.R. 447.272 effective as of October 1, 2022 for comparable services and on a hospital-specific basis equal to or less than the provider's customary and prevailing charges for comparable services in accordance with 42 C.F.R. 447.253 effective as of October 1, 2022.

(e) Amounts of third-party payments reported to the department as described in rules 5160-1-08 and 5160-2-25 of the Administrative Code reflect the actual amounts received.

(f) Costs reported to the department represent actual incurred, reasonable, and allowable costs in accordance with rule 5160-2-22 of the Administrative Code.

(g) Medicaid discharges, visits, and associated charges and days as reported on the cost report are consistent with those reflected for the same period in the department's paid claims history. In cases where data submitted by the hospital on the cost report are inconsistent with data in the department's paid claims data file, the cost report is subject to adjustment as described in paragraph (D)(2) of this rule. Inconsistencies subject to adjustment include, but are not limited to:

(i) Submitted discharges and visits lower than those in the department's paid claims data file;

(ii) Submitted charge-to-day ratio lower than that in the department's paid claims data file;

(iii) Submitted charges lower than those in the department's paid claims data file; and

(iv) Other inconsistencies that necessitate analysis and auditor judgment to determine the appropriate type of adjustment.

(h) Amounts related to indigent care adjustments described in rules 5160-2-09 and 5160-2-10 of the Administrative Code were based upon data described in rules 5160-2-09 and 5160-2-10 of the Administrative Code.

(2) For hospitals subject to prospective payment for inpatient and outpatient services, the audits may result in the following adjustments:

(a) If the review identified in paragraphs (C)(1)(g)(i) to (C)(1)(g)(iv) of this rule indicates that the cost report reflects fewer medicaid discharges or visits, or a discrepancy exists between reported medicaid charges and those reflected in the department's paid claims data file, the interim cost report may be adjusted to reflect inpatient days, outpatient visits, charges, and discharge counts from the department's paid claims data file.

(b) If the reviews identified in paragraphs (C)(1)(a) to (C)(1)(c) and (C)(1)(e) of this rule indicate that inappropriate charges were attributed to medicaid program charges in the cost report, the interim cost report will be adjusted to remove such charges.

(c) If the review described in paragraph (C)(1)(f) of this rule identifies that nonallowable disallowed costs were included in the cost report, the interim cost report will be adjusted to remove such costs.

(3) Overpayments determined as a result of findings made under the provisions of paragraphs (C)(1)(a) to (C)(1)(e) of this rule will be collected by the department.

(D) Interim and final settlement.

(1) Any adjustments described in paragraph (C)(2) of this rule will be reflected in the interim or final settlement cost report. Overpayments or underpayments, as described in paragraphs (C)(1)(a) to (C)(1)(d) of this rule, will be collected by the department as settlements based upon findings associated with the cost-reporting period being settled.

(2) Final settlement constitutes the implementation of the final fiscal audit for a cost-reporting period.

(a) Any adjustments not incorporated into interim settlement will be incorporated into final settlement for that cost-reporting period.

(b) Any pending request for reconsideration filed pursuant to paragraphs (B) and (C) of rule 5160-2-12 of the Administrative Code will be incorporated into final settlement.

(c) If a hospital has an outstanding medicare appeal that has not been resolved and that could affect settlement of hospital-specific rate components, the hospital may accept, with reservations, final settlement incorporating adjustments not based on unresolved medicare audit exceptions and hold open that portion of the settlement, with all rights to appeal under Chapter 119. of the Revised Code, based on unresolved medicare audit exceptions.

(d) In no instance will adjustments to rates that were in effect during the period covered by final settlement be made following final settlement. Components of rates that are based solely on hospital-specific data are subject to recalculation and adjustment after such rates have been in effect for two prospective payment periods following the implementation of rebased rate components.

Last updated June 25, 2025 at 5:48 PM

History

Effective: February 19, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-25 Coordination of benefits: hospital services.

Rule 5160-1-08 of the Administrative Code sets forth general provisions that the department make payment for covered services only after any available third-party benefits are exhausted. In addition, this rule identifies other provisions applicable to services provided by hospitals.

(A) All hospitals are to use third-party resources for all services a consumer receives while in the hospital. If a hospital receives reimbursement from a third-party after submitting a claim or after receiving payment from the department, the hospital is to repay the department by submitting a claim adjustment. Patient liabilities associated with persons eligible for medicaid are described in division 5160:1 of the Administrative Code and are considered a third-party resource. Benefits available through Title XVIII of the Social Security Act under medicare part A and part B, including medicare part A lifetime reserve days, or through medicare part C (medicare advantage) are considered third-party resources.

(B) The following payment provisions apply when billing for services provided to medicaid eligible consumers with available resources.

(1) For qualified medicare beneficiaries (QMB), including QMB plus and medicaid consumers enrolled in medicare part A, the following payment provisions apply to cost-sharing liability for inpatient services.

(a) For purposes of paragraph (B)(1) of this rule, the "medicaid maximum allowed amount" is the amount that would be payable by medicaid if the hospitalization were billed, in its entirety, to the department as a medicaid-only claim for a medicaid eligible consumer. The medicaid maximum allowed amount is calculated as:

(i) Described in rule 5160-2-65 of the Administrative Code in the case that a hospital is paid in accordance with the all patient refined diagnosis related groups (APR-DRG) prospective payment system; or

(ii) Described in rule 5160-2-22 of the Administrative Code in the case that a hospital is subject to non-DRG prospective payment.

(b) Except as described in paragraph (B)(3) of this rule, for persons described in paragraph (B)(1) of this rule, the department will pay as cost sharing for inpatient hospital services the lesser of:

(i) The sum of the deductible, coinsurance, and co-payment amount as provided by medicare part A; or

(ii) The medicaid maximum allowed amount, as described in paragraph (B)(1)(a) of this rule, minus the total prior payment, not to equal less than zero. The total prior payment includes the amount paid or payable by medicare and any other applicable third-party payment for services billed.

(c) If the department has a cost-sharing liability but is unable to calculate a medicaid maximum as described in paragraph (B)(1)(a) of this rule, the department may pay the sum of the deductible, coinsurance, and co-payment amount as provided by medicare part A.

(d) If a patient who is jointly eligible for medicare part A and medicaid exhausts medicare part A benefits while hospitalized, and the patient's hospitalization exceeds the applicable medicare threshold, the department will pay the difference between that amount payable by medicare and the medicaid maximum allowed amount as described in paragraph (B)(1)(a) of this rule.

(2) For QMB, including QMB plus and medicaid consumers enrolled in medicare part B, the following payment provisions apply to cost-sharing liability for hospital services covered by medicare part B:

(a) For purposes of paragraph (B)(2) of this rule, the "medicaid maximum allowed amount" is the amount that would be payable by medicaid if the hospitalization was billed, in its entirety, to the department as a medicaid-only claim for a medicaid eligible consumer. The medicaid maximum allowed amount is calculated as:

(i) Described in rule 5160-2-65 of the Administrative Code in the case that a hospital is paid in accordance with the APR-DRG prospective payment system; or

(ii) Described in rule 5160-2-75 of the Administrative Code in the case that a hospital is paid in accordance with the enhanced ambulatory patient grouping (EAPG) prospective payment system; or

(iii) Described in rule 5160-2-22 of the Administrative Code in the case that a hospital is subject to non-DRG prospective payment.

(b) Except as described in paragraph (B)(3) of this rule, for persons described in paragraph (B)(2) of this rule, the department will pay as cost sharing for hospital services covered by medicare part B the lesser of:

(i) The sum of the deductible, coinsurance, and co-payment amount as provided by medicare part B; or

(ii) The medicaid maximum allowed amount, as described in paragraph (B)(2)(a) of this rule, minus the total prior payment, not to equal less than zero. The total prior payment includes the amount paid or payable by medicare and any other applicable third-party payment for services billed.

(c) If the department has a cost-sharing liability but is unable to calculate a medicaid maximum as described in paragraph (B)(2)(a) of this rule, the department may pay the sum of the deductible, coinsurance, and co-payment amount as provided by medicare part B.

(3) For QMB and medicaid consumers enrolled in medicare part C managed health care plans (medicare advantage plans) the department pays in accordance with rule 5160-1-05.1 of the Administrative Code.

(4) For inpatient hospital services, if a consumer is entitled to hospital insurance benefits other than medicare including health insurance benefits, the department pays either the applicable APR-DRG prospective payment as described in rule 5160-2-65 of the Administrative Code or the payment applicable for services reimbursed on non-DRG prospective payment as described in rule 5160-2-22 of the Administrative Code, minus any resources available to the patient for hospital services including health insurance benefits. Such resources may include medicare part B payments including health insurance benefits. For outpatient hospital services, if a consumer is entitled to hospital insurance benefits other than medicare, the department pays either in accordance with rule 5160-2-75 of the Administrative Code for hospitals subject to EAPG prospective payment or in accordance with rule 5160-2-22 of the Administrative Code for hospitals subject to non-DRG prospective payment, minus any resources available to the patient. For both inpatient and outpatient services, if the resources available to a recipient equal or exceed amounts payable in accordance with this paragraph, the department makes no payment for the hospital services.

Last updated July 10, 2023 at 8:38 AM

History

Effective: July 9, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-30 Hospital franchise fee program.

This rule sets forth the assessment rate for the hospital franchise fee program implemented under sections 5168.20 to 5168.28 of the Revised Code.

(A) Definitions

For purposes of this rule, ''total facility costs'' are as defined in section 5168.20 of the Revised Code, and excludes a hospital's costs associated with providing care to recipients of the medicare program as shown on the cost-reporting data used for purposes of determining the hospital's assessment under section 5168.21 of the Revised Code.

(B) Assessment

(1) For the program year that ends in calendar year 2020, the amount of each hospital's franchise fee assessment is 3.1965 per cent of the hospital's total facility costs as defined in paragraph (A) of this rule.

(2) For the program year that ends in calendar year 2021, the amount of each hospital's franchise fee assessment is 3.35 per cent of the hospital's total facility costs as defined in paragraph (A) of this rule.

(3) For the program year that ends in calendar year 2022 through calendar year 2025, the amount of each hospital's franchise fee assessment is 3.37 per cent of the hospital's total facility costs as defined in paragraph (A) of this rule.

(4) For the program year that ends in calendar year 2026, and for each program year thereafter, the amount of each hospital's franchise fee assessment will be 4.37 per cent of the hospital's total facility costs as defined in paragraph (A) of this rule.

(5) In addition to the assessment in paragraph (B)(4) of this rule and for the purpose of supporting a statewide hospital directed payment program, hospitals will be assessed 3.641923 per cent of the hospital's total facility costs as defined in paragraph (A) of this rule for the program year that ends in calendar year 2026, and for each program year thereafter.

(6) The department may establish a rate higher or lower than the rates described in paragraphs (B)(1) to (B)(5) of this rule based on the franchise fee assessment needed to operate the current program year.

(7) The amounts collected in paragraphs (B)(4) to (B)(6) of this rule, and the amounts collected in rule 5160-2-08.1 of the Administrative Code for each program year and any other related hospital provider tax will not exceed the indirect hold harmless guarantees prescribed by the United States centers for medicare and medicaid services under the "Social Security Act," section 1903(w) and 42 C.F.R. 433.68 effective as of October 1, 2024.

(1) Hospitals, as defined in section 5168.20 of the Revised Code, that are not enrolled in the medicaid program will, upon request, submit to the department an electronic copy of the hospital's medicare cost report (CMS 2552-10) or audited financial statements for the period described in section 5168.21 of the Revised Code.

(2) Hospitals not enrolled as medicaid providers will be assessed a hospital franchise fee as described in paragraph (B) of this rule.

(3) Each hospital that is not enrolled as a medicaid provider will pay the assessment according to a schedule established by the department at the time the department mails its written notice of the final determination of the hospital's assessment.

Last updated November 5, 2025 at 8:44 AM

History

Effective: October 14, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-40 Psychiatric pre-certification review.

(A) Definitions.

For purposes of this rule, the following definitions apply:

(1) A "hospital" is a provider eligible under rule 5160-2-01 of the Administrative Code.

(2) "Medical necessity" is as defined in rule 5160-1-01 of the Administrative Code.

(3) "Pre-certification" is a process whereby the Ohio department of medicaid (ODM) or its contracted medical review entity assures that covered psychiatric services are medically necessary and are provided in the most appropriate and cost effective setting.

(4) A "psychiatric admission" is an admission of an individual to a hospital with a primary diagnosis of mental illness and not a medical or surgical admission. A discharge from a medical unit and an admission to a distinct part psychiatric unit within the same facility is considered a psychiatric admission and is subject to pre-certification.

(5) "Standards of medical practice" are nationally recognized protocols for diagnostic and therapeutic care. These protocols are approved by the medicaid program. ODM will notify providers of the standards of medical practice to be used by ODM. If ODM should change the protocols, providers will be notified sixty business days in advance.

(B) Guidelines for pre-certification.

(1) The decision that the provision of care is medically necessary will be based upon nationally recognized standards of medical practice, derived from indicators of severity of illness and intensity of services. Both severity of illness and intensity of service should be present to justify proposed care.

(2) The individual circumstances of each patient are considered when making a decision about the appropriateness of a hospital admission. Issues that will be considered in making the decision about whether or not an admission is medically necessary include psycho-social factors and factors related to the home environment including proximity to the hospital and the accessibility of alternative sites of care. These issues should be fully documented in the medical record in order to be considered as part of the review.

(3) If an inpatient stay is not deemed medically necessary, the location of service delivery may be altered as a result of pre-certification.

(1) Recipients enrolled in managed care organizations under contract with ODM for provision of health services to recipients;

(2) Patients who are jointly eligible for medicare and medicaid and who are being admitted under the medicare "part A" benefit; or

(3) Medical or surgical admissions.

(D) Pre-certification of psychiatric admissions.

(1) All pre-certification requests for psychiatric admissions for individuals who are medicaid eligible at the time of the admission will be submitted to ODM or its reviewing agency prior to an admission to a hospital or within two business days of the admission.

(2) The provider will request pre-certification for a psychiatric admission by submitting an electronic request to ODM. The reviewing agency is to make a decision on a pre-certification request within three business days of receipt of a properly submitted request, which is to include the information addressed in the standards of medical practice. A request is properly submitted if all information needed by the reviewing agency to make a decision based upon the guidelines set forth in paragraph (B) of this rule has been provided to the reviewing agency. All negative decisions will be reviewed by a physician representing ODM or its reviewing agency. The reviewing agency will notify the recipient, the requesting provider, the hospital, and ODM of all decisions in writing by the close of the fourth business day after the request is received.

(3) Pre-certification may be requested on a retrospective basis when:

(a) a patient is not identified as a medicaid recipient; or

(b) eligibility is pending at the time of admission; or

(E) Decisions made by the medical review entity as described in this rule are appealable to the medical review entity and are subject to the reconsideration process described in rule 5160-2-12 of the Administrative Code.

(F) Recipients have a right to a hearing in accordance with division 5101:6 of the Administrative Code. This hearing is separate and distinct from the provider's appeal, as described in paragraph (E) of this rule.

(G) Reimbursement subject to pre-certification review.

(1) The payment for treatment is contingent upon the acceptance of the reviewing agency's recommendation on the appropriate service location and the medical necessity of the admission.

(2) A certification that an inpatient stay is medically necessary does not guarantee payment for that service. The individual has to be a medicaid recipient at the time the service is rendered, and the service has to be a covered service.

(3) A psychiatric admission, as defined in paragraph (A)(4) of this rule, is reimbursed according to the rates for inpatient hospital services pursuant to rule 5160-2-65 of the Administrative Code for hospital admissions reimbursed on a prospective basis. Qualified provider services are reimbursed according to medicaid maximums for physician services pursuant to appendix DD to rule 5160-1-60 of the Administrative Code.

(4) In any instance when an admission that needs pre-certification occurs and the admission has not been approved, hospital payments will not be made. If separate professional provider payments have been made for services associated with the medically unnecessary admission, such payments will be recovered by ODM. Recipients should not be billed for charges associated with the admission except under circumstances described in paragraph (G)(5) of this rule.

(5) If the pre-certification process is initiated prospectively by the provider and hospital inpatient services are denied, or if an admission requiring pre-certification is not found to be medically necessary and the recipient chooses hospitalization, this admission and all associated services would be considered noncovered services and the recipient may be liable for payment of these services in accordance with rule 5160-1-13.1 of the Administrative Code.

Last updated June 13, 2022 at 12:27 PM

History

Effective: June 12, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-60 Hospital cost coverage add-on.

Effective for services or discharges on or after the effective date of this rule, payments made to Ohio hospitals under the prospective payment systems or non-diagnostic related groups (DRG) and non-ambulatory patient grouping (EAPG) prospective payment systems will receive a cost coverage add-on. The provisions of this rule do not apply to the medicaid maximum allowed amount calculation described in rule 5160-2-25 of the Administrative Code.

(A) Definitions.

(1) "Inpatient case mix" means the sum of the relative weight values for all discharges during the calendar year preceding the calendar year that precedes the state fiscal year (SFY) of the cost coverage add-on divided by the total number of discharges during the same calendar year.

(2) "Freestanding psychiatric hospital" means a privately-owned psychiatric hospital with more than sixteen beds that is eligible to provide medicaid services as described in rule 5160-2-01 of the Administrative Code.

(3) "Outpatient case mix" means the sum of the relative weight values for each enhanced ambulatory patient grouping (EAPG) detail line paid with a relative weight during the calendar year preceding the calendar year that precedes the state fiscal year of the cost coverage add-on divided by the total number of EAPG detail lines paid with a relative weight during the same calendar year.

(4) "Total medicaid inpatient discharges" for each hospital means the sum of medicaid fee for service (FFS) discharges reported on "Ohio Medicaid Hospital Cost Report" ODM 02930, schedule C-1, section I, columns 2 and 3, line 54 for the applicable SFY and medicaid managed care plan (MCP) discharges reported on ODM 02930, schedule C-1, section I, columns 6 and 7, line 54.

(5) "Total medicaid inpatient charges" for each hospital means the sum of FFS medicaid inpatient charges reported on ODM 02930, schedule H, column 1, line 8 and MCP inpatient charges reported on ODM 02930, schedule I, column 2, line 202.

(6) "Total medicaid outpatient charges" for each hospital means the sum of FFS medicaid outpatient charges reported on ODM 02930, schedule H, column 1, line 16 and MCP outpatient charges reported on ODM 02930, schedule I, column 4, line 202.

(7) "Total medicaid inpatient costs" for each hospital means the sum of FFS medicaid inpatient costs reported on ODM 02930, schedule H, column 1, line 1 and MCP inpatient costs reported on ODM 02930, schedule I, column 3, line 202.

(8) "Total medicaid outpatient costs" for each hospital means the sum of FFS medicaid outpatient costs reported on ODM 02930, schedule H, column 1, line 10 and MCP outpatient costs reported on ODM 02930, schedule I, column 5, line 202.

(9) "Total medicaid outpatient visits" for each hospital means the sum of medicaid FFS visits reported on ODM 02930, schedule C-1, section I, columns 2 and 3, line 56 and medicaid MCP visits reported on ODM 02930, schedule I, column 4, line 205.

(B) Source data for calculations

The calculations described in this rule will be based on cost-reporting data described in rule 5160-2-23 of the Administrative Code, which reflects the interim settled Ohio medicaid hospital cost report (ODM 02930) for each hospital's cost reporting period ending in the SFY prior to the SFY that ends immediately preceding the SFY to which the cost coverage add-on will apply. The data policies described in rules 5160-2-08 and 5160-2-09 of the Administrative Code that use the same cost report data described in this paragraph will apply to the data used for the cost coverage add-on, except for hospitals that have closed or are known to be closing.

(1) Inpatient cost coverage standard pool, which is the lesser of 259,229,112.31 dollars or 36.38 per cent of the appropriated funds.

(2) Outpatient cost coverage standard pool, which is the lesser of 168,054,601.29 dollars or 23.59 per cent of the appropriated funds.

(3) Cost coverage sustainability pool is the sum of:

(a) The lesser of 233,000,000.00 dollars or 32.70 per cent of the appropriated funds; and

(b) The greater of 7.33 per cent or the balance of the appropriated funds.

(4) Freestanding psychiatric hospitals as described in paragraph (A)(2) of this rule will receive 1.86 per cent of the amount described in paragraph (C)(3)(b) of this rule.

(D) Inpatient cost coverage.

(1) Cost coverage standard pool.

(a) From the amount specified in paragraph (C)(1) of this rule, 15,939,479.00 dollars will be allocated to children's hospitals, as defined in rule 5160-2-05 of the Administrative Code, based on the payments made to each children's hospital from funds specifically appropriated by Am. Sub. HB 49 of the 132nd General Assembly.

(b) Each hospital will be allocated from paragraph (C)(1) of this rule, an amount equal to the inpatient non-claims specific lump sum payments not resulting from an alternative payment model or the hospital care assurance program (HCAP) as described in rule 5160-1-70 or 5160-2-09 of the Administrative Code, less the amount allocated in paragraph (D)(1)(a) of this rule.

(c) Any amounts in paragraph (D)(1)(b) of this rule allocated to a closed hospital are reallocated to the remaining hospitals based on the ratio of each hospital's allocation in paragraph (D)(1)(b) of this rule to the sum of the allocation for all remaining hospitals.

(d) For each hospital, sum the amount allocated in paragraphs (D)(1)(a) to (D)(1)(c) of this rule.

(2) Divide ten per cent of the cost coverage sustainability pool described in paragraph (C)(3) of this rule by the total medicaid discharges for all hospitals, then multiply the resulting quotient by the number of total medicaid discharges for each hospital.

(3) For freestanding psychiatric hospitals, divide the amount described in paragraph (C)(4) of this rule by the total medicaid discharges for all freestanding psychiatric hospitals, then multiply the resulting quotient by the number of medicaid discharges for each freestanding psychiatric hospital.

(E) Outpatient cost coverage.

(1) Cost coverage standard pool.

(a) Each hospital will be allocated from paragraph (C)(2) of this rule an amount equal to the outpatient non-claims specific lump sum payments not resulting from an alternative payment model or HCAP as described in rule 5160-1-70 or 5160-2-09 of the Administrative Code.

(b) Any amounts in paragraph (E)(1)(a) of this rule allocated to a closed hospital are reallocated to the remaining hospitals based on the ratio of each hospital's allocation in paragraph (E)(1)(a) of this rule to the sum of the allocation for all remaining hospitals.

(c) For each hospital, sum the amount allocated in paragraph (E)(1)(a) of this rule and the amount calculated in paragraph (E)(1)(b) of this rule.

(2) Divide ninety per cent of the cost coverage sustainability pool described in paragraph (C)(3) of this rule less the amount described in paragraph (C)(4) of this rule by the total medicaid visits for all hospitals, then multiply the resulting quotient by the number of total medicaid visits for each hospital.

(F) Inpatient cost coverage add-on amount per discharge for hospitals paid in accordance with rule 5160-2-65 of the Administrative Code.

(1) For each hospital, divide the sum of paragraphs (D)(1) to (D)(3) of this rule by the total medicaid discharges used in the inpatient case-mix calculation as described in paragraph (A)(1) of this rule.

(2) For each hospital, divide the results in paragraph (F)(1) of this rule by the inpatient case-mix as defined in paragraph (A)(1) of this rule.

(3) The cost coverage add-on per discharge amount is equal to the amount calculated in paragraph (F)(2) of this rule, rounded to two decimal places.

(4) The amount calculated in paragraph (F)(3) of this rule will be added to the hospital's inpatient base rate.

(G) Outpatient cost coverage add-on amount per detail for hospitals paid in accordance with rule 5160-2-75 of the Administrative Code.

(1) For each hospital, divide the sum of paragraphs (E)(1) and (E)(2) of this rule by the total EAPG detail lines used in the outpatient case-mix calculation as described in paragraph (A)(3) of this rule.

(2) For each hospital, divide the results in paragraph (G)(1) of this rule by the outpatient case-mix as defined in paragraph (A)(3) of this rule.

(3) The cost coverage add-on per detail amount is equal to the amount calculated in paragraph (G)(2) of this rule, rounded to two decimal places.

(4) The amount calculated in paragraph (G)(3) of this rule will be added to the hospital's outpatient base rate.

(H) Inpatient cost coverage add-on for hospitals paid in accordance with rule 5160-2-22 of the Administrative Code.

(1) For each hospital, calculate total inpatient payments by multiplying total medicaid inpatient charges as described in paragraph (A)(5) of this rule by the inpatient cost-to-charge ratio described in rule 5160-2-22 of the Administrative Code calculated from the source data described in paragraph (B) of this rule.

(2) For each hospital, divide the amount in paragraph (H)(1) of this rule by the total medicaid inpatient costs as described in paragraph (A)(7) of this rule.

(3) For each hospital, sum the inpatient payments calculated in paragraph (H)(1) of this rule and the amounts distributed in paragraphs (D)(1) to (D)(3) of this rule.

(4) For each hospital, divide the result in paragraph (H)(3) of this rule by the total medicaid inpatient costs as described in paragraph (A)(7) of this rule.

(5) For each hospital, calculate the inpatient cost coverage increase by subtracting the result in paragraph (H)(2) of this rule from the result in paragraph (H)(4) of this rule and dividing the result by paragraph (H)(2) of this rule, rounded to four decimal places.

(6) For each hospital, multiply the result in paragraph (H)(5) of this rule by the inpatient cost-to-charge ratio calculated in paragraph (H)(1) of this rule.

(7) Apply the amount calculated in paragraph (H)(6) of this rule as an increase to the hospital's inpatient cost-to-charge ratio as follows:

(a) For each July first, the hospital's inpatient cost-to-charge ratio calculated the previous January in accordance with rule 5160-2-22 of the Administrative Code.

(b) For each January first, the hospital's inpatient cost-to-charge ratio as calculated in rule 5160-2-22 of the Administrative Code.

(I) Outpatient cost coverage add-on for hospitals paid in accordance with rule 5160-2-22 of the Administrative Code.

(1) For each hospital, calculate total outpatient payments by multiplying total medicaid outpatient charges as described in paragraph (A)(6) of this rule by the outpatient cost-to-charge ratio described in rule 5160-2-22 of the Administrative Code calculated from the source data described in paragraph (B) of this rule.

(2) For each hospital, divide the amount in paragraph (I)(1) of this rule by the total medicaid outpatient costs as described in paragraph (A)(8) of this rule.

(3) For each hospital, sum the outpatient payments calculated in paragraph (I)(1) of this rule and the distribution pools in paragraphs (E)(1) and (E)(2) of this rule.

(4) For each hospital, divide the result in paragraph (I)(3) of this rule by the total medicaid outpatient costs as described in paragraph (A)(8) of this rule.

(5) For each hospital, calculate the outpatient cost coverage increase by subtracting the result in paragraph (I)(2) of this rule from the result in paragraph (I)(4) of this rule and dividing the result by paragraph (I)(2) of this rule, rounded to four decimal places.

(6) For each hospital, multiply the result in paragraph (I)(5) of this rule by the outpatient cost-to-charge ratio calculated in paragraph (I)(1) of this rule.

(7) Apply the amount calculated in paragraph (I)(6) of this rule as an increase to the hospital's outpatient cost-to-charge ratio as follows:

(a) For each July first, the hospital's outpatient cost-to-charge ratio calculated the previous January in accordance with rule 5160-2-22 of the Administrative Code.

(b) For each January first, the hospital's outpatient cost-to-charge ratio as calculated in rule 5160-2-22 of the Administrative Code.

(J) To ensure that funds appropriated for the cost coverage add-on are fully expended in support of the intended purpose, the department may make short term adjustments to increase or decrease hospital-specific rates. Such adjustments will be calculated in accordance with the cost coverage sustainability pool as described in paragraphs (D)(2) and (E)(2) of this rule. The number of discharges or visits used to establish a case-mix adjusted hospital-specific rate, may be adjusted to reflect the time period for which the rate will be in effect. Any such adjustments will be developed in consultation with the department's actuary and approved by the medicaid director.

Last updated January 2, 2024 at 8:53 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-65 Inpatient hospital reimbursement.

This rule sets forth the payment policies for inpatient hospital services for discharges on or after the effective date of this rule.

(A) Hospitals defined as eligible providers of hospital services in rule 5160-2-01 of the Administrative Code and grouped in paragraph (B)(1) of rule 5160-2-05 of the Administrative Code are subject to the all patient refined diagnosis related groups (APR-DRG) prospective payment methodology as described in this rule.

(B) Hospital peer groups. For purposes of setting rates and making payments under the APR-DRG prospective payment system, the Ohio department of medicaid (ODM) classifies all hospitals not defined in paragraph (A) of this rule into one of the mutually exclusive peer groups defined in this paragraph.

(1) Children's hospitals as defined in rule 5160-2-05 of the Administrative Code that are located in Ohio.

(2) Children's hospitals as defined in rule 5160-2-05 of the Administrative Code that are not located in Ohio.

(3) Critical access hospitals as defined in rule 5160-2-05 of the Administrative Code that are located in Ohio.

(4) Rural hospitals as defined in rule 5160-2-05 of the Administrative Code that are located in Ohio.

(5) Teaching hospitals as defined in rule 5160-2-05 of the Administrative Code that are located in Ohio.

(6) Teaching hospitals as defined in rule 5160-2-05 of the Administrative Code that are not located in Ohio.

(7) Urban hospitals as defined in rule 5160-2-05 of the Administrative Code that are located in Ohio.

(8) For purposes of this rule, freestanding psychiatric hospitals (FSPs) as defined in rule 5160-2-05 of the Administrative Code are so named for the implementation of special payment policies as described in this rule.

(9) All other hospitals that are not located in Ohio that are not classified in paragraph (B)(2) or (B)(6) of this rule.

(1) Each discharge is assigned a DRG and one of four severity of illness (SOI) factors based upon the date of discharge.

(2) If a claim submitted by a hospital is deemed ungroupable because it does not contain valid values for one or more of the variables needed by the APR-DRG grouper, then the claim will be denied payment by ODM.

(D) Payment formula.

(1) The formula used in the APR-DRG prospective payment system is as follows: total payment, rounded to the nearest whole penny, equals (a) base payment plus (b) capital allowance plus (c) medical education allowance (if hospital is eligible) plus (d) outlier payment (if applicable) plus (e) other payments for organ transplants where;

(a) Base payment equals the hospital base rate as described in paragraph (G) of this rule multiplied by the corresponding relative weight for the DRG/SOI as described in paragraph (H) of this rule.

(b) Capital allowance equals the per case add-on as described in paragraph (J) of this rule.

(c) Medical education allowance equals the per case add-on, case mix adjusted, as described in paragraph (K) of this rule.

(d) Outlier payment equals the eligible outlier costs multiplied by the outlier payment percentage as described in paragraph (I) of this rule.

(e) Other payments for transplant related services as described in paragraph (L) of this rule.

(2) The formula used for per diem payments is described in paragraph (M) of this rule.

(E) Payments under the prospective payment system are made on the basis of a prospectively determined rate as provided in this rule. No year-end retrospective adjustment is made for prospective payments. Except as provided in rules 5160-2-24, 5160-2-13, and 5160-2-40 of the Administrative Code, a hospital may keep the difference between its prospective payment rate and costs incurred in furnishing inpatient services and is at risk for costs which exceed the prospective payment amounts.

(F) Sources for inputs in the payment formula.

(1) The dataset used as inputs in the determination of hospital base rates consists of:

(a) Inpatient hospital claims with dates of discharge from January 1, 2018 through December 31, 2021;

(b) Cost reports submitted by hospitals to ODM on its medicaid cost report for the hospital years that end in state fiscal years 2019 (ODM 02930 rev. 5/2019), 2020 (ODM 02930 rev. 5/2020), 2021 (ODM 02930 rev. 5/2021) and 2022 (ODM 02930 rev. 5/2022); and

(c) Inflation factors computed for Ohio by a nationally-recognized research firm that computes similar factors for the medicare program. The inflation factors were used to apply an inflationary value to the total cost computed for each case inflating it to December 31, 2023.

(2) The dataset used as inputs in the determination of relative weights consists of:

(a) Inpatient hospital claims with dates of discharge from January 1, 2018 through December 31, 2021;

(G) Computation of hospital peer group base rates.

(1) The base rate for Ohio children's hospitals is equal to:

(a) Fifty-two and three hundredths per cent of the total inflated costs for the cases assigned to a children's hospital divided by the number of cases assigned to the children's hospital; divided by

(b) The peer group case mix score as calculated in paragraph (G)(5) of this rule.

(2) The base rate for Ohio teaching hospitals as described in rule 5160-2-05 of the Administrative Code is equal to:

(a) Fifty-eight and three tenths per cent of the total inflated costs for the cases assigned to a teaching hospital divided by the number of cases assigned to the teaching hospital; divided by

(b) The peer group case mix score as calculated in paragraph (G)(5) of this rule.

(3) The base rate for each Ohio FSP hospital is equal to:

(a) Ninety and thirty-two hundredths per cent of the total inflated costs for the cases assigned to a hospital divided by the number of cases assigned to the FSP hospital; divided by

(b) The case mix score as calculated in paragraph (G)(6) of this rule.

(4) The base rate for hospitals in Ohio peer groups other than children's, teaching or FSP hospitals is equal to:

(a) Forty-nine and three tenths per cent of the total inflated costs for the cases assigned to a peer group; divided by the number of cases in the peer group; divided by

(b) The peer group case mix score as calculated in paragraph (G)(5) of this rule.

(5) The peer group case mix score is equal to:

(a) The sum of the relative weight values across all cases assigned to a peer group; divided by

(b) The number of cases in the peer group.

(6) For non-Ohio hospital peer groups, the peer group base rate is equal to the value assigned to the peer group effective January 1, 2024. For dates of service on or after the effective date of this rule, the amount will be equal to;

(a) For non-Ohio children's hospitals, eighty-seven and thirty-nine hundredths per cent of the base rate in effect on the effective date of this rule for Ohio children's hospitals.

(b) For non-Ohio teaching hospitals, eighty-five and seventy-one hundredths per cent of the base rate in effect on the effective date of this rule for Ohio teaching hospitals.

(c) For all other non-Ohio hospitals, seventy-six and seventy-three hundredths per cent of the base rate in effect on the effective date of this rule of Ohio hospitals that are not considered teaching, children's and psychiatric hospitals.

(7) The statewide per diem rate for each FSP hospital is equal to:

(a) Eighty-nine and six tenths per cent of the total inflated costs for all cases; divided by

(b) The total length of stay (LOS) for all cases.

(8) The FSP peer group per diem rate for each peer group defined in paragraphs (B)(4) and (B)(7) of this rule is equal to:

(a) Between eighty-eight and twenty-nine hundredths per cent and ninety-six and ninety-three hundredths per cent of total inflated costs for all cases, dependent upon the peer group; divided by

(b) The total LOS for all cases within the peer group.

(9) Effective January 1, 2026, the calculated base rate for the hospital peer groups will increase by the following percentages:

(a) Critical access hospitals will increase by 34.56 per cent;

(b) Rural hospitals will increase by 17.53 per cent;

(d) Teaching hospitals will increase by 1.55 per cent;

(e) Urban hospitals will increase by 1.62 per cent, except for southeast hospitals which will increase by 15.85 per cent.

(10) Effective January 1, 2026, the calculated per diem rate for each FSP hospital peer group increase by the following percentages:

(a) Rural hospitals will increase by 12.55 per cent;

(b) Children's hospitals will increase by 15.43 per cent;

(d) Urban hospitals will increase by 15.63 per cent.

(H) The computation of relative weights for all DRGs is equal to:

(1) The average inflated cost per case within the DRG/SOI; divided by

(2) The average inflated cost per case across all DRG/SOIs.

(3) ODM computed two sets of relative weights:

(a) One set of relative weights within the behavioral health and substance use disorder (BH/SUD) DRGs 740-776. The average relative weight within the BH/SUD DRGs was adjusted to eighty per cent of the natural result.

(b) One set of relative weights for acute care DRGs.

(I) Computation of outlier payments.

(1) If a discharge is eligible for an outlier payment, the payment will be equal to eighty per cent of the value of eligible outlier costs.

(2) Eligible outlier costs are equal to the cost of the case minus an outlier threshold.

(a) When discharges are submitted for payment by hospitals, the cost of the case is computed as the product of covered billed charges and a hospital-specific medicaid inpatient cost-to-charge ratio as described in rule 5160-2-22 of the Administrative Code.

(b) The outlier threshold is equal to the base payment as described in paragraph (D)(1)(a) of this rule plus a fixed outlier threshold as described in paragraph (I)(2)(c) of this rule.

(c) The fixed outlier threshold varies and can be either DRG specific or peer group specific. The fixed outlier threshold for neonate and tracheostomy DRGs is fifty thousand dollars. The fixed outlier threshold for cases other than neonate and tracheostomy billed by hospitals among other peer groups is seventy-five thousand dollars.

(3) For any claim that qualifies for an outlier payment, the final claim payment will be limited to the lesser of covered billed charges or the total payment calculated in paragraph (D)(1) of this rule.

(J) Computation of capital payments.

(1) For Ohio hospitals, a capital allowance will be paid as described in rule 5160-2-66 of the Administrative Code.

(2) For non-Ohio hospitals a capital allowance will be paid as described in rule 5160-2-66 of the Administrative Code.

(K) Computation of medical education payments.

(1) For Ohio hospitals, a medical education allowance will be paid as described in rule 5160-2-67 of the Administrative Code.

(2) For non-Ohio hospitals, the calculated base rate as described in paragraph (G)(6) of this rule includes an allowance for medical education.

(L) Other payments for transplant related services.

(1) Reimbursement for all organ transplant services, except for kidney transplants, is contingent upon review and recommendation by the "Ohio Solid Organ Transplant Consortium" based on criteria established by Ohio organ transplant surgeons and authorization from ODM.

(2) Reimbursement for bone marrow transplant and hematopoietic stem cell transplant is contingent upon review and the recommendation by the "Ohio Hematopoietic Stem Cell Transplant Consortium" based on criteria established by Ohio experts in the field of bone marrow transplant and authorization from ODM. Reimbursement is further contingent upon:

(a) Membership in the "Ohio Hematopoietic Stem Cell Transplant Consortium"; or

(b) Compliance with the performance standards described in agency 3701 of the Administrative Code, and the performance of ten autologous or ten allogeneic bone marrow transplants, dependent on which volume criteria is appropriate for the transplant requested.

(3) Organ acquisition and transportation costs for heart, heart/lung, liver, pancreas, single/double lung, and liver/small bowel transplant services will be reimbursed at one hundred per cent of billed charges.

(4) For harvesting costs for bone marrow transplant services, the prospective payment amount will be either:

(a) The DRG amount as described in this rule if the donor is a medicaid recipient or if the bone marrow transplant is autologous.

(b) The product of the covered billed charges times the hospital-specific, medicaid inpatient cost-to-charge ratio as described in rule 5160-2-22 of the Administrative Code, if the donor is not a medicaid recipient.

(M) Other payment policies.

(1) A claim for inpatient services qualifies for interim payment on the thirtieth day of a consecutive inpatient stay and at thirty-day intervals thereafter. Under interim payment, hospitals will be paid on a percentage basis of charges. The percentage will represent the hospital-specific medicaid inpatient cost-to-charge ratio as described in rule 5160-2-22 of the Administrative Code. For those hospitals which do not file a cost report under the provisions of rule 5160-2-23 of the Administrative Code, the statewide average medicaid inpatient cost-to-charge ratio as described in rule 5160-2-22 of the Administrative Code will be used. Interim payments are made as a credit against final payment of the final discharge bill. Amounts of difference between interim payment made and the prospective payment described in paragraph (A) of this rule for the final discharge will be reconciled when the final discharge bill is processed.

(2) Payments for transfers as defined in rule 5160-2-02 of the Administrative Code are subject to the following provisions. If a hospital paid under the prospective payment system transfers an inpatient to another hospital or receives an inpatient from another hospital and that transfer is appropriate as defined in rule 5160-2-13 of the Administrative Code, then each hospital is paid a per diem rate for each day of the patient's stay in that hospital, plus capital, medical education and outlier allowances, as applicable, not to exceed, for nonoutlier cases, the final prospective payment rate that would have been paid for the appropriate DRG/SOI as described in paragraph (D) of this rule. When a patient is transferred, ODM's payment is based on the DRG/SOI under which the patient was treated at each hospital.

The per diem rate is determined by dividing the product of the hospital's base rate multiplied by the DRG/SOI relative weight as described in this rule by the statewide average length of stay calculated for the specific DRG/SOI into which the case falls.

For inpatient services provided to patients who are discharged, within the same hospital, from an acute care bed and admitted to a bed in a psychiatric unit distinct part, payment will be made based on the DRG representing services provided in the acute care section and the services provided in the psychiatric unit distinct part.

Transfers received by or discharging from a freestanding psychiatric hospital are not subject to the provisions of paragraph (M)(2) of this rule. For transfers from one unit of a hospital to another distinct unit of the same hospital, the claim with an admit source indicating that the transfer results in a separate claim to medicaid is not subject to the provisions of paragraph (M)(2) of this rule, provided that the discharge status does not indicate transfer.

(3) The per diem rates for the FSPs are calculated based on the sum of all the amounts calculated in paragraph (D) of this rule plus the eligible hospital specific add-on amounts in accordance with rule 5160-2-60 of the Administrative Code, divided by the total days for these claims in the rate setting database. As a transitional step, FSPs may be paid the resulting value in accordance with paragraph (D) of this rule.

The FSP per diem payment is calculated by multiplying each covered billed day by the per diem rate as described in paragraph (G) of this rule.

(4) In instances when a recipient's eligibility begins after the date of admission to the hospital or is terminated during the course of a hospitalization, payment will be made on a per diem basis as described in paragraph (M)(2) of this rule plus the allowance for capital, medical education and outliers, as applicable.

(5) Readmissions are defined in rule 5160-2-02 of the Administrative Code. A readmission within one calendar day of discharge, to the same institution, is considered to be one discharge for payment purposes so that one DRG payment is made. If two claims are submitted, the second claim processed will be rejected. In order to receive payment for the entire period of hospitalization, the hospital will need to submit an adjustment claim reflecting services and charges for the entire hospitalization.

(6) In the case of deliveries, hospitals submit separate claims based respectively on the mother's individual eligibility and the child's individual eligibility.

(7) Carved out injectable drugs and biologicals, as defined in rule 5160-2-75 of the Administrative Code, are reimbursed in accordance with rule 5160-2-75 of the Administrative Code.

(N) Adjustments to relative weights.

(1) In accordance with section 5164.721 of the Revised Code, long-acting reversible contraceptive (LARC) devices may be billed and paid separately when provided during an inpatient hospitalization.

(2) In accordance with section 5164.072 of the Revised Code, the relative weights for neonate DRGs 580-640 with an SOI of major or extreme, as calculated in paragraph (H) of this rule, were increased by five and thirteen hundredths per cent to provide for enhanced payments for donor breast milk and milk fortifiers.

(3) Effective January 1, 2026, the relative weights for delivery DRGs 539 to 542 and 560 will increase by 12.59 per cent.

(4) Effective January 1, 2026, the relative weights for neonate DRGs 580 to 640 will increase by 12.59 per cent.

(5) Effective January 1, 2026, the relative weights for behavioral health and substance use disorder (BH/SUD) DRGs 740 to 776 will increase by 15.51 per cent.

Last updated January 12, 2026 at 10:23 AM

History

Effective: January 10, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-66 Capital costs.

This rule outlines the calculation of capital payments for hospitals that are subject to the all patient refined diagnosis related groups (APR-DRG) prospective payment methodology, effective for dates of discharges occurring on or after January 1, 2024.

(A) For purposes of this rule, capital costs include the categories of costs recognized by medicare on the centers for medicare and medicaid services (CMS) CMS 2552-10 revised October 2016 and filed in accordance with CMS instructions, available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals.html (revised June 2022).

(B) Capital-related costs for services provided by Ohio hospitals paid under prospective payment will be subject to prospective payment without subsequent settlement to actual capital costs.

(1) The calculation of interim capital payments resulting in the capital allowance identified in rule 5160-2-65 of the Administrative Code is based on the hospital's cost-reporting period.

On an annual basis, the interim capital payments will be redetermined by identifying eighty-five per cent of the capital-related costs reported on the ODM 02930, "Ohio Medicaid Hospital Cost Report"; multiplying that cost by the per cent of the sum of the medicaid inpatient charges to total charges; and dividing the result by the sum of the number of medicaid discharges that occurred during the cost-reporting period. The cost report used to complete these calculations is the interim settled cost report ending in the state fiscal year ending in the calendar year preceding the immediate past calendar year prior to January first of the calendar year to which the new capital rate will apply.

(D) Non-Ohio hospital capital reimbursement.

(1) The average statewide capital cost is computed by summing, for all Ohio hospitals, the identified capital costs as described in paragraph (C) of this rule and multiplying that cost by the per cent of the sum of medicaid inpatient charges to total charges for all Ohio hospitals, and dividing by total discharges for all Ohio hospitals as described in paragraph (C) of this rule.

(2) The capital allowance for non-Ohio hospitals will be eighty-five per cent of the amount calculated in paragraph (D)(1) of this rule.

(3) The average statewide capital cost is updated annually using capital costs from cost reports as described in paragraph (C) of this rule.

(4) The amounts derived in paragraph (D) of this rule will reflect a statewide average calculated to be in effect at the beginning of the prospective rate year and not subject to retrospective adjustments.

Last updated January 2, 2024 at 8:53 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-67 Medical education.

Effective for dates of discharge on or after the effective date of this rule, to qualify for a medical education payment as described in this rule, Ohio hospitals must have an approved medical education program as defined in 42 C.F.R. 415.152 (October 1, 2016) and the costs of the approved medical education program were reflected in their state fiscal year (SFY) 2014 Ohio medicaid hospital cost report (ODM 02930 rev. 6/2014). This rule describes the methodology used for computing the direct graduate medical education and indirect medical education components of each hospital's medical education add-on rate.

(A) Computation of direct graduate medical education (DGME) costs, which are the costs that are directly related to the training of interns and residents and allied professionals in an approved medical education program.

(1) Tabulate the costs captured on the ODM 02930 for interns and residents and allied professionals.

(2) Tabulate the total facility charges and total medicaid fee-for-service and managed care charges reported on the ODM 02930. Calculate the medicaid factor by dividing the sum of total medicaid fee-for-service and managed care charges by total charges.

(3) Tabulate the total medicaid fee-for-service and managed care discharges from the ODM 02930.

(4) The medicaid portion of DGME costs equal the total DGME costs as described in paragraph (A)(1) of this rule multiplied by the medicaid factor as described in paragraph (A)(2) of this rule.

(5) A cost per discharge is computed using the medicaid portion of DGME costs as described in paragraph (A)(4) of this rule divided by the total number of medicaid discharges as described in paragraph (A)(3) of this rule.

(B) Computation of indirect medical education (IME) costs, which are the costs that recognize the increased costs of patient care that results from operating an approved medical education program.

(1) Identify the number of interns and residents and number of beds reported on the ODM 02930.

(2) Compute the IME factor by using the logarithmic formula 1.35 * ((1+((interns and residents)/beds)^0.405)-1).

(3) Tabulate the total medicaid fee-for-service and managed care net operating costs reported on the ODM 02930.

(4) The medicaid portion of IME is the medicaid net operating costs as described in paragraph (B)(3) of this rule multiplied by the IME factor as described in paragraph (B)(2) of this rule.

(5) A cost per discharge is computed using the medicaid portion of IME costs as described in paragraph (B)(4) of this rule divided by the total number of medicaid discharges as described in paragraph (A)(3) of this rule.

(a) The IME cost per discharge is capped. The capped value is the statewide mean IME cost per discharge plus one standard deviation.

(b) If the hospital's IME cost per discharge is greater than the capped IME cost per discharge as described in paragraph (B)(5)(a) of this rule, then the hospital's IME cost per discharge is equal to the capped IME cost per discharge as described in paragraph (B)(5)(a) of this rule.

(1) The case-mix score for each hospital equals the sum of the relative weight values for all SFY 2014 discharges divided by the total number of medicaid discharges as described in paragraph (A)(3) of this rule.

(2) Sum the DGME cost per discharge as described in paragraph (A)(5) of this rule and the IME cost per discharge as described in paragraph (B)(5) of this rule.

(3) Divide the sum of the DGME cost per discharge and IME cost per discharge as described in paragraph (C)(2) of this rule by the case-mix score as described in paragraph (C)(1) of this rule. The resulting value is the hospital's total medical education add-on rate.

(4) The hospital's total medical education add-on rate as described in paragraph (C)(3) of this rule shall be subject to a payment neutrality adjustment of fifty-nine and seven-tenths per cent.

(D) Medical education and stop-loss/stop-gain.

(1) For each hospital, determine the total value of current medical education payments as reimbursed by the all patient refined diagnosis related groups prospective payment system prior to July 1, 2017 by multiplying the hospital's medical education add-on rate effective January 1, 2017 by the hospital's case-mix score in effect prior to July 1, 2017 by the total number of medicaid discharges for the twelve month period used to estimate the fiscal impact.

(2) Determine the hospital's projected medical education payments by multiplying the case-mix adjusted medical education add-on rate as described in paragraph (C) of this rule by the total number of medicaid discharges for the twelve month period used to estimate the fiscal impact.

(3) If the hospital's current medical education payments as described in paragraph (D)(1) of this rule are greater than the projected medical education payments as described in paragraph (D)(2) of this rule, then the hospital's medical education add-on rate shall be the medical education add-on rate used to calculate current medical education payments as described in paragraph (D)(1) of this rule.

(4) If the hospital's projected medical education payments as described in paragraph (D)(2) of this rule are more than one-hundred and ten per cent of current medical education payments as described in paragraph (D)(1) of this rule, then the hospital's medical education payments shall be the current medical education add-on rate multiplied by one-hundred and ten per cent.

(5) If the hospital's projected medical education payments as described in paragraph (D)(2) of this rule are greater than its current medical education payments as described in paragraph (D)(1) of this rule but less than one-hundred and ten per cent of its current medical education payments as described in paragraph (D)(1) of this rule, then the hospital's medical education add-on rate is the add-on rate used to calculate projected medical education payments as described in paragraph (D)(2) of this rule.

(E) Recognition of approved medical education programs outside of rebasing.

(1) For rate years when a rebasing is not being conducted, hospitals that have added an approved graduate medical education program and demonstrate such costs on the interim-settled cost report that ends in the SFY ending in the calendar year preceding the immediate past calendar year prior to January first of the rate year, the interim medical education add-on rate shall be the sum of eighty per cent of the statewide average DGME add-on rate plus fifty per cent of the statewide average IME add-on rate.

(2) For a hospital that only demonstrates costs for medical education of allied professionals on the interim-settled cost report that ends in the SFY ending in the calendar year preceding the immediate past calendar year prior to January first of the rate year, the medical education add-on rate will be fifty per cent of the statewide average DGME add-on rate.

(3) For a hospital that has a newly approved graduate medical education program but whose costs are not yet reflected on a cost report, the medical education add-on rate will be fifty per cent of the statewide average DGME add-on rate.

(a) A hospital with a newly approved graduate medical education program must notify the department no later than October first of the calendar year immediately preceding January first of the rate year.

(b) Notification to the department must include documentation from the "Accreditation Council of Graduate Medical Education" that the hospital has an approved medical education program or documentation of medicare's recognition of the hospital's approved full-time equivalent interns and residents count, or both.

(4) For a hospital whose interim-settled cost report that ends in the SFY ending in the calendar year preceding the immediate past calendar year prior to January first of the rate year no longer reflects costs for interns and residents, the medical education add-on rate will be reduced by the portion of the add-on rate that represented their IME costs.

(5) For a hospital whose interim-settled cost report that ends in the SFY ending in the calendar year preceding the immediate past calendar year prior to January first of the rate no longer reflects costs for interns and residents and allied professionals, the medical education add-on rate will be reduced to zero.

(F) The medical education payment is the product of a hospital's medical education add-on rate as described in either paragraph (C), (D), or (E) of this rule and the relative weight of the claim's assigned all patient refined diagnosis related group and severity of illness as described in rule 5160-2-65 of the Administrative Code.

History

Effective: December 16, 2017
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-75 Outpatient hospital reimbursement.

For the purposes of this rule, eligible providers of hospital services, as defined in rule 5160-2-01 of the Administrative Code, and assigned to prospective payment peer groups as defined in rule 5160-2-05 of the Administrative Code, are subject to the enhanced ambulatory patient grouping(EAPG) system. This is a prospective payment methodology utilized by the Ohio department of medicaid (ODM) as described in this rule.

(A) The following definitions are applicable to Chapter 5160-2 of the Administrative Code:

(1) "Enhanced ambulatory patient grouping (EAPG)" is a group of outpatient procedures, encounters, or ancillary services, that reflect similar patient characteristics and resource utilization. This grouping incorporates the use of international classification of diseases (ICD) diagnosis codes, current procedural terminology (CPT) codes, and healthcare common procedure coding system (HCPCS) procedure codes.

(2) "EAPG grouper" is the software provided by "Solventum" to group outpatient claims based on services performed and resource intensity.

(3) "Default EAPG settings" are the default EAPG grouper options in "Solventum" core grouping software for each EAPG grouper version.

(4) "Discounting factor" is a factor applicable for multiple significant procedures or repeated ancillary services designated by default EAPG settings, or both. The appropriate percentage (fifty or one hundred per cent) will be applied to the highest weighted of the multiple procedures or ancillary services payment group.

(a) "Full payment" is the EAPG payment with no applicable discounting factor.

(b) "Consolidation factor" is a factor of zero per cent applicable for services designated with the same procedure consolidation flag or clinical procedure consolidation flag by the EAPG grouper under default EAPG settings.

(c) "Packaging factor" is a factor of zero per cent applicable for services designated with a packaging flag by the EAPG grouper under default EAPG settings.

(5) "EAPG base rate" is the dollar value that will be multiplied by the final EAPG weight for each EAPG on a claim to determine the total allowable medicaid payment.

(6) "Hospital peer groups" has the same meaning as in rule 5160-2-05 of the Administrative Code.

(7) "Outpatient claim" encompasses the outpatient services rendered to one eligible medicaid recipient on one date of service.

(8) "Outpatient invoice" is a bill submitted in accordance with Chapter 5160-1 of the Administrative Code, to ODM for services rendered to one eligible medicaid recipient on one or more date(s) of service. For an invoice encompassing more than one date of service, each date will be processed separately as an individual claim. An invoice should be limited to thirty calendar days.

(9) "Procedure code" is a CPT or HCPCS code as identified in rule 5160-1-19 of the Administrative Code. A list of covered procedure codes is published on ODM's website, http://medicaid.ohio.gov/.

(10) "Relative weight" is a factor specific to each EAPG that represents that EAPG's relative cost compared to an average case. The relative weights for all EAPGs are calculated as described in paragraph (F) of this rule.

(11) "Revenue center codes" are those in effect on the date of service and are listed in ODM's hospital billing guidelines as published on ODM's website, http://medicaid.ohio.gov/.

(12) "Carved out injectable drugs and biologicals" are the cell and gene therapy drugs identified on the "Carved Out Injectable Drugs and Biologicals" list, which is published on the medicaid website, https://medicaid.ohio.gov/stakeholders-and-partners/phm/carved-out-drugs.

(B) EAPG payment formula.

The total EAPG payment is the product of the following for each detail line:

(1) Peer group base rate in paragraph (D)(2) of this rule or base rate as adjusted in paragraph (E) of this rule; multiplied by

(2) EAPG relative weight for which the service was assigned by the EAPG grouper, rounded to the nearest whole cent;

(3) Multiply the product of paragraphs (B)(1) and (B)(2) of this rule by the applicable discounting factor(s) as defined in paragraph (A)(4) of this rule;

(a) Laboratory services will be reimbursed the lesser of charges or the assigned EAPG payment.

(b) Radiology services will be reimbursed the lesser of charges or the assigned EAPG payment.

(4) Rounded to the nearest whole cent.

The dataset used as inputs in the payment formula and determination of relative weights established for dates of service on or after the effective date of this rule consists of:

(1) All outpatient hospital claims with dates of service from January 1, 2017, through June 30, 2021;

(2) Cost reports submitted by hospitals to ODM on its Ohio medicaid hospital cost report for the hospital years that end in state fiscal years 2017 (ODM 02930 rev. 4/2017) through 2021 (ODM 02930 rev. 5/2021); and

(3) Inflation factors computed for Ohio by a nationally recognized research firm that computes similar factors for the medicare program. The inflation factors were used to inflate the total cost computed for each case inflating it to June 30, 2024.

(D) Computation of case mix adjusted average cost per case (base rate).

(1) For each Ohio peer group, calculate the total inflated cost for all cases, divide it by the number of cases assigned to each peer group and multiply the result as follows:

(a) For teaching hospitals, by seventy per cent;

(b) For urban hospitals in the southeast region as defined in the appendix to rule 5160-2-05 of the Administrative Code, by sixty-eight per cent;

(c) For urban hospitals in the southwest region as defined in the appendix to rule 5160-2-05 of the Administrative Code, by sixty-three per cent; and

(d) For all other Ohio hospitals, by sixty-two per cent.

(2) For each Ohio peer group, sum the relative weight values for all cases assigned to the peer group, divided by the number of cases in the peer group.

(3) For each Ohio peer group, multiply the amount described in paragraph(D)(1) of this rule by the result of paragraph (D)(2) of this rule.

(4) For non-Ohio peer groups, the peer group base rate is ninety-three dollars and fourteen cents.

(5) The following peer group increases take effect on January 1, 2026:

(a) For critical access hospitals, 14.06 per cent in addition to the result of paragraph (D)(1)(d) of this rule.

(b) For rural hospitals, 22.61 per cent in addition to the result of paragraph (D)(1)(d) of this rule.

(d) For teaching hospitals, 0.83 per cent in addition to the result of paragraph (D)(1)(a) of this rule.

(e) For all other Ohio hospitals, 0.83 per cent in addition to the result of paragraph (D)(1)(d) of this rule.

(E) Risk corridors.

Effective for dates of service on or after the effective date of this rule, ODM will apply the following to Ohio hospital peer groups except those defined in paragraphs (A)(6)(a) and (A)(6)(b) of this rule:

(1) If the peer group base rate calculated in paragraph (D) of this rule results in the fiscal impact at the individual hospital level that results in the reduction of payments from current levels, the individual hospital base rate is adjusted to a zero per cent reduction in payments; or

(2) If the peer group base rate calculated in paragraph (D) of this rule results in the fiscal impact at the individual hospital level that results in the increase of payments from current levels that is greater than ten per cent, the individual hospital base rate is adjusted to a ten per cent increase in payments.

(F) Computation of relative weights.

The relative weight is equal to:

(1) The average inflated cost per case within each EAPG; divided by

(2) The average inflated cost per case across all EAPGs.

(3) Adjustments to relative weights effective January 1, 2026.

(a) The relative weights for neonates, obstetric procedures, pregnancy, childbirth, and the puerperium EAPG categories were increased by 48.64 per cent.

(b) The relative weights for behavioral health services assigned to EAPG categories sixteen, seventy-one, and seventy-two, were increased by 14.04 per cent.

(G) Items conditionally payable outside of EAPG.

(1) Pharmaceuticals.

(a) When applicable, reimbursement for provider-administered pharmaceuticals HCPCS J-code or Q-code billed with revenue center code 025X or 0636 will be the lesser of charges or the payment amounts in the provider-administered pharmaceutical fee schedule as published on ODM's website, http://medicaid.ohio.gov/.

(b) Additional payments for pharmaceuticals will be made in accordance with the discounting factors as determined by the EAPG grouper.

(d) Charges listed in line items that carry revenue center code 025X or 0636 with a provider-administered pharmaceutical HCPCS J-code or Q-code that are not listed on the provider-administered pharmaceutical fee schedule or listed as "by report" will pay in accordance with paragraph (G)(3)(b)(iv) of this rule.

(e) Carved out injectable drugs and biologicals, as defined in paragraph (A)(12) of this rule, will be reimbursed at actual acquisition cost plus one-half of one per cent.

(2) Durable medical equipment (DME).

(a) Additional payments may be made for items grouping to a DME EAPG type.

(b) Reimbursement for outpatient hospital DME will be the lesser of charges or the payment amounts in the medicaid durable medical equipment fee schedule as published on ODM's website, http://medicaid.ohio.gov/.

(c) Additional payments for DME will be made in accordance with the discounting factors as determined by the EAPG grouper.

(3) Independently billed services for drugs or medical supplies and devices.

(a) To request independently billed payment under EAPG, hospitals will report all services provided on the date of service; and

(b) Report modifier UB with the primary procedure performed. Claims submitted with modifier UB are subject to the following payment methodology:

(i) Charges listed in line items that carry revenue center codes 025X or 0636 with a provider administered HCPCS J-code or Q-code will be reimbursed in accordance with the provider-administered pharmaceutical fee schedule.

(ii) Charges listed in line items that carry revenue center code 0250 without a provider-administered pharmaceutical CPT/HCPCS code or revenue center code 027X with or without a DME HCPCS code will be reimbursed in accordance with paragraph (G)(3)(b)(iv) of this rule.

(iii) Charges listed in line items that carry revenue center code 025X or 0636 with a provider-administered pharmaceutical HCPCS J-code or Q-code that are not listed on the provider-administered pharmaceutical fee schedule or listed as "by report" will be reimbursed in accordance with paragraph (G)(3)(b)(iv) of this rule.

(iv) Payment for charges listed in paragraph (G)(3)(b)(ii) or (G)(3)(b)(iii) of this rule is the product of the following for each detail line:

(a) Allowed charges multiplied by the hospital's specific medicaid outpatient cost-to-charge ratio as described in paragraph (B)(2) of rule 5160-2-22 of the Administrative Code, rounded to the nearest whole cent.

(b) Multiply the product of paragraph (G)(3)(b)(iv)(a) of this rule by sixty per cent; rounded to the nearest whole cent.

(v) All other detail lines on the same date of service will be paid zero.

(4) Dental services.

(a) Reimbursement for items assigned to a dental service EAPG type will be paid at a flat rate of one thousand four hundred thirty dollars.

(b) Payments will be multiplied by any applicable discounting factor and rounded to the nearest whole cent.

(5) Vaccines for children (VFC).

(a) The administration of immunizations covered under the VFC program may be reimbursed for recipients eighteen years or younger.

(b) Reimbursement for the administration of immunizations covered under the VFC program will be ten dollars for individuals eighteen years of age or younger, contingent upon the EAPG grouper. However, no payment will be made for vaccines that can be obtained at no cost through the federal VFC program.

(c) Additional payments for designated free vaccines will be made in accordance with the discounting factors as determined by the EAPG grouper.

(6) Observation services.

(a) Payment for observation services with HCPCS code G0378 will be made based on an average rate. Payment will be made for the following types of observation services:

(i) Acute care related observation services; and

(ii) Behavioral health (BH) and/or substance use disorder (SUD) observation services.

(b) Payments for observation services will be limited to a maximum of two consecutive days, except as provided in paragraph (G)(6)(c) of this rule.

(c) Payments for observation services reported with HCPCS code G0378 will be made for up to twenty-four units per day or forty-eight consecutive units (which could extend over a three-day period).

(d) Outpatient claims for observation services described in paragraph (G)(6)(a)(ii) of this rule will include:

(i) A BH/SUD primary diagnosis code; and

(ii) Modifier 'HE' at the detail level for the observation code.

(H) Coverage for acupuncture services is limited to the treatment of the services defined in rule 5160-8-51 of the Administrative Code.

Last updated February 9, 2026 at 7:46 AM

History

Effective: February 9, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-77 Consumer co-payments for non-emergency emergency department services.

(A) This rule establishes a consumer co-payment for non-emergency emergency department services as authorized by section 5162.20 of the Revised Code.

(B) For purposes of this rule, the following definitions apply.

(1) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent lay person, as defined in paragraph (B)(2) of this rule, could reasonably expect the absence of immediate medical attention to result in any of the following: placing the health of the individual (or, with respect to a pregnant woman, the health of her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.

(2) "Prudent lay person" means a person with an average knowledge of health and medicine to determine, within reason, that emergency services are necessary.

(3) "Non-emergency emergency department service" means an emergency department service that does not meet the definition of emergency medical condition, as defined in paragraph (B)(1) of this rule.

For dates of service on or after the effective date of this rule, medicaid consumers will pay a co-payment equal to three dollars for non-emergency emergency department services, as defined in paragraph (B)(3) of this rule, except as excluded in paragraphs (D) and (E) of this rule.

(D) Exclusions and additional limitations to the co-payment requirement for non-emergency care provided in an emergency department are in accordance with rule 5160-1-09 of the Administrative Code, except as provided in paragraph (E) of this rule.

(E) A hospital may take action to collect a co-payment as provided in section 5162.20 of the Revised Code.

(F) Reimbursement for services subject to the co-payment for non-emergency emergency department services.

The department will reimburse the emergency department claim the allowable medicaid payment, in accordance with rule 5160-2-75 of the Administrative Code, minus the applicable co-payment as described in paragraph (C) of this rule and any third party resources available to the patient, in accordance with rule 5160-2-25 of the Administrative Code.

Last updated July 1, 2021 at 10:50 AM

History

Effective: July 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-2-79 Reimbursement for LARC devices.

(A) Notwithstanding the provisions of rules 5160-2-65 and 5160-2-75 of the Administrative Code, long-acting reversible contraceptive (LARC) devices may be billed separately when provided during an inpatient hospitalization.

(B) LARC devices may include intrauterine devices (IUD) and subdermal contraceptive implants.

(1) The provisions of this rule are effective for claims associated with the provision of a LARC device in an inpatient hospital setting on or after the effective date of this rule.

(2) Only one outpatient claim for a LARC device may be submitted for a recipient in conjunction with an inpatient obstetrical delivery claim.

(D) Payment for LARC devices.

(1) Payment for the LARC device will be made in accordance with paragraph (E) of rule 5160-4-12 of the Administrative Code, at the rate in effect on the date of service.

(2) The corresponding inpatient obstetrical delivery claim will be paid in accordance with rule 5160-2-65 of the Administrative Code.

History

Effective: July 6, 2017
Promulgated Under: 119.03

Chapter 5160-3 Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for Individuals with Intellectual Disabilities.

Ohio Adm.Code 5160-3-01 Nursing facilities (NFs): definitions.

Except as otherwise provided in Chapter 5160-3 of the Administrative Code, and in addition to the definitions in section 5165.01 of the Revised Code:

(A) "Allowable costs" has the same meaning as in section 5165.01 of the Revised Code and are determined in accordance with the following reference material, in the following priority:

(1) Title 42 Code of Federal Regulations (C.F.R.) Chapter IV (October 1, 2017).

(2) The centers for medicare and medicaid services (CMS) publication 15-1 entitled "The Provider Reimbursement Manual - Part 1" (rev. 9/21/17).

(3) Generally accepted accounting principles in accordance with standards prescribed by the "American Institute of CPAs" (AICPA) as in effect June 26, 2018.

(B) "Intermediate care facility for individuals with intellectual disabilities" (ICF-IID) has the same meaning as in section 5124.01 of the Revised Code.

(C) "Minimum data set" (MDS) is the resident assessment instrument approved by CMS as described in rule 5160-3-43.1 of the Administrative Code. The MDS provides the resident assessment data that is used to classify a resident into a resource utilization group in the RUG case mix classification system as described in rule 5160-3-43.2 of the Administrative Code.

(D) "Patient" includes resident or individual.

(E) "Quarterly facility average case mix score" is a facility average case mix score based on data submitted for one reporting quarter.

(F) "Related party" has the same meaning as in section 5165.01 of the Revised Code.

In cases of a change of provider (CHOP), the following apply:

(1) The amount of indirect ownership is determined by multiplying the percentage of ownership interest at each level (e.g., forty per cent interest in corporation "A" which owns fifty per cent of corporation "B" results in a twenty per cent indirect interest in corporation "B").

(2) If a provider transfers an interest or leases an interest in a facility to another provider who is a related party, the capital cost basis shall be adjusted for a sale of a facility to or a lease to a provider that is not a related party if all of the following conditions are met:

(a) For a NF transfer:

(i) The related party is a relative of owner.

(ii) The provider making the transfer retains no interest in the facility except through the exercise of the creditor's rights in the event of default.

(iii) ODM determines that the transfer is an arm's length transaction if all the following apply:

(a) Once the transfer goes into effect, the provider that made the transfer has no direct or indirect interest in the provider that acquires the facility or the facility itself, including interest as an owner, officer, director, employee, independent contractor, or consultant, but excluding interest as a creditor. If the provider making the transfer maintains an interest as a creditor, the interest rate of the creditor shall not exceed the lesser of:

(i) The prime rate, as published by the "Wall Street Journal" (June 26, 2018) on the first business day of the calendar year, plus four per cent; or

(ii) Fifteen per cent.

(b) The provider that made the transfer does not reacquire an interest in the facility except through the exercise of a creditor's rights in the event of a default. If the provider reacquires an interest in the facility in this manner, ODM shall treat the facility as if the transfer never occurred when ODM calculates its reimbursement rates for capital costs.

(c) The provider transferring their facility shall provide ODM with certified appraisal(s) at least ninety days prior to the actual change of provider agreement(s). The certified appraisal(s) shall be conducted no earlier than one hundred eighty days prior to the actual change of provider agreement(s) for each facility transferred to a related party.

(iv) Except in the case of hardship caused by a catastrophic event, as determined by ODM, or in the case of a provider making the transfer who is at least sixty-five years of age, not less than twenty years have elapsed since, for the same facility, the capital cost basis was determined or adjusted most recently; or actual, allowable cost of ownership was determined most recently.

(b) For a NF lease:

(i) The related party is a relative of the owner.

(ii) The lessor retains an ownership interest in only real property and any improvements on the real property except when a lessor retains ownership interest through the exercise of a lessor's rights in the event of default.

(iii) ODM determines that the lease is an arm's length transaction if all the following apply:

(a) Once the lease goes into effect, the lessor has no direct or indirect interest in the lessee or, except as provided in this rule, the facility itself, including interest as an owner, officer, director, employee, independent contractor, or consultant, but excluding interest as a lessor.

(b) The lessor does not reacquire an interest in the facility except through the exercise of a lessor's rights in the event of a default. If the lessor reacquires an interest in the facility in this manner, ODM shall treat the facility as if the lease never occurred when ODM calculates its reimbursement rates for capital costs.

(c) A lessor that proposes to lease a facility to a relative of owner shall obtain a certified appraisal(s) for each facility leased. The lessor of the facility shall provide ODM with certified appraisal(s) at least ninety days prior to the actual change of provider agreement(s). The certified appraisal(s) shall be conducted no earlier than one hundred eighty days prior to the actual change of provider agreement(s) for each facility leased to a related party.

(iv) Except in the case of hardship caused by a catastrophic event, as determined by ODM, or in the case of a lessor who is at least sixty-five years of age, not less than twenty years have elapsed since, for the same facility, the capital cost basis was determined or adjusted most recently; or actual, allowable cost of ownership was determined most recently.

(v) The provisions set forth in this paragraph do not apply to leases of specific items of equipment.

(c) The provider shall notify ODM in writing and shall supply sufficient documentation demonstrating compliance with the provisions of this rule no less than ninety days before the anticipated date of completion of the transfer or lease. If the provider does not supply any of the required information, the provider shall not qualify for a rate adjustment. ODM shall issue a written decision determining whether the transfer meets the requirements of this rule within sixty days after receiving complete information as determined by ODM.

(d) Any rate adjustments which result from the provisions contained in paragraph (G)(2) of this rule shall take effect as specified in rule 5160-3-24 of the Administrative Code, following a determination by ODM that the requirements of paragraph (G)(2) of this rule are met.

(G) "Replacement beds" are beds that are relocated to a new building or portion of a building attached to and/or constructed outside of the original licensed structure of a NF. Replacement beds may originate from within the licensed structure of a NF or from another NF.

(H) "RUG" is the resource utilization groups system of classifying NF residents into case mix groups as described in rule 5160-3-43.2 of the Administrative Code.

History

Effective: September 22, 2018
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-02 Nursing facilities (NFs): provider agreements.

In addition to provisions in Chapters 5164. and 5165. of the Revised Code regarding provider agreements, and provisions in rules 5160-3-02.1 and 5160-3-02.2 of the Administrative Code, execution and maintenance of a provider agreement between the Ohio department of medicaid (ODM) and the operator of a NF also are contingent upon compliance with requirements set forth in this rule.

(A) Definitions.

(1) "Closure" means the discontinuance of the use of the building or part of the building that houses the facility as a NF, and that results in the relocation of the facility's residents who continue to require NF services. If the building is converted to a different use and acquires a new type of license, residents who require services offered under the new license type may remain.

(a) A facility's closure occurs regardless of whether there is a replacement of the facility whereby the operator completely or partially replaces the facility's physical plant through the construction of a new physical plant or the transfer of the facility's license from one physical plant location to another.

(b) Facility closure occurs regardless of whether residents of the closing facility elect to be relocated to the operator's replacement facility or to another NF.

(c) A facility closure occurs regardless of action taken by the Ohio department of health (ODH) related to the facility's certification under Title XIX of the Social Security Act, 42 U.S.C. 1396 (April 16, 2015), that may result in the transfer of part of the facility's survey findings to a replacement facility, or related to retention of a license as a NF under Chapter 3721. of the Revised Code.

(d) The last effective date of the provider agreement of a closed facility will be the date of the relocation of the last resident.

(2) "Continuing care" and "life care" refer to the living setting that provides the individual with different types of care based on a resident's need over time and may include an apartment or lodging, meals, maintenance services, and when necessary, nursing home care. All services are provided on the premises of the continuing care or life care community. The individual signs a contract that identifies the continuum of services to be covered by the individual's initial entrance fee and subsequent monthly charges. If a continuing care or life care contract provides for a living arrangement that specifically states that all health care services including nursing home services are met in full, medicaid payment cannot be made for those services covered by the contract. If a continuing care or life care contract provides for only a portion of the resident's health care services, that portion shall be deducted from the actual cost of nursing home care and medicaid shall pay the difference up to the medicaid maximum per diem. An individual who entered into a life care or continuing care contract may be eligible for medicaid under the conditions in rule 5160:1-3-05.1 of the Administrative Code.

(3) "Failure to pay" means that an individual has failed, after reasonable and appropriate notice, to pay or to have the medicare or medicaid program pay on the individual's behalf, for the care provided by the NF. An individual shall be considered to have failed to have the individual's care paid for when the individual has a medicaid application in pending status, if both of the following are the case:

(a) The individual's application, or a substantially similar previous application, has been denied by the county department of job and family services (CDJFS); and

(b) If the individual appealed the denial pursuant to division (C) of section 5101.35 of the Revised Code, the director of ODM upheld the denial.

(4) "Medicaid eligible" means an individual has been determined eligible by the CDJFS under Chapter 5160:1-3 of the Administrative Code and has been issued an effective date of health care coverage for the time period in question.

(5) "Operator" means the individual, partnership, association, trust, corporation, or other legal entity that operates a NF.

(6) "Voluntary withdrawal" means that the operator of a NF, in compliance with section 1919(c)(2)(F) of the Social Security Act, voluntarily elects to withdraw from participation in the medicaid program but chooses to continue providing services of the type provided by NFs.

(B) A provider of a NF shall:

(1) Execute the provider agreement in the format provided by ODM.

(2) Apply for and maintain a valid license to operate if required by law.

(3) Comply with the provider agreement and all applicable federal, state, and local laws and rules.

(4) Keep records and file cost reports as required in rule 5160-3-20 of the Administrative Code.

(5) Open all records relating to the costs of its services for inspection and audit by ODM and otherwise comply with rule 5160-3-20 of the Administrative Code.

(6) Supply to ODM such information as the department requires concerning NF services to individuals who are medicaid eligible or who have applied to be medicaid recipients.

(7) Unless the conditions described in paragraph (H) of this rule are applicable, retain as a resident any individual who is medicaid eligible, becomes medicaid eligible, or applies for medicaid eligibility. Residents in a NF who are medicaid eligible, become medicaid eligible, or apply for medicaid eligibility are considered residents in the NF during any absence for which bed-hold days are reimbursed in accordance with rule 5160-3-16.4 of the Administrative Code.

(8) Unless the conditions described in paragraph (H) of this rule are applicable, admit as a resident an individual who is medicaid eligible, whose application for medicaid is pending, or who is eligible for both medicare and medicaid, and whose level of care determination is appropriate for the admitting facility. This applies unless at least twenty-five per cent of the NF's medicaid certified beds are occupied by medicaid recipients at the time the individual would otherwise be admitted, in accordance with section 5165.08 of the Revised Code.

(a) In order to comply with these provisions, the NF admission policy shall be designed to admit individuals sequentially based on the following:

(i) The requested admission date.

(ii) The date and time of receipt of the request.

(iii) The availability of the level of care or range of services necessary to meet the needs of the applicants.

(iv) Gender: sharing a room with a resident of the same sex (except married couples who agree to share the same room).

(b) The NF shall maintain a written list of all requests for each admission. The list shall include the name of the potential resident; date and time the request was received; the requested admission date; and the reason for denial if not admitted. This list shall be made available upon request to the staff of ODM, the CDJFS, and ODH.

(i) Bed-hold days are exhausted.

Medicaid eligible residents of NFs who are on hospital stays, visiting with family and friends, or participating in therapeutic programs and have exhausted coverage for bed-hold days under rule 5160-3-16.4 of the Administrative Code must be readmitted to the first available semi-private bed in accordance with the provisions of rule 5160-3-16.4 of the Administrative Code.

(ii) Facility is a county home.

Any county home organized under Chapter 5155. of the Revised Code may admit individuals exclusively from the county in which the county home is located.

(iii) Facility has a religious sponsor.

Any religious or denominational NF that is operated, supervised, or controlled by a religious organization may give preference to persons of the same religion or denomination.

(iv) NF has continuing care or life care contracts.

A NF may give preference to individuals with whom it has contracted to provide continuing care or life care.

(v) Prolonged "medicaid pending" application status.

A NF may decline to admit a medicaid applicant if that facility has a resident whose application was pending upon admission and has been pending for more than sixty days, as verified by the CDJFS. The NF shall submit the necessary documentation in a timely manner as required in rules 5160-3-15.1 and 5160-3-15.2 of the Administrative Code.

(9) Provide the following necessary information to ODM and the CDJFS to process records for payment and adjustment:

(a) Submit the ODM 09401 "Facility/CDJFS Transmittal" (7/2014) to the CDJFS to inform the CDJFS of any information regarding a specific resident for maintenance of current and accurate records at the CDJFS and the facility.

(b) Submit claims to ODM as required in rule 5160-3-39.1 of the Administrative Code.

(10) Permit access to the facility and the facility's records for inspection by ODM, ODH, the CDJFS, representatives of the office of the state long-term care ombudsman, and any other state or local government entity having authority to inspect, to the extent of that entity's authority.

(11) In the case of a change of operator as defined in section 5165.01 of the Revised Code, follow the procedures in paragraphs (B)(11)(a) to (B)(11)(d) of this rule.

(a) The exiting operator or owner and entering operator must provide a written notice to ODM, as provided in section 5165.51 of the Revised Code, at least forty-five days prior to the effective date of any actions that constitute a change of operator for the NF, but at least ninety days if residents are to be relocated. An exiting operator that does not give proper notice is subject to the penalties specified in section 5165.42 of the Revised Code.

(b) The entering operator must submit documentation of any transaction (e.g., sales agreement, contract, or lease) as requested by ODM to determine whether a change of operator has occurred as specified in section 5165.51 of the Revised Code.

(c) The entering operator shall submit an application for participation in the medicaid program and a written statement of intent to abide by ODM rules, the provisions of the assigned provider agreement, and any existing CMS 2567 "Statement of Deficiencies and Plan of Correction" (rev. 2/1999) submitted by the exiting operator.

(d) An entering operator is subject to the same survey findings as the exiting operator unless the entering operator does not accept assignment of the exiting operator's provider agreement. Refusal to accept assignment results in termination of certification on the last day of the exiting operator's participation in medicaid. An entering operator who refuses assignment may reapply for medicaid participation and must undergo a complete initial certification survey by ODH. There may be gaps in medicaid coverage at the facility.

(12) Ensure the security of all personal funds of residents in accordance with rule 5160-3-16.5 of the Administrative Code.

(13) Comply with Title VI and Title VII of the Civil Rights Act of 1964, 42 U.S.C. 1971 (July 27, 2006) and the Americans with Disabilities Act of 1990, 42 U.S.C. 12101 et seq (March 15, 2011), and shall not discriminate against any resident on the basis of race, color, age, sex, creed, national origin, or disability.

(14) Provide notice to ODM within thirty days of any bankruptcy or receivership pertaining to the provider. Notice shall be mailed to: "Office of Legal Services, Ohio Department of Medicaid, P.O. Box 182709, Columbus, Ohio 43218" and to: "Office of the Attorney General, 30 East Broad Street, 14th Floor, Columbus, Ohio 43215".

(15) Provide a statement to the individual explaining the individual's obligation to reimburse the cost of care provided during the medicaid application process if it is not covered by medicaid.

(16) Comply with the requirements in rule 5160-3-04.1 of the Administrative Code to repay ODM the federal share of payments under the circumstances required by sections 5165.71 and 5165.85 of the Revised Code.

(17) During a closure or voluntary withdrawal from the medicaid program, provide ODM, the resident or guardian, and the residents' sponsors a written notice at least ninety days prior to the closure or voluntary withdrawal. A NF that does not issue the proper notice is subject to the penalties specified in section 5165.42 of the Revised Code.

(18) Comply with the following requirements when voluntarily withdrawing from the medicaid program:

(a) Continue to provide NF services to residents of the facility who were residing in the facility on the day before the effective date of the withdrawal (including those residents who were not entitled to medical assistance as of such day).

(i) A NF operator's voluntary withdrawal from participation in the medicaid program is not an acceptable basis for the transfer or discharge of these residents.

(ii) Nothing in this provision invalidates other legal grounds for NF-initiated discharge of medicaid residents after the effective date of withdrawal.

(b) Provide residents admitted after the effective date of withdrawal with information that the facility is not participating in the medicaid program with respect to those residents.

(1) Charge fees for the application process of a medicaid individual or applicant.

(2) Charge a medicaid individual an admission fee.

(3) Charge a medicaid individual an advance deposit. However, a NF may charge an individual whose medicaid eligibility is pending, typically in the form of a pre-admission deposit or payment for services after admission. A NF that has charged a resident for services between the first month of eligibility established by the state and the date notice of eligibility is received is obligated to refund any payments received for that period less the state's determination of any resident's share of the NF costs for that same period.

(4) Require a third party to accept personal responsibility for paying the facility charges out of his or her own funds. However, the facility may require a representative who has legal access to an individual's income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the individual's income or resources if the individual's medicaid application is denied and if the individual's cost of care is not being paid by medicare or another third-party payor. A third-party guarantee is not the same as a third-party payor (i.e., an insurance company), and this provision does not preclude the facility from obtaining information about medicare and medicaid eligibility or the availability of private insurance. The prohibition against third-party guarantees applies to all individuals and prospective individuals in all certified NFs regardless of payment source. This provision does not prohibit a third party from voluntarily making payment on behalf of an individual.

(D) ODM shall:

(1) Execute a provider agreement in accordance with the certification provisions set forth by the secretary of health and human services (HHS) and ODH.

(2) In the case of a change of operator, issue an assigned provider agreement to the entering operator contingent upon the entering operator's compliance with paragraph (B)(11)(c) of this rule.

(3) Provide access on the ODM website to a listing of the rules ODM has filed for adoption, admendment, or rescission under section 119.03 or 111.15 of the Revised Code.

(4) Make payments in accordance with Chapter 5165. of the Revised Code and Chapter 5160-3 of the Administrative Code to the NF for services to individuals eligible and approved for payment under the medicaid program.

(E) ODM may terminate, suspend, not enter into, or not revalidate, the provider agreement upon thirty days written notice to the provider for violations of Chapters 5164. and 5165. of the Revised Code; Chapters 5160-1 and 5160-3 of the Administrative Code; and if applicable, subject to Chapter 119. of the Revised Code.

(F) Any NF violating provisions defined in paragraphs (B)(7) and (B)(8) of this rule will be subject to a penalty in accordance with provisions of section 5165.99 of the Revised Code.

(G) The CDJFS shall use the ODM 09401 to communicate with NFs regarding the assessment of payment for specific individuals.

(H) Exclusions.

The provisions of paragraphs (B)(7) and (B)(8) of this rule do not require an individual to be admitted or retained at the NF if the individual meets one of the following conditions:

(1) The individual requires a level of care or range of services that the NF is not certified or otherwise qualified to provide.

(2) The individual has a medicaid application in pending status and meets the definition of "failure to pay" in this rule.

History

Effective: June 24, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-02.1 Nursing facilities (NFs): length and type of provider agreements.

(A) Definitions.

(1) "Reasonable assurance period" means a certain period of time, determined by the centers for medicare and medicaid services (CMS), for which a nursing facility operator whose provider agreement has been involuntarily terminated is required to operate without recurrence of the deficiencies that were the basis for termination. Participation in the medicare and medicaid programs may resume only following that period. If corrections were made before submission of a new request for participation, the period of compliance before the new request is counted as part of the period.

(2) "State survey agency" means the agency that is under contract with the state medicaid agency and that inspects nursing facilities for the purposes of survey and certification. The state survey agency in Ohio is the Ohio department of health (ODH). The state medicaid agency in Ohio is the Ohio department of medicaid (ODM).

(B) Effective dates.

(1) Initial certification of NFs and skilled nursing facilities/nursing facilities (SNF/NFs).

(a) Effective dates of NF and SNF/NF provider agreements generally are assigned by the state survey agency on the basis of findings of compliance or substantial compliance with standards of certification.

(b) The effective date shall not be earlier than the date on which compliance is documented via the state survey agency's onsite visits to the facility.

(c) The effective date of a provider agreement of a nursing facility that participates in the medicaid program as a SNF/NF shall be the same as that of the facility's medicare provider agreement.

(2) NFs subsequently approved to operate as SNF/NFs.

(a) Upon approval from CMS of a NF to participate in the medicare program as a SNF/NF, ODM shall issue a SNF/NF provider agreement.

(b) The effective date of this provider agreement shall be the same as that of the facility's medicare provider agreement.

(3) Re-entry into the program following involuntary termination.

(a) Following involuntary termination of the medicaid provider agreement for a nursing facility, the provider agreement effective date of a facility re-entering the medicaid program shall be the same effective date as the date CMS issues for the facility's medicare provider agreement.

(b) Re-entry may occur only after the successful completion of a reasonable assurance period as determined by CMS.

(1) A NF or SNF/NF provider agreement shall expire no later than five years from the effective date of the agreement in accordance with section 5164.32 of the Revised Code. The process for revalidation of a NF or SNF/NF provider agreement is specified in rule 5160-1-17.4 of the Administrative Code

(2) The term of a NF or SNF/NF provider agreement shall be determined by the period of certification established by the state survey agency, which is based upon compliance with certification standards. The term of a NF or SNF/NF provider agreement may be less than, but shall not exceed, five years.

History

Effective: June 24, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-02.2 Nursing facilities (NFs): termination, denial, and non-revalidation of provider agreements.

(A) Written notice.

(1) The Ohio department of medicaid (ODM) may terminate, deny, or not revalidate a NF provider agreement upon thirty days written notice to the NF.

(2) Notices and termination orders must comply with provisions set forth in sections 5164.38 and 5165.77 of the Revised Code.

(B) Reasons for which ODM may terminate, deny, or not revalidate a NF provider agreement.

(1) In accordance with section 5164.33 of the Revised Code, ODM may terminate, deny, or not revalidate a NF provider agreement if ODM determines such an agreement is not in the best interests of the state or the medicaid residents of the NF.

(2) ODM may terminate, deny, or not revalidate a NF provider agreement on the basis of best interest including, but not limited to, the following reasons:

(a) The provider has not fully and accurately disclosed information to ODM as required by the provider agreement or any rule contained in Chapter 5160-3 of the Administrative Code.

(b) The provider has failed to abide by or to have the capacity to comply with the terms and conditions of the provider agreement and/or rules and regulations promulgated by ODM

(d) The provider has failed to file cost reports as required in rule 5160-3-20 of the Administrative Code.

(e) The provider has made false statements or has altered records, documents, or charts. Alteration does not include properly documented correction of records.

(f) The provider has failed to cooperate or provide requested records or documentation for purposes of an audit or review of any provider activity by any federal, state, or local agency.

(g) The provider has been found in violation of section 504 of the Rehabilitation Act of 1973, 29 U.S.C 794 (March 24, 2014), the Civil Rights Act of 1964, 42 U.S.C. 1971 (July 27, 2006) or the Americans with Disabilities Act of 1990, 42 U.S.C. 12101 et seq (March 15, 2011) in relation to the employment of individuals, the provision of services, or the purchase of goods and services.

(h) The attorney general, auditor of state, or any board, bureau, commission, or department has recommended ODM terminate the provider agreement where the reason for the request bears a reasonable relationship to the administration of the medicaid program or the integrity of state and/or federal funds.

(i) In accordance with rule 5160-1-13.1 of the Administrative Code, the provider has violated the prohibition against billing medicaid residents for covered services, or has requested the resident to share in the cost of covered services through deductibles, coinsurance, co-payments, or other similar charges, other than medicaid co-payments as defined in rule 5160-1-09 of the Administrative Code.

(j) The facility has been found by the Ohio department of health (ODH) during a survey of the facility to have an emergency that is the result of a deficiency or cluster of deficiencies, and that constitutes immediate jeopardy.

(k) The provider fails to pay the full amount of a franchise permit fee (FPF) installment when due pursuant to section 5168.52 of the Revised Code.

(1) ODM shall terminate, deny, or not revalidate a NF provider agreement for, but not limited to, the following reasons:

(a) The provider has been terminated, suspended, or excluded by the medicare program and/or by the United States centers for medicare and medicaid services (CMS) and that action is binding on participation in the medicaid program or renders federal financial participation unavailable for participation in the medicaid program. Under these conditions, medicaid termination and payment sanction dates shall be the same as medicare termination and payment sanction dates.

(b) The facility has been decertified by ODH and/or the United States department of health and human services.

(c) The provider has pled guilty to or been convicted of a criminal activity materially related to either the medicare or medicaid program.

(d) Any license, permit, or certificate that is required by ODM or the terms of the provider agreement has been denied, suspended, revoked, or not renewed.

(2) ODM shall terminate, deny, or not revalidate a NF provider agreement for, but not limited to, the following reasons set forth in Chapters 5164. and 5165. of the Revised Code, and Chapters 5160-1 and 5160-3 of the Administrative Code:

(a) In accordance with division (D) of section 5164.35 of the Revised Code, there has been a conviction of, or the entry of a judgment in either a criminal or civil action against the provider or its owner, officer, authorized agent, associate, manager, or employee in an action brought pursuant to section 109.85 of the Revised Code.

(b) The provider has committed medicaid fraud as defined in rule 5160-1-29 of the Administrative Code.

(c) In accordance with section 5165.073 of the Revised Code, the provider does not comply with the requirements of section 3721.071 of the Revised Code for the installation of fire extinguishing and fire alarm systems.

(d) Any of the scenarios specified under division (B) of section 5165.771 of the Revised Code regarding the special focus facility program apply to the provider.

(e) In accordance with section 5165.106 of the Revised Code, the provider fails to file a cost report required by section 5165.10 of the Revised Code by the date it is due or by the date, if any, to which the due date is extended pursuant to division (D) of section 5165.10 of the Revised Code, unless the provider submits a complete and adequate cost report within thirty days after notice of termination by ODM.

(f) The provider has failed to ensure a nursing facility's full participation in the medicare program as a skilled nursing facility (SNF) pursuant to section 5165.082 of the Revised Code and rule 5160-3-02.4 of the Administrative Code.

(g) In accordance with section 5165.072 of the Revised Code, the provider fails to maintain eligibility for the provider agreement as set forth in section 5165.06 of the Revised Code.

(h) In accordance with division (B)(1) of section 5164.32 of the Revised Code, the provider fails to file a complete application for revalidation within the time and in the manner required by the revalidation process as specified by ODM.

(3) If ODH terminates certification of a nursing facility, ODM shall terminate the facility's provider agreement pursuant to section 5164.38 and section 5165.79 of the Revised Code.

(D) Adjudication order.

(1) In accordance with section 5164.38 of the Revised Code, the director of ODM shall terminate, deny, or not revalidate an existing NF provider agreement by issuing an order pursuant to an adjudication conducted in accordance with Chapter 119. of the Revised Code, unless such action occurred as the result of events described in division (E) of section 5164.38 of the Revised Code.

(2) In accordance with division (E) of section 5165.77 of the Revised Code, if ODM issues a termination order as the result of events set forth in paragraph (B)(2)(j) of this rule, the termination may take effect prior to or during the pendency of the proceeding under Chapter 119. of the Revised Code.

(E) Impact of provider actions on CMS-imposed reasonable assurance periods.

(1) When seeking reentry to the medicaid program, providers are subject to procedures set forth in CMS publication 100-07 entitled "State Operations Manual" at Chapter 7 section 7321 (6/12/14) for SNFs and NFs, to comply with the provisions at 42 CFR 489.57 (October 1, 2015) that govern reinstatement after termination, and require that the reason for termination of the previous agreement has been removed and there is reasonable assurance that it will not recur.

(2) After CMS has initiated involuntary termination action for a dually certified SNF/NF, or after ODH has initiated involuntary termination action for a medicaid-certified NF, a provider of a NF who is permitted to voluntarily terminate, voluntarily withdraw, or undergoes a change of operator, or the subsequent operator of the same facility, shall be subject to reasonable assurance requirements set by CMS when seeking reentry to the medicaid program.

(3) CMS or ODH initiates a termination action when it sends a provider the initial notice certifying noncompliance and proposing termination.

History

Effective: June 24, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-02.3 Nursing facilities (NFs): institutions eligible to participate in medicaid as NFs.

(A) Definitions.

(1) "Certification" means the process by which the state survey agency certifies its findings to the federal centers for medicare and medicaid services (CMS) or the Ohio department of medicaid (ODM) with respect to a facility's compliance with health, safety, and resident rights requirements of divisions (a), (b), (c), and (d) of section 1919 of the Social Security Act, 42 U.S.C. 1396r (December 20, 2006).

(2) "Certified beds" mean beds that are counted in a provider facility that meets medicaid standards. A count of facility beds may differ depending on whether the count is used for certification, licensure, eligibility for medicare or medicaid payment formulas, or other purposes.

(3) "Distinct part" means a portion of an institution or institutional complex that is certified to provide skilled nursing facility (SNF) and/or nursing facility (NF) services. A distinct part shall be physically distinguishable from the larger institution and fiscally separate for cost reporting purposes. A distinct part may be a separate building, wing, floor, hallway, or one side of a corridor. A hospital-based SNF or NF is a distinct part by definition. A long term care facility with both SNF and NF distinct parts is one facility, even though the distinct parts are certified separately for medicare and medicaid. "Distinct part", when applied to NFs or SNF/NFs, has the same definition and requirements as in 42 C.F.R. 483.5 (October 1, 2015).

(4) "Dually participating" means simultaneous participation of an institution or institutional complex in both the medicare and medicaid programs.

(5) "Dually participating long term care facility" means an institution that participates as both a SNF under the medicare program, and as a NF under the medicaid program. Such a facility is referred to as a SNF/NF.

(6) "Facility" means the entity subject to certification and approval in order for the provider to be approved for medicaid payment. A facility may be an entire institution such as a free-standing nursing home, or may be a distinct part of an institution such as a hospital or continuing care retirement community.

(7) "Long term care facility" means a NF, SNF, or dually participating SNF/NF.

(8) "Long term care institutional services" means those medicaid funded, institutional medical, health, psycho-social, habilitative, rehabilitative, and/or personal care services that may be provided to eligible individuals in a NF or SNF/NF.

(9) "NF services" means those services available in institutions, or parts of institutions, that are certified as nursing facilities by the Ohio department of health (ODH) or by the state survey agency of another state.

(10) "Religious non-medical health care institution" (RNHCI) means an institution as defined in section 1861(ss)(1) of the Social Security Act, 42 U.S.C. 1395x (ss) (1) (August 5, 1997), such as the "Christian Science RNHCIs" accredited by the "Commission for Accreditation of Christian Science Nursing Organizations/Facilities, Inc." RNHCIs are subject to conditions of participation in the medicaid program according to 42 C.F.R. 403 subpart G (October 1, 2015).

(11) "State survey agency" means the agency designated as the state health standard setting authority, and state health survey agency responsible for certifying and determining compliance of long term care facilities with the requirements for participation in the medicaid program. The state survey agency in Ohio is ODH.

(B) Types of long term care institutional services.

(1) The types of long term care institutional services covered in compliance with the provisions of Chapter 5160-3 of the Administrative Code are NF services provided to eligible residents requiring either a skilled level of care or an intermediate level of care as set forth in rule 5160-3-08 of the Administrative Code.

(2) Institutions not eligible for participation are:

(a) An institution licensed or approved as a tuberculosis hospital.

(b) A prison, juvenile criminal facility, or an institution used to incarcerate individuals involuntarily who have committed a violation of a criminal or civil law.

(c) An institution for mental diseases, as defined in rule 5160-3-06.1 of the Administrative Code, for persons under sixty-five years old.

To participate in the Ohio medicaid program and receive payment from ODM for long term care institutional services to eligible residents, operators of long term care facilities shall meet all of the following requirements:

(1) Operate an institution that meets the licensure, registration, and other applicable state standards as set forth in this rule.

(2) Operate an institution certified by ODH or by the state survey agency of another state as being in compliance with applicable federal regulations for medicaid participation as a NF with a minimum of four NF certified beds.

(3) Operate an institution for which a current, completed, and signed ODM 03623 "Ohio Medicaid Provider Agreement for Long Term Care Facilities (NFs, SNF/NFs and ICFs-IID)" (rev. 4/2014) is on file with ODM.

(D) Qualified types of Ohio NFs.

To be eligible for certification as a NF, an institution shall qualify as one of the following:

(1) A nursing home licensed by ODH under section 3721.02 of the Revised Code, or a nursing home licensed by a political subdivision certified under section 3721.09 of the Revised Code. Licensed nursing homes eligible for medicaid certification include:

(a) RHNCIs.

(b) Veterans' homes operated under Chapter 5907. of the Revised Code.

(2) A county home, county nursing home, or district home owned by the county and operated by the county commissioners in accordance with Chapter 5155. of the Revised Code, or operated by the board of county hospital trustees in accordance with section 5155.011 of the Revised Code; or

(3) A unit of any hospital registered under section 3701.07 of the Revised Code that contains beds categorized before August 5, 1989, as skilled nursing facility beds in accordance with section 3702.521 of the Revised Code; or

(4) A unit of any hospital registered under section 3701.07 of the Revised Code that contains beds categorized as long term care beds as defined in section 3702.51 of the Revised Code.

(E) Mandatory dual participation.

To participate as a NF, all Ohio facilities shall comply with the provisions in section 5165.082 of the Revised Code and in rule 5160-3-02.4 of the Administrative Code regarding dual participation in the medicare program as a SNF/NF.

(F) Certification of NFs and beds subject to certification survey.

(1) Certification.

A facility's certification as a NF by ODH or by the state survey agency of another state governs the types of services the operator of the facility may provide.

(2) Provider agreements.

(a) A provider agreement with the operator of an Ohio NF or SNF/NF shall include any part of the facility that meets standards for certification of compliance with federal and state laws and rules for participation in the medicaid program.

(b) Exceptions to this provision are NFs or SNFs that between July 1, 1987 and July 1, 1993 added beds licensed as nursing home beds under Chapter 3721. of the Revised Code. Such facilities are not required to include those beds in a provider agreement, unless otherwise required by federal law. This exception continues to apply if such facilities subsequently undergo a change of operator.

(3) Beds subject to certification survey.

(a) All beds in a medicaid participating NF or SNF/NF, except those licensed nursing home beds added between July 1, 1987 and July 1, 1993, shall be surveyed to determine compliance with the applicable certification standards and, if certifiable, included in the provider agreement as NF or SNF/NF beds.

(b) Beds that could quality as NF or SNF/NF beds and were added between July 1, 1987 and July 1, 1993 may be surveyed for compliance at the discretion of the operator. Such facilities are not required to include those beds in a provider agreement, unless otherwise required by federal law.

(4) The only other basis for allowing nonparticipation of a portion of an Ohio NF or SNF/NF that is not hospital-based is certification of noncompliance by ODH.

(G) Requirements for out-of-state providers of long term care institutional services.

(1) To participate in the Ohio medicaid program and receive payment from ODM for long term care institutional services to eligible Ohio residents, an operator of a long term care facility located outside Ohio shall meet all of the following requirements in their state of origin:

(a) The operator of the facility shall hold a valid state-required license, registration, or equivalent from the respective state that specifies the level(s) of care the facility is qualified to provide.

(b) The operator of the facility shall hold a valid and current medicaid provider agreement from the respective state as a NF or SNF/NF provider type.

(2) Additionally, out-of-state providers shall meet the following Ohio requirements:

(a) The operator of the facility shall have a current, completed and signed ODM 03623 on file with ODM.

(b) The operator of the facility shall obtain resident-specific and date-specific prior authorization from ODM in accordance with rule 5160-1-11 of the Administrative Code.

History

Effective: June 24, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-02.4 Nursing facilities (NFs): mandatory dual participation in the medicare program.

(A) Definitions.

(1) For purposes of this rule, the terms "certified beds," "dually participating," "facility," and "religious non-medical health care institution" (RNHCI) are defined in rule 5160-3-02.3 of the Administrative Code.

(2) For purposes of this rule, the term "reasonable assurance period" is defined in rule 5160-3-02.1 of the Administrative Code.

(3) "Fully participating" means participation of an institution in its entirety, either in the medicare or medicaid program, or both. A fully participating skilled nursing facility (SNF) is one in which every bed is certified for participation in medicare. A fully participating nursing facility (NF) is one in which every bed is certified for participation in medicaid. A fully participating SNF/NF is one in which every bed is certified for participation in both medicare and medicaid.

(B) Mandatory medicare participation and exceptions.

(1) Operators of Ohio NFs shall have all medicaid-certified beds as counted in the medicaid provider agreement also certified under medicare as SNF beds, in accordance with section 5165.082 of the Revised Code and the provisions of this rule.

(2) Exceptions to mandatory medicare participation are:

(a) RNHCIs.

(b) Veteran's homes operated under Chapter 5907. of the Revised Code.

(c) Out-of-state providers of long term care institutional services in accordance with the criteria specified in paragraph (G) of rule 5160-3-02.3 of the Administrative Code.

(d) Hospital beds re-categorized as skilled nursing beds after August 5, 1989 in accordance with section 3702.521 of the Revised Code. These beds are not permitted to be covered by a medicaid provider agreement.

(1) Operators of Ohio NFs currently holding a medicaid provider agreement under which all medicaid-certified beds are also medicare-certified are in compliance with the requirement for NFs to be both dually and fully participating SNF/NFs.

(2) Pursuant to rule 5160-3-02.2 of the Administrative Code, the Ohio department of medicaid (ODM) shall terminate or not revalidate an operator's provider agreement if the provider fails to ensure a nursing facility's full participation in the medicare program as a SNF.

(D) Enrollment of new facilities.

(1) Operators of Ohio facilities requesting participation in the medicaid NF program must provide documentation that they have requested full participation in the medicare SNF program.

(2) Operators of Ohio facilities requesting participation in the medicaid NF program that have been recommended for medicaid certification by the Ohio department of health (ODH) and that have provided documentation that they have requested full participation in the medicare SNF program, may be issued a fully participating NF medicaid provider agreement with an effective date determined in accordance with rule 5160-3-02.1 of the Administrative Code.

(3) After ODM is notified by the centers for medicare and medicaid services (CMS) that a facility operator's request for medicare certification has been approved, a SNF/NF provider agreement may be issued by ODM using the medicare SNF's effective date of certification in accordance with rule 5160-3-02.1 of the Administrative Code.

(4) If ODM is notified by CMS that a facility operator's request for medicare participation has been denied and all appeals have been exhausted, ODM shall terminate the NF's provider agreement in accordance with rule 5160-3-02.2 of the Administrative Code.

(E) Readmission to the medicaid program.

(1) A facility operator requesting readmission to the medicaid program must provide documentation of the request for admission or readmission, and of full participation in the medicare SNF program.

(2) If a facility's participation in the medicaid program ends due to voluntary withdrawal from participation by the operator, and the operator requests readmission to the medicaid NF program, enrollment will be processed in the same manner as for a new facility as set forth in paragraph (D) of this rule.

(3) If a facility's participation in the medicaid program ends due to involuntary termination, cancellation, or non-revalidation by ODM, and ODH recommends that the facility receive certification, ODM may issue a provider agreement that begins on or after the effective date of medicare certification or recertification. If CMS has imposed a reasonable assurance period prior to re-entry to the medicare program, the reasonable assurance period also shall be imposed for medicaid enrollment purposes.

(F) Change of operator.

If a SNF/NF undergoes a change of operator that results in a change of provider agreement, the entering operator must either accept assignment of the exiting operator's provider agreement and survey results, or refuse assignment and undergo a new certification survey. An operator may accept or refuse assignment of the medicare provider agreement and/or the medicaid provider agreement.

(1) If an entering operator of a SNF/NF accepts assignment of both the medicare and medicaid provider agreements of the exiting operator, ODM shall issue a SNF/NF provider agreement to the entering operator. The entering operator must continue to operate a dually participating facility that fully participates in both the medicare and medicaid programs.

(2) If an entering operator of a SNF/NF refuses to accept assignment of the exiting operator's medicare provider agreement, but does accept assignment of the exiting operator's medicaid provider agreement, the entering operator must meet requirements for medicare participation in the same manner as for a new facility as set forth in paragraph (D) of this rule.

(3) If an entering operator of a SNF/NF refuses to accept assignment of the exiting operator's medicaid provider agreement, ODM shall terminate the agreement of the exiting operator. To enter the medicaid program, the entering operator must apply for medicaid participation as a new facility. Upon notice of certification approval from ODH, ODM may issue a medicaid provider agreement to the entering operator in the same manner as for new facilities as set forth in paragraph (D) of this rule.

History

Effective: June 24, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-02.7 Nursing facilities (NFs): emergency and disaster plan, resident relocation, and required notifications.

(A) Purpose.

The purpose of this rule is to set forth provisions for the preparation for, response to, and recovery from an emergency or disaster at a NF. The provisions of this rule are in addition to the requirements set forth in sections 5165.77, 5165.80, and 5165.81 of the Revised Code, and in rule 3701-17-25 of the Administrative Code.

(B) Emergencies and disasters.

"Emergencies and disasters" are unexpected situations or sudden occurrences of a serious or urgent nature that create a substantial likelihood that one or more of a facility's residents may be harmed and/or may need to be relocated. Events that may constitute an emergency or disaster include, but are not limited to, the following:

(1) Tornado, severe wind, severe storm, flood, or other natural disaster.

(2) Fire.

(3) Explosion.

(4) Loss of electrical power.

(5) Release of hazardous chemicals or other hazardous material.

(6) Outbreak of contagious disease.

(7) Civil disturbance such as a riot.

(8) A labor strike that suddenly causes the number of staff members in a facility to be below that necessary for resident care.

(9) A missing resident, where there is the liklihood that the resident may be harmed while absent from the facility.

(1) In accordance with 42 C.F.R. 483.75(m) (October 1, 2015), each facility shall have a detailed written plan of procedures to be followed in the event of an emergency or disaster. The emergency and disaster plan shall include the following components regarding resident relocation:

(a) Procedures for securing emergency shelter, including resident identification and tracking.

(b) Procedures for resident care, including supplies, equipment, and staffing.

(c) Procedures for contacting physicians, family, guardians, other individuals responsible for residents, and government agencies.

(d) Procedures for resident transportation, hospitalization, therapy, and other appropriate services, including post-emergency transportation.

(e) Procedures for records transfer.

(2) In accordance with 42 C.F.R. 483.75(m), each facility shall train all employees in the facility's emergency and disaster procedures when they begin to work in the facility, periodically review the procedures with existing staff, and carry out unannounced staff drills using those procedures.

(D) Notification.

(1) In the event of any emergency or disaster, the provider shall notify each resident's family, guardian, sponsor, next of kin, or other person responsible for the resident.

(2) In cases where residents are relocated, within one working day after the relocation of residents, the provider shall give notification of the following to the Ohio department of health (ODH):

(a) The name and location of the facility experiencing the emergency or disaster.

(b) The nature of the emergency or disaster.

(3) In cases where residents are relocated, within one working day after the relocation of residents, the provider shall give notification of the following to the county department of job and family services (CDJFS), the Ohio department of medicaid (ODM) bureau of long term care services and supports (BLTCSS) designated emergency relocation coordinator, and all applicable managed care plans:

(a) The name and location of the facility experiencing the emergency or disaster.

(b) The nature of the emergency or disaster.

(d) The new location of residents.

(e) The plans for restoration or rehabilitation of the facility to allow residents to re-occupy the facility.

(f) An estimated timeframe for the resumption of facility operations, if applicable.

(4) In cases where residents are relocated, the provider shall submit weekly updates to the ODM BLTCSS emergency relocation coordinator, all applicable managed care plans, and ODH until the facility is permanently closed or all relocated residents are returned.

(E) Compliance and reimbursement.

In cases where residents are relocated, the provider should consult with the ODM BLTCSS emergency relocation coordinator regarding nursing facility functions that may be impacted by the temporary relocation of residents, including the following:

(1) Level of care and pre-admission reviews.

(2) Claims processing.

(3) Minimum data sets (MDS) assessments and reporting.

(4) Personal needs allowance (PNA) accounts.

(5) Transportation.

(6) Cost reporting.

(F) Termination of NF services.

Pursuant to section 5165.01 of the Revised Code, a NF closure does not occur if all of the facility's residents are relocated due to an emergency evacuation and one or more of the residents return to a medicaid-certified bed in the facility not later than thirty days after the evacuation occurs.

History

Effective: June 24, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-03.2 Nursing facilities (NFs): resident protection fund and collection of fines.

(A) Definitions.

(1) "Fines" means civil money penalties (CMPs) and other assessments imposed against a NF as a remedy for deficiencies or a cluster of deficiencies that were not substantially corrected before a survey.

(2) "Interest" means the interest rate determined by the tax commissioner on the fifteenth day of October each year by rounding the federal short-term rate to the nearest whole number per cent and adding three per cent. This is the interest rate per annum used in computing the interest that accrues during the following calendar year.

(B) Procedure for collection of fines imposed by the centers for medicare and medicaid services (CMS).

(1) If CMS has been unable to collect a CMP fine directly and notifies the Ohio department of medicaid (ODM), ODM will attempt to collect the fine.

(2) ODM will inform the NF, via certified mail, of the following available payment options:

(a) Lump sum payment.

A lump sum payment, including any interest accrued, from the provider; or

(b) Periodic payments.

Periodic payments, including any interest accrued, in accordance with a schedule approved by ODM for a period not to exceed twelve months; or

Following the date on which the fine plus interest becomes due, an appropriate reduction to medicaid payments made to the provider for care rendered to medicaid eligible residents in accordance with a schedule approved by ODM for a period not to exceed twelve months; or

(d) Attorney general's office (AGO).

If the facility is no longer active in the medicaid program, the fine may be referred to the AGO for collection in accordance with section 131.02 of the Revised Code.

(3) Not later than ten days after notification, the NF is responsible for selecting a payment option and advising ODM in writing.

(4) If the NF fails to adhere to the terms of the payment agreement or fails to select a payment option within ten days, ODM will immediately implement collection from an actively participating facility by medicaid payment offset(s). If a facility is not actively participating in the medicaid program, the fine will be referred to the AGO for collection.

(5) The fine and any interest collected from the NF will be retained in the resident protection fund.

(6) ODM will notify CMS in writing when the CMP fine has been collected in full.

(1) Proceeds from all fines, including interest collected, are deposited in the state treasury to the credit of the resident protection fund.

(2) ) Monies in the resident protection fund may only be used in accordance with 42 CFR 488.433 and 488.442 (October 1, 2019) for activities that protect or improve the quality of care or quality of life for residents of NFs.

(D) Management of the resident protection fund.

ODM will provide budgetary, accounting, and other related management functions for the resident protection fund. When medicaid payment offset is used as a means of collection, the amount equal to the reduction in medicaid payments will be deposited to the credit of the resident protection fund.

(E) Disbursement of funds.

Upon CMS approval of disbursement of monies in accordance with paragraph (C)(2) of this rule, a purchase order will be created by ODM against which invoices or intrastate transfer vouchers are submitted, or, in the event of an emergency at a nursing facility, a state issued payment card will be used.

(F) The provisions of this rule are applicable only to the extent that monies are available in the resident protection fund.

Last updated June 25, 2025 at 5:51 PM

History

Effective: August 15, 2020
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-04 Nursing facilities (NFs): payment during the Ohio department of medicaid (ODM) administrative appeals process for denial or termination of a provider agreement.

(A) When ODM is required to provide an adjudicatory hearing pursuant to Chapter 119. of the Revised Code, payment shall continue for medicaid-covered services provided to eligible residents during the appeal of, and the proposed termination or non-revalidation of, a nursing facility (NF) provider agreement. Payment shall not be made under this provision for services rendered on or after the effective date of ODM issuance of a final order of adjudication pursuant to Chapter 119. of the Revised Code, except as provided in paragraph (B) of this rule.

(B) Payment may be provided up to thirty days following the effective date of termination or non-revalidation of a NF provider agreement; or after an administrative hearing decision that upholds the ODM termination or non-revalidation action. Payment will be available if both of the following conditions are met:

(1) Residents were admitted to the NF before the effective date of termination or expiration; and

(2) The NF cooperates with the state, local, and federal entities in the effort to transfer residents to other NFs, institutions, or community programs that can meet the residents' needs.

(C) When ODM acts under instructions from the United States department of health and human services, payment ends on the termination date specified by that agency.

Last updated June 25, 2025 at 6:53 PM

History

Effective: December 10, 2017
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-04.1 Nursing facilities (NFs): payment during the survey agency's administrative appeals process for termination or non-renewal of medicaid certification.

(A) For the purposes of this rule, the following definitions shall apply:

(1) "State survey agency" means for the purpose of medicaid certification, the Ohio department of health (ODH).

(2) "Effective date of termination" means the date set by the state survey agency or the United States department of health and human services for the termination of certification.

(B) When medicaid certification is either terminated or not renewed, the Ohio department of medicaid (ODM) must also either terminate or not revalidate the medicaid provider agreement.

(1) During the appeals process provided by the state survey agency for the proposed termination or non-renewal of certification, payment for covered services provided to eligible residents is available if:

(a) Payment is for those residents admitted prior to the effective date of an order issued under section 5165.72, 5165.74, 5165.77, or 5165.84 of the Revised Code, denying medicaid payments to the facility for all medicaid eligible residents admitted after the effective date of the order; and

(b) The appeal is conducted prior to the effective date of termination or non-renewal.

(2) If the NF appeal process results in an adjudication order that upholds the ODH action or if the administrative hearing is not completed prior to the certification termination/non-renewal date, payment for services provided to eligible residents may be available for an additional thirty days if:

(a) The eligible resident was admitted prior to the effective date of an order that was issued as specified in paragraph (C)(1)(a) of this rule; and

(b) The NF cooperates with the state, local, and federal entities in the effort to transfer residents to other NFs, institutions, or community programs that can meet the residents' needs.

(3) If a NF's appeal of the termination or non-renewal of its certification is upheld, payment for covered services provided to eligible residents is resumed. If the appeal decision is reached after the termination/ non-renewal date, payment is made retroactive to the date of termination.

(4) When the state survey agency certifies that there is jeopardy to residents' health and safety by issuing an order under Chapter 5165. of the Revised Code, or when it fails to certify that there is no jeopardy, payment will end on the effective date of termination.

(5) When ODM acts under instructions from the United States department of health and human services, payment ends on the date specified by that agency.

Last updated June 25, 2025 at 5:51 PM

History

Effective: December 10, 2017
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-05 Level of care definitions.

(A) For purposes of determining an individual's nursing-facility (NF) based level of care, the following definitions apply unless a term is otherwise defined in a specific rule:

(1) "Activity of daily living (ADL)" means a personal or self-care task that enables an individual to meet basic life needs. "ADL" includes the following defined activities:

(a) "Bathing" means the ability of an individual to cleanse one's body by showering, tub, or sponge bath, or any other generally accepted method.

(b) "Dressing" means the ability of an individual to complete the activities necessary to dress oneself and includes the following two components:

(i) Putting on and taking off an item of clothing or prosthesis; and

(ii) Fastening and unfastening an item of clothing or prosthesis.

(c) "Eating" means the ability of an individual to feed oneself. Eating includes the processes of getting food into one's mouth, chewing, and swallowing, or the ability to use and self-manage a feeding tube.

(d) "Grooming" means the ability of an individual to care for one's appearance and includes the following three components:

(i) Oral hygiene;

(ii) Hair care; and

(iii) Nail care.

(e) "Mobility" means the ability of an individual to use fine and gross motor skills to reposition or move oneself from place to place and includes the following three components:

(i) "Bed mobility" means the ability of an individual to move to or from a lying position, turn from side to side, or otherwise position the body while in bed or alternative sleep furniture;

(ii) "Locomotion" means the ability of an individual to move between locations by ambulation or by other means; and

(iii) "Transfer" means the ability of an individual to move between surfaces, including but not limited to, to and from a bed, chair, wheelchair, or standing position.

(f) "Toileting" means the ability of an individual to complete the activities necessary to eliminate and dispose of bodily waste and includes the following four components:

(i) Using a commode, bedpan, or urinal;

(ii) Changing incontinence supplies or feminine hygiene products;

(iii) Cleansing self; and

(iv) Managing an ostomy or catheter.

(2) "Adverse level of care determination" means a determination that an individual does not meet the criteria for a specific level of care.

(3) "Alternative form" means a form that is used in place of and contains all of the data elements of, the ODM 03697, "Level of Care Assessment" to request a level of care determination from the Ohio department of medicaid (ODM) or its designee.

(4) "Assistance" means the hands-on provision of help in the initiation or completion of a task.

(5) "Authorized representative" has the same meaning as in rule 5160-1-33 of the Administrative Code.

(6) "Current diagnoses" means a written medical determination by the individual's attending physician, whose scope of practice includes diagnosis, listing those diagnosed conditions that currently impact the individual's health and functional abilities.

(7) "Delayed in-person visit" means an in-person visit that occurs within a specified period of time after a desk review has been conducted that includes the elements of a long-term care consultation, in accordance with Chapter 173-43 of the Administrative Code, for the purposes of exploring home and community-based services (HCBS) options and making referrals to the individual as appropriate.

(8) "Desk review" means a level of care determination process that is not conducted in person.

(9) "Developmental disabilities level of care" means the level of care as described in rule 5123-8-01 of the Administrative Code.

(10) "ICF-IID" means an intermediate care facility for individuals with intellectual disabilities as defined in section 5124.01 of the Revised Code.

(11) "Immediate need" means an individual has a need that may result in substantial harm or decline in functioning if waiver services and supports are not received within thirty calendar days.

(12) "In-person" means a level of care assessment and determination process conducted in the physical presence of the individual for the purposes of exploring nursing facility services or HCBS options and making referrals to the individual as appropriate, that is not conducted by a desk review only.

(13) "Individual" means a medicaid recipient or person applying for medicaid eligibility.

(14) "Instrumental activity of daily living (IADL)" means the ability of an individual to complete community living skills. "IADL" includes the following defined activities:

(a) "Community access" means the ability of an individual to use available community services and supports to meet one's needs and includes the following three components:

(i) "Accessing transportation" means the ability to get and use transportation.

(ii) "Handling finances" means the ability of an individual to manage one's money. Handling finances includes all of the following:

(a) Knowing where money is;

(b) Knowing how to get money;

(d) Knowing how to get and use benefits and services, including but not limited to:

(i) Health benefits and insurance;

(ii) Social benefits; and

(iii) Home utilities.

(iii) "Telephoning" means the ability to make and answer telephone calls or use technology to connect to community services and supports.

(b) "Environmental management" means the ability of an individual to maintain the living arrangement in a manner that ensures the health and safety of the individual and includes the following three components:

(i) "Heavy chores" means the ability to move heavy furniture and appliances for cleaning, turn mattresses, and wash windows and walls; and

(ii) "House cleaning" means the ability to make beds, clean the bathroom, sweep and mop floors, dust, clean and store dishes, pick up clutter, and take out trash;

(iii) "Yard work and maintenance" means the ability to care for the lawn, rake leaves, shovel snow, complete minor home repairs, and paint.

(d) "Personal laundry" means the ability of an individual to wash and dry one's clothing and household items by machine or by hand.

(e) "Shopping" means the ability to obtain or purchase one's necessary items. Necessary items include, but are not limited to, groceries, clothing, and household items. Shopping does not include handling finances or accessing transportation.

(15) "Less than twenty-four hour support" means that an individual needs the presence of another person, or the presence of a remote monitoring device that does not need the individual to initiate a response, during a portion of a twenty-four hour period of time.

(16) "Level of care determination" means an assessment and evaluation by ODM or its designee of an individual's physical, mental, social, and emotional status, using the processes described in rule 5160-3-14 of the Administrative Code, to compare the criteria for all of the possible levels of care as described in rules 5160-3-06 to 5160-3-08 of the Administrative Code, and make a decision about whether an individual meets the criteria for a level of care.

(17) "Level of care validation" means the verification process for ODM or its designee that includes verifying the preadmission screening and resident review criteria have been met for an individual as well as reviewing and entering an individual's current level of care in the electronic records that are maintained by ODM.

(18) "Long-term services and supports" means institutional or community-based medical, health, psycho-social, habilitative, rehabilitative, or personal care services that may be provided to medicaid-eligible individuals.

(19) "Medication administration" means the ability of an individual to prepare and self-administer all forms of over-the-counter (OTC) and prescription medication. Intravenous medication administration will be considered a skilled nursing service for the purposes of determining NF-based level of care, OTC and all other self-administered prescription medication will not be considered a skilled nursing service.

(20) "Need" means the inability of an individual to complete a necessary and applicable task independently, safely, and consistently. An individual does not have a need when:

(a) The individual is not willing to complete a task or does not have the choice to complete a task.

(b) The task can be completed with the use of available assistive devices and accommodations.

(21) "Nursing facility (NF)" has the same meaning as in section 5165.01 of the Revised Code. A facility that has submitted an application packet for medicaid certification to the Ohio department of health is considered to be in the process of obtaining its initial medicaid certification and will be treated as a NF for the purposes of this rule.

(22) "NF-based level of care" means the intermediate and skilled levels of care, as described in rule 5160-3-08 of the Administrative Code.

(23) "NF-based level of care program" means a NF, a home and community-based services medicaid waiver that uses a NF-based level of care, or other medicaid program that uses a NF-based level of care.

(24) "PASRR" means the preadmission screening and resident review requirements mandated by section 1919(e)(7) of the Social Security Act and implemented in accordance with rules 5160-3-14, 5160-3-15.1, 5160-3-15.2, 5122-21-03, and 5123-14-01 of the Administrative Code.

(25) "Physician" means a person licensed under Chapter 4731. of the Revised Code or licensed in another state as defined by applicable law, to practice medicine and surgery or osteopathic medicine and surgery.

(26) "Skilled nursing services" means specific tasks that are, in accordance with Chapter 4723. of the Revised Code, provided by a licensed practical nurse (LPN) at the direction of a registered nurse or by a registered nurse directly.

(27) "Skilled rehabilitation services" means specific tasks that are, in accordance with Title 47 of the Revised Code, provided directly by a licensed or other appropriately certified technical or professional health care personnel.

(28) "Supervision" means either of the following:

(a) Reminding an individual to perform or complete an activity; or

(b) Observing while an individual performs an activity to ensure the individual's health and safety.

(29) "Twenty-four hour support" means that an individual needs the continuous presence of another person throughout the course of the entire day and night during a twenty-four hour period of time.

(30) "Unstable medical condition" means clinical signs and symptoms are present in an individual and a physician has determined that:

(a) The individual's signs and symptoms need extensive monitoring and ongoing evaluation of the individual's status and care and there are supporting diagnostic or ancillary testing reports that justify the need for frequent monitoring or adjustment of the treatment regimen; and

(b) Changes in the individual's medical condition are uncontrollable or unpredictable and may need immediate interventions.

Last updated July 1, 2025 at 8:05 AM

History

Effective: July 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-06 Criteria for the protective level of care.

(A) The criteria for the protective level of care is met when:

(1) The individual's needs for long-term services and supports (LTSS) are less than the criteria for the intermediate or skilled levels of care, as described in paragraphs (A)(4), (B), and (C) of rule 5160-3-08 of the Administrative Code.

(2) The individual's LTSS needs are less than the criteria for the developmental disabilities level of care, as defined in rule 5123-8-01 of the Administrative Code.

(3) The individual has a need for:

(a) Less than twenty-four hour support in order to prevent harm due to a cognitive impairment, as diagnosed by a physician or other licensed health professional acting within his or her applicable scope of practice, as defined by law; or

(b) Supervision of one activity of daily living (ADL), as defined in rule 5160-3-05 of the Administrative Code and as described in paragraph (B) of this rule, or supervision of medication administration; and

(c) Assistance with three instrumental activities of daily living (IADL), as defined in rule 5160-3-05 of the Administrative Code and as described in paragraph (C) of this rule.

(d) If the individual is age seventeen years or younger, the age-appropriate need for supervision or assistance with items described in paragraphs (A)(3)(b) and (A)(4)(c) of this rule will be assessed in accordance with the ODM-approved assessment guide.

(B) For the purposes of meeting the criteria described in paragraph (A)(3) of this rule, an individual age eighteen years or older who needs supervision of an ADL needs:

(1) Supervision of mobility in at least one of the following three components:

(a) Bed mobility;

(b) Locomotion; or

(2) Supervision of bathing.

(3) Supervision of grooming in all of the following three components:

(a) Oral hygiene;

(b) Hair care; and

(4) Supervision of toileting in at least one of the following four components:

(a) Using a commode, bedpan, or urinal;

(b) Changing incontinence supplies or feminine hygiene products;

(d) Managing an ostomy or catheter.

(5) Supervision of dressing in at least one of the following two components:

(a) Putting on and taking off an item of clothing or prosthesis; or

(b) Fastening and unfastening an item of clothing or prosthesis.

(6) Supervision of eating.

(C) For the purposes of meeting the criteria described in paragraph (A)(3) of this rule, an individual age eighteen years or older who needs assistance with an IADL needs:

(1) Assistance with meal preparation.

(2) Assistance with environmental management in all of the following three components:

(a) Heavy chores;

(b) House cleaning; and

(3) Assistance with personal laundry.

(4) Assistance with community access in at least one of the following three components:

(a) Accessing transportation;

(b) Handling finances; or

(5) Assistance with shopping.

Last updated July 1, 2025 at 8:05 AM

History

Effective: July 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-06.1 Institutions for mental diseases (IMDs).

(A) The purpose of this rule is to set forth the process by which the Ohio department of medicaid (ODM) shall identify nursing facilities (NFs) that are at risk of becoming IMDs, the preventive measures to be taken by ODM when such facilities have been identified, and the course of action to be taken if a NF is identified as an IMD.

Medicaid payment is not available for services provided to individuals in an IMD who are age twenty-one and over, and in certain circumstances age twenty-two and over, and under age sixty-five, except as permitted in 42 C.F.R. 438.6(e) (October 1, 2016).

(B) Definitions.

(1) "At risk facility". A NF is considered to be an at risk facility if it meets two or more of the IMD evaluation criteria set forth in paragraph (C)(2)(b) of this rule but has not been determined to meet the definition of IMD set forth in paragraph (B)(2) of this rule.

(2) "Institution for mental diseases (IMD)" means a hospital, nursing facility, or other institution of more than sixteen beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care and related services. A NF is considered to be an IMD if its overall character is that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. An intermediate care facility for the mentally retarded (ICF-MR) is not an IMD.

(3) "Mental diseases" means diseases listed as mental disorders in the "International Classification of Diseases, Tenth Revision, Clinical Modification," or the most recent edition, with the exception of mental retardation, senility, and organic brain syndrome. This publication is available on the internet via the website http://www.cdc.gov/nchs/icd/icd10cm.htm.

(4) "Potentially at risk of becoming an IMD". A NF is considered to be potentially at risk of becoming an IMD if any one of the following applies:

(a) The NF is licensed as a mental nursing home as defined in rule 3701-17-01 of the Administrative Code;

(b) The NF was identified as an at risk facility during a prior IMD review; or

(c) Forty-five per cent or more of the NF's residents have been determined to need specialized services for serious mental illness by the Ohio department of mental health and addiction services (ODMHAS) in accordance with rules 5160-3-15.1, 5160-3-15.2, and 5122-21-03 of the Administrative Code.

(1) ODM shall identify and maintain a list of NFs that are potentially at risk of becoming IMDs.

(2) IMD reviews shall be conducted for any potentially at risk facility on the list.

(a) IMD reviews shall be scheduled as follows:

(i) ODM shall schedule and complete an initial on-site IMD review of any NF that is newly identified as meeting the criteria set forth in paragraphs (B)(4)(a) and/or (B)(4)(c) of this rule. Initial reviews shall be completed within sixty calendar days following the identification of the NF's potentially at risk status;

(ii) ODM shall conduct annual on-site IMD reviews in each potentially at risk facility for at least two consecutive years after it is identified as potentially at risk of becoming an IMD.

(b) IMD review criteria. The following criteria shall be used to evaluate the overall character of a NF:

(i) Whether the NF is licensed as a psychiatric facility. For purposes of this rule, this includes licensure as a mental nursing home in accordance with rule 3701-17-01 of the Administrative Code;

(ii) Whether the NF is accredited as a psychiatric facility by the "Joint Commission," which accredits and certifies health care organizations and programs in the United States;

(iii) Whether the NF is under the jurisdiction of the ODMHAS;

(iv) Whether the NF specializes in providing psychiatric and/or psychological care and treatment, as evidenced by any of the following indicators:

(a) Fifty per cent or more of individuals residing in the NF have medical records indicating that they are receiving psychiatric/psychological care and treatment;

(b) Fifty per cent or more of the NF's staff have specialized psychiatric/psychological training; or

(v) Whether the current need for institutionalization for more than fifty per cent of all the individuals residing in the NF results from mental diseases. In determining whether this criterion is met, the reviewer must consider whether more than fifty per cent of individuals residing in the NF have serious mental illness (as defined in rule 5160-3-15 of the Administrative Code) and have been determined by ODMHAS to need specialized services for serious mental illness in accordance with rule 5160-3-15.1 or 5160-3-15.2, and rule 5122-21-03 of the Administrative Code.

(i) The NF is not at risk of becoming an IMD;

(ii) The NF is an at risk facility as defined in paragraph (B)(1) of this rule; or

(iii) The facility is determined to be an IMD.

(D) ODM action pursuant to IMD review results. Upon completion of the IMD review, ODM shall proceed with the follow-up activities corresponding to the determination that was made for the NF:

(1) For NFs determined not to be at risk of becoming an IMD:

(a) Any NF that is determined not to meet the criteria for potential risk shall be notified and removed from the list of facilities that are potentially at risk of becoming an IMD.

(b) Any NF determined to be potentially at risk of becoming an IMD but that does not meet at least two of the IMD review criteria set forth in paragraph (C)(2)(b) of this rule shall be notified of its status as a potentially at risk facility and that it shall continue to be subject to annual IMD reviews, and retained on the list of facilities that are potentially at risk of becoming an IMD.

(2) NFs determined to be at risk of becoming an IMD shall be notified of the determination, offered the opportunity to receive technical assistance to prevent them from becoming IMDs, and shall be monitored closely by ODM following the at risk determination. Such monitoring may include the performance of additional, unannounced, on-site IMD reviews by ODM.

(3) For NFs determined to be an IMD:

(a) The NF shall be notified by certified mail of the determination, that eligibility to receive medicaid vendor payment shall be terminated with respect to all individuals residing in that NF who are under age sixty-five and age twenty-one and over, and, in certain circumstances age twenty-two and over, except as permitted in 42 C.F.R. 438.6(e), and that it has thirty days from the date the notice was mailed to exercise its reconsideration rights pursuant to paragraph (D) of rule 5160-70-02 of the Administrative Code;

(b) If the facility requests a reconsideration pursuant to paragraph (D) of rule 5160-70-02 of the Administrative Code, eligibility to receive vendor payment will continue until the issuance of a final decision by ODM.

(c) On the thirty-first day following the date the IMD determination notice was mailed to the NF, or upon issuance of a final decision by ODM, if the IMD determination is upheld on reconsideration, ODM shall notify the county department of job and family services (CDJFS) in writing, to initiate the process for termination of the vendor payment and a redetermination of the residents' continued eligibility for medicaid and to provide notice of all applicable appeal rights to all affected residents of that IMD in accordance with Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.

(E) A NF which has been determined to be an IMD may, following a period of not less than six months, submit a written request that ODM conduct a redetermination survey when changes have been made in its overall character such that the administrator of the facility believes it would no longer qualify as an IMD. ODM shall respond to such requests by conducting a redetermination survey within sixty days of the receipt of the request.

(1) If the redetermination survey finds that the NF no longer meets the definition of an IMD set forth in paragraph (B)(2) of this rule, ODM shall:

(a) Follow the procedures set forth in paragraph (D)(1) or (D)(2) of this rule; and

(b) Notify the CDJFS in writing, of the effective date of the determination that the facility is not an IMD, to initiate vendor payment, regardless of the age of the individual and in accordance with rule 5160-3-15 of the Administrative Code, on behalf of medicaid eligible individuals seeking medicaid payment of their stay in that NF.

(2) If the redetermination survey finds that the NF continues to be an IMD, the NF shall be notified by certified mail of the determination, the basis for the determination, that it has thirty days from the date the notice was mailed to exercise its reconsideration rights pursuant to paragraph (D) of rule 5160-70-02 of the Administrative Code, and that if the NF does not exercise its reconsideration rights within that time it may not request another redetermination survey for at least six months from the date of the determination.

Last updated June 18, 2025 at 8:31 AM

History

Effective: August 17, 2017
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-08 Criteria for nursing facility-based level of care.

(A) The criteria for the intermediate level of care is met when:

(1) The individual's needs for long-term services and supports (LTSS) exceed the criteria for the protective level of care, as described in paragraph (A)(3) of rule 5160-3-06 of the Administrative Code;

(2) The individual's LTSS needs are less than the criteria for the skilled level of care, as described in paragraph (C) of this rule;

(3) The individual's LTSS needs do not meet the criteria for the developmental disabilities level of care or meets one of the following:

(a) The individual has been evaluated through an Ohio department of medicaid (ODM)-approved assessment tool and determined to have medical condition(s) or related need(s) necessitating an immediate need for support as determined by (ODM), or

(b) The individual receives a non-adverse level II pre-admission screening and resident review (PASRR) determination indicating the need for NF services.

(4) The individual needs a minimum of one of the following:

(a) Assistance with the completion of a minimum of two activities of daily living (ADL), as defined in rule 5160-3-05 of the Administrative Code and as described in paragraph (B) of this rule;

(b) Assistance with the completion of a minimum of one ADL as described in paragraph (B) of this rule, and assistance with medication administration;

(d) Twenty-four hour support in order to prevent harm due to a cognitive impairment, as diagnosed by a physician or other licensed health professional acting within his or her applicable scope of practice, as defined by law; or

(e) If the individual is age seventeen years or younger, the age-appropriate need for assistance with items described in paragraphs (A)(4)(a) and (A)(4)(b) of this rule will be assessed in accordance with the ODM-approved assessment guide.

(B) For the purposes of meeting the criteria described in paragraph (A)(4) of this rule, an individual age eighteen years or older who needs assistance with an ADL needs:

(1) Assistance with mobility in at least one of the following three components:

(a) Bed mobility;

(b) Locomotion; or

(2) Assistance with bathing.

(3) Assistance with grooming in all of the following three components:

(a) Oral hygiene;

(b) Hair care; and

(4) Assistance with toileting in at least one of the following four components:

(a) Using a commode, bedpan, or urinal;

(b) Changing incontinence supplies or feminine hygiene products;

(d) Managing an ostomy or catheter.

(5) Assistance with dressing in at least one of the following two components:

(a) Putting on and taking off an item of clothing or prosthesis; or

(b) Fastening and unfastening an item of clothing or prosthesis.

(6) Assistance with eating.

(1) The individual's LTSS needs exceed the criteria for the protective level of care, as described in paragraph (A)(3) of rule 5160-3-06 of the Administrative Code;

(2) The individual's LTSS needs exceed the criteria for the intermediate level of care as described in paragraph (A)(4) of this rule;

(3) The individual's LTSS needs exceed the criteria for the developmental disabilities level of care;

(4) The individual needs a minimum of one of the following:

(a) One skilled nursing service within the day on no less than seven days per week; or

(b) One skilled rehabilitation service within the day on no less than five days per week; and

(5) The individual has an unstable medical condition.

(D) When an individual has been previously determined to meet the criteria for the intermediate or skilled level of care and has been enrolled in a NF-based home and community-based services (HCBS) waiver and has maintained enrollment, failure to meet the criteria in paragraph (A)(3) of this rule will not be a sufficient reason alone to deny level of care at the annual reassessment.

(E) When an individual meets the criteria for a skilled level of care, as described in paragraph (C) of this rule, the individual may request placement in an intermediate care facility for individuals with intellectual disabilities (ICF-IID) that provides services to individuals who have a skilled level of care. When an individual with a skilled level of care requests placement in an ICF-IID they will need to meet the criteria for the developmental disabilities level of care.

Last updated July 1, 2025 at 8:05 AM

History

Effective: July 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-14 Process and timeframes for a level of care determination for nursing facility-based level of care programs.

(A) Level of care determination process, generally:

(1) A level of care determination may occur in-person, by a desk review, or by telephone and is one component of medicaid eligibility to receive medicaid payment for services provided in a nursing facility (NF) or through a NF-based home and community-based services (HCBS) waiver or other NF-based level of care program.

(2) An individual who is seeking admission to a NF is subject to both a preadmission screening and resident review (PASRR) process, as described in rules 5160-3-15, 5160-3-15.1, 5160-3-15.2, 5122-21-03, and 5123-14-01 of the Administrative Code, and a level of care determination process.

(a) The preadmission screening process will be completed before a level of care determination or a level of care validation can be issued.

(b) In order for the Ohio department of medicaid (ODM) to consider payment for services provided to an individual in a NF who is eligible for medicaid, the individual will have received a non-adverse PASRR determination and subsequent NF-based level of care determination.

(i) NF services that predate the PASRR determination are not eligible for medicaid payment.

(ii) The level of care effective date cannot precede the date that the PASRR criteria were met.

(iii) A level of care cannot be requested or determined retroactively with an effective date prior to or within an active post-payment claim review period.

(iv) Not-withstanding paragraphs (A)(2)(b)(i), (A)(2)(b)(ii), and (A)(2)(b)(iii) of this rule if an individual is admitted to a NF for a stay of thirty calendar days or less under a hospital exemption that has been submitted in accordance with rule 5160-3-15.1 of the Administrative Code, the level of care criteria will be deemed met for the first thirty days after admission. If the individual remains in the NF after the thirtieth calendar day, a level of care determination will be requested in accordance with paragraphs (B) to (H) of this rule.

(v) If an individual receives a non-adverse level II PASRR determination indicating the need for NF services and the individual meets the criteria for the intermediate level of care described in paragraphs (A)(4) and (B) of rule 5160-3-08 of the Administrative code, or the skilled level of care described in paragraph (C) of rule 5160-3-08 of the Administrative Code, a level of care determination may be issued effective on or after the date that the PASRR criteria were met.

(vi) Not-withstanding paragraph (A)(2)(b)(iv) of this rule, if a NF receives medicaid payment from ODM or its designee for an individual who does not have a NF-based level of care determination, the NF is subject to the claim adjustment for overpayments process described in rule 5160-1-19 of the Administrative Code.

(vii) If an individual receives an adverse level II PASRR determination, the individual appearing to meet the criteria described in paragraphs (A)(4) and (B), or paragraph (C) of rule 5160-3-08 of the Administrative Code or receipt of a non-adverse NF-based level of care determination will not be used to overturn the adverse level II determination.

(3) Services will not be eligible for medicaid payment for any individual applying for a NF-based HCBS waiver or other NF-based level of care program until the specific program eligibility criteria are met.

(B) Level of care request.

(1) In order for ODM or its designee (hereafter referred to as ODM) to make a level of care determination, ODM will receive a complete level of care request from a NF or a complete application for a NF-based HCBS waiver or program. A level of care request is considered complete when all necessary data elements are included and completed on the ODM 03697, "Level of Care Assessment" or alternative form and any necessary supporting documentation is submitted with the ODM 03697 or alternative form, as described in paragraphs (B)(2) to (B)(5) of this rule.

(2) A complete level of care request, alternative form, or submitted documentation will not be considered a substitute for a level of care determination.

(3) Necessary data elements:

(a) Individual's legal name;

(b) Individual's medicaid case number, if applicable;

(d) Individual's current address, including county of residence;

(e) Individual's current diagnoses or diagnoses as of the requested retroactive effective date, if applicable;

(f) Date of onset for each diagnosis, if available;

(g) Individual's current medications, treatments, and required medical services or as of the requested retroactive effective date, if applicable;

(h) A description of the individual's current activities of daily living and instrumental activities of daily living or description as of the requested retroactive effective date, if applicable;

(i) A description of the individual's current mental and behavioral status or status as of the requested retroactive effective date, if applicable; and

(j) Type of service setting requested.

(4) Certification on the ODM 03697 or alternative form.

(a) A certification means a signature from a physician, nurse practitioner as defined in Chapter 4723. of the Revised Code, or physician assistant as defined in Chapter 4730. of the Revised Code and date. ODM will allow an electronic signature or signature received via fax or mail for the certification.

(b) A certification will be obtained within thirty calendar days of submission of the ODM 03697 or alternative form.

(i) When an individual resides in the community and ODM determines that the individual's health and welfare is at risk and that it is not possible for the submitter of the ODM 03697 or alternative form to obtain a physician, nurse practitioner, or physician assistant signature and date at the time of the submission of the ODM 03697 or alternative form, a verbal certification is acceptable.

(ii) ODM will obtain a certification within thirty days of the verbal certification.

(5) Necessary supporting documentation with the ODM 03697 or alternative form when the individual is subject to a preadmission screening process:

(a) A copy of the ODM 03622, "Preadmission Screening/Resident Review (PAS/RR) Identification Screen" and ODM 07000, "Hospital Exemption from Preadmission Screening Notification", as applicable, in accordance with rules 5160-3-15.1 and 5160-3-15.2 of the Administrative Code; and

(b) Any preadmission screening results and assessment forms.

(1) ODM will issue a level of care determination and notify the individual and authorized representative, as applicable, of the level of care determination. If the determination is adverse, information regarding the individual's hearing rights will be included with the determination in accordance with division 5101:6 of the Administrative Code.

(2) In accordance with rules 5160:1-2-01 and 5160:1-6-03.1 of the Administrative Code, the county department of job and family services (CDJFS) will determine medicaid eligibility and issue proper notice and hearing rights to the individual.

(D) When an incomplete level of care request is received:

(1) ODM will notify the submitter and specify the necessary information to be provided on or with the ODM 03697 or alternative form and allow fourteen calendar days to provide the information. If the submitter provides a complete level of care within fourteen calendar days, the steps described in paragraph (C) of this rule will be performed.

(a) If a complete level of care request is not received within fourteen calendar days of the notification of an incomplete request, the request may be denied and documented in the electronic record maintained by ODM.

(2) In accordance with rules 5160:1-2-01 and 5160:1-6-03.1 of the Administrative Code, the CDJFS will determine medicaid eligibility and issue proper notice and hearing rights to the individual.

(E) Desk review level of care determination.

(1) A desk review level of care determination will occur within one business day from the date of receipt of a complete level of care request when:

(a) ODM determines that an individual is seeking admission or re-admission to a NF from an acute care hospital or hospital emergency room.

(b) A CDJFS requests a level of care determination for an individual who is receiving adult protective services, as defined in rule 5101:2-20-01 of the Administrative Code, and the CDJFS submits an ODM 03697 or alternative form at the time of the level of care request.

(2) A desk review level of care determination will occur within five calendar days from the date of receipt of a complete level of care request when:

(a) ODM determines that an individual who resides in a NF is requesting to change from a non-medicaid payor to medicaid payment for the individual's continued NF stay.

(b) ODM determines that an individual who resides in a NF is requesting to change from medicaid managed care to medicaid fee-for-service as payment for the individual's continued NF stay.

(F) In-person level of care determination.

(1) An in-person level of care determination will occur within ten calendar days from the date of receipt of a complete level of care request when:

(a) An individual or the authorized representative of an individual requests an in-person level of care determination.

(b) ODM makes an adverse level of care determination during a desk review level of care determination.

(c) ODM determines that the information needed to make a level of care determination through a desk review is inconsistent.

(d) An individual resides in the community and ODM verifies that the individual does not have a current NF-based level of care.

(e) ODM determines that an individual has a pending disenrollment from a NF-based HCBS waiver due to the individual no longer having a NF-based level of care.

(2) An in-person level of care determination will occur within two business days from the date of a level of care request from a CDJFS for an individual who is receiving adult protective services when the CDJFS does not submit an ODM 03697 or alternative form at the time of the level of care request.

(3) Except as provided in paragraph (F)(1) or (F)(2) of this rule, ODM will allow a telephonic or video conference level of care determination at the request of the individual.

(G) Delayed in-person visit.

(1) A delayed in-person visit will occur within ninety calendar days after ODM conducts a desk review level of care determination for an individual as described in paragraph (E)(1)(a), (E)(1)(b), or (E)(2)(a) of this rule.

(2) Not-withstanding paragraph (G)(1) of this rule a delayed in-person visit does not have to occur for the following:

(a) An individual as described in paragraph (E)(2)(b) or (E)(2)(c) of this rule.

(b) An individual who declines a delayed in-person visit.

(c) An individual who has had a long-term care consultation, in accordance with Chapter 173-43 of the Administrative Code, since the individual's NF admission.

(d) An individual who has had an in-person resident review, in accordance with rule 5160-3-15.2 of the Administrative Code, since the individual's NF admission.

(e) An individual who is receiving care under a medicaid care management system that utilizes a care management, case management, or care coordination model, including but not limited to case management services provided through an HCBS waiver.

(H) Level of care validation.

ODM may conduct a level of care validation in lieu of an in-person level of care determination within one business day from the date of a level of care request for:

(1) An individual who is currently enrolled on a NF-based HCBS waiver and is seeking admission to a NF.

(2) An individual who is currently a NF resident and is seeking readmission to the same NF after a hospitalization.

Last updated July 1, 2025 at 8:05 AM

History

Effective: July 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-15 Preadmission screening and resident review (PASRR) definitions.

(A) The purpose of this rule is to set forth the definitions for terms contained in rules 5160-3-15.1, 5160-3-15.2, 5122-21-03 and 5123-14-01 of the Administrative Code.

(B) Definitions:

(1) "Adverse determination" means a determination made in accordance with rules 5160-3-15.1, 5160-3-15.2, 5122-21-03 and 5123-14-01 of the Administrative Code, that an individual does not require the level of services provided by a nursing facility or that the individual does or does not require specialized services.

(2) "Attending Physician" means the physician to whom a person, or the family of a person, has assigned primary responsibility for the treatment or care of the person or, if the person or the person's family has not assigned that responsibility, the physician who has accepted that responsibility.

(3) "Categorical determination" means a preadmission level II determination which may be made for an individual without a face to face assessment for an individual diagnosed with a serious mental illness (SMI) and/or developmental disability (DD) as defined in paragraphs (B)(6) and (B)(28) of this rule when the individual's circumstances fall within one of the following two categories:

(a) The individual requires an 'emergency nursing facility stay', as defined in paragraph (B)(7) of this rule;

(b) The individual is seeking admission to a nursing facility for a 'respite nursing facility stay' as defined in paragraph (B)(26) of this rule.

(4) "Community" for PASRR purposes means a new admission from a setting other than a nursing facility, Ohio hospital or a unit of a hospital that is not operated by or licensed by the Ohio department of mental health and addiction services (OhioMHAS).

(5) "Current diagnoses" means a written medical determination by the individual's attending physician, whose scope of practice includes diagnosis, listing those diagnosed conditions which currently impact the individual's health and functional abilities. To be considered current, the written documentation of the diagnoses must reflect the diagnoses assigned by the individual's attending physician within one hundred eighty calendar days of submission for the preadmission screening review certifying that the listed diagnoses are an accurate reflection of the individual's current condition.

(6) "Developmental disability (DD)." An individual is considered to have a DD when he or she meets the conditions described in rule 5123-14-01 of the Administrative Code.

(7) "Emergency nursing facility stay" refers to the temporary admission of an individual to a nursing facility pending further assessment in emergency situations requiring protective services as defined in rule 5101:2-20-01 of the Administrative Code, with placement in a nursing facility not to exceed seven days.

(8) "Guardian" has the same meaning as in section 2111.01 of the Revised Code.

(9) "Hospital discharge exemption," also known as hospital exemption means an exemption from the preadmission screening as defined in paragraph (B)(21) of this rule, when an individual meets the hospital discharge exemption criteria in rule 5160-3-15.1 of the Administrative Code.

(10) "Indications of developmental disabilities (DD)." An individual shall be considered to have indications of developmental disabilities when the individual meets the criteria specified in rule 5123-14-01 of the Administrative Code or the individual receives services from a county board of DD.

(11) "Indications of serious mental illness (SMI)." An individual shall be considered to have indications of an SMI when the individual meets the criteria specified in rule 5122-21-03 of the Administrative Code.

(12) "Individual," for the purposes of this rule, means a person, regardless of payment source, who is seeking admission, readmission or transfer to a medicaid certified nursing facility, or who resides in a medicaid certified nursing facility or facility in the process of becoming medicaid certified as a nursing facility.

(13) "Level I" or "level I screening" refers to the initial screening that must be given to all individuals seeking new admission as defined in paragraph (B)(17) of this rule to a medicaid-certified nursing facility, regardless of payor source, for the purpose of identifying individuals who may have or are suspected to have indications of a DD as defined in paragraph (B)(10) of this rule and/or a SMI as defined in paragraph (B)(11) of this rule.

(14) "Level II entities" refers to the state level II authorities which is the OhioMHAS and the Ohio department of developmental disabilities (DODD).

(15) "Level II" or "level II evaluation" refers to the in-depth evaluation of an individual that has been identified as having indications or suspected of having indications of a DD and/or a SMI as defined in paragraphs (B)(10) and (B)(11) of this rule by the level I screening outcome. The level II entity must confirm or disconfirm the existence of a DD and/or a SMI and make a written determination of the following:

(a) The individual's need or continued need for nursing facility services as defined in paragraph (B)(19) of this rule; and

(b) If the nursing facility is or continues to be the most appropriate setting to meet the individual's long-term care needs; and

(c) Identification and recommendation for specialized services as defined in paragraphs (B)(30) and/or (B)(31) of this rule, if any, that would be needed for the individual during the individual's nursing facility stay.

(16) "Long-term resident" means an individual who has continuously resided in a nursing facility or a consecutive series of nursing facilities and/or medicare skilled nursing facilities for at least thirty months prior to the first resident review determination in which the individual was found not to require the level of services provided by a nursing facility, but to require specialized services as defined in paragraphs (B)(30) and (B)(31) of this rule. The thirty months may include temporary absences for hospitalization, therapeutic leave, or visits with family or friends as defined in rule 5160-3-16.4 of the Administrative Code.

(17) "New admission" means the admission to an Ohio medicaid certified nursing facility of an individual:

(a) Who was not a resident of any nursing facility immediately preceding:

(i) The current nursing facility admission; or

(ii) A hospital stay for which the individual is to be admitted directly to a nursing facility;

(b) Seeking admission or admitted to a nursing facility from another state, regardless of prior residence; or

(i) Adverse level II or a resident review determination; or

(ii) Overruled appeal of an adverse level II determination.

(d) For PASRR purposes only and effective on the date the facility submits its application packet for medicaid certification to the Ohio department of medicaid, individuals seeking admission to, or who are currently residing in, a facility that is in the process of obtaining its initial medicaid certification by Ohio department of health, and

(e) With the exception of those circumstances specified in paragraphs (B)(17)(a) to (B)(17)(c) of this rule, nursing facility transfers and readmissions as defined in paragraphs (B)(20) and (B)(24) of this rule are not considered to be new admissions for the purposes of this rule.

(18) "Nursing facility" has the same meaning as in section 5111.20 of the Revised Code. A long term care facility that has submitted an application packet for medicaid certification to the Ohio department of medicaid is considered to be in the process of obtaining its initial medicaid certification by the Ohio department of health and shall be treated as a nursing facility for the purposes of this rule.

(19) "Nursing facility level of service" for the purposes of PASRR means a determination made by the DODD and/or OhioMHAS in accordance with rules 5123-14-01 and 5122-21-03 of the Administrative Code as required by section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019 that the individual's need for treatment does not exceed the level of services which can be delivered by the nursing facility to which the individual is seeking admission or is currently admitted to either through nursing facility services alone or, where necessary, through nursing facility services supplemented by specialized services provided by or arranged for by the state.

(20) "Nursing facility transfer." A nursing facility transfer occurs when an individual is transferred from any Ohio medicaid certified nursing facility to another Ohio medicaid certified nursing facility, with or without an intervening hospital stay.

(21) "Preadmission screening" refers to the level I screening as defined in paragraph (B)(13) of this rule and when applicable the completion of the level II evaluation as defined in paragraph (B)(15) of this rule that results in a PASRR determination from the DODD and/or OhioMHAS administered prior to the individuals admission to the nursing facility.

(22) "PASRR" means the preadmission screening and resident review of individuals for the purposes of identifying individuals with serious mental illness as defined in rule 5122-21-03 of the Administrative Code and/or a developmental disability as defined in rule 5123-14-01 of the Administrative Code and required by the "Social Security Act," 42 U.S.C 1396r(e)(7).

(23) "Physician" means a doctor of medicine or osteopathy who is licensed to practice medicine.

(24) "Readmission" means the individual is readmitted to the same nursing facility from a hospital to which he or she was sent for the purpose of receiving care.

(25) "Resident review " is a post admission level II evaluation as defined in paragraph (B)(15) of this rule that results in a determination for nursing facility residents which must be implemented upon a significant change in condition as defined in paragraph (B)(29) of this rule and in accordance with section 1919(e)(7) of the Social Security Act, as in effect on July 1, 2019, which must be implemented in accordance with rules 5160-3-15.2, 5122-21-03 and 5123-14-01 of the Administrative Code.

(26) "Respite nursing facility stay" means the admission of an individual to a nursing facility for a maximum of fourteen days in order to provide respite to in-home caregivers to whom the individual is expected to return following the respite stay.

(27) "Ruled out" means a determination made by the DODD and/or the OhioMHAS that the individual is not subject to further review. An individual may be ruled out at any time during the PASRR assessment when it is determined that the individual:

(a) Does not have a DD and/or SMI; or

(b) Has a primary diagnosis of dementia (including alzheimer's disease or a related disorder); or

(c) Has a non-primary diagnosis of dementia without a primary diagnosis that is a SMI, and does not have a diagnosis of a DD or a related condition.

(28) "Serious mental illness" means an individual meets the conditions described in rule 5122-21-03 of the Administrative Code.

(29) "Significant change of condition" means any major decline or improvement in the individual's physical or mental condition, as described in 42 C.F.R. 483.20, as in effect on July 1, 2019 and when at least one of the following criteria is met:

(a) There is a change in the individual's current diagnosis(es), mental health treatment, functional capacity, or behavior such that, as a result of the change, the individual who did not previously have indications of a SMI, or who did not previously have indications of a DD, now has such indications; or

(b) The change is such that it may impact the mental health treatment or placement options of an individual previously identified as having SMI and/or may result in a change in the specialized services needs of an individual previously identified as having a DD.

(30) "Specialized services for serious mental illness" means those services specified by the level II or the resident review determination for an individual with a SMI which are arranged by OhioMHAS in accordance with rule 5122-21-03 of the Administrative Code and may be provided under the behavioral health services as described in rules 5160-8-05 and 5160-27-02 of the Administrative Code, which when combined with services by the nursing facility, results in the continuous and aggressive implementation of an individualized plan of care in accordance with 42 CFR 483.120, as in effect July 1, 2019.

(31) 'Specialized services for developmental disabilities' means the services or supports specified by the level II or the resident review determination for an individual with a DD which is provided or arranged for by the county board of DD in accordance with rule 5123-14-01 of the Administrative Code.

History

Effective: December 30, 2019
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-15.1 Preadmission screening requirements for individuals seeking admission to nursing facilities.

(A) The purpose of this rule is to set forth the level I and level II preadmission screening requirements pursuant to section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019, to ensure that individuals seeking admission, as defined in rule 5160-3-15 of the Administrative Code, to a medicaid-certified nursing facility (NF) who have serious mental illness (SMI) and/or a developmental disability (DD) as defined in rules 5122-21-03 and 5123-14-01 of the Administrative Code are identified and not admitted to a NF unless a thorough evaluation indicates that such placement is appropriate and adequate services will be provided regardless of payor source.

(B) A level I screening as defined in rule 5160-3-15 of the Administrative Code is required:

(1) Prior to any new admission, as defined in rule 5160-3-15 of the Administrative Code, to a NF.

(2) Prior to a categorical determination, as defined in rule 5160-3-15 of the Administrative Code.

(3) When an individual is directly admitted to a NF from any of the following:

(a) A hospital that is maintained, operated, managed or governed by the Ohio department of mental health and addiction services (OhioMHAS) under section 5119.14 of the Revised Code for the care and treatment of mentally ill persons; or

(b) A free standing hospital, or unit of a hospital licensed by OhioMHAS under section 5119.33 of the Revised Code; or

(4) When a non Ohio resident is seeking admission to an Ohio NF from an out-of-state NF.

(a) If the non Ohio resident has been determined or suspected to have a SMI and/or DD by the other state, the other state's level II evaluation(s) of the individual and any additional supporting documentation should be submitted with the preadmission request.

(b) Submission of the required forms and documentation does not constitute completion of the level I process.

(c) The NF can not admit an individual until the PASRR screening process as defined in rule 5160-3-15 of the Administrative Code is complete and a determination for the individual is received by the NF pursuant to section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019.

(1) Level I will be administered by the Ohio department of medicaid (ODM) or its designee, OhioMHAS or its designee, the Ohio department of developmental disability (DODD) or its designee, social worker, professional counselor, hospital discharge planners or one of the professionals listed in paragraph (H)(6) of this rule.

(2) The level I has to be submitted via the electronic system designated by ODM.

(3) The submitter of the level I is responsible for gathering information from the individual, family, legal guardian and available medical records to ensure an accurate level I and, when applicable, level II determination outcomes.

(4) The submitter is expected to include any necessary supporting documentation within the electronic system designated by ODM for validation.

(5) The submitter of the level I has to certify that the level I information that is submitted is true, accurate and complete to the best of their knowledge. The absence of such certification by the submitter will result in an incomplete level I submission.

(6) For an individual seeking medicaid payment, the ODM approved level of care (LOC) assessment will be completed in accordance with rule 5160-3-14 of the Administrative Code, unless the individual is enrolled in a medicaid managed care plan as defined in rule 5160-26-01 of the Administrative Code.

(7) The NF is responsible for ensuring every individual residing in the NF has completed the PASRR screening process as defined in rule 5160-3-15 of the Administrative Code prior to NF admission.

(D) Level I screening outcomes.

(1) An individual will be considered to have indications of DD when the individual meets the criteria specified in rule 5123-14-01 of the Administrative Code or the individual receives services from a county board of DD.

(a) Individuals with indications of DD will be subject to further review by DODD in accordance with rule 5123-14-01 of the Administrative Code.

(b) Such individuals will not be considered to have completed the PASRR screening requirements as defined in rule 5160-3-15 of the Administrative Code until DODD has issued the level II determination pursuant to section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019 and in accordance with rule 5123-14-01 of the Administrative Code.

(2) An individual will be considered to have indications of a SMI when the individual meets the criteria specified in rule 5122-21-03 of the Administrative Code.

(a) Individuals with indications of a SMI shall be subject to further review by OhioMHAS, in accordance with rule 5122-21-03 of the Administrative Code.

(b) Such individuals will not be considered to have completed the PASRR screening process as defined in rule 5160-3-15 until OhioMHAS has issued the level II determination pursuant to section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019 and in accordance with rule 5122-21-03 of the Administrative Code.

(3) Individuals determined to have no indications of a SMI and/or DD are not subject to a level II evaluation.

(a) Such individuals are considered to have met PASRR screening requirements effective on the date an accurate and complete level I screening was submitted.

(b) The printed result letter generated via the electronic system designated by ODM is evidence of PASRR compliance.

(4) Individuals with indications of both SMI and DD will be subject to further review by both OhioMHAS and DODD in accordance with rules 5122-21-03 and 5123-14-01 of the Administrative Code. Such individuals will not be considered to have met PASRR screening requirements as defined in rule 5160-3-15 of the Administrative Code until both OhioMHAS and DODD have issued the level II determination.

(5) Any individual who has been determined by DODD or OhioMHAS to be ruled out, in accordance with rules 5122-21-03 and 5123-14-01 of the Administrative Code as defined in rule 5160-3-15 of the Administrative Code, is not subject to further PASRR review.

(E) ODM or its designee, OhioMHAS and/or DODD, are the only entities that have the authority to render level I screening result outcomes. The individual must not be admitted into the NF until prescreening requirements as defined in rule 5160-3-15 of the Administrative Code have been met pursuant to section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019.

(F) Categorical determination requirements.

(1) Consists of a level I with sufficient documentation that the individual meets one of the following categories:

(a) Emergency NF stay when the individual is temporarily admitted to a NF pending further assessment in emergency situations requiring protective services, not to exceed seven days; or

(b) Respite NF stay when the individual is being admitted to a NF for a maximum of fourteen days in order to provide respite to in-home caregivers to whom the individual is expected to return following the respite stay.

(2) A face to face assessment is not required for a categorical determination provided there is enough data to determine that the individual meets the categorical requirements.

(3) The NF has to submit the request for a categorical determination via the electronic system designated by ODM.

(4) The NF has to initiate a resident review as defined in rule 5160-3-15 of the Administrative Code for residents admitted under a categorical determination that require a stay longer than the specified time limit for the category.

(5) The NF can not admit an individual requesting a categorical determination until the NF receives a determination for the individual from the appropriate level II entity.

(G) Hospital discharge exemption requirements.

(1) An individual does not qualify for admission using the hospital discharge exemption unless:

(a) The individual is being admitted to a NF directly from an Ohio hospital or a unit of a hospital that is not operated by or licensed by OhioMHAS under section 5119.14 or section 5119.33 of the Revised Code, after receiving acute inpatient care at that hospital; or

(b) The individual is an Ohio resident seeking admission to a NF directly from an out-of-state hospital that is not an out-of-state psychiatric hospital or psychiatric unit within an out-of-state hospital, after receiving acute inpatient care at that hospital; and

(c) The individual requires the level of services provided by a NF for the condition for which he or she was treated in the hospital; and

(d) The individual's attending physician provides written certification that is signed and dated no later than the date of discharge from the hospital that the individual is likely to require the level of services provided by a NF for less than thirty days.

(2) The discharging hospital has to request a hospital discharge exemption via the electronic system designated by ODM.

(3) When the NF accepts the placement of the individual, the NF acknowledges that the individual meets the criteria described in paragraph (G) of this rule.

(4) The admitting NF is expected to maintain the hospital discharge exemption documentation in the resident's record at the NF.

(5) The NF has to initiate a resident review, as defined in rule 5160-3-15.2 of the Administrative Code, prior to the individual's thirtieth day in the NF when an individual requires a continued stay beyond thirty days.

(6) When an individual is admitted under the hospital discharge exemption and is subsequently admitted to a hospital or transfers to another NF during the first thirty days of the individual's NF stay, the days in the hospital or previous NF count towards the individual's thirty day hospital discharge exemption time period. A new hospital discharge exemption can not be granted during the existing exemption time period.

(7) When an adverse determination has been issued by OhioMHAS or DODD within the last sixty calendar days prior to the new NF admission, the individual is not eligible for a hospital discharge exemption. A level I screening has to be initiated in accordance with paragraph (C) of this rule.

(H) Level II evaluation and determination requirements.

(1) The new admission of an individual with a SMI or DD is not permitted unless the individual has either been determined, in accordance with rules 5122-21-03 and 5123:2-14-01 of the Administrative Code, to need the level of services provided by a NF, or qualifies for admission under the hospital discharge exemption provision set forth in paragraph (G) of this rule, regardless of the individual's payor source.

(2) Individuals determined by OhioMHAS and/or DODD not to meet NF level of service as defined in rules 5160-3-15, 5122-21-03 and 5123-14-01 of the Administrative Code will not be admitted and medicaid payment will not be available for NF services.

(3) The level II evaluation will be complete and determination made prior to any new admission of an individual to a NF in the process of obtaining its initial medicaid certification and NF provider agreement.

(4) For current residents of a facility in the process of obtaining its initial medicaid certification and NF provider agreement, the level II requirements have to be met prior to the effective date of the NF provider agreement between ODM and the newly certified NF or prior to the availability of medicaid payment for the medicaid eligible individual.

(5) The level II determinations are made by OhioMHAS and/or DODD in accordance with section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019.

(6) Before an adverse determination as defined in rule 5160-3-15 of the Administrative Code can be issued, both of the following conditions have to be met:

(a) A face-to-face, telephonic, or video conference assessment of the individual and a review of the medical records accurately reflecting the individual's current condition are performed by one of the following professionals within the scope of his/her practice:

(i) Medical doctor or doctor of osteopathic medicine;

(ii) Registered nurse (RN);

(iii) Master of science of nursing;

(iv) Clinical nurse specialist;

(v) Certified nurse practitioner;

(vi) Licensed social worker, under supervision of a licensed independent social worker (LISW);

(vii) Licensed independent social worker;

(viii) Professional counselor, under supervision of a licensed professional clinical counselor (PCC);

(ix) Professional clinical counselor;

(x) Psychologist;

(xi) Qualified mental health professional as defined in rule 5122-21-03 of the Administrative Code; or

(xii) Qualified intellectual disability professional; or

(xiii) Service and support administrator as defined in section 5126.15 of the Revised Code.

(b) Authorized personnel from OhioMHAS and DODD other than the personnel identified in paragraph (H)(6)(a) of this rule who have conducted the face-to-face, telephonic, or video conference assessment, have reviewed the assessment and, made the final determination regarding the need for NF services and specialized services.

(I) NF to NF transfer requirements.

(1) The admitting NF is responsible for ensuring that all individuals have met the PASRR screening requirements as defined in rule 5160-3-15 of the Administrative Code prior to entering the NF.

(2) The admitting NF will initiate a referral for a resident review as defined in rule 5160-3-15 of the Administrative Code for any individual transferred to its facility upon the discovery of a significant change in the individual's condition as defined in rule 5160-3-15 of the Administrative Code.

(3) The admitting NF is responsible for ensuring that copies of the resident's most recent level I screening results letter and, if applicable, level II evaluation and determination accompany the transferring resident.

(4) The admitting NF is expected to retain the written notification of the level II determinations received from the transferring NF in the individual's resident record at the facility.

(J) Level I and level II requests for additional information.

(1) ODM or its designee, OhioMHAS and/or DODD may request any additional information required in order to make a preadmission screening determination.

(2) When ODM or its designee, OhioMHAS and/or DODD need additional information in order to make the preadmission screening determination, they will provide written notice to the NF, the individual, the hospital, the referring entity, and the individual's representative, if applicable. This notice will specify the missing forms, data elements and other documentation needed to make the required determinations.

(3) In the event the individual and/or other entity does not provide the necessary information within fourteen calendar days, ODM or its designee, OhioMHAS and DODD is expected to provide written notice to the individual, the individual's guardian or authorized representative, if applicable, and the NF that the admission is not permitted due to failure to provide information necessary for the completion of the preadmission screening process and that the individual may appeal the determination in accordance with the provisions of division 5101:6 of the Administrative Code. The individual, regardless of payment source, cannot be admitted to the NF.

(4) When the individual or other entity submits the requested information within the timeframes specified in the notice, ODM or its designee, OhioMHAS and/or DODD will proceed with the preadmission screening process.

(K) An individual will undergo a new level I screening in accordance with the provisions of this rule when:

(1) The individual received a completed preadmission screening as defined in rule 5160-3-15 of the Administrative Code indicating that NF services are needed but the individual has not been admitted to a NF within one hundred eighty days of the most recent level II that was not a categorical determination, as defined in rule 5160-3-15 of the Administrative Code; or

(2) The individual received a categorical determination by OhioMHAS and/or DODD that NF services are needed and the individual has not been admitted to a NF immediately following discharge from a hospital setting, or within twenty fours hours from the date of the catergorical emergency determination, or within sixy days from the date of the categorical respite determination.

(L) Level I and level II notification and record retention.

(1) In accordance with all requirements specified in rule 5101:6-2-32 of the Administrative Code, ODM, or its designee, has to report the outcome of the level I to the individual, their guardian, or authorized representative, if applicable, the NF and the appropriate level II entity.

(2) In accordance with all requirements specified in rule 5101:6-2-32 of the Administrative Code, DODD and OhioMHAS will provide a printed copy of the level II determination to the individual, their guardian or authorized representative, if applicable, the individual's physician and the NF. The level II determination will contain notice of the individual's right to appeal an adverse determination made by the level II entities.

(3) When an adverse determination is issued, the facility will provide the individual, their guardian or authorized representative, if applicable, with notice of the intent to discharge in accordance with section 3721.16 of the Revised Code.

(4) The NF is expected to maintain a printed copy of the level I result notice and, if applicable, a printed copy of the level II determination received from OhioMHAS and DODD in the individual's resident record at the facility

(M) Preadmission screening compliance.

(1) NFs which, whether intentionally or otherwise, fail to accept any new admission, readmission, or NF transfers pursuant to this rule are in violation of their medicaid provider agreements. This is true regardless of the payment source for the individual's NF stay.

(2) PASRR level I screening and/or level II determinations will not be backdated.

(3) An adverse determination as the result of a preadmission evaluation performed by OhioMHAS or DODD may be appealed in accordance with division 5101:6 of the Administrative Code.

(4) Level II determinations made by OhioMHAS or DODD in accordance with section 1919(e)(7) of the Social Security Act, as in effect, July 1, 2019 cannot be overturned by ODM and/or Ohio department of health. Only appeal determinations made in accordance with division 5101:6 of the Administrative Code may overturn an adverse PASRR determination.

(5) Medicaid payment is not available for NF stays for individuals who are otherwise medicaid-eligible until the date on which the preadmission screening requirements as defined in rule 5160-3-15 of the Administrative Code have been met.

(6) ODM has authority to ensure compliance with the provisions of this rule, including but not limited to the following:

(a) Official notice to the NF of PASRR noncompliance;

(b) Development of a compliance corrective action plan;

(d) NF site visits;

(e) Recoupment of funds for number of days PASRR requirements were not met for the resident.

(7) NF, local administrators, hospitals and all state agencies and their designees will comply, with accuracy and timeliness, to all requests for records and compliance plans issued by ODM.

Last updated April 8, 2021 at 1:29 PM

History

Effective: April 2, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-15.2 Resident review requirements for individuals residing in nursing facilities.

(A) The purpose of this rule is to set forth resident review requirements in compliance with section 1919(e)(7) of the Social Security Act, as in effect on July 1, 2019, which prohibits nursing facilities (NF) from retaining individuals with serious mental illness (SMI) as defined in rule 5160-3-15 of the Administrative Code and/or developmental disabilities (DD) as defined in rule 5160-3-15 of the Administrative Code unless a thorough evaluation indicates that such placement is appropriate and adequate services are provided. A resident review will be completed whenever an individual experiences a significant change in condition as defined in rule 5160-3-15 of the Administrative Code and that change has a material impact on their functioning as it relates to their mental illness or developmental disability status.

(B) Resident review requirements.

(1) No individual with SMI or DD can be retained as a resident in a nursing facility (NF), regardless of payment source, unless it has been determined in accordance with rules 5122-21-03 and 5123:14-01 of the Administrative Code, that:

(a) The individual needs the level of services provided by a NF; or

(b) The individual had resided in a NF for at least thirty months at the time of the first resident review determination that established that the individual does not require the level of services provided by a NF, and

(i) Requires specialized services only; and

(ii) The individual has chosen to remain in a NF after being informed of service alternatives to NF placement.

(2) The NF will initiate and submit a resident review via the electronic system designated by ODM.

(3) The NF will include supporting documentation of the individual's current condition, including evidence of the individual's need for services in a NF, when submitting the resident review.

(4) The NF is responsible for the accurate and timely submission of the resident review request to the Ohio department of developmental disabilities (DODD) and/or Ohio department of mental health and addiction services (OhioMHAS) and for ensuring that a copy of the resident review determination is maintained in the resident's file in accordance with the provisions of this rule.

(1) The individual was admitted under the hospital discharge exemption as defined in rule 5160-3-15 of the Administrative Code, and has since been found to require more than thirty days of services at the NF. The resident review will be submitted no later than the twenty-ninth day from the date of admission; or

(2) The individual had been in a NF and was admitted directly into a different NF following an intervening hospital stay for psychiatric treatment, or was readmitted to the same NF directly following a hospital stay for psychiatric treatment. A resident review for a significant change in condition will be submitted within twenty-four hours of the individual's NF admission to a different NF or readmission to the same NF; or

(3) The individual has experienced a significant change in condition as defined in rule 5160-3-15 of the Administrative Code. The resident review will be submitted within seventy-two hours following identification of the significant change; or

(4) The individual was admitted as a result of a negative level I preadmission screening and there is subsequent evidence of possible, but previously unrecognized or unreported, SMI and/or DD; or

(5) The individual received a categorical determination as defined in rule 5160-3-15 of the Administrative Code, and has since been found to need a stay in a NF that will exceed the specified time limit for that category. Unless the individual meets the criteria for a resident review extension described in paragraph (F) of this rule, the resident review has to be submitted as soon as the NF has reason to believe the individual may need to remain in a NF beyond the expiration date of the categorical determination but no later than the expiration date of the categorical determination; or

(6) The individual received a resident review determination for a specified period of time as established by DODD or OhioMHAS and has since been found to need a stay in a NF exceeding the specified period of time. The resident review will be submitted at least thirty days prior to the expiration of the determination.

(D) Resident review outcomes.

(1) Individuals determined to have no indications of SMI or DD are not subject to further resident review.

(2) Individuals determined to have indications of SMI or DD will be subject to further resident review by the OhioMHAS or DODD in accordance with rules 5122-21-03 and 5123-14-01 of the Administrative Code.

(3) Individuals determined to have indications of both SMI and DD will not be considered to have completed the resident review process until both OhioMHAS and DODD have issued the resident review determinations.

(4) If an individual who is subject to a resident review has indications of SMI or DD and is discharged from the NF after submission of the resident review request, but prior to the determination, or prior to the due date for the request, the NF will notify OhioMHAS and/or DODD.

(5) Individuals previously determined by OhioMHAS and/or DODD to be ruled out from preadmission screening in accordance with rules 5122-21-03 and 5123-14-01 of the Administrative Code are not subject to further review.

(E) Resident review placement determinations.

(1) OhioMHAS and DODD may approve a determination that the level of services provided by the NF will meet the individual's long term needs and for an unspecified period of time.

(2) OhioMHAS and DODD may approve a determination that the level of services provided by a NF will meet the individual's short term needs and for a specified period of time.

(a) OhioMHAS and DODD may approve such a determination for no more than one hundred eighty days.

(b) Unless a resident review extension is requested and granted in accordance with paragraph (F) of this rule, the NF will initiate a resident review in accordance with paragraph (C)(4) of this rule when the individual stay exceeds the specified period of time.

(c) In conjunction with local entities, the NF will initiate and continue discharge planning activities throughout the period of time specified on the determination notice.

(F) Resident review extension request requirements.

(1) A resident review determination extension may be requested by the NF on behalf of an individual that received a resident review determination for a specified period of time as established by the DODD or OhioMHAS and is believed to need a stay in a NF exceeding the specified period of time.

(2) The NF will submit the resident review extension request for consideration directly to DODD or OhioMHAS for approval via the electronic system approved by ODM.

(3) Extension requests and approvals cannot exceed ninety days.

(4) In order to receive consideration for an extension to the initial determination, the NF will initiate a resident review at least thirty days prior to the expiration of the determination.

(a) The NF is responsible for the accurate and timely submission of the resident review extension request to DODD or OhioMHAS in accordance with the provisions of this rule.

(b) Resident review extension requests submitted after the expiration of the individual's determination are in violation of this rule and the NF will be considered out of compliance with PASRR requirements in accordance with this rule from the day after the expiration of specified date stated on the initial resident review until the day the resident review extension is subsequently approved if applicable, by DODD or OhioMHAS.

(c) DODD and OhioMHAS are expected to notify ODM in writing when instances specified in paragraph (F)(4)(b) of this rule occur.

(5) The NF will include supporting documentation of the individual's current condition including evidence of the individual's need for services in a NF past the specified period of time established by DODD and/or OhioMHAS when submitting the request for an extension.

(6) A request for an extension is expected to include documentation of discharge planning activities. The written record of discharge planning activities has to include the alternative settings and services explored and the steps taken to ensure that a safe and orderly discharge occurs.

(7) DODD and OhioMHAS will keep a record of all resident review extension requests received by NFs and approved or denied by DODD or OhioMHAS.

(8) DODD and OhioMHAS will submit a resident review extension summary in the form of a list to ODM on a monthly basis with the following information:

(a) Date extension request was received by DODD or OhioMHAS;

(b) Name of NF;

(d) Date of original specified resident review;

(e) The number of previous granted extensions and number of days currently being requested by the NF;

(f) Reason for extension; and

(g) Date of approval or denial of extension request.

(9) The NF is expected to maintain a printed copy of the resident review extension approval and all supporting documentation in the resident's record at the NF.

(G) NF to NF transfers:

(1) If an individual is to be transferred to another Ohio NF after submission of the resident review request but prior to receipt of the resident review determination:

(a) The transferring NF will notify the appropriate level II entity of the transfer. Written notice will be provided to the level II entity by the NF no later than the day the individual is transferred. The transferring NF is expected to provide sufficient contact information to enable the completion of the resident review process.

(b) At or prior to the time the individual is transferred, the transferring NF will provide the admitting NF with copies of all PASRR related documents pertaining to the individual and written notice of the individual's current PASRR status. If known, the notice should include contact information for the resident review evaluator assigned by OhioMHAS and DODD.

(c) The admitting NF cannot accept the individual as a NF transfer unless it receives this information at or prior to the time the individual is admitted to the NF.

(d) If the transferring individual is medicaid eligible at the time of the transfer, the transferring NF will also provide written notice of the transfer and the current PASRR status of the individual to ODM or its designee. Such notice will be provided no later than the date on which the individual is transferred.

(H) Resident review requests for additional information:

(1) OhioMHAS and DODD may request additional information necessary to make a resident review determination.

(2) If OhioMHAS or DODD request additional information to make the resident review determination, the agency will provide written notice to the NF, the individual, and the individual's representative, if applicable. This notice will specify the missing forms, data elements and other documentation needed to make the required determinations.

(3) In the event the individual or other entity does not provide the necessary information within fourteen calendar days, the agency that requested the information will provide written notice to the individual, the individual's representative, if applicable, and the NF that a continued stay in the NF is not permitted due to failure to provide information necessary for the completion of the resident review process and the individual may appeal the determination in accordance with the provisions of division 5101:6 of the Administrative Code.

(I) Resident review notification:

(1) In accordance with rule 5101:6-2-32 of the Administrative Code, the appropriate level II entity will provide written notification of all resident review determinations made.

(a) Such written notice will be provided to:

(i) The evaluated individual and his or her legal representative;

(ii) The NF in which the individual is a resident;

(iii) The individual's attending physician;

(iv) The individual's medicaid managed care plan, if applicable, as defined in rule 5160-26-01 of the Administrative Code.

(b) Such written notice has to include all of the following components:

(i) The determination as to whether and, when applicable, the estimated length of time the individual requires the level of services provided by a NF;

(ii) The determination as to whether the individual requires specialized services for SMI and/or DD;

(iii) The placement and/or service options that are available to the individual consistent with those determinations; and

(iv) The individual's right to appeal the determination(s).

(2) Upon receipt of the written notice of an adverse determination, the NF will provide the individual with notice of the intent to discharge. When an expiration date is specified in the written notice, the NF will provide the individual with notice of the intent to discharge at least thirty days prior to the expiration date.

(3) All individuals who are subject to a resident review and who do not meet the retention criteria set forth in paragraph (B)(1) of this rule will be discharged from the NF and relocated to an appropriate setting in accordance with section 3721.16 of the Revised Code.

(4) The NF will maintain a written record of discharge planning activities which will include the alternative settings and services explored and the steps taken to ensure that a safe and orderly discharge occurs.

(5) The NF will retain the written notification of the resident review determinations received from OhioMHAS and DODD in the resident's record at the facility.

(J) Medicaid payment for services.

(1) Medicaid payment is available for the provision of NF services to medicaid-eligible individuals subject to resident review only when the individual has met the criteria for retention set forth in paragraph (B)(1) of this rule.

(2) A resident review determination is not a level of care determination. Individuals seeking medicaid payment for the NF stay will meet the level of care requirements in accordance with Chapter 5160-3 of the Administrative Code.

(3) For medicaid eligible individuals, medicaid payment is available through the time period specified in the notice or during the period an appeal is in progress.

(4) When a resident review is not initiated by the NF within the timeframes specified in paragraph (C) of this rule, but is performed at a later date, medicaid payment is not available for services furnished to the eligible individual from the date the resident review was due through the date in which the resident review determination was received by the NF.

(K) Resident review compliance.

(1) NFs who fail to initiate a resident review or request a resident review extension pursuant to this rule are in violation of their medicaid provider agreements. This is true regardless of the payment source for the individual's NF stay.

(2) Adverse PASRR determinations may be appealed in accordance with division 5101:6 of the Administrative Code.

(3) Level II resident review determinations made by OhioMHAS or DODD in accordance with section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019 cannot be overturned by ODM or Ohio department of health. Only appeals determinations made in accordance with division 5101:6 of the Administrative Code may overturn an adverse PASRR determination.

(4) If the individual is subject to resident review and there is no record of the determination in the medical record and no indication that they are in progress, the NF will notify OhioMHAS and/or DODD.

(5) OhioMHAS and DODD will utilize criteria relating to the need for NF care or specialized services that is consistent with section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019, and the ODM approved state plan for medicaid, including criteria consistent with Chapter 5160-3 of the Administrative Code, in making their determinations whether individuals with SMI and/or DD meet the level of services provided by a NF.

(6) ODM has authority to ensure compliance with the provisions of this rule, including but not limited to the following:

(a) Official notice to the NF of PASRR noncompliance;

(b) Development of a compliance corrective action plan;

(d) NF site visits;

(e) Recoupment of funds for number of days PASRR requirements were not met for the resident in accordance with 42 C.F.R. 483.122.

History

Effective: December 30, 2019
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-16.3 Nursing facilities (NFs): private rooms.

(A) A NF may provide private room accommodations, if available, as follows:

(1) For a medicaid eligible resident if the resident requires a private room due to medical necessity such as the need for infection control or for therapeutic purposes; or

(2) Semi-private or ward accommodations are not available; or

(3) In accordance with sections 5165.01 and 5165.158 of the Revised Code.

(B) Reimbursement for private rooms

(1) Unless approved for a private room incentive payment pursuant to section 5165.158 of the Revised Code, medicaid payment for private rooms permitted under paragraphs (A)(1) and (A)(2) of this rule will be paid in accordance with section 5165.15 of the Revised Code.

(2) Private room incentive payments pursuant to section 5165.158 of the Revised Code will only be available to approved providers and will be paid an amount in addition to the total per medicaid day payment rate determined for the facility under section 5165.15 of the Revised Code.

(3) Except as otherwise provided herein, medicaid payment for private rooms is considered payment in full, and no supplemental payment may be requested or accepted from a resident or from a resident's authorized representative or family.

(4) Unless approved for a private room incentive payment pursuant to section 5165.158 of the Revised Code, if semiprivate or ward accommodations are available and are offered to a resident but the resident or the resident's representative or family member makes a written request for a private room, the private room will be considered a non-covered service for which the facility may seek supplemental payment from the resident or from the resident's authorized representative or family as follows:

(a) The supplemental payment amount will represent no more than the difference between the charge to a private pay resident for a semiprivate room and the charge to a private pay resident for a private room;

(b) The charge for the private room cannot include charges for services covered by medicaid, whether or not medicaid payment meets a NF's costs for the per diem services;

(c) A NF should detail both monthly and annual supplemental charges, if applicable, on a resident's statement of charges so that the additional cost of a private room is evident to the resident and to the resident's authorized representative and family;

(d) The written request for a private room will be kept in the resident's file; and

(e) The amount of any supplemental payment will not be considered when calculating the resident's patient liability.

(5) Medicaid bed hold payments for individuals in a private room approved by the department pursuant to section 5165.158 of the Revised Code will be paid in accordance with section 5165.34 of the Revised Code. The private room incentive payment will not be used in determining the bed hold payment rate.

(1) Application process

The following information is to be submitted to the Ohio department of medicaid (department) by a NF seeking a private room incentive payment to demonstrate that the room meets the prerequisites identified in section 5165.158 of the Revised Code:

(a) Application in the form and manner prescribed by the department.

(b) List of all NF rooms and their corresponding number of beds, designating the rooms for which private room incentive payment approval is requested and identifying which rooms are category one and category two private rooms as defined in section 5165.158 of the Revised Code.

(c) Floor plan of the entire facility which identifies and shows the location of each private room with the designated room number and designated bathroom. Arrows should indicate the path between each resident room and the bathroom and each resident room and the hallway.

(d) Documentation evidencing the private room meets the criteria in paragraph (C)(2) of section 5165.158 of the Revised Code.

(e) Attestation in the form and manner prescribed by the department that the information submitted by the facility is accurate and truthful.

(2) Approval process

Applications will be held in a pending status in the order received until the centers for medicare and medicaid services (CMS) approves the private room incentive payments and the department determines a NF is qualified for the private room incentive payment.

(a) The department will review all applications and supporting information to determine if a NF is eligible to receive the incentive payment for private rooms.

(b) Additional information may be requested by the department to ensure a NF's eligibility. NFs will have ten business days from the date of the request to provide this additional information. Failure to submit the requested information within ten business days will invalidate the original application submission. NFs with invalidated applications may reapply.

(d) Eligible applications will be approved in the order received until the funding limit identified in the Revised Code is reached.

(e) A NF that is approved will receive written authorization from the department including the effective date for the approval.

(f) If a private room is created by surrendering beds, adding space to the NF, or renovating non-bedroom space, the surrender, addition, or renovation, whichever is applicable, does not have to be completed at the time of application but will need to be completed before an application will be approved by the department.

(3) Reconsideration

(a) A NF that submits an application that is denied in full or in part by the department may request a reconsideration.

(i) If an application is approved in part and denied in part, a reconsideration request will proceed on the denied portion only. The approved portion may proceed and is not held pending the outcome of the reconsideration on the denied portion,

(ii) Denied applications or parts of applications will be held in a pending status in the order received until the conclusion of the reconsideration process.

(b) The reconsideration will be conducted by the department director, assistant director, or deputy director over the area where the contestation arose, or their designee, provided the person conducting the reconsideration was not involved in the original decision.

(c) The denial decision will include information about deadlines and supporting documentation needed for submission of the reconsideration.

(i) Deadlines will be no fewer than thirty days from the date on the notice of the denial decision.

(ii) Reconsideration requests and supporting documentation received after the deadline may be considered at the department's discretion.

(d) Reconsideration decisions will not be further reconsidered.

(4) Change of operator.

If a NF notifies the department of its intent to change operator and an application for private room incentive payments is in a pending status, the new operator will not need to reapply and will maintain the NF's order in the pending status. The new operator will need to attest that the original information submitted by the NF is true and accurate and disclose any information that is different from the original application submission.

Last updated June 26, 2025 at 1:18 AM

History

Effective: September 9, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-16.4 Nursing facilities (NFs): covered days and bed-hold days.

(A) Definitions.

(1) "Home and community-based services" (HCBS) means services that enable individuals to live in a community setting rather than in an institutional setting such as a NF, an intermediate care facility for individuals with intellectual disabilities (ICF-IID), or a hospital.

(2) "Hospitalization" means transfer of a NF resident to a medical institution as defined in paragraph (A)(4) of this rule. A NF resident is considered hospitalized if the resident is formally admitted to a medical institution, or is on observation status in a medical institution.

(3) "Institution for mental disease" (IMD) means a hospital, NF, or other institution of more than sixteen beds that is engaged primarily in the diagnosis, treatment, and care of persons with mental diseases, and that provides medical attention, nursing care, and related services. An institution is determined to be an IMD when its overall character is that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such.

(4) "Medical institution" means an institution other than a NF that meets all of the following criteria:

(a) Is organized to provide medical care, including nursing and convalescent care.

(b) Has the necessary professional personnel, equipment, and facilities to manage the medical, nursing, and other health care needs of patients on a continuing basis in accordance with accepted standards.

(d) Is staffed by professional personnel who are responsible to the institution for professional medical and nursing services. Professional medical and nursing services shall include all of the following:

(i) Adequate and continual medical care and supervision by a physician.

(ii) Registered nurse or licensed practical nurse supervision and services sufficient to meet nursing care needs.

(iii) Nurses' aid services sufficient to meet nursing care needs.

(iv) A physician's guidance on the professional aspects of operating the institution.

(5) "NF admission" means the act that allows an individual who was not considered a resident of any Ohio medicaid certified NF during the time immediately preceding their current NF residence to officially enter a facility to receive NF services. This may include former NF residents who have exhausted their bed-hold days while in the community and/or hospital and returned to the facility. A NF admission may be a new admission or a return admission after an official discharge. A NF admission is distinguished from the readmission of a resident who has not exhaused all bed-hold days..

(6) "NF bed-hold day," also referred to as "NF leave day," means a day for which a bed is reserved for a NF resident while the resident is temporarily absent from the NF for hospitalization, therapeutic leave days, or visitation with friends or relatives. Payment for NF bed-hold days may be made only if the resident has the intent and ability to return to the same NF. A resident on NF bed-hold day status is not considered discharged from the NF.

(7) "NF discharge" means the full release of a NF resident from the facility, allowing the resident who leaves the facility to no longer be counted in the NF's census. Reasons for NF discharge include but are not limited to the resident's transfer to another facility, exhaustion of NF bed-hold days, decision to reside in a community-based setting, or death.

(8) "NF occupied day" means one of the following:

(a) A day of admission or readmission.

(b) A day during which a medicaid eligible resident's stay in a NF is eight hours or more, and for which the facility receives the full per resident per day payment directly from medicaid in accordance with Chapter 5165. of the Revised Code.

(9) "NF readmission" means the status of a resident who is readmitted to the same NF following a stay in a hospital to which the resident was sent to receive care, or the status of a resident who returns after a therapeutic program or visit with friends or relatives. A NF resident can only be readmitted to a facility if that individual was not officially discharged from the facility during that NF stay.

(10) "NF therapeutic leave day" means a day that a resident is temporarily absent from a NF with intent and ability to return, and is in a residential setting other than a long-term care facility, hospital, or other entity eligible to receive federal, state, or county funds to maintain a resident, for the purpose of receiving a regimen or program of formal therapeutic services.

(11) "NF transfer" means the events that occur when a person's place of residence changes from one Ohio medicaid certified NF to another, with or without an intervening hospital stay. However, when the person has an intervening IMD admission, or when the person is discharged from a NF during a hospital stay due to exhaustion of available NF bed-hold days and is admitted to a different NF immediately following that hospital stay, the change of residence is not considered a NF transfer.

(12) "Skilled nursing facility" (SNF) means a facility certified to participate in the medicare program.

(B) Prohibition of preadmission NF bed-hold payment.

(1) The Ohio department of medicaid (ODM) shall not make payment to reserve a bed for a medicaid eligible prospective NF resident.

(2) A NF provider shall not accept preadmission bed-hold payments from a medicaid eligible prospective NF resident or from any other source on the prospective resident's behalf as a precondition for NF admission.

To determine whether a specific day during a resident's stay is payable as a NF bed-hold day or a NF occupied day, the following criteria shall be used:

(1) The day of NF admission or readmission counts as one occupied day.

(2) The day of NF discharge is not counted as either a bed-hold or an occupied day.

(3) When NF admission and NF discharge occur on the same day, the day is considered a day of admission and counts as one occupied day, even if the day is less than eight hours.

(4) The day a resident leaves on bed-hold status counts as one occupied day for payment purposes if the resident is in the NF for eight hours or more. A day begins at twelve a.m. and ends at eleven fifty-nine p.m.

(D) Limits and payment for NF bed-hold days.

(1) For medicaid eligible residents in a certified NF, except those described in paragraph (K) of this rule, ODM shall pay the NF provider to reserve a bed only for as long as the resident intends to return to the facility, but for not more than thirty days in any calendar year, and only if the requirements of paragraph (D)(3) of this rule are met.

(2) According to section 5165.34 of the Revised Code, payment for NF bed-hold days shall be as follows:

(a) Fifty per cent of the NF provider's per diem rate if the facility had an occupancy rate in the preceding calendar year exceeding ninety-five per cent; or

(b) Eighteen per cent of the NF provider's per diem rate if the facility had an occupancy rate in the preceding calendar year of ninety-five per cent or less.

(3) Payment for NF bed-hold days according to paragraph (D)(2) of this rule shall be considered payment in full, and the NF provider shall not seek supplemental payment from the resident.

(4) Payment for NF bed-hold days shall be made for the following reasons:

(a) Hospitalization.

NF bed-hold days used for hospitalization of NF residents, including NF residents on HCBS waivers, shall be authorized only until:

(i) The day the resident's anticipated level of care (LOC) at the time of NF discharge from the hospital changes to a LOC that the NF provider is not certified to provide; or

(ii) The day the resident is discharged from the hospital, including discharge resulting in transfer to another hospital-based or free-standing NF or SNF; or

(iii) The day the resident decides to go to another NF upon discharge from the hospital and notifies the first NF provider; or

(iv) The day the hospitalized resident dies.

(b) NF therapeutic leave days.

(i) Any plan to use therapeutic leave days must be approved in advance by the resident's primary physician and documented in the resident's medical record. The documentation shall be available for viewing by the county department of job and family services (CDJFS) and ODM staff.

(ii) A NF provider shall make arrangements for the resident to receive required care and services while on approved therapeutic leave, but medicaid shall not pay for care and services that are included in medicaid's continued payments, including but not limited to home health care, personal care services, durable medical equipment (DME), and private duty nursing.

(iii) NF therapeutic leave days are not payable for NF residents who are on an HCBS waiver and do not count towards the annual leave day limit specified in this rule.

(i) Any plan for a limited absence to visit with friends or relatives must be approved in advance by the resident's primary physician and documented in the resident's medical record. The documentation shall be available for viewing by the CDJFS and ODM staff.

(ii) The number of days per visit is flexible within the maximum NF bed-hold days, allowing for differences in the resident's physical condition, the type of visit, and travel time.

(iii) The NF provider shall make arrangements for the resident to receive required care and services while on approved visits, but medicaid shall not pay for care and services that are included in medicaid's continued payments, including but not limited to home health care, personal care services, DME, and private duty nursing.

(iv) Leave days for visits with friends or relatives are not payable for NF residents who are on an HCBS waiver and do not count towards the annual leave day limit specified in this rule.

(5) The number and frequency of NF bed-hold days used shall be considered in evaluating the continuing need of a resident for NF care.

(E) Submission of claims for NF bed-hold days.

A NF provider shall submit claims for NF bed-hold days electronically to ODM in accordance with rule 5160-3-39.1 of the Administrative Code.

(F) NF admission after depletion of NF bed-hold days.

(1) A resident who leaves a facility and has already exhausted their bed-hold days is considered in a NF discharge status.

(2) A NF provider shall establish and follow a written policy under which a medicaid resident who has expended their annual allotment of thirty NF bed-hold days, and therefore is no longer entitled to a reserved bed under the medicaid bed-hold limit, and is considered to be discharged, shall be admitted to the first available medicaid certified bed in a semiprivate room.

(a) The first available bed means the first unoccupied bed not being held by a resident (regardless of the source of payment) who has elected to make payment to hold that bed.

(b) Unless involuntary discharge hearing and notice requirements were issued as set forth in section 3721.16 of the Revised Code for the previous admission span, a resident shall be admitted to the first available medicaid certified bed in a semiprivate room even if the resident has an outstanding balance owed to the NF provider from the previous admission. The admitted NF resident may be discharged if the NF provider can demonstrate that nonpayment of charges exists, and if hearing and notice requirements have been issued as set forth in section 3721.16 of the Revised Code.

(3) A medicaid eligible NF resident whose absence from the facility exceeds the bed-hold limit or for whom no bed-hold coverage is available may choose to do one of the following:

(a) Return to the NF upon the availability of the first semiprivate bed in the facility.

(b) Ensure the timely availability of a specific bed upon return to the facility by making bed-hold payments for any days of absence in excess of the medicaid limit or for which no bed-hold coverage is available. Such payment is separate and distinct from the prohibition of any third party payment guarantee as set forth in rule 5160-3-02 of the Administrative Code.

(4) A medicaid eligible resident's NF bed-hold day rights extend only to situations in which the resident leaves the NF for hospitalization, therapeutic leave days, or visits with friends or relatives, and has the intent and ability to return to the same NF.

(a) If a resident who has depleted medicaid covered NF bed-hold days is transferred from a NF to a hospital and then undergoes a NF transfer to a second NF because the second NF provider offers services the first NF provider does not, the first NF provider has no obligation to admit the resident.

(b) If a resident who has depleted medicaid NF bed-hold days is admitted from a NF to a hospital and then is transferred to a hospital-based NF or SNF, the type of NF or SNF to which the resident is transferred does not change the requirements stated in paragraph (F) of this rule. Therefore, a resident transfer to a hospital-based NF or SNF shall be considered the same as a transfer to any other NF or SNF, and the first NF provider has no obligation to admit the resident.

(5) NF admission following the depletion of bed-hold days during a prior stay and subsequent NF discharge requires that a resident has a NF LOC and is eligible for medicaid NF services.

(G) Information and notice prior to leave.

(1) Prior to a resident's use of NF bed-hold days, a NF provider shall furnish the resident and their family member or legal representative written information about the facility's bed-hold policies, which shall be consistent with paragraph (F) of this rule.

(2) At the time a resident is scheduled for a temporary leave of absence, a NF provider shall furnish the resident and their family member or legal representative a written notice that specifies all of the following:

(a) The maximum duration of medicaid covered NF bed-hold days as described in this rule.

(b) The duration of bed-hold status during which the resident is permitted to return to the NF.

(d) The resident's option to make payments to hold a bed beyond the medicaid bed-hold day limit, and the amount of such payments.

(H) Emergency hospitalization.

(1) In the case of emergency hospitalization, a NF provider shall furnish the resident and a family member or legal representative a written notice as described in paragraph (G) of this rule within twenty-four hours of the hospitalization.

(2) This requirement is met if the resident's copy of the notice is sent to the hospital with other documents that accompany the resident.

(I) Maximum number of NF bed-hold days.

(1) Medicaid payment for covered NF bed-hold days is considered payment for reserving a bed for a resident who intends to return to the same NF and is able to do so.

(2) The number of NF inpatient days as defined in section 5165.01 of the Revised Code for the calendar year shall not exceed one hundred per cent of available bed days.

(J) Residents eligible for payment of NF bed-hold days.

(1) Medicaid payment for NF bed-hold days is available under the provisions specified in this rule if a resident meets all of the following criteria:

(a) Is eligible for medicaid services and has met the patient liability and financial eligibility requirements as stated in rule 5160:1-3-04.3 of the Administrative Code.

(b) Requires a NF LOC or is using medicare part A SNF benefits as described in paragraph (J)(2) of this rule.

(c) Is not a participant of special medicaid programs or assigned special status as outlined in paragraph (K) of this rule.

(2) Dual eligible for both medicare and medicaid.

(a) If a resident meets all of the criteria in paragraph (J)(1) of this rule and is both medicare part A and medicaid eligible, medicaid payment shall be made for NF bed-hold days up to the bed-hold day limit specified in this rule. Medicaid will, therefore, pay NF bed-hold days during the acute care hospitalization of a medicaid eligible resident who had been receiving medicare part A SNF benefits in the NF immediately prior to and/or following the period of hospitalization.

(b) A level of care evaluation is not necessary in the following circumstances:

(i) A medicaid eligible resident receives medicare part A SNF benefits in the NF.

(ii) A medicaid eligible resident who receives medicare part A SNF benefits in the NF is transferred to the hospital, and the NF bills the hospital bed-hold days to medicaid.

(3) Medicaid pending.

If a resident meets all of the criteria in paragraph (J)(1) of this rule, and is pending approval of a medicaid application and requires NF bed-hold days, medicaid payment shall be made retroactive to the date the resident became medicaid eligible and approved for NF medicaid payment, through the date the resident returns from a leave or until the maximum number of NF bed-hold days are exhausted.

(4) Medicaid eligible.

If a resident meets all of the criteria in paragraph (J)(1) of this rule, and is approved for NF medicaid payment, medicaid payment shall be made for NF bed-hold days up to the maximum number of days as specified in this rule. Medicaid eligible residents include low resource utilization residents for whom medicaid payment is made in accordance with section 5165.152 of the Revised Code.

(5) HCBS waiver.

If a resident using the NF for a short-term stay is enrolled in an HCBS waiver program and is not using short-term respite care as a waiver service, medicaid payment shall be made for NF bed-hold days for hospitalization up to the bed-hold day limit specified in this rule. Payment for NF bed-hold days shall not be made for NF residents who are on an HCBS waiver for purposes other than hospitalization.

(K) Exclusions.

NF bed-hold days are not available to medicaid eligible NF residents in the following situations:

(1) Hospice.

A person enrolled in a medicare or medicaid hospice program is not entitled to medicaid covered NF bed-hold days. It is the hospice provider's responsibility to contract with and pay the NF provider. Hospice program provisions and criteria are stated in Chapter 5160-56 of the Administrative Code.

(2) IMD.

A resident age twenty-one and over, and in some circumstances age twenty-two and over, and under age sixty-five who becomes a patient of an IMD is not entitled to NF bed-hold days, and a NF provider shall not receive reimbursement for NF bed-hold days during the period the person is hospitalized in an IMD except as permitted in 42 C.F.R. 438.6(e) (October 1, 2016).

(3) HCBS waiver.

NF bed-hold days do not apply to a person enrolled in a HCBS waiver program who is using the NF for short-term respite care as a waiver service.

(4) Restricted medicaid coverage.

A person who is medicaid eligible but is in a period of restricted medicaid coverage because of an improper transfer of resources is not eligible for NF bed-hold days until the period of restricted coverage has been met. The criteria for the determination of restricted medicaid coverage are specified in rule 5160:1-3-07.2 of the Administrative Code.

(5) Facility closure and resident relocation.

NF bed-hold days are not available to residents who have relocated due to the facility's anticipated closure, voluntary withdrawal from participation in the medicaid program, or other termination of the facility's medicaid provider agreement. No span of NF bed-hold days shall be approved that ends on a facility's date of closure or termination from participation in the medicaid program.

(L) Compliance.

(1) Without limiting such other remedies provided by law for noncompliance with the provisions of this rule, ODM may do one or both of the following:

(a) Require the provider to submit and implement a corrective action plan approved by ODM on a schedule specified by ODM.

(b) Terminate the facility's NF provider agreement.

(2) A NF provider shall cooperate with any investigation and shall provide copies of any records requested by ODM.

Last updated February 9, 2024 at 1:18 PM

History

Effective: August 17, 2017
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-16.5 Nursing facilities (NFs): personal needs allowance (PNA) accounts and other resident funds.

A NF resident's rights concerning his or her personal financial affairs shall be in accordance with 42 CFR 483.10 (October 4, 2016).

(A) Definitions.

(1) "Personal needs allowance (PNA) account" means an account or petty cash fund that holds the money of a NF resident and is managed for the resident by the NF provider.

(2) "Letters of administration," also known as letters testamentary, means court papers allowing a person to take charge of the property of a deceased person in order to distribute it.

(3) "Surety bond" means an agreement between the principal (i.e., the NF provider), the surety (i.e., the insurance company), and the obligee (i.e., the resident and/or the Ohio department of medicaid (ODM) acting on behalf of the resident), wherein the principal and the surety agree to compensate the obligee for any loss of the obligee's funds that the principal holds, safeguards, manages, and accounts for.

The purpose of a surety bond is to guarantee that a NF provider will pay a resident, or ODM on behalf of a resident, for losses occurring from any failure by the facility to hold, safeguard, manage, and account for the resident's funds, including losses incurred as a result of acts of error or negligence, incompetence, or dishonesty. The principal assumes the responsibility to compensate the obligee for the amount of the loss up to the entire amount of the surety bond.

(B) PNA.

(1) A medicaid resident who receives care in a NF certified to participate in the medicaid program is eligible to retain a PNA account for the purchase of items and services of his or her choice.

(2) The PNA account is the exclusive property of the resident, who may use the funds in the account as he or she chooses to meet personal needs.

(3) Unless a medicaid resident receives additional irregular contributions from another source, all of his or her personal expenses shall be met through the PNA account.

(1) A NF resident has the right to manage his or her personal financial affairs.

(2) A NF provider shall not require a resident to deposit his or her PNA funds with the provider. However, if a resident requests assistance from the NF staff in managing his or her PNA account, the request shall be in writing.

(3) Upon written authorization from a resident, a NF shall hold, safeguard, manage, and account for a resident's PNA funds deposited with the provider.

(4) A NF provider shall explain verbally and in writing to the resident or the resident's representative that PNA funds are for the resident to use as he or she chooses. If a representative is the payee for the resident's PNA account, the representative shall be responsible for ensuring that the money is used to meet the personal needs of the resident.

(D) Deposit of PNA account funds and interest earned.

(1) Funds of fifty dollars or less.

If a resident's PNA account funds are fifty dollars or less, a NF provider may deposit the funds in an interest-bearing account, a non-interest bearing account, or a petty cash fund.

(2) Funds in excess of fifty dollars.

If a resident's PNA account funds are in excess of fifty dollars, the NF provider shall deposit the funds in an interest-bearing account (or accounts) that is separate from any of the NF provider's operating accounts within five banking days from the date the balance exceeds fifty dollars.

(3) A NF provider shall credit any interest earned on a resident's PNA funds to the resident's PNA account balance. If pooled accounts are used, the provider shall prorate interest per resident on the basis of actual earnings or end-of-quarter balance.

(4) A NF provider shall not charge a resident a fee for managing the resident's PNA account. Banks, however, may charge the resident a fee for handling the account.

(E) Accounting and records.

(1) A NF provider shall establish and maintain a system that ensures full, complete, and separate accounting of each resident's PNA account funds.

(2) A NF provider shall not commingle a resident's accounts or funds with the provider's accounts or funds, or with the accounts or funds of any individual other than another NF resident.

(3) A NF provider shall provide a resident with access to petty cash (less than fifty dollars) on an ongoing basis and shall arrange for the resident to access larger funds (fifty dollars or more). A NF provider shall give residents a receipt for every transaction, and the NF provider shall retain a copy.

(4) A NF provider shall obtain a resident's signature upon the resident's receipt of PNA funds. If the resident is unable to sign his or her name, he or she shall acknowledge receipt of the money by marking an "X." Two persons shall verify through signature that they have witnessed the resident's action.

(5) A NF provider shall maintain an individual ledger account of revenue and expenses for each PNA account managed by the facility. The ledger account shall meet all the following criteria:

(a) Specify all funds received by or deposited with the NF provider. For PNA account funds deposited in banks, monies shall be credited to the resident's bank account within three business days; and

(b) Specify the dates and reasons for all expenditures; and

(c) Specify at all times the balance due the resident, including interest earned as last reported by the bank to the provider; and

(d) Be available to the resident or the resident's representative for review.

(6) Upon request, a NF provider shall provide receipts to a resident or the resident's representative for purchases made with the resident's PNA funds.

(7) Within thirty days after the end of the quarter, a NF provider shall provide a written quarterly statement to each resident or resident's representative of all financial transactions made by the provider on the resident's behalf.

(F) Notification of certain balances or transactions that may affect medicaid eligibility.

(1) Notice to resident.

(a) A NF provider shall give written notification to each resident who receives medicaid benefits, and whose funds are managed by the NF provider, when the amount in the resident's PNA account reaches two hundred dollars less than the supplemental security income resource limit specified in section 1611(a)(3)(A) or section 1611(a)(3)(B) of the Social Security Act.

(b) The notice shall inform the resident that he or she may lose medicaid eligibility if the amount in his or her PNA account, in addition to the value of the other nonexempt resources, reaches the resource limit amount.

(2) Notice to the county department of job and family services (CDJFS).

(a) A NF provider shall report to the CDJFS any PNA account balance in excess of the resource limit. The CDJFS shall apply the excess amount to the routine cost of NF care.

(3) If a resident is considering using PNA funds to purchase life insurance, grave space, a burial account, or other item that may be considered a countable resource, the NF provider shall refer the resident or the resident's representative to the CDJFS for an explanation of the effect the purchase may have on the resident's medicaid eligibility.

(G) Release of funds upon discharge.

(1) Upon discharge of a resident, a NF provider shall release all the resident's funds, up to and including the maximum resource limit amount.

(2) Other than for items and services that the resident has requested and that may be charged to the resident's PNA account in accordance with this rule, a NF provider shall not withhold PNA account funds to pay any outstanding balance a resident owes the provider at the time of discharge.

(H) Conveyance of funds upon death.

(1) First thirty days.

A NF provider shall not retain the money in a resident's PNA account beyond thirty days following the resident's death if letters testamentary or letters of administration are issued, or an application for release from administration is filed under section 2113.03 of the Revised Code concerning the resident's estate within that thirty-day period. In these circumstances, the provider shall transfer the funds in the resident's PNA account and a final accounting of those funds to the administrator, executor, commissioner, or person who filed the application for release from administration. If these conditions for release are not met, the provider shall follow paragraph (H)(2) or (H)(3) of this rule.

(2) First sixty days.

If, within sixty days after a resident's death, letters testamentary or letters of administration are issued, or an application for release from administration is filed under section 2113.03 of the Revised Code concerning the resident's estate, the provider shall transfer the resident's PNA account funds and a final accounting of those funds to the administrator, executor, commissioner, or person who filed the application for release from administration.

(3) After sixty days.

(a) If, within sixty days after a resident's death, letters testamentary or letters of administration concerning the resident's estate are not issued, or an application for release from administration is not filed under section 2113.03 of the Revised Code concerning the resident's estate, and if the resident was a recipient of medicaid benefits, the provider shall transfer all the resident's PNA account funds to ODM no earlier than sixty and no later than ninety days after the death of the resident, with the exception listed in paragraph (H)(3)(c) of this rule.

(b) PNA account funds transferred to ODM shall be paid by check or money order made payable to "Attorney General's Office" and shall be accompanied by a completed ODM 09405 (rev. 4/2017) entitled "Personal Needs Allowance (PNA) Account Remittance Notice." The payment and completed ODM 09405 shall be mailed to the Ohio attorney general's office.

(c) If funeral and/or burial expenses for a deceased resident have not been paid, and all the resident's resources other than the PNA have been exhausted, the resident's PNA account funds shall be used to pay the funeral and/or burial expenses.

(d) If, sixty-one or more days after a resident dies, letters testamentary or letters of administration are issued, or an application for release from administration under section 2113.03 of the Revised Code is filed concerning the resident's estate, ODM shall transfer all the resident's PNA account funds received by the department to the administrator, executor, commissioner, or person who filed the application for release from administration, unless ODM is entitled to recover the money under section 5162.21 of the Revised Code.

(I) Financial security.

A NF provider shall purchase a surety bond or provide a reasonable alternative as described in this rule in order to protect all resident funds deposited with and managed by the NF provider.

(1) Surety bond.

(a) A surety bond shall be executed by a licensed surety company pursuant to Chapters 1301., 1341., and 3929. of the Revised Code.

(b) At a minimum, surety bond coverage shall protect at all times the full amount of resident funds deposited with the NF provider, including interest earned and refundable deposit fees.

(c) The surety bond shall provide for repayment of funds lost due to any failure of the NF provider, whether by commission, bankruptcy, omission, or otherwise, to hold, safeguard, manage, and account for resident funds.

(d) The surety bond shall designate either the NF provider, or ODM on behalf of the resident, as the obligee.

(e) If an entity purchases a surety bond that covers more than one of its facilities, the surety bond shall protect the full amount of all resident funds on deposit in all the entity's facilities.

(2) Reasonable alternative to the surety bond.

A reasonable alternative to the surety bond shall provide protection equivalent to that afforded by a surety bond. Neither self insurance nor deposit of funds in bank accounts protected by the federal deposit insurance corporation (FDIC) or a similar entity are acceptable alternatives to a surety bond. A NF provider electing not to purchase a surety bond shall submit a proposal for an alternative to ODM for approval. An acceptable alternative shall meet all of the following criteria:

(a) At a minimum, protect at all times the full amount of resident funds deposited with the NF provider, including interest earned and refundable deposit fees; and

(b) Designate either ODM or the residents of the NF as the entity or entities that will collect payment for lost funds; and

(c) Guarantee repayment of funds lost due to any failure of the NF provider, whether by commission, bankruptcy, omission, or otherwise, to hold, safeguard, manage, and account for resident funds; and

(d) Be managed by a third party unrelated in any way to the NF provider or its management; and

(e) Not name the NF provider as a beneficiary.

(3) Provision of assurance to ODM.

A NF provider or entity that operates multiple facilities shall submit copies of either the multi-facility surety bond or a reasonable alternative to the multi-facility surety bond to ODM upon request for review and approval. If the NF provider, surety company, or issuer of an ODM-approved surety bond alternative cancels the surety bond or reasonable alternative to a surety bond, they shall notify ODM by certified mail thirty days prior to the effective date of cancellation.

(J) Limitations on charges to the PNA account.

(1) A NF provider shall not charge a resident's PNA account for items and services that the provider is required to furnish in order to participate in the medicare and medicaid programs, and that are included in medicare and medicaid payments made to the provider.

(2) A NF provider shall inform residents of the coverage and limitations of the medicare and medicaid programs. If a resident's representative is the payee for the resident's PNA account, the NF provider shall also explain the coverage and limitations to the representative.

(3) A NF provider shall not use a resident's PNA account funds to pay for costs associated with guardianship proceedings, including but not limited to the costs for assessments, medical exams, and filing fees.

(K) Items and services covered by medicare or medicaid.

(1) A NF provider shall not charge a resident's PNA account for items and services that the provider is required to furnish in order to participate in the medicare and medicaid programs.

(2) Items and services that may not be purchased with PNA account funds include, but are not limited to, the following:

(a) Nursing services; and

(b) Dietary services; and

(d) Room and bed maintenance services; and

(e) Routine personal hygiene items and services required to meet the needs of the resident, including but not limited to hair hygiene supplies, comb, brush, bath soap, disinfecting soap or specialized cleansing agents when indicated to treat special skin problems or to fight infection, razor, shaving cream, toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss, moisturizing lotion, tissues, cotton balls, deodorant, incontinence care supplies, sanitary napkins and related supplies, towels, washcloths, hospital gowns, over the counter drugs, hair and nail hygiene services, bathing, and basic personal laundry; and

(f) Medically related social services; and

(g) Medical supplies such as irrigation trays, catheters, drainage bags, syringes, and needles; and

(h) Durable medical equipment; and

(i) Air conditioners, or charges to residents for the use of electricity; and

(j) Therapy or podiatry services; and

(k) Charges for telephone consultation by physicians or other personnel.

(L) Resident requests for items and services.

(1) A NF provider shall not charge a resident's PNA account for any item or service not requested by the resident, whether or not the item or service is requested by a physician.

(2) A NF provider shall not require a resident or the resident's representative to request an item or service as a condition for admission to or continued stay in the NF.

(3) When a resident requests an item or service for which a charge to the resident's PNA account will be made, the NF provider shall inform the resident that there will be a charge and the amount of the charge.

(M) Items and services that may be charged to the PNA account.

(1) If a resident clearly expresses a desire for a particular brand or item not available from the NF provider, PNA funds may be used as long as a comparable item of reasonable quality is available to the resident from the NF provider at no charge. The NF provider may charge the resident only the difference in cost between the available item and the resident's preferred item.

(2) Items and services that may be charged to a resident's PNA account include, but are not limited to, the following:

(a) Telephone, including a cellular phone; and

(b) Television, radio, personal computer, or other electronic device for personal use; and

(d) Cosmetics and grooming items and services in excess of those for which payment is made under the medicaid or medicare programs, including hair cuts, permanent waves, hair coloring, and relaxing performed by barbers and beauticians; and

(e) Personal reading material; and

(f) Stationary or stamps; and

(g) Personal clothing; and

(h) Specialty laundry services such as dry cleaning, mending, or hand-washing; and

(i) Flowers or plants; and

(j) Gifts purchased on behalf of a resident; and

(k) Non-covered special care services such as privately hired nurses or nurse aides; and

(l) Social events or entertainment offered outside the scope of the NF provider's activities program; and

(m) Private rooms, except when therapeutically required for infection control or similar reasons; and

(n) Specially prepared or alternative food requested instead of food generally prepared by the NF provider; and

(o) Burial plots.

(N) Monitoring.

The CDJFS is responsible for monitoring PNA accounts. At least annually, a designated CDJFS employee shall determine if a NF provider is following the provisions of this rule, and shall report any questions concerning inappropriate use or inadequate record keeping of PNA funds to ODM and to the Ohio department of health (ODH) for further action. Inappropriate use of PNA account funds by a payee or a NF provider does not, however, reduce the scope or duration of medicaid benefits for a medicaid recipient.

Last updated June 26, 2025 at 3:29 AM

History

Effective: October 16, 2017
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-18 Nursing facilities (NFs): ventilator program.

(A) Purpose.

In accordance with section 5165.157 of the Revised Code, this rule establishes an alternative purchasing model for the provision of nursing facility (NF) services to ventilator dependent individuals which may include ventilator weaning.

(B) Definitions.

For purposes of this rule the following definitions apply:

(1) "Discrete unit" means an area in a NF that is set aside from the larger facility. A discrete unit may be a separate building, wing, floor, hallway, one side of a corridor, or a room or group of rooms. Beds in the unit may be utilized for individuals who are not ventilator dependent provided that the NF can accommodate all the ventilator dependent individuals covered under this rule and as required by this rule.

(2) "ODM NF ventilator program" means the ventilator services, which may include ventilator weaning services, provided to ventilator dependent individuals by a NF in accordance with this rule, where the NF is eligible to receive an enhanced payment rate for providing those services.

(3) "Respiratory care professional" (RCP) means the same as in division (B) of section 4761.01 of the Revised Code.

(4) "Ventilator-associated pneumonia (VAP)" means pneumonia in an individual intubated and ventilated at the time of, or within forty-eight hours before, the onset of the pneumonia.

(5) "VAP baseline rate" means the average of a NF's VAP rate for a fiscal year calculated by ODM using the data from the submission of quarterly reports for the most recent full calendar year beginning January first and ending December thirty-first.

(6) "VAP threshold rate" means a maximum number of VAP episodes determined by ODM based on the VAP baseline rates for all NFs statewide.

(7) "VAP rate" means the number of VAP episodes occurring in the NF per one-thousand ventilator days.

(8) "Ventilator dependent" means the use of any type of mechanical ventilation to sustain daily respiration for any part of the day.

(9) "Ventilator weaning" means the gradual withdrawal of ventilator support.

(10) "Ventilator weaning services" means the services provided to support the individual resident's ventilator weaning and includes a post ventilator weaning evaluation period of up to fourteen days.

In order to qualify as an ODM NF ventilator program provider and receive an enhanced payment rate for providing ventilator services or ventilator weaning services, a NF shall meet all of the following criteria:

(1) Be a licensed and medicaid certified NF and meet the requirements for NFs in accordance with 42 U.S.C. 1396r (10/19/2018).

(2) Provide services to individuals who are ventilator dependent and have medicaid as their primary payer.

(3) Comply with the provisions in Chapters 5164. and 5165. of the Revised Code regarding provider agreements, and with the provisions in rules 5160-3-02 to 5160-3-02.2 of the Administrative Code regarding execution and maintenance of provider agreements between ODM and the operator of a NF.

(4) Cooperate with ODM or its designee during all provider oversight and monitoring activities including but not limited to:

(a) Being available to answer questions pertaining to the ODM NF ventilator program.

(b) Providing necessary requested documentation.

(5) Designate a discrete unit within the NF for the use of individuals in the ODM NF ventilator program. If there is a change in the size or location of the designated discrete unit or number of beds in the discrete unit, the NF shall notify ODM of the change via email to nfpolicy@medicaid.ohio.gov within five business days of the change.

(6) Have ventilators connected to emergency outlets, which are connected to an on site backup generator in an amount sufficient to meet the needs of the ventilator dependent individuals.

(7) Have not been in the centers for medicare and medicaid services (CMS) special focus facility (SFF) program for the previous six months.

(a) A NF participating in the ODM NF ventilator program that becomes a SFF must notify ODM of the SFF status within one business day of receipt of the CMS SFF letter via email to nfpolicy@medicaid.ohio.gov and attach a copy of the letter.

(b) Any individuals participating in the ODM NF ventilator program at the time a NF becomes an SFF shall remain as participants in the ODM NF ventilator program. The NF shall not admit new individuals to the ODM NF ventilator program until the NF has been graduated from the SFF program for a period of six consecutive months. At that time, the NF must submit a new request to participate in the ODM NF ventilator program in accordance with paragraph (D) of this rule. The NF may begin admitting new individuals to the ODM NF ventilator program after the NF receives notice of approval by ODM.

(8) Provide all of the following services:

(a) For at least five hours per week, the services of an RCP or the services of a registered nurse (RN) who has worked for a minimum of one year with ventilator dependent individuals. The RCP or the RN as applicable, shall provide direct care to the ventilator dependent individuals.

(b) If ordered by a physician, initial assessments for physical therapy, occupational therapy, and speech therapy within forty-eight hours of receiving the order for a ventilator dependent individual.

(c) If ordered by a physician, up to two hours of therapies per day, six days per week for each ventilator dependent individual.

(d) In emergency situations as determined by a physician, access to laboratory services that are available twenty-four hours per day, seven days per week with a turnaround time of four hours.

(e) For new admissions, administer pain medications to a ventilator dependent individual within two hours from the receipt of the physician order.

(9) Have an approved ODM 10198, "Addendum To ODM Provider Agreement: Nursing Facility Ventilator Program" ()(12/2018).

(D) Request to participate in the ODM NF ventilator program.

(1) A NF who wishes to participate in the ODM NF ventilator program shall email a completed ODM 10227 "Request to Participate in the ODM Nursing Facility Ventilator Program" (12/2018) to nfpolicy@medicaid.ohio.gov. The request shall demonstrate that the NF is capable of fulfilling all of the requirements specified in this rule, including ventilator weaning services if requested. ODM may request additional information regarding a NF's qualifications to participate.

(2) ODM will respond to a request via return email within ten business days of receipt of the request. If the request is approved, ODM will provide the ODM 10198 for the NF to complete and submit to ODM.

(3) If the request to participate in the ODM NF ventilator program is not approved, the NF may request a reconsideration by the medicaid director or designee within thirty calendar days of receipt of the non-approval via email to nfpolicy@medicaid.ohio.gov. The decision of the director or designee regarding the reconsideration shall be final.

(4) The ODM 10227 shall be re-submitted to, and re-approved by ODM, as part of each subsequent provider agreement revalidation unless the provider chooses to withdraw from the ODM NF ventilator program or is determined by ODM to no longer meet the eligibility requirements as set forth in paragraph (C) of this rule and, if applicable, paragraph (E) of this rule. ODM will respond to a request via return email within ten business days of receipt of the request. If the request is approved, ODM will provide the ODM 10198 for the NF to complete and submit to ODM. If the request to participate is not approved, the NF shall follow the information in paragraph (D)(3) of this rule.

(5) In the case of a change of operator (CHOP), if the exiting provider participated in the ODM NF ventilator program and the entering provider wishes to continue to participate in the program, the entering provider should submit the ODM 10227 to nfpolicy@medicaid.ohio.gov. Notwithstanding rule 5160-3-65.1 of the Administrative Code, if the ODM 10227 is submitted within sixty days of the effective date of the CHOP and ODM approves the ODM 10198, the entering provider is eligible to receive the enhanced rate or rates retroactive to the effective date of the CHOP or the date the requirements to participate in the NF ventilator program are met, whichever occurs later. If the ODM 10227 is not submitted within sixty days of the effective date of the CHOP but ODM approves the ODM 10198, the entering provider is eligible to receive the enhanced rate or rates effective on the date of ODM approval. If there is no approved ODM 10198, the entering provider's participation in the ODM NF ventilator program shall cease effective on the effective date of the CHOP.

(E) Ventilator weaning services.

NFs that are approved to participate in the NF ventilator program may provide ventilator weaning services if they meet the following criteria:

(1) Have an approved ODM 10198 with approval to provide ventilator weaning services.

(2) Have a ventilator weaning protocol in place established by a physician trained in pulmonary medicine who is available by phone twenty-four hours per day seven days per week while ventilator weaning services are provided.

(3) Have an RCP with training in basic life support on-site eight hours per day seven days per week and available by phone during the remaining hours of the day while ventilator weaning services are provided.

(4) Have a registered nurse or RCP with training in basic life support on-site twenty-four hours per day seven days per week while ventilator weaning services are provided.

(F) ODM NF ventilator program payment rate.

(1) The total per medicaid day payment rate determined under section 5165.15 of the Revised Code shall not be paid for NF services provided under the ODM NF ventilator program. Instead, the total per medicaid day payment rate for services provided by a NF under the NF ventilator program for each state fiscal year shall be as follows:

(a) For ventilator weaning services, sixty per cent of the statewide average of the total per medicaid day payment rate for those individuals receiving ventilator services in a long-term acute care hospital for the prior calendar year. Payment at the enhanced ventilator weaning rate is limited to ninety days per calendar year per individual, and includes a post ventilator weaning evaluation period of up to fourteen days.

(b) For ventilator only services, fifty per cent of the statewide average of the total per medicaid day payment rate for those individuals receiving ventilator services in a long-term acute care hospital for the prior calendar year.

(2) Prior to the establishment of the VAP threshold rate, NFs participating in the ODM NF ventilator program will receive the rate described in paragraph (F)(1)(a) of this rule for ventilator weaning services and paragraph (F)(1)(b) of this rule for ventilator only services, of this rule.

(3) ODM shall notify NFs via the Ohio department of medicaid website no later than July first of each year of each NF's specific VAP baseline rate, the VAP threshold rate, and the ODM NF ventilator program payment rates that shall be effective for the state fiscal year.

(4) Once ODM has calculated a NF's VAP baseline rate and the VAP threshold rate, for any quarter thereafter in which a NF's VAP rate exceeds the VAP threshold rate, ODM shall notify the NF via email that a plan of action is required and a deadline for its submission to ODM.

(a) If the NF elects not to timely submit a plan of action, ODM shall follow the termination process in paragraph (I)(2) of this rule.

(b) If the NF elects to submit a plan of action, the NF shall submit the plan to ODM via email to nfpolicy@medicaid.ohio.gov within fifteen calendar days of the date on the ODM notification email regarding the required plan of action and shall include:

(i) A description of the NF's investigation of both avoidable and unavoidable factors contributing to their quarterly VAP rate being higher than the VAP threshold rate.

(ii) Specific interventions to reduce the NF's VAP rate.

(iii) A completion date for the plan of action which shall be within sixty days of sending the plan of action via email to ODM.

(c) Within ten business days of receipt of a plan of action, ODM will review the plan and make one of the following decisions:

(i) Approve the plan and notify the NF via return email of the approval. The NF shall submit to ODM a statement of completion of their plan of action within fifteen calendar days of their completion date via email to nfpolicy@medicaid.ohio.gov.

(ii) Disapprove the plan and notify the NF via return email of the disapproval and the deficiencies identified in their plan of action. If the NF elects not to submit a revised plan of action, ODM shall follow the termination process in paragraph (I)(2) of this rule.

(iii) If the NF elects to submit a revised plan of action, the NF shall submit the revised plan to ODM via email to nfpolicy@medicaid.ohio.gov within fifteen calendar days of the date on the ODM notification email regarding the disapproval.

(a) Within ten business days of receipt of a revised plan of action, ODM will review the revised plan and make one of the following decisions:

(i) Approve the revised plan and notify the NF via return email of the approval. The NF shall submit to ODM a statement of completion of their revised plan of action within fifteen calendar days of their completion date via email to nfpolicy@medicaid.ohio.gov.

(ii) Disapprove the revised plan and notify the NF via return email of the disapproval. ODM may decide a NF is no longer eligible to participate in the ODM NF ventilator program. In such cases ODM shall follow the termination process in paragraph (I)(2) of this rule.

(d) If the VAP rate exceeds the VAP threshold rate for two consecutive quarters, ODM may reduce the ODM NF ventilator program payment rates for both ventilator only services and ventilator weaning services by a maximum of five per cent. The reduced ODM NF ventilator program payment rate or rates if ventilator weaning services are provided, will become effective during the next full quarter following report submission, and shall remain in effect for that entire quarter.

(i) ODM shall notify the NF via certified mail return receipt requested of the reduced payment rate and the applicable quarter.

(ii) Within thirty days of receiving receipt of the reduced payment rate or rates if ventilator weaning services are provided, the NF may request a reconsideration by the medicaid director or designee via email to nfpolicy@medicaid.ohio.gov. The decision of the director or designee regarding the reconsideration shall be final.

(5) If an individual is no longer ventilator dependent, the per medicaid day payment rate for that individual shall be the rate determined under section 5165.15 of the Revised Code beginning the first day the individual is no longer ventilator dependent or at the conclusion of the post ventilator weaning evaluation period, whichever is later.

(6) Except in the case of a CHOP as described in paragraph (D)(5) of this rule, NFs without a current approved ODM 10198 shall be paid the total per medicaid day payment rate determined under section 5165.15 of the Revised Code.

(G) Bed-hold days.

Bed-hold days for individuals receiving services under the ODM NF ventilator program shall be paid at the NF's per medicaid day payment rate for reserving beds determined under section 5165.34 of the Revised Code.

(H) Quarterly reports.

(1) ODM NF ventilator program providers shall submit ODM 10228 "Nursing Facility Quarterly Ventilator Program Report" (12/2018) to ODM on a calendar quarter basis. The reporting period end date is the last day of each calendar quarter. The quarterly report is due to ODM by day twenty-five of the month after the reporting period end date. A provider does not have to submit quarterly reports if the provider had no ventilator dependent residents during the reporting period.

(2) Quarterly reports shall be submitted to ODM via secure email to nfpolicy@medicaid.ohio.gov.

(I) Ensuring providers meet ODM NF ventilator program eligibility requirements.

(1) ODM shall biannually select a random sample of the total of all ODM NF ventilator program providers, and shall review their compliance with all of the eligibility requirements of this rule as specified in paragraph (C) and paragraph (E) of this rule if the NF provides ventilator weaning services.

(2) ODM shall terminate a NF from the ODM NF ventilator program if ODM determines that the NF has failed to meet the requirements of this rule.

(a) If a NF fails to continue to meet the requirements in paragraph (E) of this rule but meets the requirements in paragraph (C) of this rule, ODM will terminate the NF's ability to provide ventilator weaning services and to receive the enhanced rate for ventilator weaning in accordance with paragraph (F)(1)(a) of this rule. The NF may continue to provide ventilator only services and to receive the enhanced rate for ventilator only services in accordance with paragraph (F)(1)(b) of this rule, as long as the eligibility requirements in paragraph (C) of this rule are met.

(b) ODM shall notify the provider of the termination via certified mail return receipt requested.

(c) Within thirty calendar days of receipt of termination, the NF may request a reconsideration by the medicaid director or designee. The decision of the director or designee regarding the reconsideration shall be final.

(3) If, at the time of revalidation of the medicaid provider agreement, a request to sign a new provider agreement addendum is not approved, ODM shall terminate the NF from the program.

(a) ODM shall notify the NF via certified mail return receipt requested.

(b) Within thirty calendar days of receipt of the termination, the NF may request a reconsideration by the medicaid director or designee. The decision of the director or designee regarding the reconsideration shall be final.

(J) Change in services.

A NF that chooses to no longer provide ventilator weaning services or to no longer participate in the ODM NF ventilator program under this rule shall do one of the following:

(1) If the NF is not providing services to any individual under the NF ventilator program and chooses to no longer participate in the NF ventilator program:

(a) The NF shall send notice to ODM via email to nfpolicy@medicaid.ohio.gov.

(b) The notice shall include a statement that the facility no longer chooses to participate in the NF ventilator program and the desired date of withdrawal.

(2) If the NF no longer chooses to provide ventilator weaning services under the NF ventilator program but chooses to continue to participate in the NF ventilator program:

(a) The NF shall send notice to ODM via email to nfpolicy@medicaid.ohio.gov.

(b) The notice shall include a statement that the facility no longer chooses to provide ventilator weaning services but chooses to continue to participate in the NF ventilator program.

(d) The written notice will serve as a modification to the NF's approved ODM 10198.

(3) If the NF is providing services, which may include ventilator weaning services, and chooses to withdraw from the NF ventilator program:

(a) At least sixty days before the last day of participation in the ODM NF ventilator program, the NF shall send notice of the withdrawal to ODM via email to nfpolicy@medicaid.ohio.gov.

(b) The notice shall include a statement that the NF chooses to withdraw from the ODM NF ventilator program and the last date the NF will participate in the program.

(c) If the NF decides to discharge current ventilator dependent individuals, the NF shall discharge in accordance with rule 3701-61-03 of the Administrative Code. If the NF decides to retain current ventilator dependent individuals, the per medicaid day payment rate shall be the rate determined under section 5165.15 of the Revised Code beginning the day after the last date of participation in the ODM NF ventilator program.

(d) The written notice will serve as official termination of the NF's approved ODM 10198.

Last updated September 15, 2026 at 4:31 PM

History

Effective: December 31, 2020
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-19 Nursing facilities (NFs): relationship of NF services to other covered medicaid services.

This rule identifies covered services generally available to medicaid recipients and describes the relationship of such services to those provided by a NF. Whenever reference is made to payment for services through the NF per diem, the rules governing such payment are set forth in Chapter 5160-3 of the Administrative Code.

(A) Acupuncture services.

All covered acupuncture services provided by an eligible acupuncture provider are paid directly to the provider of acupuncture services in accordance with rule 5160-8-51 of the Administrative Code.

(B) Behavioral health services.

Costs for behavioral health services are paid directly to the provider of services, not through the NF per diem.

All covered dental services provided by licensed dentists are paid directly to the provider of the dental services in accordance with Chapter 5160-5 of the Administrative Code. Personal hygiene services related to dental services provided by facility staff or contracted personnel are paid through the NF per diem.

(D) Laboratory and x-ray services.

Costs incurred for the purchase and administration of tuberculin tests, and for drawing specimens and forwarding specimens to a laboratory, are paid through the NF per diem. All costs of laboratory and x-ray procedures covered under the medicaid program are paid directly to the laboratory or x-ray provider in accordance with Chapter 5160-11 of the Administrative Code.

(E) Medical supplier services.

In accordance with rule 5160-10-02 of the Administrative Code, costs of certain medical supplies are paid through the NF per diem, and others are paid directly to the medical supply provider as follows:

(1) Items that must be paid for through the NF per diem include:

(a) "Medical supplies," defined as those items that have a very limited life expectancy, such as atomizers, nebulizers, bed pans, catheters, hypodermic needles, syringes, incontinence pads, splints, and disposable ventilator circuits.

(b) "Needed medical equipment" (and repair of such equipment), defined as items that can stand repeated use, are primarily and customarily used to serve a medical purpose, are not useful to an individual in the absence of illness or injury, and are appropriate for use in the facility. Such medical equipment items include hospital beds, wheelchairs other than custom wheelchairs, and intermittent positive-pressure breathing machines, except as noted in paragraph (E)(2) of this rule.

(2) Items for which payment is made directly to the provider include:

(a) Ventilators.

(b) "Prostheses," defined as devices that replace all or part of a body organ to prevent or correct physical deformity or malfunction, such as artificial arms or legs, electro-larynxes, and breast prostheses.

(c) "Orthoses," defined as devices that assist in correcting or strengthening a distorted part, such as arm braces, hearing aids and batteries, abdominal binders, and corsets.

(d) Contents of oxygen cylinders or tanks, including liquid oxygen; oxygen producing machines (concentrators) for specific use by an individual recipient; and costs of equipment associated with oxygen administration, such as carts, regulators/humidifiers, cannulas, masks, and demurrage.

(F) Pharmaceuticals.

(1) Costs for over-the-counter drugs, including selected over-the-counter drugs set forth in paragraph (I) of rule 5160-9-03 of the Administrative Code, and nutritional supplements are paid through the NF per diem.

(2) Pharmaceuticals for which payment is made directly to the pharmacy provider are subject to the limitations found in Chapter 5160-9 of the Administrative Code, the limitations established by the Ohio state board of pharmacy, and the following conditions:

(a) When new prescriptions are necessary following expiration of the last refill, the new prescription may be ordered only after the physician examines the patient.

(b) A copy of all records regarding prescribed drugs for all patients must be retained by the dispensing pharmacy for at least six years. A receipt for drugs delivered to a NF must be signed by the facility representative at the time of delivery and a copy retained by the pharmacy.

(G) Physical therapy, occupational therapy, speech therapy, and audiology services.

Costs incurred for physical therapy, occupational therapy, speech therapy and audiology services provided by licensed therapists or therapy assistants are paid through the NF per diem.

(H) Physician services.

(1) Physician services are not paid through the NF per diem rate. Except as provided in paragraph (H)(2) of this rule, payment is made directly to a physician for covered services he or she provides to a resident of a NF.

(2) In accordance with rule 5160-4-06 of the Administrative Code, services provided in the capacity of overall medical direction are payable only to a NF provider. Payment for such services may not be made directly to a physician.

(3) Physician visits must be provided to a resident of a NF and must conform to the following schedule:

(a) The resident must be seen by a physician at least once every thirty days for the first ninety days after admission, and at least once every sixty days, thereafter.

(b) A physician visit is considered timely if it occurs not later than ten days after the date the visit was required.

(i) Review the resident's total program of care including medications and treatments, at each required visit;

(ii) Write, sign, and date progress notes at each visit; and

(iii) Sign and date all orders except influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications; and

(d) Physician delegation of tasks.

(i) A physician may delegate tasks to a physician assistant or an advanced practice registered nurse (APRN), as defined in Chapter 4723-8 of the Administrative Code and Chapter 4723. of the Revised Code for APRNs, and in Chapter 4730. of the Administrative Code for physician assistants, who are in compliance with the following criteria:

(a) Are acting within the scope of practice as defined by state law.

(b) APRNs are practicing with a standard care arrangement entered into with each physician with whom the APRN collaborates in accordance with section 4723.431 of the Revised Code. A copy of the standard care arrangement shall be retained on file at each NF where the nurse practices.

(c) Physician assistants are practicing with a supervision agreement with a physician in accordance with section 4730.19 of the Revised Code. A copy of the supervision agreement shall be retained on file at each NF where the physician assistant practices.

(ii) At the option of the physician, required physician visits may be delegated in accordance with 42 C.F.R. 483.30.

(iii) A physician may not delegate a task when regulations specify that the physician must perform it personally, or when delegation is prohibited by state law or the facility's own policies.

(4) In accordance with rule 5160-1-18 of the Administrative Code, physician visits may be provided via telehealth.

(5) Services payable directly to the physician, physician assistant, or APRN must:

(a) Be requested by the NF resident, with the exception of required physician visits; and

(b) Be documented by entries in the resident's medical records along with any symptoms and findings. Every entry must be signed and dated by the applicable physician, physician assistant, or APRN.

(I) Podiatry services.

Costs of covered services provided by licensed podiatrists are paid directly to the authorized podiatric provider in accordance with Chapter 5160-7 of the Administrative Code.

(J) Respiratory therapy services.

Costs incurred for physician-ordered administration of aerosol therapy that is rendered by a licensed respiratory care professional are paid through the NF per diem. No payment for respiratory therapy services shall be made to a provider other than the NF through the NF per diem.

(K) Transportation services.

Payment for transporting residents by ambulance or wheelchair van to receive medical services is made directly to the transportation supplier in accordance with Chapter 5160-15 of the Administrative Code. Transportation of residents to receive medical services when the resident does not require an ambulance or wheelchair van is paid through the NF per diem.

(L) Vision care services.

All costs for covered vision care services, including examinations, dispensing, and the fitting of eyeglasses, are paid directly to authorized vision care providers in accordance with Chapter 5160-6 of the Administrative Code.

History

Effective: December 31, 2020
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-20 Nursing facilities (NFs) : medicaid cost report filing, disclosure requirements, and records retention.

In addition to the provisions contained in sections 5165.10 to 5165.109 of the Revised Code, the following provisions apply.

(A) For reporting purposes NFs shall use the chart of accounts for NFs as set forth in rule 5160-3-42 of the Administrative Code, or relate its chart of accounts directly to the cost report.

(B) Unless an extension is granted by the Ohio department of medicaid (ODM), NF cost reports should be filed electronically within ninety days after the end of the reporting period via the medicaid information technology system (MITS) web portal or other electronic means designated by ODM.

(1) For good cause shown, cost reports may be submitted within fourteen days after the original due date if written approval is received from ODM prior to the original due date of the cost report. Requests for extensions should be in writing and explain the circumstances resulting in the need for an extension.

(2) In the case of a NF that has a change of operator during a calendar year, the cost report by the new provider should cover the portion of the calendar year following the change of operator encompassed by the first day of participation up to and including December thirty-first.

(3) In the case of a NF that begins participation after January first and ceases participation before December thirty-first of the same calendar year, the reporting period should be the first day of participation to the last day of participation.

(4) Unless waived by ODM, the reporting period ends as follows:

(a) On the last day of the calendar year for a facility's year end cost report; or

(b) On the last day of medicaid participation or when the facility closes in accordance with paragraph (A)(1) of rule 5160-3-02 of the Administrative Code; or

(5) If a cost report is not received by the original due date, or by an approved extension due date if applicable, the provider may be assessed a late file penalty for each day a complete and adequate cost report is not received. The late file penalty may be assessed even if ODM has provided written notice of termination to a facility.

(a) The late file penalty is determined using the prorated medicaid days paid in the late file period multiplied by the penalty. The penalty is two dollars per patient day.

(b) The late file penalty period begins on the day after the original due date or on the day after the extension due date, whichever is applicable, and continues until the complete and adequate cost report is received by ODM or the facility is terminated from the medicaid program.

(c) The late file penalty is a reduction to the medicaid payment. No penalty is imposed during a fourteen-day extension granted by ODM.

(C) The desk review is a process of reviewing information pertaining to the cost report without detailed verification and is designed to identify problems warranting additional review.

(1) A facility may revise the cost report within sixty days after the original due date without the revised information being considered an amended cost report.

(2) The cost report is considered accepted after the cost report has passed the desk review process.

(3) After final rates have been issued, a provider that disagrees with a desk review decision may request a rate reconsideration.

(D) ODM shall not charge interest under division (B) of section 5165.41 of the Revised Code based on any error or additional information that is not required to be reported.

(E) Cost reports shall be completed using accrual basis accounting and generally accepted accounting principles unless otherwise specified in Chapter 5160-3 of the Administrative Code.

(F) Providers should identify all known related parties as set forth under paragraph (F) of rule 5160-3-01 of the Administrative Code.

(G) Providers should identify all of the following:

(1) Each known individual, group of individuals, or organization not otherwise publicly disclosed who owns or has common ownership as set forth under paragraph (F) of rule 5160-3-01 of the Administrative Code, in whole or in part, any mortgage, deed of trust, property or asset of the facility; and

(2) Each corporate officer or director, if the provider is a corporation; and

(3) Each partner, if the provider is a partnership; and

(4) Each provider, whether participating in the medicare or medicaid program or not, which is part of an organization which is owned, or through any other device controlled, by the organization of which the provider is a part; and

(5) Any director, officer, manager, employee, individual, or organization having five per cent or more direct or indirect ownership or control of the provider, or who has been convicted of or pleaded guilty to a civil or criminal offense related to his involvement in programs established by Title XVIII (December 9, 2019), Title XIX (December 9, 2019), or Title XX (December 9, 2019) of the Social Security Act; and

(6) Any individual currently employed by or under contract with the provider, or related party organization, as defined under paragraph (F) of rule 5160-3-01 of the Administrative Code, in a managerial, accounting, auditing, legal, or similar capacity who was employed by ODM, the Ohio department of health, the office of attorney general, the office of the auditor of state, the Ohio department of aging, the Ohio department of developmental disabilities, the Ohio department of commerce, or the industrial commission of Ohio within the previous twelve months.

(H) Providers are required to provide upon request all contracts in effect during the cost report period for which the cost of the service from any individual or organization is ten thousand dollars or more in a twelve-month period; or for the services of a sole proprietor or partnership where there is no cost incurred and the imputed value of the service is ten thousand dollars or more in a twelve-month period.

(1) For purposes of this rule, "contract for service" is defined as the component of a contract that details services provided exclusive of supplies and equipment. It includes any contract that details services, supplies, and equipment to the extent the value of the service component is ten thousand dollars or more within a twelve-month period.

(2) For purposes of this rule, "subcontractor" is defined as any entity, including an individual or individuals, that contracts with a provider to supply a service, either to the provider or directly to the beneficiary, where medicaid reimburses the provider the cost of the service. This includes organizations related to the subcontractor that have a contract with the subcontractor for which the cost or value is ten thousand dollars or more in a twelve-month period.

(I) Financial, statistical and medical records (which shall be available to ODM or its authorized agent and to the U.S. department of health and human services and other federal agencies) supporting the cost reports or claims for services rendered to residents shall be retained for the greater of seven years after the cost report is filed if ODM issues an audit report, or six years after all appeal rights relating to the audit report are exhausted.

(1) Failure to retain the required financial, statistical, or medical records, renders the provider liable for monetary damages that are the greater of the following:

(a) One thousand dollars per audit; or

(b) Twenty-five per cent of the amount by which the undocumented cost increased the medicaid payments to the provider during the fiscal year.

(2) Failure to retain the required financial, statistical, or medical records to the extent that filed cost reports are unauditable will result in the penalty as specified in paragraph (I)(1) of this rule. Providers whose records have been found to be unauditable will be allowed sixty days to provide the necessary documentation. If, at the end of the sixty days, the required records have been provided and are determined auditable, the proposed penalty will be withdrawn. If ODM, after review of the documentation submitted during the sixty-day period, determines that the records are still unauditable, ODM will impose the penalty as specified in paragraph (I)(1) of this rule.

(3) Refusing legal access to financial, statistical, or medical records will result in a penalty as specified in paragraph (I)(1) of this rule for outstanding medical services until such time as the requested information is made available to ODM.

(4) All requested financial, statistical, and medical records supporting the cost reports or claims for services rendered to residents shall be available at a location in the state of Ohio for facilities certified for participation in the medicaid program by this state within at least sixty days after request by the state or its subcontractors. The preferred Ohio location is the facility itself, but may be a corporate office, an accountant's office, or an attorney's office elsewhere in Ohio. The state or its subcontractors may conduct the audit or a review at the site of such records if outside of Ohio.

(J) When completing cost reports, the following guidelines shall be used to properly classify costs:

(1) All depreciable equipment valued at five thousand dollars or more per item and a useful life of at least two years or more is to be reported in the capital cost component set forth under the Administrative Code. The costs of any equipment leases executed before December 1, 1992 and reported as capital costs, shall continue to be reported under the capital cost component. The costs of any new leases for equipment executed on or after December 1, 1992, shall be reported under the capital costs component. Operating lease costs for equipment that result from extended leases under the provision of a lease option negotiated on or after December 1, 1992 shall be reported under the capital cost component.

(2) Except for employers' share of payroll taxes, workers compensation, employee fringe benefits, and home office costs, allocation of commonly shared expenses across cost centers is not allowed. Wages and benefits for staff, including related parties, who perform duties directly related to functions performed in more than one cost center that would be expended under separate cost centers if performed by separate staff may be expended to separate cost centers based upon documented hours worked, provided the facility maintains adequate documentation of hours worked in each cost center. For example, the salary of an aide who is assigned to bathing and dressing chores in the early hours but works in the kitchen as a dietary aide for the remainder of the shift may be expended to separate cost centers provided the facility maintains adequate documentation of hours worked in each cost center.

(3) The costs of resident transport vehicles are reported under the capital cost component. Maintenance and repairs of these vehicles is reported under the ancillary/support cost component.

Last updated June 26, 2025 at 12:45 PM

History

Effective: March 23, 2020
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-24 Nursing facilities (NFs): prospective rate reconsideration for possible calculation errors.

(A) A nursing facility provider, or a group or association of nursing facility providers, may request a reconsideration of a prospective NF rate on the basis of a possible error in the calculation of the rate as follows:

(1) A request for reconsideration shall be filed with the Ohio department of medicaid (ODM) no more than thirty days after the later of the date on the rate setting package notification or the effective date of the rate.

(2) The request for a reconsideration shall be filed in accordance with the following procedures:

(a) The request for rate reconsideration shall be in writing; and

(b) The request shall be addressed to "Ohio Department of Medicaid, Fiscal Operations - LTC Rate Methodology Unit, P.O. Box 182709, Columbus, Ohio 43215-3414"; and

(c) The request shall indicate that it is a request for rate reconsideration due to a possible error in the calculation of the rate; and

(d) The request shall include a detailed explanation of the possible error and the proposed corrected calculation; and

(e) The request shall include references to the relevant sections of the Revised Code or paragraphs of the Administrative Code as appropriate.

(3) ODM shall respond in writing within sixty days of receiving each written request for reconsideration. If ODM requests additional information to determine whether a rate adjustment is warranted, the NF shall respond in writing and shall provide additional supporting documentation no more than thirty days after the receipt of the request for additional information. ODM shall respond in writing within sixty days of receiving the additional information to the request for reconsideration.

(4) If a rate adjustment is warranted as the result of a reconsideration of a prospective rate, the adjustment shall be implemented retroactively to the initial service date for which the rate is effective.

(B) ODM's decision at the conclusion of the rate reconsideration process is final and shall not be subject to any administrative proceedings under Chapter 119. or any other provision of the Revised Code or Administrative Code.

Last updated June 25, 2025 at 11:18 PM

History

Effective: November 24, 2019
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-30.4 Nursing facilities (NFs), nursing homes (NHs), and long term care hospital beds: procedure for terminating the franchise permit fee (FPF).

(A) Definitions.

"Effective FPF termination date" (EFTD) means the date on which the centers for medicare and medicaid services (CMS) determines that the FPF does not qualify for federal financial participation.

(B) Determination of the FPF as an impermissible health care related tax.

If CMS determines that the FPF is an impermissible health care related tax, the Ohio department of medicaid (ODM) shall take all necessary actions to cease implementation of the FPF program, pursuant to section 5168.42 of the Revised Code.

ODM shall notify each facility previously assessed the FPF of the effective date of the termination of the FPF program, and what impact this change will have on the facility.

(D) Reconciliation procedure.

ODM shall conduct an accounting of the funds paid to or collected from each facility as a result of the FPF program and shall do all of the following:

(1) Reconcile FPFs paid by NFs, NHs, and hospitals.

(a) The annual assessment of the FPF shall be prorated on a daily basis.

(b) FPF assessments for the days preceding the EFTD shall remain due and payable.

(d) FPF assessments issued for days on and after the EFTD shall be rescinded.

(i) ODM shall issue refunds to NHs and hospitals for any FPF remittances representing payment for daily fees on or beyond the EFTD, unless a NF or skilled nursing facility/nursing facility (SNF/NF) has already received medicaid payment for service dates described in paragraph (D)(3) of this rule.

(ii) The source of the refunds shall be the funds established by the FPF assessments as set forth in section 5168.54 of the Revised Code, if necessary, to each NH and hospital assessed the FPF.

(2) Adjust NF rates set by ODM that include reimbursement for FPF assessment payments by medicaid certified NFs and SNF/NFs. ODM shall adjust the per diem rate of a NF to remove any FPF reimbursement-related amount retroactively and/or prospectively from the rate for dates of service on and after EFTD.

(3) Reconcile paid claims for service dates on and following the EFTD with rates adjusted according to paragraph (D)(2) of this rule.

(a) Active providers.

(i) If claims have already been submitted to ODM and processed for dates of service on or after the EFTD, ODM shall offset the amount of overpayment received with the amount of refund due from paragraph (D)(1) of this rule.

(ii) If the offset results in amounts owed to the facility, refunds shall be issued.

(iii) If the offset results in amounts owed to ODM, the amount payable may be collected via offsets of future payments.

(b) Inactive providers.

(i) If claims have already been submitted to ODM and processed for dates of service on or after the EFTD by a NF or SNF/NF provider that no longer participates in the medicaid program, ODM shall offset the amount of overpayment received with the amount of refund due from paragraph (D)(1) of this rule.

(ii) If the offset results in amounts owed to the facility, refunds shall be issued if the provider has furnished an adequate forwarding address.

(iii) If the offset results in amounts owed to ODM, the amount payable may be collected via direct payment from the provider.

(iv) Failure to provide payment may result in certification to the attorney general for collection as set forth in section 5168.55 of the Revised Code.

History

Effective: June 24, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-32 Nursing facilities (NFs): debt estimation methodology.

(A) The Ohio department of medicaid (ODM) uses the debt estimation methodology set forth in this rule to estimate the exiting operator's actual and potential debts to ODM and the United States centers for medicare and medicaid services (CMS) under the medicaid program in cases of a change of operator, facility closure, voluntary termination, involuntary termination, or voluntary withdrawal.

(B) ODM totals the value of all of the following that are determined applicable in calculating the debt estimate:

(1) Overpayments determined due to ODM pursuant to section 5165.108 of the Revised Code, including the following:

(a) Overpayments owed to ODM for adjudicated final fiscal audit periods.

(b) Overpayments identified in proposed adjudication orders that have been issued but not adjudicated.

(c) Overpayment amounts for any outstanding periods where a final fiscal audit has not yet been issued. Such amounts are estimated by generating preliminary reports of amounts owed by the exiting operator for the applicable periods.

(2) Overpayments determined by ODM pursuant to section 5165.49 of the Revised Code, including the following:

(a) Overpayments identified in the post-payment review summary that have been issued but not collected.

(b) Overpayment amounts for any outstanding periods where a post-payment review summary has not yet been issued. Such amounts are estimated by generating preliminary reports of amounts owed by the exiting operator for the applicable periods.

(3) Monies owed to ODM and CMS resulting from penalties authorized by federal and state law, including but not limited to the following:

(a) Civil monetary penalties (CMPs) imposed by CMS that CMS has requested ODM to collect.

(b) Penalties assessed pursuant to section 5165.42 of the Revised Code for lack of proper notice of a change of operator, facility closure, or voluntary withdrawal from the medicaid program, or when a provider fails to furnish invoices or other documentation that ODM requests during an audit.

(4) Interest monies owed to ODM pursuant to section 5165.41 of the Revised Code, and to CMS pursuant to 42 C.F.R. 488.442 (October 1, 2020) that CMS has requested ODM to collect.

(5) Monies owed to ODM and CMS pursuant to sections 5165.52 and 5165.525 of the Revised Code, including a final fiscal audit for the last fiscal year or portion thereof that the exiting operator participated in the medicaid program.

(6) Franchise permit fee (FPF) owed to ODM pursuant to section 5168.47 of the Revised Code. FPF owed to ODM includes unpaid FPF for the following:

(a) Amounts due for periods assessed or to be assessed but for which payment is not yet required pursuant to section 5168.47 of the Revised Code.

(b) Amounts due that are certified to the Ohio attorney general's office for collection, including penalties assessed pursuant to section 5168.51 of the Revised Code for failure to pay the full amount when due.

(7) Monies owed due to a credit balance.

(8) Monies owed pursuant to successor liability or assumption of liability agreements the exiting operator entered into.

(9) Other amounts ODM determines are applicable.

(C) The sum of the amounts determined owed, or estimated to be owed, to ODM and CMS pursuant to paragraphs (B)(1) to (B)(9) of this rule is the total estimated debt.

(D) ODM may release a portion of funds withheld pursuant to division (A) of section 5165.521 of the Revised Code if the funds withheld are materially greater than the debt calculated by the department in the initial debt summary report issued pursuant to section 5165.525 of the Revised Code.

Last updated March 11, 2024 at 12:12 AM

History

Effective: March 11, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-32.1 Nursing facilities (NFs): debt summary report procedure.

(A) Debt summary reports issued in accordance with section 5165.525 of the Revised Code are served in the same manner as notices issued under rule 5160-70-03 of the Administrative Code.

(B) Notice to the Ohio department of medicaid (ODM) of facility closure, voluntary withdrawal of participation, and notice of change of operator.

Notice to ODM should be made in writing and emailed to LTCEnrollment@medicaid.ohio.gov, or mailed or personally delivered to ODM's office address.

(1) Any request for review or submission of additional information made as the result of notice of an initial or revised debt summary report issued pursuant to section 5165.525 of the Revised Code should be made in writing and emailed to "MCD_DebtSummary@medicaid.ohio.gov" or mailed or personally delivered to the ODM office and address identified in the debt summary report within thirty calendar days of the date ODM issues the debt summary report.

(2) If a request for review or submission of additional information is mailed to the ODM office and address identified in the debt summary report, the request or submission is deemed to have been made as follows:

(a) If the request or submission is mailed by certified mail, as of the date stamped by the U.S. postal service on its receipt form (PS form 3800 or any future equivalent postal service form).

(b) If the request or submission is mailed by regular U.S. mail, as of the date of the postmark appearing upon the envelope containing the request.

(c) If the request or submission is mailed by regular U.S. mail and the postmark is illegible or fails to appear on the envelope, as of the date of its receipt by ODM office identified in the debt summary report as evidenced by that office's time stamp.

(3) If a request for review or submission of additional information is made by electronic mail to the office identified in the debt summary report, the request or submission is deemed to have been made as of the date of its receipt as evidenced by the date of receipt shown in the source code of the electronic mail received by the office identified in the debt summary report.

(4) If a request for review or submission of additional information is mailed, personally delivered, or made by electronic mail to a party or address other than the proper office identified in the debt summary report, the request or submission is deemed to have been made as of the date of its receipt by the office identified in the debt summary report as evidenced by that office's time stamp.

(5) If a request for review or submission of additional information is personally delivered to the office identified in the debt summary report, the request or submission is deemed to have been made as of the date of its receipt as evidenced by that office's time stamp.

(6) All requests and submissions should clearly identify both the affected party involved and the debt summary report that is being contested.

(D) Computation of time deadlines.

Section 1.14 of the Revised Code controls the computing of time deadlines imposed by section 5165.525 of the Revised Code.

Last updated March 11, 2024 at 12:12 AM

History

Effective: March 11, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-32.2 Nursing facilities (NFs): successor liability agreements for operators.

(A) Successor liability agreements entered into pursuant to section 5165.521 of the Revised Code are subject to approval by the Ohio department of medicaid (ODM).

(B) Successor liability agreements must be signed by the exiting operator, ODM, and the entity assuming liability pursuant to section 5165.521 of the Revised Code.

(1) Only the ODM successor liability agreement forms (rev. November, 2014, available at http://medicaid.ohio.gov/PROVIDERS/ProviderTypes/LongTerm CareFacilities/SuccessorLiabilityAgreements.aspx) may be used for successor liability agreements entered into pursuant to section 5165.521 of the Revised Code. The ODM language on the successor liability agreement forms shall not be changed, modified, or altered in any way.

(2) Nursing facility operators shall furnish the original signed successor liability agreement form to ODM. Forms shall be submitted to "Ohio Department of Medicaid, Bureau of Network Management, P.O. Box 182709, Columbus, OH. 43218-2709." In cases of a facility closure the form shall be submitted to the attention of "LTC Enrollment Coordinator." In cases of a change of operator the form shall be submitted to the attention of "LTC CHOP Coordinator."

Last updated March 1, 2024 at 12:04 PM

History

Effective: June 24, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-33 Nursing facilities (NFs): reimbursement of NF relief payments upon sale of business or bed license.

(A) For purposes of Section 220.60 of Amended Substitute House Bill 169 of the 134th General Assembly and this rule, a "sale" occurs when a purchase agreement or similar document that outlines the terms of the purchase and results in the payment of money for the business or bed license, is signed or, if the signature is not dated, the effective date specified in the purchase agreement or similar document.

(B) Any nursing facility that sells any of its business or bed licenses in accordance with paragraph (A) of this rule from March 29, 2022 through June 30, 2023 will reimburse the state in the following manner:

(1) If the proceeds from the sale are less than the relief payment received by the nursing facility pursuant to Section 220.60 of Amended Substitute House Bill 169 of the 134th General Assembly, the nursing facility will reimburse the state the full amount of the sale proceeds;

(2) If the proceeds from the sale are greater than the relief payment received by the nursing facility pursuant to Section 220.60 of Amended Substitute House Bill 169 of the 134th General Assembly, the nursing facility will reimburse the state the full amount of the relief payment and retain any amount remaining from the sale after the relief payment is reimbursed in full.

(C) The department of medicaid will notify each nursing facility that is obligated to reimburse relief payments to the state. The notification will be by certified mail and include the manner of reimbursement and the deadline. If the reimbursement is not received by the department by the deadline, the department may, without further notice, offset from medicaid payments the amount of the reimbursement until it is paid in full.

(D) A nursing facility notified that it is obligated to reimburse the state pursuant to this rule may request a reconsideration pursuant to rule 5160-70-02 of the Administrative Code within thirty days of the date appearing on the notification.

Last updated June 25, 2025 at 6:05 PM

History

Effective: March 23, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-39 Payment and adjustment process for nursing facilities (NFs) and intermediate care facilities for the mentally retarded (ICFs-MR).

(A) Forms.

For dates of services preceding July 1, 2005, NFs shall submit the form "Nursing Facility Payment and Adjustment Authorization" (JFS 09400, rev. 10/2012) directly to the Ohio department of job and family services (ODJFS) for the reimbursement of services.

The county department of job and family services (CDJFS) and NFs shall use the "Facility/CDJFS Transmittal" (JFS 09401, rev. 4/2011) form to exchange information necessary to complete the billing process for payment.

(B) Notification of admission.

The facility shall notify the CDJFS using the JFS 09401 form within five business days of admission of a new resident who is medicaid eligible or who has an application for medicaid that is pending even if care may initially be covered under a medicare benefit.

The NF shall notify the CDJFS of the death of a medicaid resident by completing the JFS 09401 and forwarding it to the CDJFS within five business days following the death of the resident. The CDJFS shall terminate medicaid eligibility within ten days after the receipt of the JFS 09401.

For dates of service preceding July 1, 2005, the CDJFS shall stop vendor payment within ten days after the receipt of the JFS 09401.

(1) The CDJFS shall complete and return the JFS 09401, when appropriate, to the NF within ten days of the receipt of the JFS 09401 for any required payment adjustment.

(2) The NF shall complete the JFS 09400, when appropriate (e.g., final payment adjustment), within thirty days of the receipt of the JFS 09401 and submit it to the address listed on the bottom of form JFS 09400.

(D) Notification of discharge.

Discharge has the same meaning as defined in rule 5101:3-3-16.4 of the Administrative Code. The NF shall notify the CDJFS within five business days of the discharge of a medicaid eligible resident by completing the JFS 09401 identifying the type of discharge, and forwarding the JFS 09401 to the CDJFS. The CDJFS shall adjust medicaid eligibility within ten days after the receipt of the JFS 09401.

For dates of service preceding July 1, 2005, the CDJFS shall stop vendor payment within ten days after the receipt of the JFS 09401.

(1) The CDJFS shall complete and return the JFS 09401, when appropriate, to the NF within ten days after the receipt of the JFS 09401 for any required payment adjustment.

(2) The NF shall complete the JFS 09400, when appropriate (e.g., final payment adjustment), within thirty days of the receipt of the JFS 09401 and submit to the address listed on the bottom of form JFS 09400.

(E) Notification of hospice enrollment.

If a NF resident on medicaid vendor payment elects to receive medicaid hospice services in accordance with rule 5101:3-56-03 of the Administrative Code, the NF shall notify the CDJFS by completing the JFS 09401 and forwarding it to the CDJFS within five business days of receiving notice from the hospice agency that a resident elected hospice services. The CDJFS shall adjust medicaid eligibility within ten days after receipt of the JFS 09401 for the resident enrolled in hospice.

For dates of service preceding July 1, 2005, the CDJFS shall stop vendor payment within ten days after the receipt of the JFS 09401.

(1) The CDJFS shall complete and return the JFS 09401, when appropriate (e.g., final payment adjustment), to the NF within ten days of the receipt of the JFS 09401 for any required payment adjustment.

(2) The NF shall complete the JFS 09400, when appropriate, within thirty days of the receipt of the JFS 09401 and submit it to the address on the bottom of form JFS 09400.

History

Effective: January 10, 2013
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-39.1 Nursing facilities (NFs): claim submission.

(A) Nursing facilities shall submit claims in accordance with rule 5160-1-19 of the Administrative Code. Additional requirements specific to the submission of long-term care per diem claims are in paragraphs (B) to (E) of this rule.

(B) Additional requirements to be met prior to submitting claims for services included in the per diem.

(1) Individual is a medicaid recipient for the dates of service.

(2) Individual is not in a restricted medicaid coverage period (RMCP).

(3) Preadmission screening and resident review (PASRR) is completed in accordance with rules 5160-3-15, 5160-3-15.1 and 5160-3-15.2 of the Administrative Code.

(4) NF-based level of care is completed in accordance with rules 5160-3-05, 5160-3-06, 5160-3-08, and 5160-3-14 of the Administrative Code.

(C) Per diem claims must be submitted as one claim per calendar month which includes all dates for which a medicaid individual is considered a resident. All dates within the monthly claim are to be identified as those eligible for medicaid reimbursement, per rule 5160-3-16.4 of the Administrative Code, or billed as non-covered days. Any claim for less than the full month is limited to admission, discharge, death, changes in payer, and hospice enrollment that occurs during the month.

(D) If a medicaid recipient in the NF has a patient liability (PL) obligation as determined by the Ohio department of medicaid or its designee, the amount of PL in accordance with rule 5160:1-6-07 of the Administrative Code, is to be reported by the NF on the recipient's monthly claim. The PL will be applied as an offset against the amount medicaid would otherwise reimburse for the claim. If the PL exceeds the amount medicaid would reimburse, the claim will be processed with a payment of zero dollars.

(E) If an individual receives a lump-sum and the county department of job and family services (CDJFS) and recipient determine that the lump-sum is to be applied to past medicaid payments, the NF provider must submit adjustment claims for as many prior months as are necessary to fully offset the amount of the lump-sum.

Last updated February 1, 2023 at 8:53 AM

History

Effective: February 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-41 Nursing facilities (NFs): placement into peer groups.

(A) NF peer groups shall be assigned according to sections 5165.16, 5165.17, and 5165.19 of the Revised Code based on the provider's geographical location and the number of licensed beds reported on the provider's annual cost report for the calendar year preceding the fiscal year for which the rate is established.

(1) For a provider new to the medicaid program, the Ohio department of medicaid (ODM) shall initially determine the number of beds in the facility from the number of licensed beds documented in the provider's licensure application as verified by the Ohio department of health (ODH). ODM shall subsequently determine the number of beds in the facility from the number of licensed beds reported on the provider's annual cost report.

(2) In the case of a change of operator, the entering operator shall be assigned to the peer group that had previously been assigned to the exiting operator on the day immediately preceding the date on which the change of operator occurred. ODM shall subsequently determine the number of beds in the facility from the number of licensed beds reported on the entering provider's annual cost report.

(B) No adjustment will be made to the provider's placement in a peer group due to a change in bed size until the first day of the fiscal year following the filing of an annual cost report that reflects the change.

History

Effective: September 22, 2018
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-42 Nursing facilities (NFs): chart of accounts.

(A) The Ohio department of medicaid (ODM) requires that all facilities file cost reports annually to comply with section 5165.10 of the Revised Code.

(1) The chart of accounts in table 1 to table 8 of appendix A to this rule is to establish the minimum level of detail to allow for cost report preparation.

(2) If the chart of accounts in appendix A to this rule is not used by the provider, it is the responsibility of the provider to relate its chart of accounts directly to the cost report.

(3) Where a chart of accounts number has sub-accounts that relate directly to a cost report line item, the provider shall capture the information requested so that the information will be broken out for cost reporting purposes.

(4) For example, when revenue accounts appear by payer type, it is required that those charges be reported by payer type where applicable; when salary accounts are differentiated between "supervisory" and "other," it is required that this level of detail be reported on the cost report where applicable.

(B) While the chart of accounts facilitates the level of detail necessary for medicaid cost reporting purposes, providers may find it desirable or necessary to maintain their records in a manner that allows for greater detail than is contained in the chart of accounts in appendix A to this rule.

(1) The chart of accounts in appendix A to this rule allows for a range of account numbers for a specified account.

(2) For example, account 1001 is listed for petty cash, with the next account, cash, beginning at account 1010. Therefore, a provider could delineate sub-accounts 1010-1, 1010-2, 1010-3, 1010-4, to 1010-9 as separate cash accounts. Providers need only use the sub-accounts applicable for their facility.

(C) Within the expense section (tables 5, 6, and 7), accounts identified as "salary" accounts are only to be used to report wages for facility employees.

(1) Wages are to include wages for sick pay, vacation pay and other paid time off, as well as any other compensation to be paid to the employee.

(2) Expense accounts identified as "contract" accounts are only to be used for reporting the costs incurred for services performed by contracted personnel employed by the facility to do a service that would otherwise be performed by personnel on the facility's payroll.

(3) Expense accounts identified as "purchased nursing services" are only to be used for reporting the costs incurred for personnel acquired through a nursing pool agency.

(4) Expense accounts designated as "other" can be used for reporting any appropriate nonwage expenses, including contract services and supplies.

(D) Completion of the cost report as required by section 5165.10 of the Revised Code will require that the number of hours paid be reported (depending on facility type of control, on an accrual or cash basis) for all salary expense accounts. Providers' record keeping should include accumulating hours paid consistent with the salary accounts included within the chart of accounts in appendix A to this rule.

View Appendix

History

Effective: April 1, 2019
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-42.3 Nursing facilities (NFs): capital asset and depreciation guidelines.

(A) Depreciation on buildings, components, and equipment used in the provision of patient care that are not reimbursable by medicaid directly to the medical equipment supplier may be paid for through the NF per diem rate.

(B) For purposes of determining if an expenditure should be capitalized, NF providers are to refer to the centers for medicare and medicaid services (CMS) publication 15-1, Chapter 1 entitled "Depreciation," (December 15, 2011), available on the internet at http://www.cms.gov/, and shall use the following guidelines:

(1) Any expenditure for an item that costs five thousand dollars or more and has a useful life of two or more years per item must be capitalized and depreciated over the asset's useful life.

(2) A provider may use a capitalization policy less than five thousand dollars per item, but is required to obtain prior approval from the Ohio department of medicaid (ODM) if the provider wishes to change its capitalization policy from its initial capitalization policy.

(C) All capital assets shall be depreciated using the straight-line method of depreciation and salvage value shall be used to adjust capital asset values when calculating depreciation.

(D) For purposes of determining the useful life of a capital asset, NF providers shall use the guidelines in the revised 2018 edition of the american hospital association (AHA) publication entitled "Estimated Useful Lives of Depreciable Hospital Assets," which is available on the internet at http://www.aha.org/, or different useful life guidelines if approved by ODM. If a capital asset is not reflected in "Estimated Useful Lives of Depreciable Hospital Assets," internal revenue service (IRS) publication 946 "How to Depreciate Property" (rev. February 15, 2019), available on the internet at http://www.irs.gov/, shall be used for purposes of determining the useful life of that capital asset.

(E) For newly acquired assets in the month that a capital asset is placed into service, no depreciation expense is recognized as an allowable expense. A full month's depreciation expense is recognized in the month following the month the asset is placed into service.

(F) The disposal of assets shall be accounted for as follows:

(1) For assets not acquired through a change in ownership, in the month that the capital asset is disposed, if the capital asset is not fully depreciated, the allowable depreciation expense is the historical cost of the asset less the accumulated depreciation of the asset. At no time shall an asset be depreciated more than its adjusted basis; or

(2) For assets acquired through a change in ownership, there shall be no recognition of the disposal of individual assets. At the time of a subsequent change of ownership the disposal of all assets acquired through a change of ownership shall be recognized.

(G) Providers shall maintain the following property records:

(1) For assets not acquired through a change in ownership, detailed depreciation schedules listing each asset acquired; or

(2) For assets acquired through a change in ownership:

(a) Depreciation schedules on a lump sum basis for land, building, and equipment; and

(b) A list of all assets disposed after the change in ownership with the applicable dates of disposal.

History

Effective: November 24, 2019
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-42.4 Nursing facilities (NFs): non-reimbursable costs.

The following costs are not reimbursable to NFs through the NF per diem, except as specified under Chapter 5160-3 of the Administrative Code. Non-reimbursable costs include but are not limited to:

(A) Fines or penalties paid under sections 5165.1010, 5165.72 to 5165.77, 5165.83, and 5165.99 of the Revised Code.

(B) Disallowances made during the audit of NF cost reports that are sanctioned through adjudication in accordance with Chapter 119. of the Revised Code.

(C) Costs that exceed prudent buyer tests of reasonableness that may be applied pursuant to the provisions of the centers for medicare and medicaid services (CMS) publication 15-1 "Provider Reimbursement Manual" (rev. 9/28/15) during the audit of NF cost reports.

(D) Costs of ancillary services rendered to NF residents by providers who bill medicaid directly. Ancillary services include but are not limited to physicians, legend drugs, radiology, and laboratory.

(E) Costs per case-mix units in excess of the applicable peer group ceiling for direct care costs.

(F) Expenses in excess of the capital costs limitations.

(G) Expenses associated with lawsuits filed against the Ohio department of medicaid (ODM) that are not upheld by the courts.

(H) Costs of meals sold to visitors or the public (e.g., meals on wheels).

(I) Costs of supplies or services sold to nonfacility residents or the public.

(J) Costs of operating a gift shop.

History

Effective: August 31, 2017
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-43.1 Nursing facilities (NFs): case mix assessment instrument - minimum data set version 3.0 (MDS 3.0).

(A) As used in this rule:

(1) "Annual facility average case mix score" is the score used to calculate the facility's cost per case-mix unit.

(2) "Assessment reference date (ARD)" is the last day of the observation (or "look back") period that the MDS 3.0 assessment covers for the resident.

(3) "Case mix report" is a report generated by the Ohio department of medicaid (ODM) and distributed to the provider on the status of all MDS 3.0 assessment data that pertains to the calculation of a quarterly, semiannual, or annual facility average case mix score.

(4) "Comprehensive assessment" means an assessment that includes completion of the appropriate MDS 3.0 assessment type listed in paragraph (B)(2) of this rule.

(5) "Critical elements" are data items from a resident's MDS 3.0 that ODM verifies prior to determining a resident's resource utilization group (RUG) classification.

(6) "Critical errors" are errors in the MDS 3.0 critical elements that prevent ODM from determining the resident's RUG classification.

(7) "Default group" is the case mix group assigned to residents with MDS 3.0 records with inconsistent date fields, missing, incomplete, out of range, or inaccurate data, including inaccurate resident identifiers, any of which precludes grouping the record into non-default RUG groups.

(8) "Encoded," when used with reference to a record, means that the record has been recorded in electronic format. The record must be encoded in accordance with MDS 3.0 data submission specifications version 1.15.0.

(9) "Filing date" is the deadline for submission of the NF's MDS 3.0 assessment data that will be used to calculate the preliminary facility quarterly average case mix score. The filing date is the fifteenth calendar day following the reporting period end date (RPED).

(10) "MDS 3.0" is the uniform resident assessment instrument specified for use in Ohio pursuant to 42 C.F.R. 483.20 (October 1, 2014) for implementing standardized resident assessments and for facilitating care management in nursing facilities. The MDS 3.0 provides the core data elements used to group residents into case mix categories. It also includes Ohio-specific data elements, designated as section S. A copy of the section S requirements is available at http://medicaid.ohio.gov/PROVIDERS/ProviderTypes/LongTerm CareFacilities.aspx.

(11) "Medicare required assessment" means the MDS 3.0 that is required only for facilities participating in the medicare prospective payment system.

(12) "Other medicare required assessment (OMRA)" is an unscheduled MDS 3.0 prospective payment system (PPS) assessment required to be completed during a resident's medicare "Part A" SNF covered stay based on the start or cessation of rehabilitation services.

(13) "PPS assessment" is the MDS 3.0 that skilled nursing facilities (SNFs) use to assess the clinical condition for each medicare resident receiving "Part A" SNF level care for reimbursement under the SNF PPS.

(14) "Quarterly facility average total case mix score" is the facility average case mix score based on both medicaid and non-medicaid resident data submitted for one reporting quarter and calculated pursuant to paragraph (B)(1) of rule 5160-3-43.3 of the Administrative Code.

(15) "Quarterly facility average medicaid case mix score" is the facility average case mix score based on only medicaid resident data submitted for one reporting quarter and calculated pursuant to paragraph (B)(2) of rule 5160-3-43.3 of the Administrative Code.

(16) "Quarterly review assessment" means an assessment that is normally conducted no less than once every three months using the MDS 3.0.

(17) "Record" means a resident's encoded MDS 3.0 assessment as described in paragraphs (B)(1) to (B)(4) of this rule.

(18) "Relative resource weight" is the measure of the relative costliness of caring for residents in one case mix group versus another, indicating the relative amount and cost of staff time required on average for defined worker classifications to care for residents in a single case mix group. The methodology for calculating relative resource weights is described in paragraph (E) of rule 5160-3-43.2 of the Administrative Code.

(19) "Reporting period end date" (RPED) is the last day of each calendar quarter.

(20) "Reporting quarter" is the calendar quarter in which the MDS 3.0 is completed, as indicated by the assessment reference date in MDS 3.0 section A, item A2300, except as specified in paragraphs (C)(7) and (C)(8) of this rule.

(21) "Resident Assessment Instrument (RAI)" is the MDS 3.0 used by NFs in Ohio to comply with regulations in 42 C.F.R. 483.20.

(22) "Resident case mix score" is the relative resource weight for the RUG group to which the resident is assigned based on data elements from the resident's MDS 3.0 assessment.

(23) "Resident identifier code" is an alternative resident identifier if the resident does not have a social security number. The resident identifier code shall be reported in MDS 3.0 section S, item S0150. The following method must be used to construct the identifier code:

(a) In the first three boxes, enter the first three letters of the resident's last name.

(b) In the next six boxes, enter the six digits of the resident's date of birth.

(24) "RUG" is the resource utilization groups system of classifying NF residents described in paragraph (B) of rule 5160-3-43.2 of the Administrative Code. Resource utilization groups are clusters of NF residents defined by resident characteristics that correlate with resource use.

(a) For rates paid for services provided before July 1, 2016, the RUG version used in Ohio is version III (RUG III).

(b) For rates paid for services provided July 1, 2016 and thereafter, the RUG version used in Ohio shall be version IV (RUG IV).

(25) "Semiannual facility average medicaid case mix score" is the average of a facility's two quarterly facility average medicaid case mix scores. It is used to establish the direct care rate and is calculated pursuant to paragraph (E) of rule 5160-3-43.3 of the Administrative Code.

(B) For the purpose of assigning a RUG classification for determining medicaid payment rates for NFs, ODM shall utilize the data from the MDS 3.0. Each NF shall assess all residents of medicaid-certified beds using the appropriate MDS 3.0. When the assessment coincides with medicare assessment time frames, one assessment shall be used to satisfy both assessments. Admission assessments must be combined with either the medicare five day or medicare fourteen day assessment. For a resident who is not a new admission to the facility, the quarterly, annual, and significant change in status assessments must be combined with any medicare assessment if the assessment reference date (ARD) is within the assigned medicare observation period. When combining the assessments, the most stringent requirement for MDS completion must be met. ODM may not utilize the data in the other medicare required assessments (OMRAs) for calculating case mix scores or determining medicaid payment rates.

(1) Comprehensive assessments, medicare-required assessments, quarterly review assessments, and significant corrections of quarterly assessments must be conducted in accordance with the requirements and frequency schedule found at 42 C.F.R. 483.20.

(2) For a comprehensive assessment, NFs must use the MDS 3.0, including section S. The comprehensive assessment is completed as specified in the MDS 3.0 RAI manual. NFs must use the quarterly MDS 3.0, including section S, for the quarterly review assessment or a significant correction to a prior quarterly assessment. The nursing home PPS assessment must be used for all medicare required assessments.

(3) NFs must use the MDS 3.0 discharge item set for any residents who transfer or are discharged, and the MDS 3.0 tracking record for any residents entering or reentering or who died in the facility in accordance with 42 C.F.R. 483.20.

(4) NFs must use the MDS correction request in section X of the MDS 3.0 for modification or inactivation of MDS records that have been accepted into the CMS database.

(C) All NFs must submit to the CMS database encoded, accurate, and complete MDS 3.0 data for all residents of medicaid certified NF beds, regardless of pay source or anticipated length of stay.

(1) MDS 3.0 data completed in accordance with paragraphs (B)(1) to (B)(4) of this rule must be encoded in accordance with MDS 3.0 data submission specifications version 1.15.0.

(2) MDS 3.0 data must be encoded. The data may be submitted at any time during the reporting quarter that is permitted by instructions in the MDS 3.0 RAI manual. Except as provided in paragraph (D) of this rule, all records used in determining the quarterly facility average total case mix score and quarterly facility average medicaid case mix score must be submitted by the filing date.

(3) If a NF submits MDS 3.0 data needed for determining the quarterly facility average total case mix score and quarterly facility average medicaid case mix score after the forty-fifth day after the RPED, ODM may assign a quarterly facility average total case mix score as set forth in paragraph (C)(3) of rule 5160-3-43.3 of the Administrative Code and a quarterly facility average medicaid case mix score as set forth in paragraph (D)(4) of rule 5160-3-43.3 of the Administrative Code.

(4) MDS 3.0 data submitted by a provider that can not be timely extracted by ODM from the CMS data server may result in assignment of a quarterly facility average total case mix score as set forth in paragraph (C)(3) of rule 5160-3-43.3 of the Administrative Code and a quarterly facility average medicaid case mix score as set forth in paragraph (D)(4) of rule 5160-3-43.3 of the Administrative Code.

(5) The annual facility average case mix score, quarterly facility average total case mix score, and quarterly and semiannual facility average medicaid case mix scores will be calculated using the MDS 3.0 record in effect on the RPED for:

(a) Residents who were admitted to the medicaid certified NF prior to the RPED and continue to be physically present in the NF on the RPED; and

(b) Residents who were admitted to the medicaid certified NF on the RPED; and

(c) Residents who were temporarily absent on the RPED but are considered residents and for whom a return is anticipated from hospital stays, visits with friends or relatives, or participation in therapeutic programs outside the facility.

(6) Records for residents who were permanently discharged from the NF, transferred to another NF, or expired prior to or on the RPED will not be used for determining the quarterly facility average total case mix score and quarterly facility average medicaid case mix score.

(7) For a resident admitted within fourteen days prior to the RPED, and whose initial assessment is not due until after the RPED, both of the following shall apply:

(a) The NF shall submit the appropriate initial assessment as specified in 42 C.F.R. 483.20 and in the MDS 3.0 RAI manual.

(b) The initial assessment, if completed and submitted timely in accordance with paragraphs (C)(1) and (C)(2) of this rule, shall be used for determining the quarterly facility average total case mix score and may be used for determining the quarterly facility average medicaid case mix score in the quarter the resident entered the facility even if the assessment reference date is after the RPED provided the record is identified as a medicaid record pursuant to the calculation methodology in rule 5160-3-43.3 of the Administrative Code.

(8) For a resident who had at least one MDS 3.0 assessment completed before being transferred to a hospital, then reenters the NF within fourteen days prior to the RPED, and has experienced a significant change in status that requires a comprehensive assessment upon reentry, the following shall apply:

(a) The NF shall submit a significant change assessment within fourteen days of reentry, as indicated by the MDS 3.0 assessment reference date (MDS 3.0, item A2300).

(b) The significant change assessment shall be used for determining the quarterly facility average total case mix score and may be used for determining the quarterly facility average medicaid case mix score for the quarter in which the resident reentered the facility even if the assessment reference date is after the RPED provided the record is identified as a medicaid record pursuant to the calculation methodology in rule 5160-3-43.3 of the Administrative Code.

(D) Corrections to MDS 3.0 data must be made in accordance with the requirements in the MDS 3.0 RAI manual.

(1) For use in determining the quarterly facility average total case mix score and quarterly facility average medicaid case mix score, the facility must transmit the corrections to the CMS database no later than forty-five days after the RPED.

(2) For use in determining the quarterly facility average total case mix score and quarterly facility average medicaid case mix score, all significant correction assessments must contain an assessment reference date within the reporting quarter.

(3) The provider shall submit an accurate, encoded MDS 3.0 record for each resident in a medicaid certified bed on the RPED.

(a) The provider shall transmit MDS assessments that were completed timely but omitted from the previous transmissions and ODM shall use the resident case mix scores from the assessments for determining the quarterly facility average total case mix score, and may use them for determining the quarterly facility average medicaid case mix score if the assessments are transmitted no later than forty-five days after the RPED provided the record is identified as a medicaid record pursuant to the calculation methodology in rule 5160-3-43.3 of the Administrative Code. If the assessments are not transmitted within forty-five days after the RPED, ODM may assign a default group for those records.

(b) The provider shall notify ODM within forty-five days of the RPED of any records for residents in medicaid certified beds on the RPED that were not completed timely and were not transmitted to the CMS database. ODM may assign default scores to those records.

(c) The provider has forty-five days after the RPED to transmit the appropriate discharge assessment to the CMS database if more residents are determined to be in the facility on the RPED than the number of medicaid certified beds in the facility on that same date. If the facility does not correct the error within forty-five days after the RPED, ODM may assign a quarterly facility average total case mix score as specified in paragraph (C)(3) of rule 5160-3-43.3 of the Administrative Code and a quarterly facility average medicaid case mix score as specified in paragraph (D)(4) of rule 5160-3-43.3 of the Administrative Code.

(d) The provider shall notify ODM within forty-five days of the RPED of any residents who were reported to be residents of the facility on the RPED, but who had actually been discharged prior to the RPED. If the provider fails to correct the error within forty-five days after the RPED, ODM may assign a quarterly facility average total case mix score as specified in paragraph (C)(3) of rule 5160-3-43.3 of the Administrative Code and a quarterly facility average medicaid case mix score as specified in paragraph (D)(4) of rule 5160-3-43.3 of the Administrative Code.

(e) The provider has forty-five days after the RPED to submit appropriate modifications or discharge assessments to rectify any discrepancy between the records selected for determining the quarterly facility average total case mix score and the facility census on the RPED. If the facility does not correct the error(s) within forty-five days after the RPED, ODM may assign a quarterly facility average total case mix score as specified in paragraph (C)(3) of rule 5160-3-43.3 of the Administrative Code and a quarterly facility average medicaid case mix score as specified in paragraph (D)(4) of rule 5160-3-43.3 of the Administrative Code.

(4) If the provider's number of records assigned to the default group in accordance with paragraphs (D)(3)(a) and (D)(3)(b) of this rule is greater than ten per cent, ODM may assign a quarterly facility average total case mix score as specified in paragraph (C)(3) of rule 5160-3-43.3 of the Administrative Code and a quarterly facility average medicaid case mix score as specified in paragraph (D)(4) of rule 5160-3-43.3 of the Administrative Code.

History

Effective: March 1, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-43.2 Nursing facilities (NFs): case mix classification system - resource utilization groups (RUG).

The Ohio department of medicaid (ODM) shall pay each eligible NF a per resident per day rate for direct care costs established prospectively for each facility. The department shall establish each facility's rate for direct care costs semiannually. Each facility's rate for direct care costs shall be based on a case mix payment system.

(A) The Ohio medicaid case mix payment system for direct care contains the following core components:

(1) As set forth in rule 5160-3-43.1 of the Administrative Code, a uniform resident assessment instrument (minimum data set version 3.0 (MDS 3.0)), that provides the data used to group residents into case mix categories. The MDS 3.0 includes section S. Information regarding section S is available on the ODM website at http://medicaid.ohio.gov/PROVIDERS/ProviderTypes/ LongTermCareFacilities.aspx.

(2) A methodology for grouping residents into case mix groups in a way that is clinically meaningful and uses criteria that sufficiently differentiates one group from another, as provided in paragraphs (B) to (E) of this rule.

(3) A means of measuring the relative costliness of caring for residents in one group versus another, known as "relative resource weights," as described in paragraph (D) of this rule.

(B) The Ohio case mix payment system shall use the following methodologies for grouping residents:

(1) For rates paid for services provided before July 1, 2016, resource utilization groups version III (RUG III) classification system. The RUG III major categories listed in paragraph (C) of rule this rule are listed in descending order of hierarchy. Based on the items in the MDS 3.0, if a resident meets the criteria for placement in more than one group, the resident will be placed in a group within the highest major category of resident types according to the hierarchy unless the activities of daily living (ADL) index score is not met for placement within the highest major category of resident types.

(2) For rates paid for services provided July 1, 2016 and thereafter, resource utilization groups version IV (RUG IV) classification system. The RUG IV major categories listed in paragraph (C) of this rule are listed in descending order of hierarchy. Based on the items in the MDS 3.0, if a resident meets the criteria for placement in more than one group, the resident will be placed in a group according to the hierarchy.

(3) ODM will use the forty-five grouper model with the RUG III methodology.

(4) ODM will use one of the following grouper models with the RUG IV methodology:

(a) Forty-eight grouper model.

(b) Fifty-seven grouper model.

(1) RUG III using the forty-five grouper model:

(a) Extensive services.

(b) Special rehabilitation.

(d) Clinically complex.

(e) Impaired cognition.

(f) Behavior problems.

(g) Reduced physical function.

(2) RUG IV using the forty-eight, fifty-seven, or sixty-six grouper model:

(a) Rehabilitation plus extensive services (sixty-six grouper model only).

(b) Rehabilitation.

(d) Special care high.

(e) Special care low.

(f) Clinically complex.

(g) Behavioral symptoms and cognitive performance.

(h) Reduced physical function.

(D) All MDS 3.0 data elements related to the RUG classification system must be completed before a resident can be classified. Residents whose MDS 3.0 forms contain missing or out-of-range responses to data elements used to determine the RUG classification shall be assigned to the default group. Corrections to MDS 3.0 data may be made only as described in paragraph (D) of rule 5160-3-43.1 of the Administrative Code.

(E) Each of the RUG groups is assigned a relative resource weight. This weight indicates the relative amount of staff time required on average for workers in the registered nurse (RN), licensed practical nurse (LPN), and nurse aide (NA) worker classifications to deliver care to residents in that RUG group.

(1) The relative resource weights are calculated as follows using the average minutes per worker classification per RUG group provided by the United States department of health and human services (HHS), and the most recent available three-year averages of RN, LPN, and NA wages in Ohio medicaid certified NFs as reported in annual medicaid cost reports submitted by providers to ODM pursuant to section 5165.10 of the Revised Code.

(a) By setting the NA wage weight at one, wage weights for RNs and LPNs are calculated by dividing the NA wage into the RN or LPN wage.

(b) To calculate the total weighted minutes for each RUG group, the wage weight for each worker classification is multiplied by the average number of minutes that classification of workers spends caring for a resident in the RUG group, and then the products for each RUG group are summed.

(c) Relative resource weights are calculated by dividing the lowest group's total weighted minutes into each group's total weighted minutes. Weight calculations are rounded to the fourth decimal place. The RUG group with the lowest total weighted minutes receives a relative resource weight of one.

(2) The lowest weight for the RUG groups is used as the weight for the default group.

(3) Relative resource weights are set forth on the ODM website at http://medicaid.ohio.gov/PROVIDERS/ProviderTypes/LongTermCareFacilities .aspx.

History

Effective: March 1, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-43.3 Nursing facilities (NFs): calculation of case mix scores.

(A) The definitions of all terms used in this rule are the same as set forth in rules 5160-3-01, 5160-3-43.1, and 5160-3-43.4 of the Administrative Code.

(B) To determine resident case mix scores, the Ohio department of medicaid (ODM) shall process resident assessment data submitted by NFs in accordance with rule 5160-3-43.1 of the Administrative Code, and shall classify residents in accordance with rule 5160-3-43.2 of the Administrative Code. These resident case mix scores, based on relative resource weights calculated in accordance with rule 5160-3-43.2 of the Administrative Code, are used to establish two quarterly facility average case mix scores each quarter.

(1) The first quarterly facility average case mix score shall be calculated using all records selected for the quarter and shall be the quarterly facility average total case mix score.

(2) The second quarterly facility average case mix score shall be calculated using only the records selected for the quarter that ODM identifies as medicaid records and shall be the quarterly facility average medicaid case mix score.

(C) ODM shall calculate a quarterly facility average total case mix score for all providers meeting the following requirements:

(1) In accordance with rule 5160-3-43.1 of the Administrative Code, the provider submitted resident assessment information by the filing date, and the data included resident assessments for all residents in medicaid certified beds as of the reporting period end date, and

(a) The provider's resident assessment data submitted timely for that reporting quarter provided sufficient information for accurately classifying at least ninety per cent of all residents in medicaid certified beds into RUG non-default groups, or

(b) The provider's resident assessment data submitted timely and corrected timely, in accordance with the procedures outlined in rule 5160-3-43.1 of the Administrative Code for correcting incomplete or inaccurate information, for that reporting quarter, provided sufficient information for accurately classifying at least ninety per cent of all residents in medicaid certified beds into RUG non-default groups; and

(c) There were no errors that prevented ODM from verifying the records to be used in determining the quarterly facility average total case mix score.

(d) The prospective payment system (PPS) other medicare required assessments (OMRAs) may not be selected for calculating case mix scores.

(2) The quarterly facility average total case mix score for providers that submitted their minimum data set version 3.0 (MDS 3.0) data in compliance with paragraph (C)(1) of this rule shall be calculated as follows:

(a) All resident case mix scores for the quarter, including resident case mix scores in the RUG default group, are added together; then

(b) The sum of resident case mix scores is divided by the total number of residents.

(3) If a provider does not comply with paragraph (C)(1) of this rule, ODM may assign the NF a penalty score. If assigned, the penalty score for the quarterly facility average total case mix score shall be a score that is five per cent less than the quarterly facility average total case mix score for the preceding calendar quarter.

(a) If the facility was subject to an exception review for the preceding quarter in accordance with rule 5160-3-43.4 of the Administrative Code, the assigned quarterly facility average total case mix score shall be the score that is five per cent less than the score determined by the exception review.

(b) If the facility was assigned a quarterly facility average total case mix score for the preceding calendar quarter, the assigned quarterly facility average total case mix score shall be the score that is five per cent less than the score assigned for the preceding quarter.

(D) ODM shall calculate a quarterly facility average medicaid case mix score for all providers meeting the following requirements:

(1) The provider's resident assessment data submitted timely for that reporting quarter provided sufficient information for classifying at least ninety per cent of records identified as medicaid records into RUG non-default groups, or

(a) The provider's resident assessment data submitted timely and corrected timely in accordance with the procedure outlined in rule 5160-3-43.1 of the Administrative Code for correcting incomplete or inaccurate information for that reporting quarter, provided sufficient information for accurately classifying at least ninety per cent of all residents into RUG non-default groups; and

(b) There were no errors that prevented ODM from verifying the records to be used in determining the quarterly facility average medicaid case mix score.

(2) ODM shall identify a MDS 3.0 assessment as a medicaid record if the MDS 3.0 assessment meets the following requirements:

(a) The MDS 3.0 assessment is not completed to meet the requirements for a medicare part A stay.

(b) The social security number (SSN) on the MDS 3.0 assessment matches a SSN on the medicaid recipient master file (RMF)

(c) The assessment reference date (ARD) on the MDS 3.0 assessment falls within the recipient's medicaid eligibility span.

(3) The quarterly facility average medicaid case mix score for providers that submitted their MDS 3.0 data in compliance with paragraph (C)(1) of this rule shall be calculated as follows:

(a) Medicaid resident case mix scores for the quarter, including resident case mix scores in the RUG default group, are added together; then

(b) The sum of medicaid resident case mix scores is divided by the total number of medicaid residents.

(4) If a provider does not comply with paragraph (D)(1) of this rule, ODM may assign the NF a penalty score. If assigned, the penalty score for the quarterly facility average medicaid case mix score shall be a score that is five per cent less than the quarterly facility average medicaid case mix score for the preceding calendar quarter.

(a) If the facility was subject to an exception review for the preceding quarter in accordance with rule 5160-3-43.4 of the Administrative Code, the assigned quarterly facility average medicaid case mix score shall be the score that is five per cent less than the score determined by the exception review.

(b) If the facility was assigned a quarterly facility average medicaid case mix score for the preceding calendar quarter, the assigned quarterly facility average medicaid case mix score shall be the score that is five per cent less than the score assigned for the preceding quarter.

(5) ODM may use a facility's assigned penalty score to calculate the semiannual facility average medicaid case mix score.

(E) ODM shall calculate the semiannual facility average medicaid case mix score as follows:

(1) The semiannual facility average medicaid case mix score for the payment period beginning the first day of July for a given fiscal year shall be the average of the quarterly facility average medicaid case mix score from the preceding December and March reporting quarters. If a facility does not have a quarterly facility average medicaid case mix score for both the December and March reporting quarters, the median annual facility average case mix score for the NF's peer group shall be assigned as the semiannual facility average medicaid case mix score to determine the direct care rate.

(2) The semiannual facility average medicaid case mix score for the payment period beginning the first day of January for a given fiscal year shall be the average of the quarterly facility average medicaid case mix score from the preceding June and September reporting quarters. If a facility does not have a quarterly facility average medicaid case mix score for both the June and September reporting quarters, the median annual facility average case mix score for the NF's peer group shall be assigned as the semiannual facility average medicaid case mix score to determine the direct care rate.

(F) ODM shall calculate the annual facility average case mix score as follows:

(1) The annual facility average case mix score shall be calculated only for facilities with at least two quarterly facility average total case mix scores meeting the requirements of paragraphs (C)(1) and (C)(2) of this rule. In addition, for any score meeting the requirements of paragraphs (C)(1) and (C)(2) that was adjusted, the adjusted score will be substituted according to the following hierarchy:

(a) Adjusted quarterly facility average total case mix scores established by a rate reconsideration decision resulting from an exception review of resident assessment information conducted before the effective date of the rate; or

(b) Adjusted quarterly facility average total case mix scores as a result of exception review findings.

(2) If ODM assigned a facility a quarterly facility average total case mix score in accordance with paragraph (C)(3) of this rule, the assigned score will not be used to calculate the provider's annual facility average case mix score.

(3) The qualifying case mix scores shall be summed and divided by the total number of quarters of qualifying scores to arrive at the annual facility average case mix score.

(G) For each provider that submits MDS 3.0 data in a given week, ODM shall send the "Case Mix Report" containing the following four components:

(1) The "Provider Detail Listing of Successfully Grouped Records," which identifies records that were successfully grouped by ODM. The report will include all records received, even if the records will not be used in the quarterly score calculation.

(2) The "Critical Error Summary," which identifies the records that will be assigned into the default group unless they are corrected before the end of the reporting quarter in accordance with rule 5160-3-43.1 of the Administrative Code.

(3) The "Provider Detail Listing of Records with Critical Errors," which provides detail for each record listed on the "Critical Error Summary" identifying the failed edits.

(4) The "Discharge and Reentry Tracking Form Summary," which identifies all discharge assessments and reentry tracking forms that were received by ODM.

(H) ODM shall provide two preliminary "Calculation of Facility Case Mix Scores" reports. The first report will reflect records submitted up to the quarterly filing date. The second report will reflect records submitted up to approximately two weeks prior to the quarterly corrections deadline. Both reports will include a calculation of the quarterly facility average total case mix score and the quarterly facility average medicaid case mix score. Providers may file corrections to the extent permitted by rule 5160-3-43.1 of the Administrative Code.

(I) After the quarterly corrections deadline specified in rule 5160-3-43.1 of the Administrative Code, ODM shall provide a final "Calculation of Facility Case Mix Scores" report. The report will include a calculation of the quarterly facility average total case mix score and the quarterly facility average medicaid case mix score.

(J) Following the determination of the two quarterly facility average medicaid case mix scores used to calculate the semiannual facility average medicaid case mix scores effective July first and January first of the fiscal year, ODM shall provide a "Semiannual Medicaid Case Mix Score Calculation Report" to each provider.

(K) Following the calculation of the annual facility average case mix score, ODM shall provide an "Annual Facility Average Case Mix Score Calculation Report" to each provider.

Last updated June 25, 2025 at 5:51 PM

History

Effective: December 31, 2020
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-43.4 Nursing facilities (NFs): exception review process.

(A) The definitions of all terms not defined in this rule are the same as set forth in rules 5160-3-01 and 5160-3-43.1 of the Administrative Code.

(1) "Combination review" is a type of exception review where the Ohio department of medicaid (ODM) reviews records selected in one of the following ways:

(a) A combination of records selected pursuant to random and targeted criteria.

(b) Records initially selected for a targeted review, but insufficient records were available to meet the targeted review sample size requirements, combined with randomly selected records to complete the sample size.

(c) Records initially selected for a random review, combined with records selected for a targeted review as a result of findings of the random review.

(2) "Effective date of the rate" is either the first day of July or January for a given fiscal year.

(3) "Exception review" is a review of minimum data set (MDS) assessment data. It is conducted at selected NFs by registered nurses and other appropriate licensed or certified health professionals as determined by ODM who are employed by or under contract with ODM. The purpose of an exception review is to identify any patterns or trends related to resident assessments submitted in accordance with rule 5160-3-43.1 of the Administrative Code that could result in inaccurate case mix scores used to calculate the direct care component of the nursing facility per diem rate. Exception reviews shall be conducted in accordance with section 5165.193 of the Revised Code.

(4) "Exception review tolerance level" is the level of variance between the facility and ODM in MDS assessment item responses affecting the resource utilization groups (RUG) classification of a facility's residents. Two kinds of tolerance levels have been established for exception reviews: initial sample tolerance level, and expanded review tolerance level.

(a) "Initial sample tolerance level" is the percentage of unverifiable records found during the initial sample of an exception review, below which no further review will be pursued for the same six month period. The initial sample tolerance level shall be less than fifteen per cent of the entire sample.

(b) "Expanded review tolerance level" is an acceptable level of variance in the calculation of a provider's quarterly facility average medicaid case mix score or an acceptable per cent of the records sampled at exception review that were unverifiable.

(5) "Random review" is a type of exception review that examines randomly selected records from any of the RUG major categories listed in paragraph (C) of rule 5160-3-43.2 of the Administrative Code.

(6) "Targeted review" is a type of exception review that targets records in restorative nursing programs, current toileting program or trial, and/or bowel toileting program, clinically complex with depression, or one or more of the RUG major categories listed in paragraph (C) of rule 5160-3-43,2 of the Administrative Code.

(7) The "variance" is the percentage difference between the quarterly facility average medicaid case mix score based on exception review findings and the quarterly facility average medicaid case mix score from the provider's submitted MDS records.

(a) The exception review tolerance level shall be either less than a two per cent variance between the quarterly facility average medicaid case mix score based on exception review findings and the quarterly facility average medicaid case mix score from the provider's submitted MDS records or less than twenty per cent of the medicaid records sampled at exception review were unverifiable.

(b) The variance calculation will not recognize modifications to MDS assessments and new assessments following an inactivation, submitted by the facility after notification of the exception review.

(8) A "verifiable MDS record" is a provider's completed MDS assessment form, based on facility supplied MDS assessment data submitted to ODM for a resident for a specific reporting quarter, which upon examination by ODM during an exception review has been determined to accurately represent the aspects of the resident's condition that affect the correct RUG classification of that record during the specified assessment time frame.

(9) An "unverifiable MDS record" is a provider's completed MDS assessment form, based on facility supplied MDS assessment data, submitted to ODM for a resident for a specific reporting quarter which, upon examination by ODM, has been determined to inaccurately represent the aspects of the resident's condition that affect the RUG classification of that record during the specified assessment time frame. MDS coding may be deemed unsupported if inconsistencies are found in the sources of information through verification activities.

(B) All exception reviews will comply with the applicable provisions of the medicare and medicaid programs.

(1) The findings of a certification survey conducted by the Ohio department of health (ODH) that may indicate that the facility is not accurately assessing residents, which may result in the resident's inaccurate classification into the RUG system.

(2) A risk analysis profile that may include, but is not limited to, one or more of the following:

(a) A change in the frequency distribution of residents who receive nursing rehabilitation/restorative care in accordance with section O of the minimum data set version 3.0 (MDS 3.0), or who meet the RUG criteria for depression in accordance with section D of the MDS 3.0.

(b) The frequency distribution of residents who receive nursing rehabilitation/restorative care in accordance with section O of the MDS 3.0, or who meet the RUG criteria for depression in accordance with section D of the MDS 3.0 exceeds statewide averages.

(c) A sudden or drastic change in the quarterly facility average total case mix score or the quarterly facility average medicaid case mix score.

(d) A change in the frequency distribution of coded responses to a MDS item.

(3) Prior resident assessment performance of the provider, may include, but is not limited to, ongoing problems with assessment submission deadlines, error rates, incorrect assessment dates, and apparent unchanged assessment practice(s) following a previous exception review.

(D) Exception reviews shall be conducted at the facility by registered nurses and other licensed or certified health professionals as determined by ODM who are under contract with or employed by ODM. When a team of reviewers conducts an on-site exception review, the team shall be led by a registered nurse. Persons conducting exception reviews on behalf of ODM shall meet the following conditions:

(1) During the period of their professional employment or contract with ODM, whichever is applicable, reviewers must neither have nor be committed to acquire any direct or indirect financial interest in the ownership, financing, or operation of a NF for which they conduct an exception review. Employment of a member of a reviewer's family by a provider at which the reviewer does not conduct an exception review does not constitute a direct or indirect financial interest in the ownership, financing, or operation of the provider on the part of the reviewer.

(2) Reviewers shall not conduct an exception review at any facility where a member of their family is a current resident.

(3) Reviewers shall not conduct an exception review at any facility that has been a client of the reviewer within the past twenty-four months.

(4) Reviewers shall not conduct an exception review at any facility that has been an employer of the reviewer within the past twenty-four months.

(E) Prior notice: ODM shall notify the provider by telephone at least two working days prior to the review.

(F) Providers selected for exception reviews must provide reviewers with reasonable access to residents, professional and nonlicensed direct care staff, the facility assessors, and completed resident assessment instruments and supporting documentation regarding the residents' care needs and treatments. Providers must also provide ODM with sufficient information to be able to contact the resident's attending or consulting physicians, other professionals from all disciplines who have observed, evaluated, or treated the resident, such as contracted therapists, and the resident's family or significant others. These sources of information may help to validate information provided on the resident assessment instrument submitted to ODM. Verification activities may include reviewing resident assessment forms and supporting documentation, conducting interviews with staff knowledgeable about the resident during the observation period for the MDS, and observing residents.

(G) An exception review shall be conducted of a random, targeted, or a combination of random and targeted samples of completed resident assessment instruments. The initial sample size shall be greater than or equal to the minimum sample size. The expanded sample size is based on the initial sample findings. Sample sizes are available on the ODM website at http://medicaid.ohio. gov/PROVIDERS/ProviderTypes/LongTermCare Facilities.aspx.

(H) Results from review of the initial sample shall be used to decide if further action by ODM is warranted. If the initial sample is to be expanded for further review, ODM reviewers shall hold a conference with facility representatives advising them of the next steps of the review and discussing the initial sample findings. If the sample of reviewed records exceeds the initial sample tolerance level described in paragraph (A)(4)(a) of this rule, ODM may subsequently expand the exception review process as follows:

(1) If the initial sample was a targeted review, the expanded sample size shall be the lesser of the remaining records in the targeted category or the applicable minimum expanded sample size.

(2) If the initial sample was a random review that became a targeted review, the expanded sample shall be the lesser of the remaining records in the targeted category or the applicable minimum expanded sample size.

(3) If the initial sample was a random review, the expanded sample size shall be at least the applicable minimum sample size.

(4) If the initial sample was a combination review, the expanded sample size shall be at least the applicable minimum sample size. The expanded sample may consist of the remaining records in the targeted and random categories.

(5) If the expanded review tolerance level is exceeded, ODM may subsequently expand the sample size for the same reporting quarter up to and including one hundred per cent of the records and continue the review process.

(I) At the conclusion of the on-site portion of the exception review process, reviewers shall hold an exit conference with facility representatives. Reviewers will share preliminary findings and/or concerns about verification or failure to verify RUG classification for reviewed records. Reviewers will give provider representatives one written preliminary copy of the exception review findings indicating whether the facility was under or over the established tolerance levels.

(J) All exception reviews shall include a final written summary of the exception review findings, including the final facility tolerance level calculations as well as the revised quarterly facility average total case mix score and the revised quarterly facility average medicaid case mix score. ODM shall mail a copy of the final written summary to the provider.

(K) All exception review reports shall be retained by ODM for at least six years.

(L) If the expanded review tolerance level is exceeded, ODM shall use the exception review findings to calculate or recalculate resident case mix scores, quarterly facility average total case mix scores, quarterly and semiannual facility average medicaid case mix scores, and annual facility average case mix scores. Calculations or recalculations shall apply only to records actually reviewed by ODM and shall not be based on extrapolations to unreviewed records of findings from reviewed records. For example, ODM shall recalculate the quarterly facility average total case mix score and quarterly facility average medicaid case mix score by replacing resident case mix scores of reviewed records and not changing the resident case mix scores of unreviewed records.

(M) ODM shall use the quarterly facility average total case mix score, quarterly and semiannual facility average medicaid case mix scores, and annual facility average case mix score based on exception review findings that exceed the exception review tolerance level to calculate or recalculate the facility's rate for direct care costs for the appropriate six month period(s). However, scores recalculated based on exception review findings shall not be used to override any assignment of a quarterly facility average total case mix score, quarterly facility average medicaid case mix score, or a peer group cost per case mix unit made in accordance with rule 5160-3-43.3 of the Administrative Code as a result of the facility's failure to submit, or submission of incomplete or inaccurate resident assessment information, unless the recalculation results in a lower quarterly facility average total case mix score, or lower quarterly or semiannual facility average medicaid case mix score, or lower peer group cost per case mix unit than the one to be assigned.

(1) If the exception review of a specific reporting quarter is conducted before the effective date of the rate for the corresponding six month period, and the review results in findings that exceed the tolerance level, ODM shall use the recalculated quarterly facility average total case mix score and quarterly facility average medicaid case mix score to calculate the facility's semiannual facility average medicaid case mix score for the facility's direct care rate for that six month period. Calculated rates based on exception review findings may result in a rate increase or rate decrease compared to the rate based on the facility's submission of assessment information.

(2) If the exception review of a specific reporting quarter is conducted after the effective date of the rate for a corresponding six month period, and the review results in findings that exceed the exception review tolerance level and indicate the facility received a lower rate than it was entitled to receive, ODM shall increase the direct care rate prospectively for the remainder of the six month period, beginning one month after the first day of the month after the exception review is completed.

(3) If the exception review of a specific reporting quarter is conducted after the effective date of the rate for a corresponding six month period, and the review results in findings that exceed the exception review tolerance level and indicate the facility received a higher rate than it was entitled to receive, ODM shall reduce the direct care rate and apply it to the six month periods when the provider received the incorrect rate to determine the amount of the overpayment. Overpayments are payable in accordance with rule 5160-3-22 of the Administrative Code.

(N) Except for additional information submitted to ODM as part of the processes set forth in paragraphs (O) and (P) of this rule, the ODM exception review determination for any resident case mix score shall be considered final. A provider may submit corrections for individual records in accordance with rule 5160-3-43.1 of the Administrative Code; however, the exception review determination for any resident assessment case mix score will be used to establish the quarterly facility average total case mix score, quarterly and semiannual facility average medicaid case mix scores, and annual facility average case mix score.

(O) A provider may seek reconsideration of any prospective direct care rate that was established by recalculating the direct care rate as a result of an exception review of resident assessment information conducted before the effective date of the rate.

(1) A reconsideration of a prospective direct care rate on the basis of a dispute with ODM exception review findings shall be submitted by the provider to ODM in accordance with the following:

(a) The request shall be submitted no later than thirty days after receipt of the exception review finding.

(b) The request shall be in writing, and shall be addressed to "Ohio Department of Medicaid, Bureau of Long Term Care Services and Supports, P.O. Box 182709, 5th Floor, Columbus, Ohio, 43218".

(c) The request shall indicate that it is a request for rate reconsideration due to a dispute with exception review findings.

(d) The request shall include a detailed explanation of the items on the resident assessment records under dispute as well as copies of relevant supporting documentation from specific individual records. The request shall also include the provider's proposed resolution.

(2) ODM shall respond in writing within sixty days of receiving each written request for a rate reconsideration related to disputed exception review findings. If ODM requests additional information to determine if the rate adjustment is warranted, the provider shall respond in writing and shall provide additional supporting documentation no more than thirty days after the receipt of the request for additional information. ODM shall respond in writing within sixty days of receiving the additional information.

(3) If the rate is increased pursuant to a rate reconsideration due to disputed exception review findings, the rate adjustment shall be implemented retroactively to the initial service date for which the rate is effective.

(4) When calculating the annual facility average and semiannual facility average medicaid case mix scores in accordance with rule 5160-3-43.3 of the Administrative Code, ODM shall use any resident case mix scores adjusted as a result of a rate reconsideration determination in lieu of the resident case mix scores from the exception review findings.

(P) The findings of an exception review conducted after the effective date of the rate may be appealed under Chapter 119. of the Revised Code. ODM shall not withhold from the facility's current payments any amounts ODM claims to be due from the facility as a result of the exception review findings while the provider is pursuing administrative or judicial remedies in good faith.

History

Effective: March 1, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-50 Nursing facilities (NFs): use of additional dollars as a result of rebasing of rates.

(A) Definitions.

For purposes of this rule:

(1) "Ancillary and support costs," "cost center," "direct care costs," "rebasing" and "tax costs" have the same meaning as in section 5165.01 of the Revised Code.

(2) "Cost center report" means a report submitted to the Ohio department of medicaid (ODM) by a nursing facility provider that identifies the amount spent on each cost center included in rebasing.

(B) Direct care spending.

(1) In accordance with section 5165.36 of the Revised Code, nursing facilities should increase direct care spending by at least seventy percent of any additional dollars received as a result of rebasing.

(2) For purposes of determining compliance with section 5165.36 of the Revised Code, the increased spending in direct care will be evaluated using calendar year 2019 medicaid nursing facility cost report data for direct care.

(1) In accordance with Section 333.240 of Amended Substitute House Bill 110 of the 134th General Assembly, for state fiscal years 2022 and 2023, cost center reports are to be submitted as follows:

(a) The first cost center report is to be submitted not later than ninety days after the end of calendar year 2021 and should cover the period of July 1, 2021 through December 31, 2021.

(b) Subsequent cost center reports should cover one calendar year each and should be submitted not later than ninety days after the end of the applicable calendar year.

(2) Reports should include only direct care, ancillary and support, and tax costs as well as inpatient days.

(3) Reports should be submitted on an electronic form prescribed by ODM.

(D) Extensions.

For good cause shown, cost center reports may be submitted within fourteen days after the original due date if written approval is received from ODM prior to the original due date of the report. Requests for extensions should be sent via email to LTCAudits@medicaid.ohio.gov and explain the circumstances resulting in the need for an extension.

(E) Late reporting penalties.

(1) If a report is not received by the original due date, or by an approved extension due date if applicable, the provider may be assessed a late reporting penalty for each day a complete and adequate report is not received

(2) The late reporting penalty period begins on the day after the original due date or on the day after the extension due date, whichever is applicable, and continues until the complete and adequate report is received by ODM.

(3) The late reporting penalty will be one hundred dollars per calendar day for each day after the original due date or the extension due date, whichever is applicable, that a nursing facility does not submit a cost center report.

(4) The late reporting penalty is assessed annually and will be a reduction in payments to providers that submit claims directly to ODM or by payment submitted to ODM outside the claims process for providers that do not submit claims directly to ODM. No penalty is imposed during a fourteen-day extension granted by ODM.

(F) Change of operator (CHOP).

In cases of a change of operator, the exiting operator's 2019 cost reports and the additional dollars received as a result of rebasing will be used for the purposes of determining the entering operator's compliance with section 5165.36 of the Revised Code and Section 333.240 of Amended Substitute House Bill 110 of the 134th General Assembly.

(G) New providers.

For state fiscal years 2022 and 2023, nursing facilities with an initial medicaid certification date on or after January 1, 2020 are excluded from the requirements set forth in paragraphs (B) and (C) of this rule.

(H) Reviews.

For purposes of determining compliance with this rule, Section 333.240 of Amended Substitute House Bill 110 of the 134th General Assembly, and section 5165.36 of the Revised Code, ODM may conduct reviews of cost center report data beginning with calendar year 2022 data.

(I) Reimbursement of funds to ODM.

(1) Any amounts spent on cost centers other than as permitted by this rule, Section 333.240 of Amended Substitute House Bill 110 of the 134th General Assembly, and section 5165.36 of the Revised Code will be reimbursed to ODM with interest.

(a) The interest will be no greater than two times the current average bank prime rate determined at the mid-point of the reporting quarter.

(b) Interest will accrue from the mid-point of the reporting quarter until the date funds are recouped from medicaid payments or until payment is submitted to ODM outside the claims process for providers who do not submit claims directly to ODM.

(2) Reimbursement of funds pursuant to a review as set forth in paragraphs (H) and (I) of this rule is not subject to appeal under Chapter 119. of the Revised Code.

Last updated July 11, 2022 at 1:35 PM

History

Effective: July 10, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-57 Nursing facilities (NFs): tax costs payment rate.

(A) The Ohio department of medicaid (ODM) shall pay a provider a per medicaid day payment rate for tax costs determined under section 5165.21 of the Revised Code except for the initial rate for new providers. ODM shall determine each new nursing facility's initial per medicaid day payment rate for tax costs in accordance with section 5165.151 of the Revised Code.

(B) For purposes of calculating the initial rate for tax costs pursuant to division (A)(4)(a) of section 5165.151 of the Revised Code, a new nursing facility shall provide ODM with the facility's projected tax costs for the calendar year in which the new nursing facility obtains an initial provider agreement. The projected tax costs may include any of the type of tax costs reportable on schedule "B-1" of the medicaid nursing facility cost report, which is available at http://medicaid.ohio.gov/PROVIDERS/ProviderTypes/LongTermCareFacilities/AutomatedCostReporting.aspx. The projected tax costs must be accompanied by the state and county tax records and assessments supporting the projection. The tax records and assessments provided must be for amounts payable by the new provider. If such state and county tax records and assessments are not available, the new facility may provide any other documentation satisfactory to ODM that verifies the amount and type of tax costs reportable on schedule "B-1" of the medicaid nursing facility cost report,

(1) If any documentation required under this rule is not received within thirty days of approval of the initial provider agreement or is determined to be unsatisfactory, the initial tax rate shall be the statewide median tax rate for tax costs for the new facility's peer group in which the facility is placed under division (B) of section 5165.16 of the Revised Code.

(2) The effective date of the initial tax cost rate for a new nursing facility shall be the same as the effective date of the new facility's medicaid provider agreement.

(3) All documentation required under this rule shall be submitted to "Ohio Department of Medicaid, Fiscal Operations

Rate Setting Section, P.O. Box 182709, Columbus, Ohio 43215-3414."

(C) If a nursing facility does not have a cost report filed with ODM for the applicable calendar year used to determine the rate for tax costs under section 5165.21 of the Revised Code, the tax rate shall be the statewide median tax rate for tax costs for the peer group in which the facility is placed under division (B) of section 5165.16 of the Revised Code.

Last updated June 25, 2025 at 5:51 PM

History

Effective: September 22, 2018
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-64 Nursing facilities (NFs): payment for medicare part A cost sharing.

(A) For nursing facility services the nursing facility provides on or after January 1, 2012, "medicaid maximum allowable amount" means one hundred per cent of the nursing facility's medicaid rate on the date that the service was provided.

(B) For qualified medicare beneficiaries (QMB) as defined in rule 5160:1-3-02.1 of the Administrative Code and medicaid consumers admitted to a nursing facility as a medicare part A benefit, the Ohio department of medicaid (ODM) will pay as cost sharing for nursing facility services the lesser of:

(1) The coinsurance amount as provided by the medicare part A plan; or

(2) The medicaid maximum allowable amount for the identified service or services minus the medicare part A plan's payment to a nursing facility for the same service or services. If the medicare part A plan's payment to a nursing facility for a service or services identified is greater than the medicaid maximum allowable amount, ODM will pay nothing for the same identified service or services.

(C) The medicaid provider is ultimately responsible for accurate and valid reporting of medicaid claims submitted for payment. Providers submitting medicare part A crossover claims to the medicaid program must be able to provide upon request documentation supporting that the information provided on the claim matches the information on the part A plan's remittance advice.

Last updated June 25, 2025 at 5:51 PM

History

Effective: August 31, 2017
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-64.1 Nursing facilities (NFs): payment for cost-sharing other than medicare part A.

(A) For medicaid eligible NF residents, the NF per diem rate includes medicaid payments for medicare or other third-party insurance cost-sharing, including coinsurance or deductible payments, associated with services that are included in the NF per diem rate.

(B) Neither the medicaid eligible NF resident nor the Ohio department of medicaid (ODM) is responsible for any medicare or other third-party insurance cost-sharing, including coinsurance or deductibles, associated with services that are included in the NF per diem rate.

History

Effective: February 14, 2019
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-65 Nursing facilities (NFs): rates for providers with an initial date of certification on or after July 1, 2006.

(A) In accordance with section 5165.151 of the Revised Code, the Ohio department of medicaid (ODM) shall determine the initial rate for the fiscal year in which the NF begins participation in the medicaid program for a NF with a first date of licensure and subsequent certification on or after July 1, 2006, including a NF that replaces one or more existing facilities, or a NF with a first date of licensure before July 1, 2006 that was initially certified for the medicaid program on or after July 1, 2006 under section 5165.151 of the Revised Code.

(1) If the number of beds in the replacement facility is greater than the number of beds in the replaced facility, the case mix score shall be equal to the weighted average of the semiannual case mix score used for the replaced beds on the last day of service at the replaced facility and the median annual average case mix score for the NF's peer group for the additional beds.

(2) If a rate for direct care costs is determined under section 5165.151 of the Revised Code for a NF using the median annual average case mix score for the NF's peer group, the rate shall be redetermined to reflect the NF's actual semiannual case mix score determined under section 5165.192 of the Revised Code after the NF submits its first two quarterly assessment data that qualify for use under paragraph (E) of rule 5160-3-43.3 of the Administrative Code. If the NF's quarterly submissions do not qualify for use in calculating a case mix score, ODM shall continue to use the median annual average case mix score for the NF's peer group in lieu of the NF's semiannual case mix score until the NF submits two consecutive quarterly assessment data that qualify for use in calculating a case mix score.

(B) After the end of the fiscal year in which the NF began participation in the medicaid program, the rates for the second fiscal year and subsequent fiscal years shall be set in accordance with section 5165.15 of the Revised Code.

History

Effective: September 22, 2018
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-65.1 Nursing facilities (NFs): rates for providers that change provider agreements.

(A) An entering operator's initial rate shall be the rate the exiting operator would have received had the exiting operator continued to participate in the medicaid program.

(B) The rate determined in paragraph (A) of this rule shall not be subject to adjustment until the following state fiscal year.

(C) After the end of the state fiscal year in which the entering operator began participation in the medicaid program, the rates for subsequent state fiscal years for other than direct care costs shall be set in accordance with sections 5165.01 to 5165.49 of the Revised Code.

(D) After the end of the state fiscal year in which the entering operator began participation in the medicaid program, the rate for direct care costs for the second state fiscal year shall be redetermined to reflect the entering operator's actual semiannual case mix score determined under section 5165.192 of the Revised Code after the NF submits its first two quarterly assessment data that qualify for use under paragraph (E) of rule 5160-3-43.3 of the Administrative Code. If the entering operator's quarterly submissions do not qualify for use in calculating a case-mix score, the median annual average case-mix score for the entering operator's peer group shall be used to calculate a case-mix score in lieu of the entering operator's actual semiannual case-mix score until the entering operator submits two consecutive quarterly assessment data that qualify for use under paragraph (E) of rule 5160-3-43.3 of the Administrative Code. The rate for direct care costs for subsequent state fiscal years shall be set in accordance with sections 5165.01 to 5165.49 of the Revised Code.

History

Effective: February 14, 2019
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-70 Nursing facilities (NFs): appeals for special focus facilities (SFFs) proposed for termination from the medicaid program.

(A) Appeal.

(1) A nursing facility may appeal under Chapter 119. of the Revised Code an order pursuant to section 5165.771 of the Revised Code terminating a nursing facility's participation in the medicaid program as provided in this rule.

(2) A nursing facility may only appeal the length of time the facility has been listed in a table as described in division (B) of section 5165.771 of the Revised Code.

(3) The appeal is to be submitted by the nursing facility to the Ohio department of medicaid (ODM) within forty-eight hours of the nursing facility's receipt of the termination order.

(B) Hearing.

(1) ODM will conduct a hearing within seven business days of the filing of the appeal by the nursing facility.

(2) For good cause shown, the hearing date may be extended.

Last updated June 25, 2025 at 5:55 PM

History

Effective: July 10, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-90 Authorization for the Ohio department of developmental disabilities (DODD) to administer the medicaid program for services provided by intermediate care facilities for individuals with intellectual disabilities (ICFs-IID).

(A) The Ohio department of developmental disabilities (DODD), through an interagency agreement with the Ohio department of medicaid (ODM), and with oversight by ODM, administers the medicaid program for services provided by intermediate care facilities for individuals with intellectual disabilities (ICFs-IID) in accordance with section 5162.35 of the Revised Code. Pursuant to section 5162.021 of the Revised Code, DODD may develop rules and policies governing the administration of the ICF-IID program, which are filed in Chapter 5123-7 of the Administrative Code upon review and approval by ODM.

(B) In collaboration with DODD, ODM will create and implement oversight measures related to the ICF-IID program in accordance with Chapter 5124. of the Revised Code. Reviews may consist of, but are not limited to, physical inspections of records and sites where services are provided, and interviews of providers and recipients of ICF-IID services. ICF-IID providers will provide any records related to the administration or provision of ICF-IID services to ODM, the centers for medicare and medicaid services (CMS), the medicaid fraud control unit, and any of their designees in accordance with the medicaid provider agreement.

(C) ODM will monitor payment made under authority of this rule as necessary to ensure that funding is used for authorized purposes in compliance with federal and state laws, regulations, and policies governing the medicaid program. ODM and DODD may recover any overpayment identified by requesting voluntary repayment, or through provider payment offsets, or formal adjudicatory or non-adjudicatory recovery proceedings.

(D) Whenever an applicant for or recipient of ICF-IID services is affected by any action proposed or taken by DODD or ODM, the entity recommending or taking the action will provide medicaid due process in accordance with section 5101.35 of the Revised Code and as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code. Such actions may include, but are not limited to, the approval, denial, or termination of enrollment or a denial of ICF-IID services. If an applicant or enrollee requests a hearing related to an action taken by DODD, the participation of DODD is necessary during the hearing proceedings to justify the decision under appeal.

Last updated June 25, 2025 at 5:51 PM

History

Effective: July 8, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-3-99 Payment methodology for state-operated intermediate care facilities for individuals with intellectual disabilities (ICFs/IID).

This rule describes the methodology for calculating payment rates for state-operated intermediate care facilities for individuals with intellectual disabilities (ICFs/IID) operated by the Ohio department of developmental disabilities (DODD) and is effective for periods on or after July 1, 2024.

(A) Definitions.

(1) "Ancillary care costs" are costs for services other than direct care, incurred by the state-operated intermediate care facility for individuals with intellectual disabilities that are reasonable and provided to ICF/IID residents through an ICF/IID employee or through a contractual arrangement with the ICF/IID. For the purpose of the ICF/IID cost reporting and rate calculation, ancillary care costs include pharmacy, radiology, and laboratory, clinic care, and physician service costs.

(2) "Base rate year" means the period used to establish the interim payment rate for each ICF/IID.

(3) "Base year cost report" means the cost report used to establish the interim payment rate.

(4) "Capital costs" as in section 5124.01 of the Revised Code.

(5)

(6) "Cost report" means an ODM approved, electronically filed, cost report format, including its supplements and attachments, used to report cost and statistical data for the operation of an ICF/IID.

(7) "Covered services" are medicaid reimbursable services provided to a resident of an ICF/IID by an ICF/IID employee or through a contractual arrangement with an ICF/IID. Covered services include ancillary care and direct care services.

(8) "Direct care costs" are costs which can be directly assigned to one program or cost center for services delivered to a resident of an ICF/IID through an ICF/IID employee or contractual arrangement with an ICF/IID. Direct care costs include wages, taxes, staff development, contracting and consulting services. Direct care costs exclude ancillary care costs.

(9) "Federal financial participation (FFP)" means the federal government's share of a state's expenditures under the medicaid program.

(10) "Final payment rate" means the rate of payment calculated using the audited rate year cost report data.

(11) "Final settlement" is the process where allowable and reasonable costs included in the audited rate year cost report are used to establish a final payment rate that is reconciled to the interim payment rate.

(12) "Interim payment rate" means the rate of payment calculated using the desk reviewed base year cost report data until the final payment rate is determined.

(13) "Medicaid days" are days an individual is eligible to receive medicaid covered services.

(14) "Medicaid paid days" are days that an ICF/IID is paid by the Ohio department of medicaid (ODM) for a medicaid eligible resident residing in an ICF/IID.

(15) "Non-medicaid days" are days an individual is not covered by medicaid and are, therefore, not billable.

(16) "Per diem" means the payment made to an ICF/IID covering all costs (direct care, ancillary care, and capital) related to the services furnished to medicaid recipients.

(17) "Rate year" means the period where calculated interim rates are paid to the ICF/ IID using the base year cost report data.

(18) "Rate year cost report" means the cost report used to establish the final payment rate.

(19) "Reasonable and allowable costs" means costs established in accordance with the centers for medicare and medicaid services (CMS) publications 15-1 ("The Provider Reimbursement Manual - Part 1") and 15-2 ("The Provider Reimbursement Manual - Part 2") as in effect October 1, 2023, available at https://www.cms.gov/ and 45 C.F.R. part 92 in effect as of October 1, 2023.

(20) "State-operated intermediate care facility for individuals with intellectual disabilities" means an institution as defined in section 1905(d) of the Social Security Act 42 U.S.C. 1396d(d) (October 1, 2023) and operated by DODD under a medicaid provider agreement with ODM.

(21) "Total inpatient days" means the sum of all days during which a resident, regardless of payment source, occupies a bed in an ICF/IID that is included in the ICF/IID certified capacity under Title XIX of the Social Security Act, 49 stat. 620, 42 U.S.C.A. 301 in effect as of October 1, 2023. Therapeutic and hospital leave days for which payment is made under section 5124.34 of the Revised Code are considered inpatient days.

(B) Source data for calculations.

(1) The cost report covers the period of July first to June thirtieth. All cost reports will be submitted to ODM in an electronic format provided by ODM. DODD will maintain, on the DODD website (http://dodd.ohio.gov/Pages/default.aspx), an electronic version of the cost report for each cost report period.

(2) The calculations described in this rule will be based on the most recent desk reviewed base year cost report data submitted to ODM. The ICF/IID cost report will:

(a) Be prepared in accordance with medicare principles governing reasonable and allowable cost reimbursement. The method used to allocate supporting cost centers will be the step-down method described in CMS publication 15-1, section 2306. The statistics on the approved cost reporting form, will be used for cost allocation purposes; and

(b) Include all information necessary for the proper determination of costs payable under medicaid including financial records and statistical data; and

(c) Include a cost report certification executed by DODD attesting to the accuracy of the cost report, and compliance with applicable federal and state rules and regulations. In addition, all subsequent revisions to the cost report will include an executed certification; and

(d) Include costs for all covered services, provided directly by ICF/IID employees or through a contractual arrangement with the ICF/IID, that are generally available to medicaid recipients and provided to a resident of an ICF/IID by the ICF/IID, and will be reimbursed only to ICF/IID. These costs are subject to all otherwise applicable audit guidelines and tests of reasonableness; and

(e) Not include the cost of pharmacy and legend drugs when these are reimbursed directly to a pharmacy provider; and

(f) Not include the cost of any goods or services that are otherwise reimbursed to a provider other than the ICF/IID regardless of the type of service.

(3) A desk review will be performed by ODM on all base year cost reports for the purpose of determining interim payment rates, all of which are subject to final settlement under paragraph (E) of this rule. Desk review procedures will take into consideration the relationship between the prior year's audited costs and the current year's reported costs. Adjustments may be made to the cost report by ODM as necessary to determine reasonable and accurate interim payment rates. Adjustments made by ODM do not preclude findings of additional cost exceptions issued as the result of an audit.

(4) An ICF/IID certified cost report will be filed with ODM within one hundred eighty days of the end of the fiscal year. If the cost report is not received within one hundred eighty days of the end of the fiscal year the rate paid will be the lower of ninety per cent of the state wide average rate or the interim payment rate.

(5) DODD may request an extension in writing and ODM may grant one extension of up to thirty calendar days for filing a cost report. ODM will designate the individual to receive the request within ODMs financial management, planning and rate setting section. The extension request will be submitted to ODM no later than one hundred fifty days after the end of the fiscal year. ODM will respond to DODD within fifteen calendar days of receipt of the extension request.

(1) Interim payment rates for each ICF/IID will be based upon the source data described in paragraph (B) of this rule.

(2) The interim payment rate will be calculated as follows:

(a) Calculation of direct care cost per diem rate.

(i) Calculate the direct care cost per diem for each ICF/IID by dividing direct care costs by total inpatient days.

(ii) For each ICF/IID multiply the ICF/IID's direct care cost per diem by the ICF/IID's total inpatient days. Sum results for all ICFs/IID and divide by the sum of the ICF/IID total inpatient days for all ICFs/IID.

(iii) Calculate the direct care cost per diem ceiling by taking the amount calculated in paragraph (C)(2)(a)(ii) of this rule and multiplying it by one hundred twelve per cent.

(iv) The interim ICF/IID direct care cost per diem will be the lower of the amount calculated in paragraph (C)(2)(a)(i) of this rule or the direct care cost per diem ceiling as calculated in paragraph (C)(2)(a)(iii) of this rule.

(b) Calculate the ancillary care cost per diem rate for each ICF/IID by dividing ancillary care costs by total inpatient days.

(c) Calculate the capital cost per diem for each state-operated ICF/IID by dividing capital costs by total inpatient days.

(d) The interim payment rate for each state-operated ICF/IID will be the sum of the amounts calculated in paragraphs (C)(2)(a)(iv), (C)(2)(b) and (C)(2)(c) of this rule, inflated from the mid-point of the base year to the midpoint of the rate year using the skilled nursing facility (SNF) market basket consumer price index as determined by the United States bureau of labor statistics..

(D) Audit.

(1) ODM will perform field audits either directly or through arrangement of the most current cost report for each ICF/IID at least once every three years or more often as determined by ODM. Cost reports for other periods may also be audited within three years from the fiscal year end, unless justified from previous audit findings. ODM will use a full or limited scope audit. The audits will be performed in accordance with auditing standards adopted by ODM. ODM will develop a risk-based methodology to determine which ICFs/IID are subject to audit.

(2) The audit scope will be determined by ODM and will be sufficient to determine if costs reflected in the cost report are accurate, made in compliance with pertinent regulations, and based on actual cost.

(3) DODD will maintain documentation to support all transactions, to permit the reconstruction of all transactions and the proper completion of all reports required by state and federal laws and regulations, and to substantiate compliance with all applicable federal laws and regulations, state laws and administrative rules. This documentation will be maintained for the greater of seven years after the cost report is filed or, if ODM issues an audit report, six years after all appeal rights relating to the audit report are exhausted. Documentation will include sufficient detail to disclose:

(a) Services provided; and

(b) Administrative costs of services provided; and

(d) Total inpatient days, medicaid days, and non-medicaid days; and

(e) Services claimed are covered under the medicaid program and made in accordance with applicable rules of the Administrative Code; and

(f) Amounts of third-party payments reported are indicative of actual amounts received; and

(g) Costs reported to ODM represent actual incurred, reasonable, and allowable costs in accordance with provisions of the CMS provider manual 15-1, Chapter 5160-3 of the Administrative Code as applicable, and 45 C.F.R. 92.

(4) Each ICF/IID will collect, report, and maintain separately all data and records sufficient to support the rate calculation including but not limited to statistical and financial data:

(a) Related to costs that are included in or listed in the cost report as reimbursable costs; and

(b) Related to non-reimbursable costs.

(5) DODD will maintain adequate systems of internal control (e.g. preventive, detective, and compensating controls) as related to federal funding to ensure:

(a) Accurate and reliable financial and administrative records; and

(b) Efficient and effective use of resources; and

(E) Final settlement.

(1) Final settlement will include adjustments to the base rate year cost report included in paragraphs (B) (2) and (D) (1) to (D) (5) of this rule.

(2) The final payment rate will be calculated as follows:

(a) Calculation of direct care cost per diem rate.

(i) Calculate the direct care cost per diem rate for each ICF/IID by dividing direct care costs by total inpatient days.

(ii) For each ICF/IID, multiply the ICF/IID's direct care cost per diem rate as calculated in paragraph (E)(2)(a)(ii) of this rule by the ICF/IID's total inpatient days. Sum results for all ICFs/IID and divide by the sum of total inpatient days for all ICFs/IID.

(iii) Calculate the direct care cost per diem ceiling by taking the amount calculated in paragraph (E)(2)(a)(ii) of this rule and multiplying it by one hundred twelve per cent.

(iv) The final ICF/IID direct care cost per diem rate will be the lower of the amount calculated in paragraph (E)(2)(a)(i) of this rule or the direct care per diem ceiling as calculated in paragraph (E)(2)(a)(iii) of this rule.

(b) Calculate the ancillary care cost per diem rate for each ICF/IID by dividing ancillary care costs by total inpatient days.

(c) Calculate the capital cost per diem rate for each ICF/IID by dividing capital costs by total inpatient days. The final rate for each ICF/IID will be the sum of the amounts calculated in paragraphs (E)(2)(a)(iv), (E)(2)(b) and (E)(2)(c) of this rule.

(3) The final payment rate calculated in paragraph (E)(2) of this rule is subtracted from the interim payment rate calculated in paragraph (C)(2) of this rule. The result is multiplied by the medicaid paid days and applicable FFP rate. The result of this calculation is the final settlement amount. Where the interim payment rate exceeds the final payment rate, the excess payment will be remitted to ODM. If the final payment rate exceeds the interim payment rate, ODM will remit the amount to DODD.

(4) The audit and final settlement will be issued within thirty-six months of receipt of the rate year cost report. If an audit is not issued for final settlement within thirty-six months, the rates calculated using the desk reviewed base year cost report will be used for final settlement.

(5) No further adjustments to payments or rates can occur after the implementation of the final cost settlement.

(F) Upper payment limit assurance.

Payments made to ICFs/IID in accordance with this rule under medicaid are, in the aggregate on a statewide basis, equal to or less than amounts which would have been recognized under Title XVIII of the Social Security Act, 42 U.S.C. 1395 for comparable services in accordance with 42 C.F.R 447.272, in effect as of October 1, 2023.

(G) Dispute resolution.

All disputes regarding the application of this rule, including but not limited to desk reviews, payment, rate setting, and audits will be resolved between ODM and DODD in accordance with terms set forth in the interagency agreement. Disputes that arise from the application of this rule will not be subject to hearings conducted under Chapter 119. of the Revised Code.

(H) Rule exclusion.

Excluding those rules referring to reasonableness ceilings, cost limitations, cost reimbursement, occupancy levels, disallowance of costs, payment calculations, payment methodology, and appeals, all other rules which govern the operation of medicaid-certified ICFs/IID under Chapters 5160-1, 5160-3, and 5123-7 of the Administrative Code will apply to ICFs/IID. The payment methodology specified in this rule will govern the reimbursement of medicaid costs for ICFs/IID.

(I) Claim submission, payment and adjustment process.

All ICFs/IID will comply with claim submission, payment, and adjustment requirements in accordance with rule 5123-7-15 of the Administrative Code.

Last updated July 7, 2025 at 6:53 PM

History

Effective: July 3, 2025
Promulgated Under: 119.03

Chapter 5160-4 Medical and Surgical Services

Ohio Adm.Code 5160-4-01 Physician services.

(A) Separate payment may be made for covered professional services rendered by a physician employed by or under contract with a facility such as a hospital or long-term care facility (i.e., a "facility-based" physician) only if the following conditions are met:

(1) The services contribute directly to the diagnosis or treatment of an individual patient;

(2) Any applicable requirements set forth in agency 5160 of the Administrative Code are satisfied; and

(3) The expenses associated with the provision of the professional services are excluded from the cost report of the facility.

(B) In addition to professional services, a facility-based physician often performs other services that are of benefit to patients in general (e.g., teaching; research; administration; supervision of professional or technical personnel, residents, interns, or fellows; or service on provider committees). Payment for such services may be made only to the employing or contracting provider.

(C) For the sole purpose of demonstrating eligibility for incentive payments made in accordance with Section 4201 of the American Recovery and Reinvestment Act of 2009 (ARRA, Pub. L. No. 111-5), codified at 42 U.S.C. 1396b (as revised December 27, 2020), and with the regulations published at 42 C.F.R. Part 495 (October 1, 2021), an optometrist operating within the appropriate scope of practice defined in section 4725.01 of the Revised Code is considered to be a physician.

Last updated September 17, 2026 at 2:01 PM

History

Effective: March 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-4-02 Supervision of professional services.

(A) Definitions that apply to this rule.

(1) "Independent practitioner" is a practitioner who, under Ohio law, may provide healthcare services without supervision.

(2) "Non-independent practitioner" is a practitioner who, under Ohio law, may provide healthcare services only with supervision.

(3) "Supervision" is a collective term encompassing two types of professional oversight:

(a) A practitioner providing direct supervision is present in the practice setting, although not necessarily in the same room, and is immediately available to provide assistance and direction throughout the provision of services. Neither availability by telephone nor presence nearby outside the practice setting constitutes direct supervision.

(b) A practitioner providing general supervision is available, although not necessarily present in the practice setting, to provide assistance and direction throughout the provision of services. A practitioner who is not physically present has the capability to provide immediate consultation by communications device and can travel to the practice setting quickly in case of emergency.

(B) Coverage. Payment may be made to the following practitioners only if the specified services are provided and the indicated conditions are met.

(1) An independent practitioner, for a service provided by a non-independent practitioner under general supervision:

(a) The non-independent practitioner functions in one of the following capacities:

(i) An employee of the supervising independent practitioner or of the practice in which the supervising independent practitioner participates; or

(ii) An independent contractor engaged by the supervising independent practitioner through a written agreement;

(b) The professional control exercised by the supervising independent practitioner or the practice of the supervising independent practitioner is the same for both employees and independent contractors; and

(c) The service was provided in connection with a covered healthcare service that represents an expense to the practice of the supervising independent practitioner.

(2) An independent practitioner, for a service provided by a non-independent practitioner under direct supervision:

(a) All of the conditions specified in paragraph (B)(1) of this rule are met; and

(b) Either of the following conditions is met:

(i) The supervising independent practitioner personally rendered a professional service to initiate the course of treatment, to which the service performed by the non-independent practitioner is incidental; or

(ii) The supervising independent practitioner rendered subsequent services at a frequency indicating continued participation in the management of the course of treatment.

(1) Services provided by an independent practitioner who is employed by or under contract with another independent practitioner are not subject to the supervision provisions set forth in this rule.

(2) Nothing in this rule constitutes an exemption either from the fundamental principle that services rendered are within a practitioner's scope of licensure or practice or from any supervision standard established in law, regulation, statute, or rule.

(3) No separate payment is made for a professional service provided in a nursing facility (NF), skilled nursing facility (SNF), intermediate care facility for individuals with intellectual disabilities (ICFIID), inpatient hospital, outpatient hospital, or hospital emergency department by a non-independent practitioner employed by the facility or hospital, even if an independent practitioner ordered the service.

Last updated September 1, 2021 at 8:28 AM

History

Effective: September 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-4-02.3 Exception for certain services provided by residents.

(A) The provisions set forth in paragraph (B) of rule 5160-4-02 of the Administrative Code do not apply when both of the following criteria are met:

(1) A healthcare service is provided by a resident participating in an approved graduate medical education (GME) program; and

(2) The conditions specified in 42 C.F.R. 415.174 (October 1, 2020) are satisfied.

(B) No separate payment will be made for services rendered by an unsupervised resident at a location not specified in 42 C.F.R. 415.174 (October 1, 2020).

Last updated September 11, 2026 at 1:22 PM

History

Effective: September 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-4-03 Services provided by a physician assistant.

(A) Definitions.

(1) "Physician assistant" has the same meaning as in Chapter 4730. of the Revised Code.

(2) "Physician" has the same meaning as in section 4730.01 of the Revised Code.

(3) "Health care facility" has the same meaning as in section 4730.01 of the Revised Code.

(4) "Service" has the same meaning as in section 4730.01 of the Revised Code.

(B) Coverage. For a covered service performed by a physician assistant who is currently enrolled as an Ohio medicaid provider, payment may be made only if the physician assistant practices under either of the following arrangements:

(1) The physician assistant provides services under the supervision, control, and direction of a physician with whom the physician assistant has entered into a supervision agreement under section 4730.19 of the Revised Code; or

(2) The physician assistant practices in a health care facility and provides services the facility has authorized the physician assistant to perform.

(1) For assistant-at-surgery services performed by a physician assistant, payment is twenty-five per cent of the medicaid maximum for the covered primary surgical procedure.

(2) For a covered immunization, injection of medication, or provider-administered pharmaceutical, payment is made in accordance with rule 5160-4-12 of the Administrative Code.

(3) For all other covered services performed by a physician assistant, payment is the lesser of the billing provider's submitted charge or eighty-five per cent of the medicaid maximum.

(4) Payment for services provided by a hospital-employed physician assistant will be made to the hospital.

Last updated September 23, 2026 at 2:37 PM

History

Effective: January 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-4-04 Advanced practice registered nurse (APRN) services.

(A) Definition. "Advanced practice registered nurse (APRN)" has the same meaning as in Chapter 4723-08 of the Administrative Code. The term encompasses a certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), certified nurse-midwife (CNM), and certified nurse practitioner (CNP).

(B) Coverage.

(1) Unless a specific exception is noted, all other rules in agency 5160 of the Administrative Code that pertain to services rendered by a physician apply also to services rendered by an APRN.

(2) For a covered service rendered by an APRN, payment may be made only if the following conditions are met:

(a) The service is rendered to an Ohio-medicaid-eligible individual in a state in which the APRN is licensed or authorized to practice;

(b) The service is within the scope of practice of the APRN's specialty;

(d) The service cannot be performed by someone who lacks the skills and training of an APRN.

(1) Payment for a covered service rendered by a CRNA is made in accordance with rule 5160-4-21 of the Administrative Code.

(2) Payment for a covered service rendered by a CNS, CNM, or CNP is the lesser of the billing provider's submitted charge or the applicable amount from the following list:

(a) For a covered service rendered in a hospital setting (inpatient hospital, outpatient hospital, or hospital emergency department), eighty-five per cent of the medicaid maximum;

(b) For a covered service rendered in a non-hospital setting, one hundred per cent of the medicaid maximum; or

(c) For assistant-at-surgery services provided by a CNS, CNM, or CNP regardless of setting, twenty-five per cent of the medicaid maximum for the covered primary surgical procedure.

(3) Payment for services rendered by a hospital-employed APRN will be made to the hospital.

(4) In the event that payment for a covered service performed by an APRN is issued both to the APRN and to a contracting or supervising provider on behalf of the APRN, one of the issued payments is subject to recovery.

Last updated September 23, 2026 at 2:41 PM

History

Effective: January 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-4-06 Specific provisions for evaluation and management (E&M) services.

(A) Site-related provisions. Policies concerning payment for evaluation and management (E&M) services may depend on the site in which the services are provided.

(1) Ambulance. Policies for E&M services provided during ambulance transport by hospital staff members are set forth in rule 5160-2-04 of the Administrative Code. Payment for E&M services provided during ambulance transport by practitioners who are not hospital staff members is subject to the following conditions:

(a) Such services involve direct face-to-face contact between a practitioner and the individual being transported, which begins when the practitioner assumes responsibility for the care of the individual at the point of pickup and ends when the receiving facility assumes this responsibility. Remote direction of emergency care en route (e.g., communication by radio with a physician located in a hospital) is not direct face-to-face contact.

(b) Routine monitoring and maintenance (e.g., the recording of vital information, pulse oximetry, the initiation of mechanical ventilation) is included; no separate payment is made.

(c) Services provided by other members of the transport team (the ambulance crew) cannot be reported by the practitioner as E&M services.

(2) Nursing facility (NF). Policies are set forth in Chapter 5160-3 of the Administrative Code. The periodic review of a NF resident's medical record, plan of care, or habilitation plan is part of overall medical direction, payment for which is made to the NF rather than to the practitioner.

(3) Federally qualified health center, outpatient health facility, or rural health clinic. Policies are set forth in Chapter 5160-28 of the Administrative Code. Specific claim formats may apply.

(B) Service-related provisions.

(1) After-hours care. Additional payment may be made for E&M services provided in a non-hospital setting after regularly scheduled business hours.

(2) Bundled services. No separate payment is made for E&M services provided in conjunction with certain covered diagnostic or therapeutic procedures, which are identified in other rules in Chapter 5160-4 of the Administrative Code.

(3) Consultation. Payment may be made for a consultation provided by a licensed medical practitioner regarding the evaluation and management of a specific medical problem.

(a) A licensed medical practitioner enrolled as a medicaid provider requests the consultation. For purposes of this rule, a medical visit initiated by someone other than a licensed medical practitioner (e.g., a patient, a family member, a teacher, a social worker) is not a consultation.

(b) The request for a consultation, the need for a consultation, the consultant's opinion, and any services that were ordered or performed in relation to the consultation are documented in the patient's medical record.

(c) Follow-up visits initiated by a consultant for the purpose of evaluation and management of a patient's condition are E&M services rather than consultation.

(d) The referring practitioner is identified on any claim for consultation that is submitted.

(4) Critical-care services. Payment for covered critical-care services provided by a single practitioner is limited to two hours per patient per day. This time limit does not apply to critical-care services rendered during the transportation of a critically ill or injured individual older than twenty-four months.

(5) Hospital observation services (including admission and discharge services). Payment may be made for not more than twenty-two hours of medical observation of an individual who is treated in a hospital but does not need to be admitted as an inpatient.

(a) Emergency department services are not observation.

(b) If during observation the individual is admitted to the hospital as an inpatient, payment for the observation services depends on the role of the practitioner.

(i) If the observing practitioner continues as the individual's attending practitioner after admission, the observation services are treated as inpatient E&M services and are reported as such on any claim submitted.

(ii) If the observing practitioner does not continue as the individual's attending practitioner after admission, the observation services are not reported as inpatient E&M services.

(6) Inpatient hospital visits following surgery. No separate payment is made for an E&M service provided within the postoperative period for a covered surgical procedure. The postoperative period, which is listed in appendix DD to rule 5160-1-60 of the Administrative Code, includes the day of surgery. The postoperative period for one surgical procedure may be extended by the performance soon afterward of another surgical procedure.

(7) Medication-assisted treatment, which is defined at 42 C.F.R. 8.2 (October 1, 2023). Separate payment may be made for the provision of self-administered take-home medication for the treatment of substance use disorder, in addition to an E&M service, if the following conditions are met:

(a) The provider complies with all applicable rules and requirements of the United States drug enforcement administration, the Ohio board of pharmacy, and the Ohio state medical board;

(b) The medication is a pharmaceutical prescribed for the treatment of opioid addiction; and

(c) The provider includes in the patient's medical record documentation that the amount of take-home medication provided was medically necessary.

(1) Payment for an E&M service that is not medically necessary in accordance with rule 5160-1-01 of the Administrative Code is subject to recovery.

(2) Concurrent care is the provision of service to one individual on one date of service by more than one practitioner in the same group practice. When concurrent care is provided, payment may be made only for one E&M service (i.e., the separate services are treated as though they were provided by the same practitioner for the same purpose) unless one of the following conditions applies:

(a) The services were provided for unrelated purposes;

(b) The practitioners had different specialties; or

(3) E&M services in excess of twenty-four during a calendar year that are provided to an individual in an outpatient setting or a NF are subject to post-payment review. The following services are excluded from the calculation of the number of E&M services provided during a calendar year:

(a) Pregnancy-related services, which are described in rule 5160-21-04 of the Administrative Code;

(b) Early and periodic screening, diagnostic, and treatment (EPSDT) services;

(d) Critical-care visits;

(e) An allergen immunotherapy service that is not provided in conjunction with an E&M service; and

(f) An E&M service provided for any of the following conditions or purposes:

(i) End-stage renal disease;

(ii) Chemotherapy or radiation therapy for malignancy;

(iii) End-stage lung disease;

(iv) Unstable diabetes or diabetes with complications;

(v) Uncontrolled hypertension or hypertension with complications;

(vi) Neoplasms or leukemia;

(vii) Organ transplantation;

(viii) Hereditary anemias;

(ix) Hemophilia or other congenital disorders of clotting factors;

(x) Acquired hemolytic anemias;

(xi) Aplastic anemias;

(xii) Deficiency of humoral immunity;

(xiii) Deficiency of cell-mediated immunity;

(xiv) Combined immunity deficiency;

(xv) Cystic fibrosis;

(xvi) Malabsorption;

(xvii) Failure to thrive;

(xviii) Infant prematurity;

(xix) Respiratory distress syndrome or other respiratory conditions of the fetus or newborn; or

(xx) The terminal stage of any life-threatening illness.

Last updated January 2, 2024 at 9:40 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-4-12 Immunizations, injections and infusions (including trigger-point injections), skin substitutes, and provider-administered pharmaceuticals.

(A) General provisions.

(1) A "not otherwise specified," "unlisted," or "miscellaneous" procedure code should be reported on a claim only if no procedure code is available that identifies the particular service or item provided.

(2) No separate payment is made for an immunization, injection, infusion, vaccine, toxoid, or provider-administered pharmaceutical as a medical service if it is provided in a hospital setting (inpatient hospital, outpatient hospital, or hospital emergency department).

(3) A provider-administered pharmaceutical reported on a claim submitted in accordance with Chapter 5160-9 of the Administrative Code is regarded as a pharmacy service rather than a professional medical service, and payment of the claim is governed by the provisions of that chapter. For example, a vaccine, toxoid, or other provider-administered pharmaceutical prescribed for a resident of a long-term care facility (LTCF) and subsequently administered by a LTCF staff member is a pharmacy service.

(4) Payment for an immunization, injection, or infusion includes related supplies (e.g., alcohol wipes, needles, syringes, and tubing).

(B) Coverage of immunizations. An immunization has two components: the administration of the vaccine or toxoid and the vaccine or toxoid itself.

(1) Payment for administration may take one of two forms:

(a) Payment for the most appropriate administration procedure; or

(b) Payment for the least complex evaluation and management service rendered to an established patient.

(2) Separate payment may be made for the vaccine or toxoid. No payment, however, will be made for vaccines that can be obtained at no cost through the federal vaccines for children (VFC) program, which is administered by the Ohio department of health (ODH).

(3) Limitations apply to certain vaccines.

(a) Regardless of the formulation, payment for hepatitis B vaccine (HBV) administered to individuals younger than nineteen years of age may be made only under the VFC program. Different procedure codes are reported on claims to distinguish HBV administered to individuals younger than nineteen from HBV administered to individuals nineteen or older.

(b) Vaccines for the human papilloma virus (HPV) are covered in accordance with the schedule regarding the appropriate periodicity, dosage, and contraindications applicable to vaccines established by the advisory committee on immunization practices of the centers for disease control and prevention, available from http://www.cdc.gov.

(C) Coverage of therapeutic, prophylactic, or diagnostic injections or infusions (excluding chemotherapy and other complex procedures).

(1) An injection or infusion has two components: the administration of a fluid medium and, except in the case of hydration, the pharmaceutical itself. No separate payment is made for the administration service if an injection or infusion is given during the course of an office visit or in conjunction with another medical service that includes an evaluation and management element.

(2) Payment may be made for an injection or infusion or a provider-administered pharmaceutical only if at least one of the following criteria is met:

(a) Its use for a particular indication has been approved by the U.S. food and drug administration; or

(b) According to accepted standards of medical practice, it is a specific or effective treatment for the particular condition for which it is given.

(3) No separate payment is made for an injection or infusion or a provider-administered pharmaceutical that meets either of the following criteria:

(a) The frequency or duration of its administration exceeds accepted standards of medical practice for the particular condition; or

(b) It is provided for or in association with non-covered medicaid services, which are defined in rule 5160-1-61 of the Administrative Code.

(4) Immune globulin is covered when it is used to provide passive immunity to an individual who is immunosuppressed; has an acquired or congenital immunodeficiency; is at risk of Rh-isoimmunization; or is in immediate danger of contracting a communicable disease through direct contact with blood, saliva, or other body fluids through an open wound, bite, puncture, or mucous membrane.

(5) Epoetin alfa (EPO) for the treatment of anemia, either associated with or not related to chronic renal failure, is covered as a medical service when a provider incurs the cost of the drug and the service is provided in a dialysis center or office setting.

(6) Certain procedure codes represent a specific number of dosage units. On a claim, the fewest number of procedure codes are to be reported together to represent the administered dosage.

(D) Coverage of trigger-point injections.

(1) A trigger point is a hyperexcitable area of the body, where the application of a stimulus will provoke pain to a greater degree than in the surrounding area. The purpose of a trigger-point injection is to treat not only the symptom but also the cause through the injection of a single substance (e.g., a local anesthetic) or a mixture of substances (e.g., a corticosteroid with a local anesthetic) directly into the affected body part in order to alleviate inflammation and pain. Payment may be made for a trigger-point injection only if the following criteria are met:

(a) The patient has a diagnosis for which the trigger-point injection is an appropriate treatment; and

(b) The following information is documented in the patient's medical record:

(i) A proper evaluation including a patient history and physical examination leading to diagnosis of the trigger point;

(ii) The reason or reasons for selecting this therapeutic option;

(iii) The affected muscle or muscles;

(iv) The muscle or muscles injected and the number of injections;

(v) The frequency of injections required;

(vi) The name of the medication used in the injection;

(vii) The results of any prior treatment; and

(viii) Corroborating evidence that the injection is medically necessary.

(2) A trigger-point injection is normally considered to be a stand-alone service. No additional payment will be made for an office visit on the same date of service unless there is an indication on the claim (e.g., in the form of a modifier appended to the evaluation and management procedure code) that a separate evaluation and management service was performed.

(3) Certain trigger-point injection procedure codes specify the number of injection sites. For these codes, the unit of service is different from the number of injections given. Payment may be made for one unit of service of the appropriate procedure code reported on a claim for service rendered to a particular patient on a particular date.

(4) Trigger-point injections should be repeated only if doing so is reasonable and medically necessary. For trigger-point injections of a local anesthetic or a steroid, payment will be made for no more than eight dates of service per calendar year per patient.

(E) Coverage of skin substitutes.

(1) Skin substitutes may be used on burns or ulcers when grafting with actual skin is not an appropriate option. Skin substitutes are expected to function as a permanent replacement for lost or damaged skin. They may be used for temporary wound coverage or wound closure as appropriate and medically necessary. Payment may be made for a skin substitute if a practitioner determines that the skin substitute will be of benefit for the particular type of wound.

(a) When a skin substitute is applied in an office setting, payment may be made to a practitioner for both the skin substitute and an appropriate skin application procedure.

(b) When a skin substitute is applied in a hospital setting (inpatient hospital, outpatient hospital, or hospital emergency department), payment may be made to a practitioner only for the skin application procedure. Payment for the skin substitute is included in the hospital's facility payment.

(c) When a skin substitute is applied in a long-term care facility (LTCF), payment may be made to a practitioner for the skin application procedure. Payment for the skin substitute may be made to the practitioner only if the practitioner supplies the skin substitute; otherwise, payment for the skin substitute is included in the LTCF's facility payment.

(2) The results of treatment are to be documented in the individual's medical record. Payment will not be made for additional applications or re-applications if the wound volume has not decreased by at least fifty per cent after three separate treatments over twelve weeks.

(F) Payment.

(1) On the department's web site, http://medicaid.ohio.gov, is a list of vaccines, toxoids, skin substitutes, and other provider-administered pharmaceuticals each of which is covered by medicaid either as a medical service or as a VFC-designated vaccine. Payment for a covered non-VFC vaccine, toxoid, skin substitute, or other provider-administered pharmaceutical is the lesser of the provider's submitted charge or the first applicable item from the following ordered list:

(a) An amount specified in or determined in accordance with the Administrative Code;

(b) The state maximum allowable cost (SMAC), which is defined in rule 5160-9-05 of the Administrative Code;

(d) One hundred seven per cent of the wholesale acquisition cost (WAC); or

(e) Eighty-five and six-tenths per cent of the average wholesale price (AWP).

(2) Payment for any other covered administration service or evaluation and management service listed in appendix DD to rule 5160-1-60 of the Administrative Code is made in accordance with that rule.

Last updated September 25, 2026 at 8:29 AM

History

Effective: March 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-4-14 Professional services associated with dialysis.

(A) Routine maintenance dialysis.

(1) Payment for professional services associated with the medical management of patients receiving maintenance dialysis is made either on a monthly capitation basis or on a daily basis.

(a) The monthly capitation payment is available to a single practitioner in the following circumstances:

(i) The practitioner alone provides monthly continuity of services to a single patient or to a group of patients; or

(ii) The practitioner serves as the primary practitioner in a joint provision (in which one person receives payment on behalf of a team of practitioners).

(b) When dialysis care is provided by more than one practitioner in the absence of a joint provision, payment may be made to each practitioner separately for the days on which dialysis care was provided.

(c) On a submitted claim, the type of service payment (monthly capitation or daily care) is differentiated by procedure code.

(2) In addition to the payment for professional services, separate payment may be made for the following services:

(a) The declotting of shunts; and

(b) Covered professional services that are unrelated to the patient's dialysis or renal condition.

(B) Inpatient dialysis services.

(1) Payment may be made for professional services that are related to dialysis performed for a hospital inpatient for one of the following reasons:

(a) Treatment of acute renal failure or renal trauma;

(b) Establishment of an initial course of dialysis (the first dialysis treatment and all subsequent dialysis treatments performed before the patient is stabilized on dialysis); or

(c) Treatment of an established dialysis patient who was admitted to the hospital for a condition or illness unrelated to the patient's renal condition.

(2) The following provisions apply to payment for professional services related to inpatient dialysis:

(a) The time when the practitioner is present with the patient during the dialysis procedure is documented in the patient's medical record.

(b) On a submitted claim, an appropriate procedure code is used to indicate inpatient dialysis care.

(c) Payment for professional services includes all evaluation and management services related to the patient's renal condition. (The payment to the hospital for inpatient dialysis includes all other patient care services that are rendered during the dialysis procedure.)

(d) If a dialysis patient is admitted to a hospital for no reason other than to receive maintenance dialysis, the dialysis is considered to be routine maintenance and payment for professional services is made accordingly.

(C) For services rendered to a single patient in a single calendar month, the following overpayments or duplicate payments are disallowed:

(1) More than one monthly capitation payment;

(2) Payment for more than thirty-one days of daily dialysis care; and

(3) Both the monthly capitation payment and payment for daily dialysis care.

Last updated May 11, 2026 at 10:21 AM

History

Effective: July 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-4-19 Allergy services.

(A) Purpose. This rule addresses payment for the professional administration and evaluation of allergy sensitivity test procedures, which can be divided into three categories: allergy testing, ingestion challenge testing, and allergen immunotherapy. Payment for related laboratory tests is addressed in Chapter 5160-11 of the Administrative Code.

(B) Coverage.

(1) Allergy testing.

(a) Testing is only appropriate if there is a reasonable probability, documented in the individual's medical file, that the individual was exposed to the antigen being used for the test.

(b) The unit of service is the test. Payment may be made only for the fewest number of tests necessary to reach a diagnosis.

(c) Payment includes all associated professional services. No payment is made for evaluation and management unless a separately identifiable service is performed.

(d) A qualitative multiallergen screen for allergen-specific immunoglobulin E (IgE) is not considered to be medically necessary.

(2) Ingestion challenge testing.

(a) The unit of service is the encounter. Payment may be made only once per visit regardless of the number of items tested.

(b) Payment includes the evaluation of the individual's response to the test items.

(3) Allergen immunotherapy.

(a) Payment includes all associated professional services. No payment is made for evaluation and management unless a separately identifiable service is performed.

(b) Payment for the antigen is made separately. No payment will be made for a service that includes administration (injection) as well as the antigen and its preparation.

(d) Separate payment for the preparation of a single-dose vial of allergen antigen may be made only if the provider prepares the antigen for injection by another entity.

(e) The date of service is the date on which the first dose is administered or the date on which the vial is dispensed for future use.

(f) Immunotherapy is not considered to be medically necessary for an allergic reaction to common environmental factors (such as dust, house plants, or natural fibers) that can be mitigated by other means.

Last updated May 11, 2026 at 10:21 AM

History

Effective: May 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-4-20 Chemotherapy.

(A) Chemotherapy has two components: administration of a chemotherapeutic agent and the chemotherapeutic agent itself. The administration of chemotherapy includes the preparation of the chemotherapeutic agent and all therapeutic services and medical supplies provided during treatment.

(B) Coverage.

(1) Chemotherapy provided in a hospital setting (inpatient hospital, outpatient hospital, emergency department) is a hospital service, for which payment is made in accordance with Chapter 5160-2 of the Administrative Code. No separate payment is made to a practitioner for either chemotherapy administration or a chemotherapeutic agent provided in a hospital setting.

(2) Separate payment may be made for chemotherapy administration that is provided in a non-hospital setting by a practitioner (such as an oncologist) or by a qualified employee supervised by a practitioner. Any place-of-service restriction on this provision is shown in appendix DD to rule 5160-1-60 of the Administrative Code.

(3) Separate payment may be made for a chemotherapeutic agent that is furnished by a practitioner, represents a cost to the practitioner, and is administered in a non-hospital setting.

(4) The process of supervising and monitoring chemotherapy treatment is included in an evaluation and management service (office visit). The actual administration of chemotherapy, however, is a professional service that is independent of evaluation and management. Separate payment may be made for evaluation and management provided in conjunction with chemotherapy administration in a non-hospital setting.

Last updated February 7, 2024 at 9:21 AM

History

Effective: January 1, 2020
Promulgated Under: 119.03

Ohio Adm.Code 5160-4-21 Anesthesia services.

(A) Scope and definitions.

(1) This rule sets forth provisions governing payment for the administration or management of anesthesia as a non-institutional professional service rendered by qualified medical practitioners. Provisions governing payment for anesthesia as a dental service are set forth in Chapter 5160-5 of the Administrative Code.

(2) "Base unit" is an anesthesia-related component representing factors other than an anesthetist's time, such as standard pre-operative and post-operative visits, the administration of fluids or blood incident to anesthesia administration, and monitoring.

(3) "Base unit value" is the value for a base unit assigned by the centers for medicare and medicaid services (CMS). A table of procedure codes and their respective base unit values is available from the CMS web site, https://www.cms.gov.

(4) "Time unit" is an anesthesia-related component representing the span, reported in minutes, during which an anesthesiologist or a medically-directed or medically-supervised qualified non-physician anesthetist is continuously present. The measured length of the time unit depends on the type of anesthesia.

(a) For neuraxial labor analgesia, the time unit begins when the analgesic is inserted and ends at delivery. Total duration is limited to two hundred forty minutes (four hours).

(b) For all other anesthesia, the time unit begins when the anesthetist starts to prepare the individual for the induction of anesthesia and ends when the presence of the anesthetist is no longer required and the individual may be safely placed under post-anesthetic care.

(5) "Time unit value" is the number of fifteen-minute increments in a time unit, rounded to the nearest tenth.

(B) Providers.

(1) Rendering providers. The following eligible medicaid providers may administer anesthesia:

(a) An anesthesiologist (i.e., a physician trained in anesthesia);

(b) A certified registered nurse anesthetist (CRNA); or

(2) Billing providers. The following eligible medicaid providers may receive medicaid payment for submitting a claim for administering anesthesia:

(a) An anesthesiologist;

(b) A CRNA;

(d) An AA.

(1) Payment may be made for the following procedures or activities as anesthesia services:

(a) Procedures performed during a surgical or diagnostic procedure:

(i) Administration of general anesthesia;

(ii) Administration of regional anesthesia;

(iii) Supplementation of local anesthesia;

(iv) Administration of post-operative pain block procedures separately from anesthesia;

(v) Provision of monitored anesthesia care (MAC); and

(vi) Performance of unusual monitoring procedures such as cardiovascular catheterization (e.g., intra-arterial, central venous, Swan-Ganz);

(b) Administration of obstetrical anesthesia for either of two purposes:

(i) Neuraxial analgesia for vaginal delivery (including repeated subarachnoid needle placement, drug injection, and necessary epidural catheter replacement during labor); or

(ii) Anesthesia for cesarean delivery; and

(2) No separate payment is made for the following services, which are considered to be part of anesthesia administration:

(a) Routine pre-operative and post-operative visits;

(b) Anesthesia care during the procedure;

(d) Usual monitoring procedures (e.g., electrocardiography, the taking of body temperature, the recording of blood pressure, oximetry, capnography, mass spectometry).

(D) Allowances and limitations.

(1) Payment may be made on a case-by-case basis for two anesthesia services provided to one individual on a single date of service only if at least one of the following conditions applies:

(a) Between the two surgical or diagnostic procedures, the individual either was released from the recovery area to the floor (or intensive care unit) or was discharged from the hospital;

(b) After completion of the surgical or diagnostic procedure, the individual had to return for a follow-up procedure on an emergency basis;

(c) It was medically necessary for two surgical or diagnostic procedures to be performed separately, and two separate anesthetics were required; or

(d) Anesthesia was administered both for a delivery and separately for a tubal ligation meeting the requirements specified in Chapter 5160-21 of the Administrative Code.

(2) In all other cases, payment may be made only for one anesthesia service provided to one individual on a single date of service.

(3) Payment for anesthesia services may be made to an anesthesiologist only if all of the following conditions are met:

(a) The anesthesiologist acts exclusively as an anesthetist and does not also act as a surgeon or assistant surgeon;

(b) The anesthesiologist completes the following tasks in preparation for anesthesia administration:

(i) Performing a pre-anesthetic examination and evaluation or, for obstetrical anesthesia, performing or approving a pre-anesthetic examination and evaluation for labor analgesia provided by a qualified anesthetist; and

(ii) Prescribing an anesthesia plan or, for obstetrical anesthesia, prescribing or approving an anesthesia plan.

(i) Personally participating in the most demanding parts of the anesthesia plan, including induction and emergence or, for obstetrical anesthesia, personally participating in all critical portions of the procedure (e.g., needle placement for neuraxial analgesia);

(ii) Ensuring that any procedures in the anesthesia plan that the anesthesiologist does not perform are performed by a qualified individual;

(iii) Monitoring the course of anesthesia administration at frequent intervals or, for obstetrical anesthesia, periodically monitoring the course of anesthesia or analgesia administration or ensuring that a qualified anesthetist performs the monitoring;

(iv) Remaining physically present and available for immediate diagnosis and treatment in case of emergency or, for obstetrical anesthesia, remaining readily available for immediate diagnosis and treatment in case of emergency; and

(v) Providing indicated post-anesthetic care.

(4) Payment for medical direction may be made to an anesthesiologist if the anesthesiologist delegates some or all of the activities listed in paragraphs (D)(3)(b) and (D)(3)(c) of this rule to not more than four qualified non-physician anesthetists performing concurrent anesthesia procedures.

(5) Payment for medical supervision may be made to an anesthesiologist if the following conditions are met:

(a) For obstetrical anesthesia, the anesthesiologist delegates some or all of the activities listed in paragraph (D)(3)(c) of this rule to qualified non-physician anesthetists, and the anesthesiologist supervises one of the following activities:

(i) A critical portion of more than four concurrent obstetrical anesthesia procedures (e.g., needle placement for neuraxial analgesia);

(ii) A critical portion of an obstetrical anesthesia procedure along with more than four concurrent surgical anesthesia procedures; or

(iii) A critical portion of an obstetrical anesthesia procedure while the anesthesiologist is not physically present in the obstetrical suite.

(b) For all other anesthesia, the anesthesiologist delegates some or all of the activities listed in paragraph (D)(3)(c) of this rule to more than four qualified non-physician anesthetists performing concurrent anesthesia procedures.

(6) In addition to payment for surgical procedures, a surgeon or a group practice of surgeons is permitted to receive payment for anesthesia services provided by a CRNA who is employed by the surgeon or group practice.

(7) The services of a CRNA or AA employed by a hospital are considered to be hospital services, payment for which is made to the hospital.

(E) Claim payment.

(1) Payment for an anesthesia service is the lesser of the provider's submitted charge or the medicaid maximum, which is determined by a formula.

(a) The amount is the product of three factors:

(i) The sum of the base unit value and the time unit value;

(ii) The appropriate conversion factor; and

(iii) The relevant multiplier.

(b) Conversion factors and multipliers are listed in the appendix to this rule.

(2) No additional payment will be made on account of physical status, age, body temperature (hypothermia or hyperthermia), emergency conditions, or time of day.

View Appendix

Last updated January 2, 2024 at 8:54 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-4-22 Surgical services.

(A) Coverage.

(1) In general, payment may be made to an eligible provider for performing a medically necessary surgical procedure on a medicaid-eligible individual. The following limitations, however, apply.

(a) No separate payment is made to the provider of a surgical service for local infiltration, the administration of general anesthesia or sedation, normal uncomplicated preoperative and postoperative care, or any procedure that is performed incidental to or as an integral part of the operation. On claims, providers should report comprehensive surgical services; they are not to itemize or "unbundle" individual components.

(b) Certain characteristics of a surgical procedure performed on the same patient by the same provider may affect how it is reported on a claim and how payment for it is made.

(i) The Ohio department of medicaid (ODM) recognizes five groups of surgical procedures defined by a particular characteristic:

(a) Multiple procedures, for which payment is reduced when more than one is performed;

(b) Bilateral procedures, for which payment is adjusted when they are performed on both body parts of a corresponding pair;

(c) Co-surgery procedures, for which payment is split between two surgeons, each in a different specialty, who perform parts of the same procedure simultaneously.

(d) Assistant-at-surgery procedures, for which payment is reduced when they are performed by an assistant at surgery; and

(e) Procedures performed on fingers, toes, eyelids, or coronary arteries.

(ii) In assigning covered procedures to these groups, ODM follows the policies of the medicare program except when otherwise noted in this rule.

(2) Payment may be made for a co-surgery procedure only if the following conditions are met:

(a) The procedure can be performed only by surgeons;

(b) Not more than two surgeons submit a claim for the procedure; and

(3) Payment for an assistant-at-surgery procedure is subject to the following constraints:

(a) No additional payment is made for the services of more than one assistant at surgery during an operation, regardless of the extent of the surgery;

(b) Payment may be made for an assistant-at-surgery procedure performed in a teaching hospital only if at least one of the following conditions is met:

(i) The surgeon who performed the assistant-at-surgery procedure was neither a resident nor an intern, and this fact is attributable to either of the following reasons:

(a) The primary surgeon does not customarily use residents or interns for any part of the particular surgical procedure (including preoperative and postoperative care); or

(b) No resident in a training program in a medical specialty appropriate to the surgical procedure was available to serve as an assistant at surgery.

(ii) The assistant-at-surgery procedure constituted concurrent care for a medical condition that necessitated active treatment during surgery by physicians of more than one specialty;

(iii) During surgery, complex medical procedures were performed that involved a team of physicians; or

(iv) Exceptional medical circumstances warranted an assistant at surgery.

(4) Payment for physician visits in addition to surgery is addressed in rule 5160-4-06 of the Administrative Code.

(5) Certain types of surgery are often supplemented by the use of a cast, splint, strap, or other traction device. For initial application and removal that is performed in conjunction with covered musculoskeletal surgery, payment for the surgery includes the application and removal procedures, all materials (casting components, splints, or straps), and incidental supplies. In all other circumstances, the following provisions apply:

(a) Payment for the work depends on the nature and purpose of the procedure.

(i) For initial application and removal that is not performed in conjunction with surgery (e.g., the casting or strapping of a sprained joint), payment may be made for an appropriate evaluation and management service;

(ii) For necessary replacement, payment may be made for an appropriate casting/strapping procedure; and

(iii) For necessary repair, payment may be made for an appropriate evaluation and management service.

(b) Separate payment may be made for materials only if the service was rendered in a non-hospital setting.

(B) Claim payment. Payment for a surgical procedure is the lesser of two figures:

(1) The provider's submitted charge; or

(2) A percentage of the medicaid maximum amount specified in rule 5160-1-60 of the Administrative Code or in appendix DD to that rule, determined in the following manner:

(a) For a procedure that is not performed incidental to or as an integral part of an operation and that is not subject to multiple-procedure payment reduction, one hundred per cent;

(b) For a procedure that is subject to multiple-procedure payment reduction, the relevant percentage from the following list:

(i) For a primary procedure (i.e., the procedure with the highest maximum amount listed in rule 5160-1-60 of the Administrative Code or in appendix DD to that rule), one hundred per cent;

(ii) For a secondary procedure (i.e., the procedure with the next highest maximum amount listed in rule 5160-1-60 of the Administrative Code or in appendix DD to that rule), fifty per cent; or

(iii) For any other procedure, twenty-five per cent;

(d) For a bilateral procedure, one hundred fifty per cent; or

(e) For an assistant-at-surgery procedure, twenty-five per cent.

Last updated September 25, 2026 at 8:23 AM

History

Effective: January 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-4-23 Covered ambulatory surgery center (ASC)surgical procedures.

(A) Payment may be made to an ambulatory surgery center (ASC) in the form of a facility fee only for covered ASC surgical procedures, which are procedures that meet the standards set forth in 42 CFR 416.166 (October 1, 2017). Such procedures are listed on the department's website https://medicaid.ohio.gov/resources-for-providers/billing/fee-schedule-and-rates/fee-schedule-and-rates.

(B) Payment may be made to a physician for performing a covered surgical procedure in an ASC even if the surgery is not itself a covered ASC surgical procedure.

(C) Payment may be made to a physician for performing the professional component of a covered laboratory, radiologic, diagnostic, or therapeutic service in an ASC only if the physician personally performed the service and was not an employee of the ASC at the time.

Last updated January 2, 2024 at 8:54 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-4-25 Radiology and imaging services.

(A) Coverage.

(1) Total (global) procedure. Payment may be made to a practitioner for performing both the professional and technical components of a radiology or imaging procedure if two conditions are met:

(a) The technical component was not performed in a hospital setting (i.e., an inpatient hospital, an outpatient hospital, or a hospital emergency department); and

(b) The practitioner who submitted the claim either performed the professional component or has an employment or written contractual arrangement with the practitioner who performed the professional component.

(2) Technical component. Payment may be made to a practitioner for performing only the technical component of a radiology or imaging procedure if three conditions are met:

(a) The professional component was performed by another practitioner;

(b) The technical component was not performed in a hospital setting; and

(c) The practitioner who submitted the claim either performed the technical component or employs the practitioner who performed the technical component.

(3) Professional component.

(a) Payment may be made to a practitioner for performing only the professional component of a radiology or imaging procedure if the professional component represents either of two services:

(i) The initial interpretation of the result of a radiology or imaging procedure; or

(ii) The interpretation by a specialist of the result of a radiology or imaging procedure that has already been interpreted by another practitioner (e.g., a treating physician).

(b) No payment is made for the interpretation by a non-specialist of the result of a radiology or imaging procedure that has already been interpreted by a specialist.

(4) Mammography services.

(a) Payment for screening mammography may be made at the following frequencies:

(i) For an individual who is at least thirty-five years of age but less than forty, once; and

(ii) For an individual who is at least forty years of age, once per twelve months.

(b) Payment for diagnostic mammography may be made for an individual, regardless of age, who shows clinical symptoms of breast cancer or who is at high risk for developing breast cancer.

(5) No separate payment is made for supplies used in connection with a radiology or imaging procedure performed in a hospital setting.

(6) No separate payment is made for conscious sedation administered in connection with a radiology or imaging procedure.

(B) Claim payment.

(1) For a covered radiology or imaging procedure or radiology or imaging procedure component performed by a non-hospital provider, payment is the lesser of the submitted charge or the product of the following two figures:

(a) The maximum payment amount listed in appendix DD to rule 5160-1-60 of the Administrative Code; and

(b) The relevant percentage indicated by the 'prof/tech split' entry listed in appendix DD to rule 5160-1-60 of the Administrative Code (or one hundred per cent if no entry is listed).

(2) If more than one advanced imaging procedure (e.g., computed tomography, magnetic resonance imaging, ultrasound) is performed by the same provider or provider group for an individual patient in the same session, then the procedure with the highest payment amount specified in appendix DD to rule 5160-1-60 of the Administrative Code is considered to be the primary procedure. The payment amount for a covered advanced imaging procedure is the lesser of the submitted charge or a percentage of the amount specified in appendix DD to rule 5160-1-60 of the Administrative Code, determined in the following manner:

(a) For a primary procedure, it is one hundred per cent.

(b) For each additional total procedure, it is fifty per cent.

(d) For the professional component alone of each additional procedure, it is ninety-five per cent.

Last updated September 23, 2026 at 2:33 PM

History

Effective: November 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-4-33 Application of topical fluoride treatments by non-dentist providers.

(A) Rendering providers. The following non-dentist practitioners may render topical fluoride treatments such as the application of fluoride varnish or silver diamine fluoride:

(1) A physician;

(2) A physician assistant; or

(3) An advanced practice registered nurse.

(B) Payment for the application of a topical fluoride treatment is made separately from payment for an evaluation and management service.

(C) Payment may be made not more frequently than once per one hundred eighty days for the topical application of fluoride varnish to the teeth of a child younger than six years of age.

(D) Payment may be made not more frequently than three times per tooth per year for the topical application of silver diamine fluoride.

Last updated May 1, 2026 at 8:17 AM

History

Effective: May 1, 2026
Promulgated Under: 119.03

Chapter 5160-5 Dental Services

Ohio Adm.Code 5160-5-01 Dental services.

(A) This rule sets forth provisions governing payment for professional, non-institutional dental services. Provisions governing payment for dental services performed as the following service types are set forth in the indicated part of the Administrative Code:

(1) Hospital services, Chapter 5160-2;

(2) Nursing facility services, Chapter 5160-3;

(3) Intermediate care facility services, Chapter 5123:2-7;

(4) Federally qualified health center services, Chapter 5160-28;

(5) Ambulatory surgery center services, Chapter 5160-22; and

(6) Telehealth services, rule 5160-1-18.

(B) Definitions.

(1) "Metropolitan statistical area (MSA)" has the same meaning as in 40 C.F.R. 58.1 (October 1, 2023).

(2) "Non-rural county" is a county to which the definition of rural county does not apply.

(3) "Rural county" is a county for which either of the following criteria is satisfied:

(a) The county is not located within a MSA; or

(b) At least seventy-five per cent of the population of the county lives outside the urban areas within the county.

(1) Rendering providers. The following eligible medicaid providers may render a dental service:

(a) A dentist practicing in Ohio;

(b) A dental resident acting within their licensure and scope of practice; or

(c) A dentist practicing in a state other than Ohio who meets the requirements established by the dental examining board in that state.

(2) Billing providers. The following eligible medicaid providers may receive medicaid payment for submitting a claim for a dental service:

(a) A dentist;

(b) A professional dental group; or

(D) Coverage policies for dental services are set forth in appendix A to this rule.

(E) Other conditions.

(1) Dental services are subject to a copayment of three dollars per date of service per provider unless the patient is excluded from the copayment requirement pursuant to rule 5160-1-09 of the Administrative Code.

(2) For an item that requires multiple fittings and special construction (e.g., dentures), the first visit date is the date of service for purposes of prior authorization or claim submission. Payment for the item will not be made, however, until it has been delivered to the patient.

(3) Additional documentation requirements apply to dental services rendered to an individual living in a supervised residence such as a long-term care facility (LTCF).

(a) Whenever a provider updates an individual's medical or dental history, diagnosis, prognosis, or treatment plan, the provider is to keep a copy on file and send a copy of the information to the staff of the residence for inclusion in the individual's file.

(b) After a request for treatment has been signed by the individual, the individual's authorized representative, or the practitioner responsible for the individual's care, the provider is to keep a copy on file and send a copy to the staff of the residence.

(c) For services that require prior authorization (PA), a copy of the signed request for treatment is to be submitted with the PA request along with any other required documentation.

(d) A prior authorization request submitted for complete or partial dentures for a resident of a long-term care facility is to be accompanied by the following documents:

(i) A copy of the resident's most recent nursing care plan;

(ii) A copy of a consent form signed by the resident or the resident's authorized representative; and

(iii) A dentist's signed statement describing the oral examination and assessing the resident's ability to wear dentures.

(F) Payment of claims.

(1) For a covered dental service that is identified by a current dental terminology (CDT) code, the following payment amounts apply:

(a) For a service rendered by a provider whose office address (specified in the provider agreement) is in a non-rural Ohio county or a county outside Ohio, payment is the lesser of the submitted charge or the amount listed in appendix DD to rule 5160-1-60 of the Administrative Code.

(b) For a service rendered by a provider whose office address is in a rural Ohio county, payment is the lesser of the submitted charge or one hundred five per cent of the amount listed in appendix DD to rule 5160-1-60 of the Administrative Code.

(2) For a covered dental service that is identified by a current procedural terminology (CPT) code, such as oral surgery, payment is the lesser of the submitted charge or the amount listed in appendix DD to rule 5160-1-60 of the Administrative Code, regardless of whether the service is provided in a rural or non-rural county.

View Appendix

Last updated October 1, 2024 at 9:06 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Chapter 5160-6 Eye Care Services

Ohio Adm.Code 5160-6-01 Eye care services.

(A) Scope. This rule sets forth general coverage and payment policy for eye care services. Additional provisions for eye care services provided through a medicaid managed care organization are described in Chapter 5160-26 of the Administrative Code.

(B) Definitions.

(1) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code.

(2) "Eye care services" is a collective term for the following services and materials involving the health of the eyes:

(a) Vision care services, which include the following procedures:

(i) Diagnostic and comprehensive examination;

(ii) Testing;

(iii) Therapeutic treatment;

(iv) Lens fitting; and

(v) Vision therapy;

(b) Vision care materials, which include the following items:

(i) Spectacle lenses and frames; and

(ii) Contact lenses;

(d) Ocular prostheses and prosthesis services.

(3) "Participating optical laboratory" is an optical laboratory that is a party to the volume purchasing contract.

(4) "Prior authorization" has the same meaning as in rule 5160-1-31 of the Administrative Code.

(5) "Volume purchase contract," for purposes of this rule, is the current contract designated "medicaid vision volume purchase program: ophthalmic laboratory services and delivery" that is maintained by the Ohio department of administrative services. The contract can be accessed at https://ohiobuys.ohio.gov/page.aspx/en/ctr/contract_browse_public.

(1) Rendering providers. The following eligible providers may receive medicaid payment for rendering an eye care service:

(a) Eye care professionals (such as ophthalmologists, optometrists, opticians, and ocularists) acting within their scope of practice in accordance with Chapter 4725. or Chapter 4731. of the Revised Code and furnishing services in accordance with professional standards; and

(b) For the provision of spectacle lenses and frames, a participating optical laboratory.

(2) Billing ("pay to") providers. The following entities may receive medicaid payment for submitting a claim for an eye care service on behalf of a rendering provider:

(a) A rendering provider;

(b) A professional organization (group practice or partnership) of ophthalmologists, optometrists, opticians, ocularists, or a combination of these practitioners organized under Chapter 1785. of the Revised Code for the sole purpose of providing vision care services;

(d) A federally qualified health center (FQHC) described in Chapter 5160-28 of the Administrative Code.

(D) Coverage.

(1) Vision care services.

(a) Payment may be made for the following classes of service:

(i) General ophthalmological services; and

(ii) Spectacle fitting.

(b) Certain specialized ophthalmological services are identified as diagnostic or therapeutic procedures comprising both professional and technical components. Payment for these services is made in accordance with Chapter 5160-4 of the Administrative Code.

(d) If an examination and a fitting are performed by the same provider, then the date of the examination may be used as the initial date of fitting.

(e) Vision care services are subject to the following copayments per date of service per claim unless the individual is excluded from the copayment provision pursuant to rule 5160-1-09 of the Administrative Code:

(i) Two dollars for the following general ophthalmological services:

(a) Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program, intermediate, new patient;

(b) Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program, comprehensive, new patient, one or more visits;

(c) Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program, intermediate, established patient; and

(d) Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program, comprehensive, established patient, one or more visits; and

(ii) One dollar for the following dispensing services:

(a) Fitting of spectacles, except for aphakia; monofocal;

(b) Fitting of spectacles, except for aphakia; bifocal; and

(2) Vision care materials.

(a) Spectacle lenses and frames.

(i) Payment may be made without prior authorization (PA) for items and services listed in the volume purchase contract that are provided by a participating optical laboratory.

(ii) Payment may be made with PA for items and services that are categorized in the healthcare common procedure coding system (HCPCS) with spectacle lenses and frames but are not listed in the volume purchase contract.

(b) Contact lenses.

(i) Payment is subject to PA, and each item may be ordered from an optical laboratory of the provider's choice.

(ii) A PA request may be denied if contact lenses have no advantage over eyeglasses for the individual. This provision does not apply to replacement contact lenses.

(iii) Contact lenses are deemed to have an advantage over eyeglasses in the treatment of any of the conditions specified in the following non-exhaustive list of examples:

(a) Aphakia;

(b) Keratoconus;

(d) Corneal ectasia;

(e) Post-operative corneal irregularity;

(f) Anisometropia with a difference of three or more diopters; or

(g) High ametropia in either eye of ten diopters or more (either plus or minus).

(c) Low-vision aids. Payment is subject to PA, and each item may be ordered from an optical laboratory of the provider's choice.

(d) Ocular prostheses and prosthesis services. Payment is subject to PA.

(3) Subject to age-based exceptions set forth in rule 5160-1-14 of the Administrative Code, the following limits are established:

(a) For an individual twenty-one years of age or older but younger than sixty years of age, payment for more than one comprehensive vision examination and one complete frame and pair of lenses per twenty-four-month period is subject to PA.

(b) For an individual younger than twenty-one years of age or sixty years of age or older, payment for more than one comprehensive vision examination and one complete frame and pair of lenses per twelve-month period is subject to PA.

(4) A vision care provider may render service to an individual living in a long-term care facility (LTCF) only after having received a request signed by the individual, the individual's authorized representative, or (if the authorized representative is not available) the individual's attending physician.

(5) Payment for the following items and services is subject to PA:

(a) Orthoptic or pleoptic training;

(b) Frames or lenses provided by a source other than a participating optical laboratory, even if they are identical to items listed in the volume purchase contract; and

(6) No separate payment is made for both an evaluation and management service and a general ophthalmological service performed during the same visit.

(7) The medicaid payment amount for a covered item is compensation for the dispensing of that item. It cannot be used as a "credit" toward payment for a substitute item. In particular, medicaid payment for a covered frame listed in the volume purchase contract cannot be applied toward a frame not listed in the contract. If no volume purchasing contract is currently in effect, however, or if no frame suited to an individual's particular needs is listed on the volume purchase contract, payment for spectacle lenses and frames may be made to an eligible medicaid provider of vision care services.

(8) Nothing in this rule is to be construed as preventing a medicaid-eligible individual from voluntarily paying out of pocket for a non-covered additional service in accordance with rule 5160-1-13.1 of the Administrative Code.

(E) Claim payment.

(1) The payment amount for a covered vision care service is the lesser of the submitted charge or the amount listed in appendix DD to rule 5160-1-60 of the Administrative Code.

(2) The payment amount for a covered spectacle lens or frame listed in the volume purchase contract is determined by the terms of the contract.

(3) The payment amount for a covered spectacle lens or frame not listed in the volume purchase contract is the lesser of the provider's submitted charge or the provider's cost.

(4) When vision care is provided in an inpatient or outpatient hospital setting, payment for the service is made in accordance with Chapter 5160-2 of the Administrative Code, and payment for materials is made in accordance with this rule.

(5) For a covered vision care service furnished at a federally qualified health center (FQHC), payment is made in accordance with Chapter 5160-28 of the Administrative Code.

Last updated February 20, 2025 at 2:23 PM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Chapter 5160-7 Podiatric Services

Ohio Adm.Code 5160-7-01 Podiatry services.

(A) For the purpose of this rule the following definitions apply.

(1) "Doctor of podiatric medicine" (or "podiatric physician" or "podiatrist") is as described in section 4731.51 of the Revised Code.

(a) Doctors of podiatric medicine are deemed to be physicians only in respect to functions they are legally authorized to perform in accordance with section 4731.51 of the Revised Code and rule 4731-20-02 of the Administrative Code.

(b) For purposes of medicaid coverage and payment, an intern or resident of podiatric medicine is not a podiatric physician. This exclusion applies even if an intern or resident is authorized to practice as a podiatric physician under the laws of the state in which services are performed or a resident holds a staff or faculty appointment or is designated as a fellow.

(2) "Podiatric group practice" is a professional association organized under Chapter 1785. of the Revised Code for the purpose of providing podiatric medicine services.

(B) Coverage.

(1) Services and procedures performed by a doctor of podiatric medicine that are within the scope of practice of a podiatric physician are considered to be physician services. They are subject to and are covered in accordance with applicable medicaid rules in the Administrative Code concerning physician services.

(2) The services of interns and residents of podiatric medicine rendered in a hospital setting are covered as hospital services in accordance with Chapter 5160-2 of the Administrative Code.

(3) Podiatric medicine services provided by a physician assistant are covered in accordance with rule 5160-4-03 of the Administrative Code.

(4) Podiatric medicine services provided by an advanced practice registered nurse are covered in accordance with rule 5160-4-04 of the Administrative Code.

(5) For a covered podiatry service rendered at a federally qualified health center (FQHC), payment is made in accordance with Chapter 5160-28 of the Administrative Code.

(1) A "by report" podiatric medicine service or procedure is covered in accordance with rule 5160-1-60.4 of the Administrative Code.

(2) Payment for evaluation and management (E&M) services is limited to the following services:

(a) Professional services of the following types necessitating straightforward medical decision-making or medical decision-making of low, moderate, or high complexity:

(i) Office or other outpatient visit;

(ii) Hospital inpatient services;

(iii) Office or outpatient consultations;

(iv) Inpatient consultations;

(v) Nursing facility services;

(vi) Domiciliary, rest home (e.g., boarding home), or custodial care services;

(vii) Home services; and

(b) Hospital discharge services, thirty minutes or less.

(3) Payment for the debridement of nails is limited to one treatment per sixty-day period.

(4) Payment may be made for the following services only if an individual has a localized infection; is under the care of another healthcare practitioner for a metabolic disease such as diabetes mellitus or another condition that may result in circulatory impairment or desensitization in the legs or feet; or has a systemic metabolic, neurologic, or peripheral vascular disease or condition that may require scrupulous foot care by another healthcare practitioner:

(a) Examinations and diagnostic services associated with routine foot care performed in the absence of a localized illness, symptoms, or injury;

(b) Cutting or removal of corns and calluses;

(d) Foot care provided for hygienic purposes; and

(e) Treatment of uncomplicated, chronic foot conditions such as flat feet or a subluxated structure in the foot.

(5) Payment may be made for the treatment of mycotic toenails only if the healthcare practitioner attending the mycotic condition furnishes the podiatric physician with clinical evidence of at least one of the following conditions:

(a) Onychomycosis of the toenail; and

(b) Mycosis or dystrophy of the toenail causing secondary infection or pain that has resulted or could result in marked limitation of ambulation.

(6) Payment may be made for the following radiology services as podiatric medicine services only if the indicated criterion is fully documented:

(a) A bilateral radiograph for a unilateral condition or surgical procedure when it is medically indicated;

(b) Radiographs in excess of three views when trauma or infection is present;

(d) A postoperative radiograph when bone involvement necessitated the surgical procedure or postoperative infection is suspected.

(7) Payment for physical medicine services is limited to acute conditions. When a disease or condition has reached a chronic stage, payment may be made only for services or procedures performed during periods of acute exacerbation.

(8) Payment may be made for a range-of-motion study separately from an examination of the foot only if the need is substantiated by a complete report.

(9) Payment may be made for vaccinations administered within a podiatrist's normal scope of practice in accordance with state law and rule 5160-4-12 of the Administrative Code.

(10) The following services are not covered as podiatric medicine services:

(a) Vitamin B-12 injection for strengthening tendons, ligaments, or other components of the foot;

(b) Medical supplies and equipment (e.g., tape, dressing, surgical trays) that are provided during a podiatric medicine visit and are not intended for take-home use; and

Last updated May 1, 2026 at 8:17 AM

History

Effective: May 1, 2026
Promulgated Under: 119.03

Chapter 5160-8 Therapeutic and Diagnostic Services

Ohio Adm.Code 5160-8-05 Behavioral health services-other licensed professionals.

(A) Scope. This rule sets forth provisions governing payment for behavioral health services provided by certain licensed professionals in non-institutional settings.

(1) Provisions governing payment for behavioral health services as the following service types are set forth in the indicated part of the Administrative Code:

(a) Cost-based clinic services, Chapter 5160-28; and

(b) Medicaid school program services, Chapter 5160-35.

(2) For services provided in a nursing facility, the cost for behavioral health services are paid directly to the provider of services and not through the nursing facility per diem rate.

(B) Definitions for the purposes of this rule.

(1) "Behavioral health service" is a service or procedure that is performed for the diagnosis and treatment of mental, behavioral, substance use, or emotional disorders by a licensed professional or under the supervision of a licensed professional. As it is used in this rule, the term includes neither psychiatry nor medication management.

(2) "Licensed psychologist" has the same meaning as in section 4732.01 of the Revised Code.

(3) "Independent practitioner" is a collective term used in this rule to designate the following persons who hold a valid license to practice in accordance with the indicated portion of the Revised Code:

(a) Licensed professional clinical counselor, section 4757.22;

(b) Licensed independent social worker, section 4757.27;

(d) Licensed independent chemical dependency counselor, rule 4758-4-01 of the Administrative Code; and

(e) School psychologist licensed by the state board of psychology has the same meaning as in rule 4732-3-01 of the Administrative Code and who is engaged in the "practice of school psychology" as that term is defined in section 4732.01 of the Revised Code.

(4) "Supervised practitioner" is a collective term used in this rule to designate the following persons who hold a valid license to practice under general supervision in accordance with the indicated portion of the Revised Code:

(a) Licensed professional counselor, section 4757.23;

(b) Licensed social worker, section 4757.28;

(d) Licensed chemical dependency counselor II, rule 4758-4-01 of the Administrative Code; and

(e) Licensed chemical dependency counselor III, rule 4758-4-01 of the Administrative Code.

(5) "Supervised trainee" is a collective term used in this rule to designate the following individuals who can operate under the general or direct supervision of a licensed practitioner:

(a) Registered counselor trainee, defined in rule 4757-13-09 of the Administrative Code;

(b) Registered social work trainee, defined in rule 4757-19-05 of the Administrative Code;

(d) Chemical dependency counselor assistant, defined in rule 4758-4-01 of the Administrative Code; and

(e) Any individual registered with the Ohio board of psychology in compliance with requirements in rule 4732-13-04 of the Administrative Code, working under the supervision of a licensed psychologist, and assigned by the supervising psychologist a title appearing in rule 4732-13-03 of the Administrative Code, such as "assistant," "psychology assistant," "psychology intern," "psychology fellow," or "psychology resident."

(6) "General supervision" is defined as the supervising practitioner being available by phone to provide assistance as needed.

(7) "Direct supervision" is defined as the supervising practitioner being immediately available and interruptible to provide assistance as needed.

(8) "Independent practice" is a business arrangement in which a professional is not subject to the administrative and professional control of an employer such as an institution, physician, or agency. In particular, a professional working from an office that is located within an entity is considered to be in independent practice when both of the following conditions are met:

(a) The part of the entity constituting the office of the professional is used solely for that purpose and is separately identifiable from the rest of the facility; and

(b) The professional maintains a private practice (i.e., offers services to the general public as well as to the customers, residents, or patients of the entity), and the practice is not owned, either in part or in total, by the entity.

(1) A licensed psychologist or licensed independent practitioner must be enrolled in the medicaid program as an eligible provider, even if services are rendered under the supervision of another eligible provider.

(2) A licensed psychologist in independent practice or independent practitioner in independent practice who can participate in the medicare program either must do so or, if the practice is limited to pediatric treatment, must meet all requirements for medicare participation other than serving medicare beneficiaries.

(D) Coverage.

(1) Payment may be made for the following behavioral health services:

(a) Psychiatric diagnostic evaluation;

(b) Psychological and neuropsychological testing;

(i) Alcohol or substance (other than tobacco) abuse, structured assessment and brief intervention, fifteen to thirty minutes;

(ii) Alcohol or substance (other than tobacco) abuse, structured assessment and intervention, greater than thirty minutes;

(d) Therapeutic services:

(i) Individual psychotherapy:

(a) Psychotherapy, thirty minutes with patient and/or family member;

(b) Psychotherapy, forty-five minutes with patient and/or family member;

(d) Psychotherapy for crisis, first sixty minutes;

(e) Psychotherapy for crisis, each additional thirty minutes; and

(f) Interactive complexity (reported separately in addition to the primary procedure);

(ii) Family psychotherapy for which the primary purpose is the treatment of the patient and not family members:

(a) Family psychotherapy without patient present; and

(b) Family psychotherapy with patient present;

(iii) Group psychotherapy:

(a) Group psychotherapy; and

(b) Multiple-family group psychotherapy;

(iv) Interactive complexity

(v) Prolonged service

(2) Payment may be made to the following eligible providers for a behavioral health service rendered as indicated:

(a) To a physician, group practice, clinic, or a community behavioral health center that meets the requirements found in rule 5160-27-01 of the Administrative Code, for a behavioral health service rendered by a licensed psychologist, or independent practitioner, employed by or under contract with the physician group practice, clinic or community behavioral health center;

(b) To a physician group practice, clinic, a community behavioral health center that meets the requirements found in rule 5160-27-01 of the Administrative Code, physician, advanced practice registered nurse, physician assistant, licensed psychologist in independent practice or independent practitioner in independent practice for a behavioral health service rendered by a supervised practitioner or supervised trainee under general supervision of the supervising practitioner who was, at a minimum, available by phone to provide assistance as needed.

(c) To a physician group practice, clinic, a community behavioral health center that meets the requirements found in rule 5160-27-01 of the Administrative Code, physician, advanced practice registered nurse, physician assistant, licensed psychologist in independent practice or independent practitioner in independent practice for a behavioral health service rendered by a supervised trainee under direct supervision if the following conditions are met:

(i) The professional responsible for the patient's care has contact with the patient during the initial visit and contact not less often than once per quarter (or during each visit if visits are scheduled more than three months apart).

(ii) The professional responsible for the patient's care reviews and updates the patient's medical record at least once after each treatment visit.

(d) To a physician, advanced practice registered nurse, physician assistant, licensed psychologist in independent practice, or independent practitioner in independent practice for a behavioral health service personally rendered by that health care professional;

(3) The following coverage limits, which may be exceeded only with prior authorization from the ODM designated entity, are established for behavioral health services provided to a medicaid recipient.

(a) For diagnostic evaluation, one encounter, per code, per billing provider, per recipient, per calendar year, not on the same date of service as a therapeutic visit;

(b) For psychological testing a maximum of twelve hours per recipient, per calendar year; and

(d) For screening, brief intervention and referral to treatment for substance use disorder, one of each code, per billing provider, per recipient, per calendar year.

(E) Constraints.

(1) Every behavioral health service reported on a claim must be within the scope of practice of the licensed professional, with appropriate certification and/or training for the service, who renders or supervises it and must be performed in accordance with any supervision requirements established in law, regulation, statute, or rule.

(2) No payment will be made under this rule for the following activities:

(a) Services that are rendered by an unlicensed individual other than a supervised trainee;

(b) Activities, testing, or diagnosis conducted for purposes specifically related to education;

(c) Services that are unrelated to the treatment of a specific behavioral health diagnosis but serve primarily to enhance skills or to provide general information, examples of which are given in the following non-exhaustive list:

(i) Encounter groups, workshops, marathon sessions, or retreats;

(ii) Sensitivity training;

(iii) Sexual competency training;

(iv) Recreational therapy (e.g., art, play, dance, music);

(v) Services intended primarily for social interaction, diversion, or sensory stimulation; and

(vi) The teaching or monitoring of activities of daily living (such as grooming and personal hygiene);

(d) Psychotherapy services if the patient cannot establish a relationship with the provider because of a cognitive deficit;

(e) Family therapy for the purpose of training family members or caregivers in the management of the patient; and

(f) Self-administered or self-scored tests of cognitive function.

(F) Documentation of services.

(1) The patient's medical record must substantiate the medical necessity of services performed, and each record is expected to bear the signature and indicate the discipline of the professional who recorded it.

(a) All relevant diagnoses pertaining to medical or physical conditions as well as to behavioral health;

(b) A treatment plan which must be completed within five sessions or one month of admission, whichever is longer and must specify mutually agreed upon treatment goals, track responses to ongoing treatment, and present a prognosis that documents that the plan has been reviewed with the patient and, as appropriate, with family members, parents, legal guardians or custodians or significant others;.

(c) The inability or refusal of the patient to participate in treatment planning or services must be documented and the reason given.

(d) Test results, if applicable, with interpretation;

(e) Evidence that the patient has sufficient cognitive capacity to benefit from treatment; and

(f) Discharge summaries which include date of admission, date of last service, outcome of the service and recommendations and referrals made to the patient.

(2) The following items must be included as progress note documentation and shall be completed at a minimum on a per provision basis, or on a daily or weekly basis:

(a) The type, description, date, time of day, duration, location and, if documenting weekly services, the frequency of treatment, with dates of service;

(b) A description of the patient's current symptoms and changes in functional impairment;

(d) The amount of time spent by the provider with the patient;

(e) The amount of time spent by the provider in interpreting and reporting on procedures represented by "Central Nervous System Testing" codes, when applicable;

(f) Progress notes shall include assessment of the patient's progress or lack of progress and a brief description of the progress made, if any, significant changes in symptoms, functioning, or events in the life of the patient and recommendation for modifications to the treatment plan, if applicable; and

(g) Evidence of clinical supervision, as required.

(G) Claim payment.

The payment amount for a behavioral health service rendered by a community behavioral health center that meets the requirements found in rule 5160-27-01 of the Administrative Code is the lesser of the provider's submitted charge or the amount specified in rule 5160-27-03 of the Administrative Code. For all other providers of behavioral health services, the payment amount is the lesser of the provider's submitted charge or the applicable percentage of the amount specified in the appendix to rule 5160-1-60 of the Administrative Code:

(1) For testing, one hundred per cent;

(2) For a behavioral health service other than testing, the percentage differs according to the provider who rendered it:

(a) For a service rendered by a physician, an advanced practice registered nurse, a physician assistant, or a licensed psychologist, it is one hundred per cent.

(b) For a service rendered by a licensed practitioner or a supervised practitioner, it is eighty-five per cent.

(c) For a service rendered by a supervised trainee/assistant under direct supervision, the rate of their supervising practitioner.

(d) For a service rendered by a supervised trainee/assistant under general supervision, it is eighty-five per cent of the rate of their supervising practitioner.

History

Effective: January 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-8-11 Chiropractic services.

(A) Scope. This rule sets forth provisions governing coverage and payment for professional, non-institutional spinal manipulation and related diagnostic imaging services.

(B) Providers.

(1) Rendering providers. The following eligible providers may render a service described in this rule:

(a) A chiropractor, defined in Chapter 4734. of the Revised Code.

(b) A mechanotherapist, defined in Chapter 4731. of the Revised Code.

(2) Billing ("pay-to") providers. The following eligible providers may receive medicaid payment for submitting a claim for a covered service on behalf of a rendering provider:

(a) A chiropractor;

(b) A mechanotherapist;

(d) A hospital, rules for which are set forth in Chapter 5160-2 of the Administrative Code;

(e) A nursing facility, rules for which are set forth in Chapter 5160-3 of the Administrative Code;

(f) An ambulatory health care clinic, rules for which are set forth in Chapter 5160-13 of the Administrative Code; or

(g) A federally qualified health center (FQHC), rules for which are set forth in Chapter 5160-28 of the Administrative Code.

(1) Payment for manual manipulation of the spine may be made only for the correction of a subluxation, the existence of which is to be determined either by diagnostic imaging or by physical examination confirming that the following criteria are met:

(a) At least one of the following two conditions exists:

(i) Asymmetry or misalignment on a sectional or segmental level; or

(ii) Abnormality in the range of motion; and

(b) At least one of the following two symptoms is present:

(i) Significant pain or tenderness in the affected area; or

(ii) Changes in the tone or characteristics of contiguous or associated soft tissues, including skin, fascia, muscle, and ligament.

(2) Payment may be made only for the following services:

(a) Spinal manipulation.

(i) Chiropractic manipulative treatment (CMT); spinal, one to two regions.

(ii) Chiropractic manipulative treatment (CMT); spinal, three to four regions.

(iii) Chiropractic manipulative treatment (CMT); spinal, five regions.

(b) Diagnostic imaging to determine the existence of a subluxation.

(i) Spine, entire; survey study, anteroposterior and lateral.

(ii) Spine, cervical; anteroposterior and lateral.

(iii) Spine, cervical; anteroposterior and lateral; minimum of four views.

(iv) Spine, cervical; anteroposterior and lateral; complete, including oblique and flexion and/or extension studies.

(v) Spine, thoracic; anteroposterior and lateral views.

(vi) Spine, thoracic; complete, with oblique views; minimum of four views.

(vii) Spine, thoracolumbar; anteroposterior and lateral views.

(viii) Spine, lumbosacral; anteroposterior and lateral views.

(ix) Spine, lumbosacral; complete, with oblique views.

(x) Spine, lumbosacral; complete, including bending views.

(d) Evaluation and management services.

(i) Office or other outpatient visit for the evaluation and management of a new patient, which involves a medically appropriate history of examination and straightforward medical decision-making. When using total time on the date of the encounter for code selection, fifteen minutes has to be met or exceeded.

(ii) Office or other outpatient visit for the evaluation and management of a new patient, which involves a medically appropriate history or examination and lowlevel of medical decision-making. When using total time on the date of the encounter for code selection, thirty minutes has to be met or exceeded.

(iii) Office or other outpatient visit for the evaluation and management of an established patientthat may not involve the presence of a physician or other qualified healthcare professional.

(iv) Office or other outpatient visit for the evaluation and management of an established patient, which involves a medically appropriate history or examination and straightforward medical decision-making. When using total time on the date of the encounter for code selection, ten minutes has to be met or exceeded.

(v) Office or other outpatient visit for the evaluation and management of an established patient, which involves a medically appropriate history or examination and low level of medicaldecision-making. When using total time on the date of the encounter for code selection, twenty minutes has to be met or exceeded.

(3) For a covered chiropractic service rendered at an FQHC, payment is made in accordance with Chapter 5160-28 of the Administrative Code.

(D) Constraints and limitations.

(1) The following coverage limits are established for the indicated services:

(a) Spinal manipulation, one treatment per date of service;

(b) Diagnostic imaging of the entire spine to determine the existence of a subluxation, two sessions per benefit year;

(d) Evaluation and management, four sessions per benefit year; and

(e) Visits in an outpatient setting, thirty dates of service per benefit year for an individual younger than twenty-one years of age, fifteen dates of service per benefit year for an individual twenty-one years of age or older.

(2) Payment will not be made under this rule for any of the following services:

(a) A service that is not medically necessary, examples of which are shown in the following non-exhaustive list:

(i) A service unrelated to the treatment of a specific medical complaint;

(ii) Treatment of a disease, disorder, or condition that does not respond to spinal manipulation, such as multiple sclerosis, rheumatoid arthritis, muscular dystrophy, sinus problems, and pneumonia;

(iii) Preventive treatment;

(iv) Repeated treatment without an achievable and clearly defined goal;

(v) Repeated imaging or other diagnostic procedure for a chronic, permanent condition;

(vi) Treatment from which the maximum therapeutic benefit has already been achieved and the continuation of which cannot reasonably be expected to improve the condition or arrest deterioration within a reasonable and generally predictable period of time; and

(vii) A service performed more frequently than the standard generally accepted by peers.

(b) A service that is performed by someone other than a chiropractor or mechanotherapist who is an eligible provider; and

(c) A service that is performed by a chiropractor or mechanotherapist who is an eligible provider but that is not chiropractic manipulation, diagnostic imaging to determine the existence of a subluxation, or evaluation and management, illustrated by the following examples:

(i) Diagnostic studies;

(ii) Drugs;

(iii) Equipment used for manipulation;

(iv) Injections;

(v) Laboratory tests;

(vi) Maintenance therapy (therapy that is performed to treat a chronic, stable condition or to prevent deterioration);

(vii) Manual manipulation for purposes other than the treatment of subluxation;

(viii) Orthopedic devices;

(ix) Physical therapy;

(x) Supplies; and

(xi) Traction.

Last updated February 2, 2026 at 8:23 AM

History

Effective: February 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-8-35 Skilled therapy services.

(A) Scope. This rule sets forth provisions governing payment for skilled therapies as non-institutional professional services furnished by skilled therapists and skilled therapist assistants or aides. Provisions governing payment for skilled therapies as the following service types are set forth in the indicated part of the Administrative Code:

(1) Hospital services, Chapter 5160-2;

(2) Nursing facility services, Chapter 5160-3;

(3) Physical medicine services furnished by or under the supervision of a physician, advanced practice registered nurse, or physician assistant, Chapter 5160-4;

(4) Physical medicine services furnished by or under the supervision of a podiatrist, Chapter 5160-7;

(5) Home health services, Chapter 5160-12;

(6) Services rendered by the following providers:

(a) Ambulatory health care clinics, Chapter 5160-13; or

(b) Federally qualified health centers (FQHCs) or rural health clinics (RHCs), Chapter 5160-28;

(7) Medicaid school program services, Chapter 5160-35; and

(8) Intermediate care facility services, Chapter 5123:2-7.

(B) Definitions.

(1) "Audiologist" is a person who holds a valid license as an audiologist under Chapter 4753. of the Revised Code.

(2) "Audiology aide" is a person who holds a valid license as an audiology aide under Chapter 4753. of the Revised Code.

(3) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code.

(4) "Maintenance services" are skilled therapy services rendered to individuals for the purpose of maintaining but not improving functionality.

(5) "Mechanotherapist" is a person who holds a valid license as a mechanotherapist under Chapter 4731. of the Revised Code and works within the scope of practice defined by state law.

(6) "Non-institutional setting" is a location that is not a hospital or long-term care facility and that is appropriate to the delivery of skilled therapy services. Examples include but are not limited to practitioners' offices, clinics, licensed child day care centers, adult day care centers, and public facilities such as community centers.

(7) "Occupational therapist" is a person who holds a valid license as an occupational therapist under Chapter 4755. of the Revised Code and works within the scope of practice defined by state law.

(8) "Occupational therapy" has the same meaning as in section 4755.04 of the Revised Code.

(9) "Occupational therapy assistant" is a person who holds a valid license as an occupational therapy assistant under Chapter 4755. of the Revised Code.

(10) "Physical therapist" is a person who holds a valid license as a physical therapist under Chapter 4755. of the Revised Code and works within the scope of practice defined by state law.

(11) "Physical therapist assistant" is a person who holds a valid license as a physical therapist assistant under Chapter 4755. of the Revised Code.

(12) "Physical therapy" has the same meaning as in section 4755.40 of the Revised Code.

(13) "Skilled therapist" is a collective term encompassing physical therapist, occupational therapist, speech-language pathologist, and audiologist.

(14) "Skilled therapy" is a collective term encompassing physical therapy, occupational therapy, speech-language pathology, and audiology.

(15) "Speech-language pathologist" is a person who holds a valid license as a speech-language pathologist under Chapter 4753. of the Revised Code.

(16) "Speech-language pathology" and "audiology" have the same meaning as in section 4753.01 of the Revised Code.

(17) "Speech-language pathology aide" is a person who holds a valid license as a speech-language pathology aide under Chapter 4753. of the Revised Code.

(18) "Treatment" is a collective term encompassing two types of skilled therapy service:

(a) "Developmental service" is a skilled therapy service rendered, in accordance with developmental milestones established by the American academy of pediatrics, to enable individuals younger than seven years of age to attain a level of age-appropriate functionality that they have not yet achieved but are expected to achieve.

(b) "Rehabilitative service" is a skilled therapy service rendered to individuals for the purpose of improving functionality.

(1) Rendering providers. The following practitioners may render a skilled therapy service in the applicable discipline, within their scope of practice, and in accordance with any requirements established by their credentialing board:

(a) A skilled therapist or mechanotherapist;

(b) A licensed physical therapist assistant, occupational therapy assistant, speech-language pathology aide, or audiology aide who provides a particular service to one individual at a time under supervision;

(c) A physical therapy student, occupational therapy student, speech-language pathology student, or audiology student who is completing an internship or externship in accordance with the clinical requirements of the specific discipline as established by the credentialing board; or

(d) A person holding a conditional license to practice speech-language pathology, if the eligible provider supervising the professional experience fulfills all applicable requirements for documentation.

(2) Billing ("pay-to") providers.

(a) The following eligible providers may receive medicaid payment for submitting a claim for a skilled therapy service on behalf of a rendering provider:

(i) A hospital;

(ii) A physician, advanced practice registered nurse, physician assistant, or podiatrist;

(iii) A professional medical group;

(iv) An ambulatory health care clinic; or

(v) An FQHC or RHC.

(b) The following eligible providers may receive medicaid payment either for rendering a skilled therapy service themselves or for submitting a claim for a skilled therapy service on behalf of a rendering provider:

(i) A skilled therapist; or

(ii) A mechanotherapist.

(D) Coverage.

(1) Payment may be made for a skilled therapy service if the following conditions are met:

(a) The service is medically necessary, in accordance with rule 5160-1-01 of the Administrative Code.

(b) The amount, frequency, and duration of service is reasonable. For rehabilitative services, reevaluation may be performed not more frequently than every thirty days nor less frequently than every sixty days; for developmental services, reevaluation may be performed not more frequently than every thirty days nor less frequently than every six months.

(c) The service is rendered on the basis of a clinical evaluation and assessment and in accordance with a treatment or maintenance plan. The performance of a clinical evaluation and assessment and the development of a treatment or maintenance plan are discrete services; payment for them is made separately from payment for skilled therapy. Copies of the clinical evaluation and assessment and the treatment or maintenance plan are to be kept on file by the provider.

(d) The service is rendered in response either to a prescription (in the case of physical therapy or occupational therapy) or to a referral (in the case of speech-language pathology and audiology) issued by a licensed practitioner of the healing arts, in accordance with 42 C.F.R. 440.110 (October 1, 2017) and rule 5160-1-17.9 of the Administrative Code. This condition does not apply to services rendered through the medicaid school program, which is described in Chapter 5160-35 of the Administrative Code.

(2) Payment for skilled therapy services rendered without prior authorization in a non-institutional setting is subject to the following limits:

(a) For physical therapy services, a total of not more than thirty visits per benefit year;

(b) For occupational therapy services, a total of not more than thirty visits per benefit year; and

(3) Payment for additional skilled therapy visits in a non-institutional setting can be requested through the prior authorization process, which is described in rule 5160-1-31 of the Administrative Code.

(4) For each type of skilled therapy, payment for evaluation services can be made not more than once per injury or condition.

(5) Unattended electrical stimulation and iontophoresis therapy are considered to be part of the associated therapy procedure or medical encounter; no separate payment is made.

(6) No payment is made for the following services as skilled therapy:

(a) Services that do not meet current accepted standards of practice;

(b) Consultations with family members or other non-medical personnel; and

(c) Services that are rendered in non-institutional settings but are listed in rule 5160-1-61 of the Administrative Code as being excluded from coverage.

(E) Clinical documentation.

(1) A clinical evaluation and assessment of the need for skilled therapy services includes the following elements:

(a) A diagnosis of the type and severity of the disorder or a description of the deficit in physical or sensory functionality;

(b) A review of the individual's current physical, auditory, visual, motor, and cognitive status;

(c) A case history, including, when appropriate, family perspectives on the individual's development and capacity to participate in therapy;

(d) The outcomes of standardized tests and any non-standardized tests that use age-appropriate developmental criteria;

(e) Other test results and interpretation;

(f) An evaluation justifying the provision of skilled therapy services, which may be expressed as one of two prognoses of the patient's rehabilitative or developmental potential:

(i) The patient's functionality is expected to improve within sixty days after the evaluation because of the delivery of rehabilitative skilled therapy services or within six months after the evaluation because of the delivery of developmental skilled therapy services, and the patient is expected to attain full functionality or make significant progress toward expected developmental milestones within twelve months; or

(ii) The patient is not expected to attain full functionality or make significant progress toward expected developmental milestones within twelve months, but a safe and effective maintenance program may be established; and

(g) Any recommendations for further appraisal, follow-up, or referral.

(2) A treatment or maintenance plan for skilled therapy services is based on the clinical evaluation and assessment. It should be coordinated, when appropriate, with services provided by non-medicaid providers or programs (e.g., child welfare, child care, or prevocational or vocational services), and it should provide a process for involving the patient or the patient's representative in the provision of services. A complete treatment or maintenance plan includes the following elements:

(a) The patient's relevant medical history;

(b) Specification of the amount, duration, and frequency of each skilled therapy service to be rendered; the methods to be used; and the areas of the body to be treated;

(c) A statement of specific functional goals to be achieved, including the level or degree of improvement expected within the appropriate time period;

(d) The date of each skilled therapy service;

(e) The signature of the practitioner responsible for the treatment or maintenance plan;

(f) Documentation of participation by the patient or the patient's representative in the development of the plan;

(g) Specific timelines for reevaluating and updating the plan;

(h) A statement of the degree to which the patient has made progress; and

(i) A recommendation for one of several courses of action:

(i) The development of a new or revised treatment plan;

(ii) The development of a new or revised maintenance plan; or

(iii) The discontinuation of therapy.

(F) Claim payment.

(1) If more than one skilled therapy service of the same discipline (e.g., physical therapy) is rendered by the same non-institutional provider or provider group to an individual on the same date, then the service with the highest payment amount specified in appendix DD to rule 5160-1-60 of the Administrative Code is considered to be the primary procedure. Payment for a covered skilled therapy service is the lesser of the provider's submitted charge or a percentage of the amount specified in appendix DD to rule 5160-1-60 of the Administrative Code, determined in the following manner:

(a) For the first unit of a primary procedure, one hundred per cent; or

(b) For each additional unit or procedure within the same therapy discipline, eighty per cent.

(2) Payment will be made only for covered services that are listed in the treatment or maintenance plan.

Last updated January 2, 2024 at 8:46 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-8-41 Services provided by a dietitian.

(A) Providers.

(1) Rendering providers. The following practitioners, defined in Chapter 4759. of the Revised Code, may enroll in medicaid as eligible providers of dietitian services:

(a) A licensed dietitian; and

(b) A registered dietitian.

(2) Billing ("pay-to") providers. The following eligible providers may receive medicaid payment for submitting a claim for a covered service on behalf of a rendering provider:

(a) An independent licensed dietitian;

(b) An independent registered dietitian;

(d) An ambulatory health care clinic; or

(e) A federally qualified health center (FQHC) or rural health clinic (RHC).

(B) Coverage. Payment may be made for the following services provided by a dietitian:

(1) Medical nutrition therapy services specified in "Current Procedural Terminology," published by the American medical association (AMA), http://www.ama-assn.org;

(2) Lactation consultation services; and

(3) Diabetes self-management training (DSMT) services, in accordance with rule 5160-8-53 of the Administrative Code.

(1) Payment for a covered service provided by a dietitian in an FQHC site or RHC site is determined in accordance with Chapter 5160-28 of the Administrative Code.

(2) Payment for a covered service provided by a dietitian in a setting other than an FQHC site or RHC site is the lesser of the submitted charge or the amount shown in appendix DD to rule 5160-1-60 of the Administrative Code.

Last updated October 1, 2024 at 9:23 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-8-42 Lactation consultation services.

(A) Definitions applicable to this rule.

(1) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code.

(2) "Lactation consultation" is the development and implementation of management strategies for complex problems related to breastfeeding and human lactation.

(3) "International Board-Certified Lactation Consultant (IBCLC)" is a professional member of the healthcare team who has earned and maintains the credential established by the "International Board of Lactation Consultant Examiners," which attests to expertise in breastfeeding management and care, including the insight, skills, and knowledge needed to identify complex breastfeeding problems, to provide education about breastfeeding, and to facilitate an optimal breastfeeding experience and environment.

(B) Providers.

(1) Rendering providers. The following eligible providers may receive medicaid payment for rendering a lactation consultation service:

(a) An IBCLC;

(b) An advanced practice registered nurse;

(d) A physician assistant.

(2) Billing ("pay-to") providers. The following eligible providers may receive medicaid payment for lactation consultation services on behalf of a rendering provider:

(a) The rendering provider;

(b) A professional medical group practice;

(d) A pharmacy;

(e) A federally qualified health center (FQHC);

(f) A rural health clinic (RHC); or

(g) An ambulatory health care clinic.

(1) Payment for a lactation consultation service is made separately from payment for other professional services. No separate payment, however, is made for a lactation consultation service provided in conjunction with nurse home visiting services (which are addressed in rule 5160-21-05 of the Administrative Code).

(2) For a lactation consultation service, the practitioner order specified in rule 5160-1-17 of the Administrative Code is waived.

(D) Claim payment.

(1) Payment for a covered lactation consultation service provided in a hospital is made in accordance with Chapter 5160-2 of the Administrative Code.

(2) Payment for a covered lactation consultation service provided by an FQHC or RHC is made in accordance with Chapter 5160-28 of the Administrative Code.

(3) Payment for a covered lactation consultation service rendered in other settings is the lesser of the submitted charge or the amount shown in appendix DD to rule 5160-1-60 of the Administrative Code.

(4) Payment for lactation pumps and supplies is made in accordance with rule 5160-10-25 of the Administrative Code.

Last updated October 1, 2024 at 9:07 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-8-43 Doula services.

(A) Definitions applicable to this rule.

(1) "Doula" is an individual listed in the registry specified in section 4723.89 of the Revised Code.

(2) "Doula service" is any of the support activities specified in section 4723.89 of the Revised Code.

(3) "Independent" and "non-independent," with respect to a doula, have the same meanings as in rule 5160-4-02 of the Administrative Code.

(B) Providers.

(1) Independent doulas may receive medicaid payment for submitting a professional claim for covered services they provide.

(2) The following eligible providers may receive medicaid payment for submitting a professional claim on behalf of a doula, either independent or non-independent, for covered services provided by the doula:

(a) An ambulatory health care clinic;

(b) A federally qualified health center (FQHC);

(d) A hospital;

(e) A professional medical group; or

(f) A rural health clinic (RHC).

(1) A coverage period is defined by the following beginning and ending dates:

(a) The date of conception, if known, or the date of the first antepartum visit; and

(b) The earlier of the following dates:

(i) Three hundred sixty-five days after delivery; or

(ii) Discontinuation of the individual's medicaid eligibility.

(2) During a coverage period, payment may be made for the following doula services:

(a) One comprehensive support service, regardless of duration, provided during labor and delivery; and

(b) Antepartum and postpartum support services, including consultation and telehealth visits, provided in fifteen-minute units up to a maximum of forty-eight units.

(c) One report of pregnancy (ROP) completed at the first identification of pregnancy and submitted on form ODM 10257, "Report of Pregnancy (ROP)," (rev. October 2023 or after), or its web-based equivalent.

(3) Payment for doula services in excess of these limits may be made through the prior authorization (PA) process described in rule 5160-1-31 of the Administrative Code.

(D) Allowances and constraints.

(1) Separate payment may be made for both an evaluation and management service and a doula service rendered by different providers to the same individual on the same date of service.

(2) There are no place-of-service restrictions for doula services.

(E) Claim payment.

(1) For a covered doula service rendered at an FQHC or RHC, payment is made in accordance with Chapter 5160-28 of the Administrative Code.

(2) For any other covered doula service, payment is the lesser of the provider's submitted charge or the maximum amount specified in appendix DD to rule 5160-1-60 of the Administrative Code.

Last updated October 1, 2025 at 8:13 AM

History

Effective: October 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-8-51 Acupuncture services.

(A) Definitions.

(1) "Acupuncture" has the same meaning as in Chapter 4762. of the Revised Code.

(2) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code.

(B) Providers.

(1) Rendering provider. The following eligible providers may render a covered acupuncture service:

(a) An acupuncturist recognized under section 4762.02 of the Revised Code; or

(b) An individual practitioner, other than an acupuncturist, who may render acupuncture services by virtue of holding a credential specified by law (e.g., a physician or a chiropractor).

(2) Billing ("pay-to") provider. The following eligible providers may receive medicaid payment for submitting a claim for a covered acupuncture service:

(a) An acupuncturist recognized under section 4762.02 of the Revised Code;

(b) An individual practitioner, other than an acupuncturist, who may render acupuncture services by virtue of holding a credential specified by law;

(c) An outpatient rehabilitation clinic, primary care clinic, or public health department clinic that meets the criteria set forth in Chapter 5160-13 of the Administrative Code;

(d) A federally qualified health center (FQHC);

(e) A rural health clinic (RHC);

(f) An individual practitioner who supervises an acupuncturist or other credentialed acupuncture provider;

(g) A professional medical group; or

(h) A hospital.

(1) Payment may be made only for an acupuncture service that meets the following criteria:

(a) It is medically necessary in accordance with rule 5160-1-01 of the Administrative Code;

(b) It is performed in accordance with section 4762.10 or 4762.11 of the Revised Code; and

(i) Low back pain;

(ii) Migraine;

(iii) Cervical (neck) pain;

(iv) Osteoarthritis of the hip;

(v) Osteoarthritis of the knee;

(vi) Nausea or vomiting related to pregnancy or chemotherapy; or

(vii) Acute post-operative pain.

(2) Payment for more than thirty acupuncture visits per benefit year is subject to prior authorization.

(3) No separate payment is made for both an evaluation and management service for any of the conditions listed in this rule and an acupuncture service rendered by the same provider to the same individual on the same day.

(4) No separate payment is made for services that are an incidental part of a visit (e.g., providing instruction on breathing techniques, diet, or exercise).

(5) No separate payment is made to a non-physician acupuncture provider who performs an acupuncture service in a hospital setting. Instead, the provider makes payment arrangements directly with the participating hospital.

(6) No payment will be made for additional treatment in either of the following circumstances:

(a) Symptoms show no evidence of clinical improvement after an initial treatment period; or

(b) Symptoms worsen over a course of treatment.

(D) Claim payment.

(1) For a covered acupuncture service rendered at an FQHC or RHC, payment is made in accordance with Chapter 5160-28 of the Administrative Code.

(2) For a covered acupuncture service rendered at any other valid place of service, payment is the lesser of the provider's submitted charge or the maximum amount specified in appendix DD to rule 5160-1-60 of the Administrative Code.

Last updated May 11, 2026 at 10:21 AM

History

Effective: April 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-8-52 Services provided by a pharmacist.

(A) Definition. "Pharmacist" has the same meaning as in Chapter 4729:1-1 of the Administrative Code.

(B) Providers. An individual pharmacist may enroll in medicaid as a pharmacist provider.

(1) Payment may be made only for a pharmacist service for which the following criteria are met:

(a) The service is within a pharmacist's scope of practice;

(b) The service is medically necessary in accordance with rule 5160-1-01 of the Administrative Code;

(c) For a service rendered by prescription, the pharmacist provider obtains an order issued by a practitioner having appropriate prescriptive authority and maintains supporting documentation; and

(d) The service is rendered for one of the following purposes:

(i) Managing medication therapy under a consulting agreement with a prescribing practitioner pursuant to section 4729.39 of the Revised Code;

(ii) Administering immunizations in accordance with section 4729.41 of the Revised Code; or

(iii) Administering medications in accordance with section 4729.45 of the Revised Code.

(2) Nothing in this rule precludes a medicaid managed care organization described in Chapters 5160-26 and 5160-58 of the Administrative Code from paying pharmacists for additional purposes, within scope of practice, including care management services that are rendered by a pharmacist without a consult agreement.

(3) Payment may be made for covered telehealth services in accordance with rule 5160-1-18 of the Administrative Code.

(4) Services may be rendered through a standing order or protocol as described in Chapter 4729. of the Revised Code.

(D) Claim payment.

(1) For a covered pharmacist service rendered at a federally qualified health center (FQHC) or rural health clinic (RHC), payment as an FQHC medical service or an RHC medical service is made in accordance with Chapter 5160-28 of the Administrative Code.

(2) For a covered immunization, injection of medication, or provider-administered pharmaceutical, payment is made in accordance with rule 5160-4-12 of the Administrative Code.

(3) For all other covered pharmacist services, payment is the lesser of the submitted charge or eighty-five per cent of the medicaid maximum amount specified in appendix DD to rule 5160-1-60 of the Administrative Code.

(4) Payment for services rendered by a hospital-employed pharmacist will be made to the hospital.

(5) In the event that payment for a covered service performed by a pharmacist is issued to both the hospital and the individual pharmacist, one of the issued payments is subject to recovery.

Last updated January 5, 2026 at 8:48 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-8-53 Diabetes prevention and self-management training.

(A) Definitions. For the purposes of this rule, the following definitions apply:

(1) "Diabetes self-management training" (DSMT) is the education and instruction of an individual with diabetes by a qualified provider for the purpose of providing the individual with necessary skills and knowledge to participate in the management of the individual's diabetes, including the self-administration of injectable drugs.

(2) "National Diabetes Prevention Program" (NDPP) is an evidence-based, educational and support program administered by the centers for disease control and prevention (CDC) designed to assist at-risk individuals from developing type 2 diabetes.

(B) DSMT.

(1) Providers.

(a) Rendering providers. The following providers may render or supervise a DSMT service:

(i) A physician;

(ii) A physician assistant;

(iii) An advanced practice registered nurse;

(iv) A registered nurse;

(v) A registered dietitian nutritionist; or

(vi) A pharmacist.

(b) Billing ("pay-to") providers. The following providers may receive medicaid payment for submitting a claim for a DSMT service on behalf of a rendering provider:

(i) A physician;

(ii) A physician assistant;

(iii) An advanced practice registered nurse;

(iv) A licensed or registered dietitian;

(v) A pharmacist;

(vi) A professional medical group;

(vii) A federally qualified health center;

(viii) A rural health clinic;

(ix) An ambulatory health care clinic; or

(x) A hospital.

(2) Coverage.

(a) Payment for diabetes self-management training can be made when the following criteria are met:

(i) The individual has a current diagnosis of diabetes.

(ii) The individual has not previously received diabetes self-management training.

(iii) Training is provided in a setting other than an inpatient hospital or an emergency department.

(b) Payment may be made, with prior authorization in accordance with rule 5160-1-31 of the Administrative Code, for follow-up sessions not to exceed a total of two hours of individual training or group training in any combination.

(1) Providers.

(a) Rendering providers. The following providers may render or supervise an NDPP service:

(i) A physician;

(ii) A physician assistant;

(iii) An advanced practice registered nurse;

(b) Billing ("pay-to") providers. The following providers may receive medicaid payment for submitting a claim for an NDPP service on behalf of a rendering provider:

(i) A physician;

(ii) A physician assistant;

(iii) An advanced practice registered nurse;

(iv) A professional medical group;

(v) A federally qualified health center;

(vi) A rural health clinic; or

(vii) An ambulatory health care clinic;

(2) Coverage.

(a) Payment for an NDPP service can be made when all of the following criteria are met:

(i) The individual is eighteen years or older;

(ii) The individual is overweight;

(iii) The individual is not currently pregnant; and

(iv) The individual does not have a diagnosis of type 1 or type 2 diabetes.

(v) At least one of the following criteria is met:

(a) The individual has been diagnosed with prediabetes;

(b) The individual has a history of gestational diabetes; or

(D) Claim payment.

(1) No payment will be made for a DSMT or NDPP service provided on the same date of service as medical nutrition therapy.

(2) Payment for a covered service performed in a hospital is made in accordance with Chapter 5160-2 of the Administrative Code.

(3) Payment for a covered service rendered by a federally qualified health center (FQHC) or rural health clinic (RHC) is made in accordance with Chapter 5160-28 of the Administrative Code.

(4) Payment for a covered service rendered in any other setting is the lesser of the submitted charge or the amount shown in appendix DD to rule 5160-1-60 of the Administrative Code.

Last updated September 25, 2026 at 8:32 AM

History

Effective: January 1, 2022
Promulgated Under: 119.03

Chapter 5160-9 Pharmacy Services

Ohio Adm.Code 5160-9-01 Pharmacy services: definitions.

(A) Covered drugs.

(1) "Compounded prescriptions" are prescription drugs made by combining two or more drugs. Active pharmaceutical ingredients (API) and excipients are listed on the ODM pharmacy program website at https://pharmacy.medicaid.ohio.gov.

(2) "Covered prescribed drug" means a drug covered by the Ohio department of medicaid (ODM) pharmacy program, or a managed care plan entity as defined in rule 5160-26-01 of the Administrative Code. Covered prescribed drugs are prescribed drugs that are dispensed to an eligible recipient for use in the recipient's residence, including a nursing facility (NF), as defined in section 5165.01 of the Revised Code, or intermediate care facility for individuals with intellectual disabilities (ICF/IID), as defined in section 5124.01 of the Revised Code, and fall into one of the following categories:

(a) "Dangerous drugs" as defined in section 4729.01 of the Revised Code that meet the definition of a "covered outpatient drug (COD)" as defined in 42 C.F.R. 447.502 (November 19, 2021) that are not non-covered drugs.

(b) Over-the-counter (OTC) drugs listed on the "OH PBM OTC List" located on the ODM pharmacy website at https://pharmacy.medicaid.ohio.gov. The list is updated regularly and is recorded with the effective date included in each new version.

(B) "Noncovered drugs" are drugs that fall into one of the following categories for which coverage is not available through the Ohio medicaid pharmacy program as described in rule 5160-9-03 of the Administrative Code.

(1) "340B ceiling price" means the highest price allowed to be charged by a manufacturer to a 340B covered entity as described in section 340B(a)(4) of the "Public Health Service Act," 42 U.S.C. 256b(a)(4) (in effect as of June 25, 2020).

(2) "Actual acquisition cost (AAC) means the best determination by the Ohio department of medicaid (ODM) of the actual amount the provider paid to purchase the prescribed drug. ODM acquires AAC data through one or more of the following: national survey of retail pharmacy providers, e.g., national average drug acquisition cost (NADAC) rate process, states' surveys of retail pharmacy providers e.g., Ohio average acquisition cost (OAAC), and published compendia prices, e.g., wholesale acquisition cost (WAC).

(3) "Administration fee" means the maximum amount payable to a provider to administer a vaccine or injectable drug that is payable under this chapter and authorized to be administered by a pharmacist or pharmacy intern in accordance with sections 4729.41 and 4729.45 of the Revised Code and the rules promulgated thereunder.

(4) "Equivalent drug product" means drug products with the same active ingredient, strength, and dosage form.

(5) "Equivalent generic drug products" means equivalent drug products that are identified by the medicaid drug rebate program (MDRP) drug product data files as non-innovator products. MDRP files are available on the federal centers for medicare and medicaid services (CMS) website at https://www.medicaid.gov.

(6) "Ingredient cost" means the portion of the total medicaid payment amount attributable to the cost of the drug product, or in the case of a compound drug, the sum of the cost of the ingredients that are covered in accordance with rule 5160-9-03 of the Administrative Code.

(7) "Long-term care facility (LTCF)" means a nursing facility as defined in section 5165.01 of the Revised Code or intermediate care facility for individuals with intellectual disabilities as defined in section 5124.01 of the Revised Code.

(8) "NADAC" means the rate determined by the CMS to be the average AAC for retail community pharmacies. NADAC rates are on the CMS website at https://www.medicaid.gov.

(9) "Ohio average acquistion cost (OAAC)" means pricing that more accurately reflects the actual acquisition cost for drugs for pharmacy providers in Ohio and is based on actual costs for the provider to purchase a drug.

(10) "Pharmacy pricing and audit consultant (PPAC)" means an organization which is responsible for pharmacy reimbursement calculation, benefit design, and pharmacy benefits management oversight and auditing.

(11) "Prescribed drug" has the same meaning as in section 5164.01 of the Revised Code.

(12) "Professional dispensing fee (PDF)" means the fee or fees determined pursuant to section 5164.753 of the Revised Code and set forth in this rule.

(13) "Single pharmacy benefits manager (SPBM)" means the pharmacy benefit manager selected by and under contract with the medicaid director under section 5167.24 of the Revised Code.

(14) "State maximum allowable cost (SMAC)" means the maximum amount determined by ODM, based upon an estimate of the statewide average acquisition cost (AAC) for a particular equivalent generic drug group, to be paid to Ohio medicaid providers for an equivalent generic drug group.

(15) "WAC" means the amount reported by a pharmaceutical manufacturer to pharmacy pricing compendia as the list price for a drug and may not represent the actual price of a particular transaction.

(D) Provider types eligible for payment for pharmacy services.

(1) "Clinic" providers with valid medicaid provider agreements and meet the criteria under the Revised Code to personally furnish pharmaceuticals, but are not eligible to become a "pharmacy provider" are eligible to apply for a "pharmacy" specialty designation and bill for self-administered take-home drugs.

(2) A "pharmacy provider" designation and provider number can be obtained by a "terminal distributor of dangerous drugs," as defined in section 4729.01 of the Revised Code, who:

(a) Has a valid drug enforcement agency (DEA) registration;

(b) Has a pharmacist as the "responsible person," as defined in rule 4729:5-2-01 of the Administrative Code; and,

(c) Complies with eligible provider rules 5160-1-17 to 5160-1-17.9 of the Administrative Code and signs a provider agreement with the Ohio department of medicaid (ODM).

(3) A "hospital" provider acting as a pharmacy can obtain a "pharmacy" specialty designation and bill for self-administered take-home drugs.

Last updated February 16, 2024 at 8:10 AM

History

Effective: February 16, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-9-02 Pharmacy services: medical supplies and durable medical equipment.

(A) Eligible pharmacies in the Ohio medicaid program may bill for medical supplies and durable medical equipment in accordance with Chapter 5160-10 of the Administrative Code, with the following stipulations:

(1) The provider must:

(a) Apply to, and be approved by, the Ohio department of medicaid (ODM) to be eligible to dispense medical supplies/durable medical equipment; and

(b) Use the same medicaid provider number as when billing for pharmaceuticals; and

(c) Be licensed, registered, or exempt from licensure or registration under Chapter 4761. of the Revised Code to bill for home medical equipment that is subject to regulation under Chapter 4752. of the Revised Code.

(2) All products require a prescription written by a practitioner authorized to prescribe. The prescription must be obtained by and kept on file at the pharmacy.

(B) Claims submission and billing.

(1) Medical supplies/durable medical equipment is billed in the appropriate claim format designated by ODM for those services.

(2) Medical supplies, durable medical equipment, prosthetic, and orthotic devices are billed by pharmacy providers in accordance with Chapter 5160-10 of the Administrative Code.

(3) Medical supplies are billed by eligible providers of pharmacy services only, except as specified in paragraph (C) of this rule. Eligible providers of pharmacy services may bill for these items without applying to ODM for eligibility for dispensation of medical supplies/durable equipment as described in Chapter 5160-10 of the Administrative Code. The list of supplies is located on the ODM pharmacy website at https://pharmacy.medicaid.ohio.gov.

(4) Quantities billed should equal the number of items dispensed (e.g., the quantity of test strips billed should equal the number of individual test strips, not the number of boxes).

(5) The medical supplies document "Pharmacy benefits: medical supplies and durable medical equipment products" is located on the ODM pharmacy website and includes five columns indicating supply item coverage and payments. The supplies in the document are billed through the pharmacy point of sale claims system using the national drug code (NDC) on the container from which the product was dispensed.

(a) Payment is the lesser of the submitted charge or the calculated allowable. The calculated allowable is the medicaid maximum payment.

(b) The calculated allowable is the medicaid maximum payment plus the professional dispensing fee applicable to the provider as described in paragraph (E)(1)(b) of rule 5160-9-05 of the Administrative Code.

(1) Contraceptive supplies listed in the appendix to this rule may be billed by both pharmacy providers and providers eligible to bill in accordance with rule 5160-10-01 of the Administrative Code. Pharmacy provider should bill through the pharmacy point of sale claims system using the NDC on the container from which the product was dispensed.

(2) Supplies billed to medicare as the primary payer and crossed over to medicaid using the medicare crossover process described in paragraph (B) of rule 5160-1-05 of the Administrative Code may be billed by any provider eligible for the medicare crossover process.

(D) Preferred medical supplies.

(1) Selected products from the medical supply categories included in the appendix of this rule are designated as preferred brands, as specified on the ODM website at https://pharmacy.medicaid.ohio.gov.

(2) Products that are not designated as preferred supplies require prior authorization.

(a) Only the prescribing provider or a member of the prescribing provider's staff may request prior authorization.

(b) The prescriber should document medical necessity for the non-preferred brand and provide the reason why preferred brand cannot be used.

(c) When a request for prior authorization is denied, the recipient is informed in writing of the denial as well as informed of the right to appeal the denial.

Last updated February 16, 2024 at 8:11 AM

History

Effective: February 16, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-9-03 Pharmacy services: covered drugs and associated limitations.

(A) Covered prescribed drugs

Drugs covered by the Ohio department of medicaid (ODM) pharmacy program, or a managed care entity as defined in rule 5160-26-01 of the Administrative Code, are prescribed drugs as defined in rule 5160-9-05 of the Administrative Code that are dispensed to an eligible recipient for use in the recipient's residence, including a nursing facility (NF), as defined in section 5165.01 of the Revised Code, or intermediate care facility for individuals with intellectual disabilities (ICF/IID), as defined in section 5124.01 of the Revised Code, and fall into one of the following categories:

(1) "Dangerous drugs" as defined in section 4729.01 of the Revised Code that meet the definition of a "covered outpatient drug (COD)" as defined in 42 C.F.R. 447.502 (November 19, 2021) that are not non-covered drugs as described in paragraph (B) of this rule.

(2) Over-the-counter (OTC) drugs listed on the "OH PBM OTC List" located on the ODM pharmacy website at https://pharmacy.medicaid.ohio.gov. The list is updated regularly and is recorded with the effective date included in each new version.

(3) Compounded prescriptions in accordance with paragraph (E) of this rule, when compounded with ingredients described in paragraphs (A)(1) to (A)(2) of this rule or with active pharmaceutical ingredients (API) and excipients listed on the ODM pharmacy program website at https://pharmacy.medicaid.ohio.gov.

(4) Vaccines, inoculations, and immunizations, other than influenza and coronavirus vaccines, are covered under fee-for-service by the ODM pharmacy program only for residents of a NF or ICF/IID; otherwise these services should be billed as physician services in accordance with Chapter 5160-4 of the Administrative Code. Influenza and coronavirus vaccines may be billed by the pharmacy for a recipient who is not a resident of a NF or ICF/IID if the vaccine will be administered at the pharmacy, or for a recipient who is a resident of a NF or ICF/IID to be administered by facility staff.

(B) Non-covered drugs

Drugs that fall into one of the following categories are non-covered by the Ohio medicaid pharmacy program:

(1) Drugs for the treatment of obesity.

(2) Drugs for the treatment of infertility.

(3) Drugs for the treatment of erectile dysfunction.

(4) Drug efficacy study implementation (DESI) drugs or drugs that are determined to be identical, similar, or related.

(5) Drugs that are covered or are eligible to be covered by medicare part D, when prescribed for a recipient who is eligible for medicare.

(6) Over-the-counter drugs that are not listed on the "OH PBM OTC List" located on the ODM pharmacy program website.

(7) Drugs being used for indications not approved by the food and drug administration unless there is compelling clinical evidence to support the experimental use.

(C) The prescribed drugs covered under the ODM pharmacy program without prior authorization are specified on the ODM website at https://pharmacy.medicaid.ohio.gov. This list indicates the drugs for which co-payments are necessary in accordance with rule 5160-9-09 of the Administrative Code, and specifies whether the drug is covered for a dual eligible as described in rule 5160-1-05 of the Administrative Code. Drugs not listed that meet the requirements of paragraph (A)(1) of this rule and are antidepressants or antipsychotics are exempted from prior authorization if the pharmacy claim indicates that the prescription meets the criteria listed in section 5167.12 of the Revised Code.

(D) Prior authorization

Dangerous drugs not listed in accordance with paragraph (C) of this rule that are medically necessary for treatment require prior authorization; however, noncovered drugs listed in paragraphs (B)(1) to (B)(5) of this rule and APIs and excipients not on the list described in paragraph (A)(3) of this rule are not eligible for prior authorization.

(1) Prior authorization of pharmacy services is administered in compliance with section 1927 of the Social Security Act (January 1, 2020), including a response by telephone or other telecommunication device within twenty-four hours of receipt of a request for prior authorization, and provisions for the dispensing of a seventy-two-hour supply of a COD in an emergency situation.

(2) Drugs not listed in accordance with paragraph (C) of this rule may be covered with prior authorization if medical necessity is documented, the drug is not excluded per paragraphs (B)(1) to (B)(5) of this rule, and a drug that does not require prior authorization cannot be used.

(3) Prior authorization must be obtained from ODM or its designee before the drug claim may be paid. All requests must be submitted in accordance with instructions issued by ODM or its designee.

(a) Only the prescribing provider or a member of the prescribing provider's staff may request prior authorization except as described in paragraph (D)(3)(b) of this rule.

(b) A pharmacist may request prior authorization for an alternative dosage form of a drug to be administered through a tube for recipients who are tube fed, if no comparable drugs that do not require prior authorization can be administered through a tube. A pharmacist may also request prior authorization of a seventy-two-hour supply of a dangerous drug that is a COD in an emergency situation if the prescribing provider or prescribing provider's staff is not available to request prior authorization. A pharmacist may also request prior authorization for a recipient resident in long term care.

(4) Drugs in therapeutic classes that are covered or are eligible to be covered under medicare part D are not available for prior authorization for a recipient who is eligible for medicare. Prior authorization may be requested for drugs in drug classes that may be covered by medicaid for a dual eligible as indicated in the list described in paragraph (C) of this rule and are subject to any stated limits.

(5) When a request for prior authorization is denied, the recipient is informed in writing of the denial and the right to a state hearing.

(E) Compounded drugs

(1) Compounded drugs are covered if the recipient's medical need cannot be met by a covered product that is a COD and at least one ingredient meets the requirements of paragraph (A) of this rule.

(2) Compounded drug claims must be submitted to ODM or its designee using the national drug code (NDC) for each ingredient that is a part of the compound.

(3) An ingredient in a compounded drug that is both a COD and a dangerous drug, not listed in accordance with paragraph (C) of this rule, will require prior authorization. If a prior authorization is not approved or if an ingredient is not eligible for authorization (i.e., not covered as described in paragraph (A) of this rule, excluded from coverage as described in paragraph (B) of this rule, or excluded from separate payment as described in paragraph (I) of this rule), the pharmacy provider may elect to receive payment only for those ingredients in the compound that are directly payable by ODM, in accordance with billing instructions issued by ODM or its designee.

(F) Dispensing limitations

(1) Days' supply limits

(a) Acute medications are limited to a thirty-four-day supply.

(b) Select chronic maintenance medications and select durable medical equipment (DME) products covered under the pharmacy benefit are limited to a one-hundred-two-day supply.

(2) Maximum quantity limits

Maximum prescription quantities are listed on the ODM pharmacy program website and represent the largest number of units per drug that may be dispensed at any one time for a single prescription or the largest number of units per drug per day (or other time period) of therapy.

(3) Maximum equivalent daily dose limits

Maximum equivalent daily doses are listed on the ODM pharmacy program website and establish the highest equivalent dose of certain therapeutic classes that may be dispensed when equivalent doses of all drugs in the therapeutic class are summed.

(4) Maximum prescription claim limits

Maximum prescription claim limits are listed on the ODM pharmacy program website and establish the maximum number of claims for drugs that are therapeutic duplicates that are paid within specified time limits.

(5) Claims submitted that exceed the limits described in paragraphs (F)(1) to (F)(4) of this rule are denied. Denials may be overridden by ODM or its designee in cases where medical necessity was determined through the prior authorization process.

(G) Refill prescriptions

(1) Unless the pharmacy is submitting an early refill for a shortened days' supply to support medication synchronization described in section 5164.7511 of the Revised Code and the claim is submitted pursuant to billing instructions for medication synchronization issued by ODM or its designee, the following limitations apply:

(a) Refills of drugs not scheduled by the federal drug enforcement administration (DEA) requested before eighty per cent of the days' supply was utilized will be denied.

(b) Refills of drugs scheduled by the DEA requested before ninety per cent of the days supply was utilized will be denied.

(2) If a new prescription was issued by the prescriber that requires increased dosing frequency, the existing prescription must be utilized until the days supply per cent threshold was met, calculated using the increased dosing frequency.

(3) Denials may be overridden by ODM or its designee for the following documented reasons:

(a) Previous supply was lost, stolen, or destroyed. ODM or its designee may limit the number of instances denials may be overridden in cases of suspected fraud, waste, or abuse, and may request additional documentation before an override is authorized.

(b) Previous claim was submitted with wrong days' supply.

(d) Multiple supplies of the same medication are needed, for example in a school or workshop setting. Multiple supplies are limited to products that cannot be broken into multiple containers, such as inhalers or other unit-of-use containers.

(e) Hospital or police kept the medication.

(f) Brand or generic was ineffective and the recipient was switched to generic or brand.

(g) The recipient is in the custody of the public children's services agency (PCSA) or other Title IV-E agency.

(H) Selected pharmaceuticals, including injectable drugs, are not covered under the pharmacy program if they are administered by a healthcare provider as defined in rule 4123-6-01 of the Administrative Code other than in a NF, ICF/IID, or pharmacy.

(1) Long-acting injectable pharmaceuticals used for substance use disorder or mental health conditions may be billed by the pharmacy for administration in a provider setting under the following circumstances:

(a) The pharmaceutical is dispensed pursuant to a valid prescription; and

(b) The pharmaceutical is labeled with the recipient name; and

(d) The pharmacy and administering provider follow any special handling requirements in the package labeling; and

(e) The pharmacy releases the pharmaceutical only to the administering provider or member of the provider's staff, and followed all regulations for a prescription pick-up station required by the Ohio state board of pharmacy. The pharmacy cannot dispense the pharmaceutical directly to the recipient, caregiver, or recipient's representative.

(2) Pharmaceuticals not described in paragraph (H)(1) of this rule administered in the physician's office must be purchased by the physician's office and billed as a professional service claim.

(I) Selected over-the-counter drugs are not separately payable when prescribed for a recipient residing in a NF. Such drugs are the responsibility of the NF and are included in the facility per diem payment. The over-the-counter drugs not separately payable are those that are classified into the following drug classes:

(1) Analgesics, including urinary analgesics;

(2) APIs and excipients used in compounded prescriptions;

(3) Cough and cold preparations and antihistamines;

(4) Ear preparations;

(5) Gastrointestinal agents, except histamine-2 receptor antagonists, proton pump inhibitors, and loperamide;

(6) Hemorrhoidal preparations;

(7) Nasal preparations, except nasal corticosteroids;

(8) Ophthalmic agents, except antihistamines;

(9) Saliva substitutes;

(10) Sedatives;

(11) Topical agents, except antifungal and acne preparations; or

(12) Vitamins and minerals, except prenatal vitamins and fluoride.

Last updated February 16, 2024 at 8:11 AM

History

Effective: February 16, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-9-04 Pharmacy services: drug utilization review.

(A) Recipient profiles, prospective drug utilization review (DUR), and recipient counseling

(1) Recipient profiles, prospective DUR and recipient counseling must be performed for medicaid recipients by medicaid pharmacy providers in accordance with agency 4729 of the Administrative Code.

(2) Documentation and records required by - agency 4729 of the Administrative Code must be maintained in accordance with rule 5160-1-17.2 of the Administrative Code.

(3) In addition to the prospective DUR required in paragraphs (A)(1) and (A)(2) of this rule, the Ohio department of medicaid (ODM) or its designee will also perform prospective DUR at the time of claim adjudication and may deny claims that exceed limitations described in rule 5160-9-03 of the Administrative Code or that, on their own or in combination with other claims previously adjudicated, have been determined to have a high risk for fraud, waste, abuse, or clinically significant adverse medical results. Denials may be overridden by ODM or its designee through the prior authorization process in cases where medical necessity has been determined.

(4) Prospective DUR is performed for the purpose of identifying prescriptions that may not be therapeutically appropriate, as described in paragraphs (B)(1)(b) to (B)(1)(j) of this rule.

(B) Retrospective DUR

(1) Retrospective DUR is performed by ODM or its designee on an ongoing periodic basis to monitor the following:

(a) Therapeutic appropriateness;

(b) Overutilization;

(d) Appropriate use of generic products;

(e) Therapeutic duplication;

(f) Drug-disease state contraindications;

(g) Drug-drug interactions;

(h) Incorrect drug dosage;

(i) Incorrect duration of drug treatment; and

(j) Clinical abuse/misuse.

(2) The "Drug Utilization Review board," defined in paragraph (C) of this rule, in compliance with 42 U.S.C. 1396r-8 (January 3, 2022), reviews and recommends criteria used for retrospective DUR using predetermined standards consistent with, but not limited to, any of the following:

(a) American hospital formulary service drug information;

(b) United States pharmacopeia drug information;

(d) Drugdex information system; and

(e) Peer-reviewed medical literature ( scientific, medical, and pharmaceutical publications in which original manuscripts are rejected or published after critical review by unbiased independent experts).

(3) Remedial strategies are recommended by the DUR board and may be approved by ODM for use when clinical concerns are identified based on the monitoring of items listed in paragraph (B)(1) of this rule.

(1) Membership

(a) The DUR board includes health care professionals appointed by the medicaid director who have recognized knowledge and expertise in one or more of the following:

(i) Clinically appropriate prescribing of covered outpatient drugs;

(ii) Clinically appropriate dispensing and monitoring of covered outpatient drugs;

(iii) Drug use review, evaluation, and intervention; or

(iv) Medical quality assurance.

(b) The DUR board is composed of four licensed and actively practicing physicians, at least one of which is a doctor of osteopathic medicine, four licensed and actively practicing pharmacists, and one nonvoting ODM staff person. Candidates may be submitted for consideration by the professional health care associations.

(c) The chairperson of the DUR board is elected by the membership for a one-year term and must be one of the licensed professionals as specified in paragraph (C)(1)(b) of this rule.

(2) Terms

(a) Two of the original physician appointments and two of the original pharmacist appointments are for two years, with the remaining appointments being for one year. Subsequent appointments are for two years in alignment with the state fiscal year. The ODM staff person is an ongoing member of the board.

(b) Vacancies are filled for the unexpired terms in the same manner as the original appointments.

(3) Duties

(a) The DUR board reviews and recommends criteria used in DUR.

(b) The DUR board recommends multiple levels of interventions for physicians and pharmacists targeted toward therapy problems or recipients identified during retrospective drug use reviews. Intervention programs include, in appropriate instances, at least:

(i) Written, oral, or electronic reminders containing recipient specified and/or drug specific information and suggested changes in prescribing or dispensing practices, communicated in a way to ensure the privacy of recipient related information;

(ii) Use of face-to-face or telephone discussions between health care professionals who are experts in rational drug therapy and selected prescribers and pharmacists who are targeted for educational intervention, including discussion of optimal prescribing, dispensing, or pharmacy care practices; and

(iii) Intensified review or monitoring of selected prescribers, dispensers, or recipients. This may include, but not be limited to, referral to the appropriate licensure board or ODM surveillance and utilization review area.

(c) Criteria and interventions utilized by ODM are reported back to the DUR board. The DUR board reevaluates interventions after an appropriate period of time to determine if the intervention improved the quality of drug therapy, evaluates the success of the interventions, and recommends modifications as necessary.

(d) The DUR board develops an informational package on the nature of the drug utilization review program.

(e) The DUR board provides for active and ongoing educational outreach programs to educate practitioners on common therapy problems and quality improvement initiatives.

(f) The DUR board prepares an annual report for ODM that includes:

(i) A description of the board's activities, including the nature and scope of the prospective and retrospective drug use review programs;

(ii) A summary of the interventions used;

(iii) An assessment of the impact of these educational interventions on quality of care; and

(iv) An estimate of the cost savings generated as a result of such program.

(4) Meetings and compensation

(a) The DUR board meets up to four times per year, unless ODM determines additional meetings are necessary, to perform the duties described in paragraph (C)(3) of this rule.

(b) The portion of the DUR board meeting dealing with the consideration of criteria and general interventions is open to any interested party.

Last updated February 16, 2024 at 8:11 AM

History

Effective: February 16, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-9-05 Pharmacy services: payment for prescribed drugs.

(A) Payment for prescribed drugs is the lesser of the provider's billed charges or the calculated allowable, after any coordination of benefits is applied as described in paragraph (E) of this rule. For prescribed drugs that are subject to a co-payment, the amount paid by the Ohio department of medicaid (ODM) is decreased by the amount equal to the co-payment billed to the recipient in accordance with rules 5160-1-09 and 5160-9-09 of the Administrative Code.

(B) The ingredient cost portion of the calculated allowable is determined in accordance with the following criteria:

(1) No ingredient cost is allowed for a pandemic vaccine or any other medication, provided by the Ohio department of health or other government entity at no cost to the provider.

(2) For any drug purchased under the 340B program, the ingredient cost is the lesser of submitted ingredient cost or the 340B ceiling price. If the 340B ceiling price is not available, the ingredient cost is the lesser of the submitted ingredient cost or fifty per cent of wholesale acquisition cost (WAC) If WAC is not available, the ingredient cost is the lesser of submitted ingredient cost or Ohio average acquisition cost (OAAC).

(3) For a clotting factor, the ingredient cost is the lesser of submitted ingredient cost or the payment limit shown in the current medicare part B drug pricing file, minus the furnishing fee assigned by medicare part B. The medicare part B pricing file is available at https://www.cms.gov.

(4) For all other ingredients not captured in paragraphs (B)(1) to (B)(3) of this rule the ingredient cost is the lesser of submitted ingredient cost or national average drug acquisition cost (NADAC). If the centers for medicare and medicaid services (CMS) has not published a NADAC for the ingredient for the date of service, the ingredient cost is the lesser of submitted ingredient cost, OAAC, or WAC.

(C) The administration fee portion of the calculated allowable for a vaccine, except for a vaccine for COVID-19, or other injectable drug administered at the pharmacy is nineteen dollars thirty-five cents. The administration fee for a vaccine for COVID-19 equals the medicare rate.

(D) The professional dispensing fee (PDF) portion of the calculated allowable is determined in accordance with the following criteria:

(1) The PDF to a provider for dispensing a non-compounded drug is assigned on the total number of prescriptions filled by the provider during the provider's last completed fiscal year prior to completing the required cost of dispensing survey and reported on the survey. The PDF is assigned in accordance with the following criteria:

(a) PDF payment amounts for dates of service prior to January 1, 2024:

(i) For providers reporting fewer than fifty thousand prescriptions, thirteen dollars and sixty-four cents.

(ii) For providers reporting between fifty thousand and seventy-four thousand nine hundred ninety-nine prescriptions, ten dollars and eighty cents.

(iii) For providers reporting between seventy-five thousand and ninety-nine thousand nine hundred ninety-nine prescriptions, nine dollars and fifty-one cents.

(iv) For providers reporting one hundred thousand or more prescriptions, eight dollars and thirty cents.

(v) For a provider who failed to submit a complete response to the required cost of dispensing fee survey for the previous reporting period, eight dollars and thirty cents.

(vi) For providers newly enrolled as medicaid providers as described in rule 5160-9-06 of the Administrative Code, the PDF is as follows:

(a) For a new provider located in Ohio, the provider is assigned a PDF of thirteen dollars and sixty-four cents.

(b) For a new provider located outside of Ohio, the provider is assigned a PDF of eight dollars and thirty cents.

(b) PDF payment amounts for dates of service on or after January 1, 2024:

(i) For providers reporting fewer than fifty thousand prescriptions, fifteen dollars and forty-seven cents.

(ii) For providers reporting between fifty thousand and seventy-four thousand nine hundred ninety-nine prescriptions, eleven dollars and forty cents.

(iii) For providers reporting between seventy-five thousand and ninety-nine thousand nine hundred ninety-nine prescriptions, nine dollars and fifty-one cents.

(iv) For providers reporting one hundred thousand prescriptions or greater, eight dollars and thirty cents.

(v) For providers newly enrolled as medicaid providers as described in rule 5160-9-06 of the Administrative Code, the PDF is as follows:

(a) For a new provider located in Ohio, the provider is assigned a PDF of fifteen dollars and forty-seven cents.

(b) For a new provider located outside of Ohio, the provider is assigned a PDF of eight dollars and thirty cents.

(2) The PDF paid to a provider for dispensing compounded drugs is paid in accordance with the following criteria:

(a) The PDF for claims for dispensing total parenteral nutrition (TPN) is fifteen dollars per one-day supply on the claim, with a maximum total PDF of one hundred fifty dollars for the claim. To qualify for the TPN PDF, the TPN compound must be mixed by the pharmacy to the final form under sterile conditions. If the products are mixed or activated at the point of administration by connecting components or breaking seals without the need for sterile conditions, the dispensing does not qualify for payment of the compounded PDF.

(b) The PDF for dispensing sterile compounds, other than TPN, that are required to be sterile for a route of administration including inhaled, infused, instilled, implanted or injected, is ten dollars per day's supply, a maximum of seventy dollars for the claim. To qualify for payment of the sterile compound PDF, the sterile compound must be mixed by the pharmacy to the final form under sterile conditions. Products mixed or activated at the point of administration by connecting components or breaking seals without the need for sterile conditions are not eligible for a sterile compound PDF.

(c) Compounded drugs that are not eligible for the TPN or sterile compound PDF will receive the PDF determined under paragraph (D) of this rule.

(3) Vaccine or injectable drug dispensing that qualifies for payment of an administration fee does not qualify for medicaid payment of a PDF.

(4) Notwithstanding paragraph (D)(1) of this rule, prescribed drugs, other than compounded drugs, dispensed to recipients residing in long term care facilities (LTCFs) are limited to one PDF per patient, per equivalent product, per month . If multiple supplies of an equivalent product are dispensed within the same month, only the ingredient cost will be paid. Exceptions to the one PDF per recipient, per product rule are:

(a) The prescriber ordered a second round of medication for an acute condition within the month.

(b) The prescriber changed the dosage.

(E) Coordination of benefits.

(1) Claims for medicare part B cost sharing as described in rule 5160-1-05 of the Administrative Code are submitted using the medical claim format and are not payable under this chapter.

(2) No payment will be made under this chapter for any drug that may be covered by medicare part D for an recipient who is eligible for coverage by medicare part D, regardless of whether the recipient is actually enrolled in a part D plan or the particular drug is covered by the recipient's part D plan.

(3) Cost-sharing for claims involving neither medicare part B nor medicare part D is determined in accordance with rule 5160-1-08 of the Administrative Code.

Last updated February 16, 2024 at 8:11 AM

History

Effective: February 16, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-9-06 Pharmacy services: billing and recordkeeping requirements.

(A) The pharmacy claims submitted to the Ohio department of medicaid (ODM) or its designee, the pharmacy point-of-sale vendor, must reflect the actual national drug code (NDC) on the container from which the product was dispensed.

(B) All records of prescriptions must comply with federal and state regulations and be retained by the provider for a period of six years from the date of payment of the claim and if an audit is initiated during this time, records must be retained until the audit is resolved.

(C) For a pharmacy claim to be eligible for payment by ODM, any prescription executed in written (and non-electronic) format must be executed on a tamper-resistant form.

(1) To be considered tamper resistant, a prescription form must contain all of the following three characteristics:

(a) One or more features designed to prevent unauthorized copying of a completed or blank prescription form;

(b) One or more features designed to prevent the erasure or modification of information written on the prescription by the prescriber; and

(2) The tamper-resistant requirement applies to all written prescriptions presented at the pharmacy when ODM pays any part of the claim, including when ODM is not the primary payer, in accordance with paragraphs (F) and (G) of this rule.

(3) The tamper-resistant requirement does not apply in the following situations:

(a) Prescriptions transmitted to the pharmacy via an electronic prescription transmission system, facsimile device, or telephone, in accordance with rules promulgated by the state board of pharmacy in agency 4729 of the Administrative Code;

(b) Orders for medications administered in a provider setting and billed by the administering provider in accordance with paragraph (H) of rule 5160-9-03 of the Administrative Code; or

(c) Orders for medications administered in a nursing facility (NF) or intermediate care facility for individuals with intellectual disabilities (ICF/IID), if the order is written in the recipient's medical record and given by medical staff directly to the pharmacy. The prescription is considered tamper resistant if the recipient does not have opportunity to handle the written order.

(4) If a written prescription that is not tamper resistant is presented at the pharmacy, the pharmacy may fill the prescription on an emergency basis and obtain a compliant tamper-resistant replacement from the prescriber within seventy-two hours of dispensing.

(a) A tamper-resistant replacement may be obtained via any of the following methods:

(i) Telephone verification from the prescriber or prescriber's staff, documented on the prescription with the name of the person at the prescriber's office verifying the prescription, date of verification, and identification of the pharmacist or pharmacy staff member requesting verification;

(ii) Obtaining a copy of the prescription from the prescriber via facsimile device;

(iii) Obtaining an electronic prescription from the prescriber; or

(iv) Obtaining a replacement written prescription from the prescriber on a tamper-resistant form.

(b) The replacement tamper-resistant prescription shall be filed with the original, non-tamper-resistant prescription.

(5) When it is determined that a recipient is retroactively eligible, and the recipient's original or refill prescription was filled during a period when the recipient is retroactively eligible, the pharmacy must ensure that the original prescription was tamper resistant before billing the pharmacy claim to ODM.

(a) If the prescription meets the provisions of paragraph (C)(3) of this rule, the tamper-resistant requirement does not apply.

(b) If the original prescription was not tamper resistant, the pharmacy may obtain a tamper-resistant replacement as described in paragraphs (C)(4)(a) and (C)(4)(b) of this rule.

(D) Claims for drugs purchased through the 340B drug discount program as defined in section 340B(a)(4) of the "Public Health Service Act," 42 U.S.C. 256b(a)(4) (as in effect as of January 7, 2011) are submitted with the provider's actual acquisition cost plus cost of dispensing, and use the codes described in billing instructions issued by ODM or its designee.

(E) Voids and reversals

(1) Return to stock

(a) When recipients fail to pick up their prescriptions, pharmacies must reverse the claim submitted to ODM as soon as possible and not later than fourteen days after preparation.

(b) When prescriptions were dispensed to a resident of a NF or ICF/IID and there is an unutilized portion of a legally redispensable drug remaining, the drug must either be:

(i) Destroyed; or

(ii) Returned to the pharmacy to be redispensed and the product cost, not including the dispensing fee, must be credited to ODM by voiding or reversing the original claim and submitting a new claim for the utilized amount plus dispensing fee.

(2) Voids, reversals, and replacement claims for other reasons

(a) Original claims should be submitted within three hundred sixty-five days of the date of service. Claims may be reversed, voided, or replaced (i.e., re-billed) at any time within the first three hundred sixty-five days after the date of service.

(b) Claims may be reversed, voided, or replaced beyond three hundred sixty-five days after the date of service in the following circumstances:

(i) Adjudicated paid claims may be reversed and replaced (i.e., re-billed) beyond three hundred sixty-five days after the date of service if the adjudication date of the replacement claim is within ninety days after the date of original claim payment.

(ii) Adjudicated denied claims may be replaced (i.e., re-billed) beyond three hundred sixty-five days after the date of service if the adjudication date of the replacement claim is within ninety days after the date of adjudication of an original denied claim.

(iii) Adjudicated paid claims may be reversed or voided beyond three hundred sixty-five days after the date of service if the adjudication date of the reversal or void is within five hundred forty-five days after the date of original claim payment.

(F) Third party liability

(1) In accordance with rules 5160-1-17.2 and 5160-1-08 of the Administrative Code, ODM is the payer of last resort.

(2) The provider's claim shall include the following indicators for each third-party payer as described in billing instructions issued by ODM or its designee.

(a) A payer identification code;

(b) Whether the claim was approved or denied, and if denied the reason for the denial;

(d) The recipient 's responsibility amount assigned by each payer.

(G) Medicare part B-covered services

Drugs covered by medicare part B for dually eligible recipients will first be billed by the provider to medicare. When appropriate, ODM pays the medicare part B cost sharing in accordance with rules 5160-1-05 to 5160-1-05.3 of the Administrative Code. Cost sharing for medicare part B services should not be billed in a pharmacy claim format and should be billed in accordance with the billing instructions issued by ODM for professional claims billed secondary to medicare part B or medicare part C.

(H) Medicare part D-covered services

Drugs that are covered or are eligible to be covered by medicare part D for dually eligible recipients are not covered by medicaid. Medicaid does not pay medicare cost sharing for medicare part D services.

(I) Provider types described in rule 5160-9-01 of the Administrative Code are required to submit a complete response to the cost of dispensing survey conducted according to section 5164.752 of the Revised Code.

(1) A complete response to the cost of dispensing survey includes supplying complete information about the terminal distributor for, at the least, all of the following categories:

(a) Demographics;

(b) Number of prescriptions dispensed annually, broken out by medicaid fee-for-service and other payers, and including a total volume for the location;

(d) Direct expenses;

(e) Overhead expenses; and

(f) Certification that the person submitting the survey believes the information to be true, correct, and complete.

(2) Providers that do not submit a complete response to the cost of dispensing survey may be paid a lower professional dispensing fee (PDF) in accordance with rule 5160-9-05 of the Administrative Code.

(3) Newly-enrolled providers are assigned to the dispensing fee described in rule 5160-9-05 of the Administrative Code.

(a) If the provider received the new provider number due to a change in ownership, the department uses the number of prescriptions reported by the previous ownership to determine the PDF.

(b) In a situation other than a change of ownership, a provider is newly enrolled if the date of approval for an application to enroll as a provider, or the date of approval of a specialty pharmacy designation, is less than ninety days prior to the distribution of the most recently conducted cost of dispensing survey then the date of approval is not the effective date of the provider agreement or specialty designation when the effective date is made retroactive by ODM.

(4) If a provider experiences a change in prescription volume during the first nine months following the implementation of a PDF category significant enough that it would result in the provider falling into a different PDF category, the provider may submit a written request with supporting documentation to ODM, no later than the thirtieth day of April of the first year, requesting assignment to a different category. If the supporting documentation justifies an adjustment, ODM will assign a new PDF category effective the first day of July for the second year.

Last updated February 16, 2024 at 8:12 AM

History

Effective: February 16, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-9-07 Pharmacy services: drug coverage review process.

(A) For a drug to be considered for coverage without prior authorization in accordance with rule 5160-9-03 of the Administrative Code, the following information may be requested from the manufacturer or labeler:

(1) Trade name of the drug.

(2) Generic name of the drug.

(3) National drug code number (NDC).

(4) Package sizes available.

(5) Strengths.

(6) Therapeutic use(s).

(7) List of therapeutic ingredients.

(8) Direct, average wholesale price, wholesale acquisition cost and average manufacturer price.

(9) Bioavailability and bioequivalency data.

(10) Letter(s) of approval of new drug application (NDA), or abbreviated new drug application (ANDA).

(11) Product labeling as approved by the food and drug administration.

(12) A statement of justification for coverage without prior authorization including cost effectiveness and relative merits.

(B) Final determination by the Ohio department of medicaid (ODM) of a drug's inclusion on or removal from the list described in paragraph (C) of rule 5160-9-03 of the Administrative Code will be based on a review and analysis of the information required in paragraph (A) of this rule in addition to an analysis of such factors as:

(1) Specific attributes and/or benefits of the drug.

(2) Availability and cost effectiveness of the drug in relation to alternative products.

(3) Availability of bioequivalent generic products.

(4) Provision of a supplemental rebate payment for a drug that reduces the acquisition cost.

(1) New products with the same active ingredient, dosage form, and brand or generic designation as a product that is already covered by ODM will be added to coverage under the same conditions as the existing covered product.

(2) New products within a therapeutic category listed on the "ODM Preferred Drug List" (PDL) will be added to coverage with prior authorization using the same criteria outlined in the PDL document until the new product is reviewed by the ODM pharmacy and therapeutics committee.

(3) New products not within a therapeutic category listed on the ODM PDL will be added to coverage with prior authorization criteria consistent with the product labeling approved by the federal food and drug administration.

Last updated December 6, 2023 at 1:08 PM

History

Effective: April 1, 2017
Promulgated Under: 119.03

Ohio Adm.Code 5160-9-09 Pharmacy services: co-payments.

(A) Adults eligible for the medicaid program will pay a three dollar co-payment for prescribed drugs that require prior authorization and a two dollar co-payment for selected trade name prescribed drugs as indicated in the list specified in paragraph (C) of rule 5160-9-03 of the Administrative Code.

(B) Rules 5160-1-09 and 5160-1-60 of the Administrative Code establish additional requirements regarding co-payments.

(C) Rule 5160-1-09 of the Administrative Code establishes exceptions to the requirement that an individual pay a co-payment.

(D) The exception established in paragraph (C)(4) of rule 5160-1-09 of the Administrative Code regarding emergency services does not extend to drugs prescribed to an individual during a visit to a hospital, clinic, office, emergency department, or other provider setting, that are intended to be used by the individual outside of the provider setting.

(E) No provider of pharmacy services may deny a prescribed drug to an individual eligible for medicaid coverage because the individual is unable to pay the co-payment. The provisions of paragraph (B) of rule 5160-1-09 of the Administrative Code apply to co-payments for prescribed drugs dispensed by a provider eligible to be paid for pharmacy services.

Last updated February 16, 2024 at 8:12 AM

History

Effective: February 16, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-9-10 Ohio average acquisition cost (OAAC) appeal and managed care pharmacy dispensing fee modification request.

(A) Ohio average acquisition cost (OAAC) appeal.

(1) OAAC is the average acquisition cost of a product calculated based on surveys submitted by pharmacy providers enrolled with the Ohio department of medicaid (ODM).

(a) The OAAC rate does not account for off-invoice adjustments between pharmacy providers and wholesalers or manufacturers and is reflective of the market conditions specific to enrolled Ohio pharmacy providers.

(b) The OAAC rate is recalculated utilizing surveys issued to pharmacy providers semiannually, in April and October.

(2) Pharmacy providers initiate OAAC rate inquiries by submitting the OAAC rate review form "Ohio average acquisition cost program request for medicaid reimbursement review." This form along with copies of purchase records for the national drug code (NDC) are submitted to pharmacy pricing and audit consultant (PPAC). This information is found at https://medicaid.ohio.gov/stakehiolders-and-partners/phm.

(a) PPAC staff evaluate and recommend whether an OAAC rate adjustment is warranted.

(b) All OAAC rate adjustments are sent by PPAC to ODM for final approval within two business days.

(c) ODM approved OAAC rate changes are provided to the single pharmacy benefit manager (SPBM) for adjustment and are backdated to cover dispensing dates included in the rate inquiry.

(3) If an OAAC rate adjustment is not recommended by PPAC, a pharmacy provider may appeal directly to ODM using the ODM 10293 form "Ohio average acquisition cost (OAAC) rate appeal." A pharmacy provider must submit an OAAC appeal form to ODM within thirty calendar days from the date of dispensing.

(a) ODM is responsible for the following:

(i) Reviewing the ODM 10293 form along with any supporting documentation submitted by the pharmacy provider and any other relevant information available to ODM.

(ii) Notifying the pharmacy provider of the final rate adjustment appeal decision using the ODM 10293 form.

(iii) Notifying PPAC of the final rate adjustment appeal decision. If approved, rate changes are provided to the SPBM for adjustment and are backdated to cover dispensing dates included in the rate appeal.

(b) ODM's decision is final and there are no state fair hearing rights or additional appeal rights for the OAAC appeal process.

(B) Managed care pharmacy dispensing fee modification request.

(1) Pharmacy providers may request a modification of their managed care dispensing fee using the ODM 10292 form "Managed care pharmacy dispensing fee modification."

(a) Existing pharmacy providers may request a modification to their dispensing fee at any time.

(b) New pharmacy providers may request a modification to their dispensing fee when there is at least one month of accumulated claims data.

(2) Dispensing fee modification requests received on or before the fifteenth of the month are effective on the first day of the following month. Modification requests received after the fifteenth of the month are effective on the first day of the month after the next month.

(3) ODM reviews the ODM 10292 form and calculates the dispensing fee modification. Calculation scoring is available in the SPBM managed care pharmacy reference guide on ODM's pharmacy website.

(4) ODM communicates the calculated dispensing fee modification to the pharmacy provider.

(5) If warranted, all managed care pharmacy dispensing fee modifications are prospective.

(6) ODM's decision is final and there are no state fair hearing rights or additional appeal rights for the dispensing fee modification process.

Last updated July 1, 2024 at 4:39 PM

History

Effective: July 1, 2024
Promulgated Under: 119.03

Chapter 5160-10 Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers

Ohio Adm.Code 5160-10-01 Durable medical equipment, prostheses, orthoses, and supplies (DMEPOS): general provisions.

(A) Scope.

(1) This rule sets forth general coverage and payment policies for durable medical equipment (DME), prostheses, orthotic devices, medical supplies, and supplier services dispensed or rendered by an enrolled DMEPOS provider.

(2) Additional conditions specific to a particular DMEPOS item or service may be set forth in other rules in this chapter of the Administrative Code.

(3) Policies set forth in other rules in this chapter supersede any provisions in this rule with which they conflict.

(B) Definitions that apply to rules in this chapter of the Administrative Code.

(1) "Base invoice charge" is the amount charged for an item to a DMEPOS provider by a distributor or manufacturer before the application of any discounts, rebates, or adjustments.

(2) "Certificate of medical necessity (CMN)" is a written statement by a prescribing practitioner that presents clinical information about an item and about the person for whom it was prescribed. This information, which often is not included in the prescription itself, aids in the determination of whether the particular item is the most medically appropriate for an individual (or even medically necessary).

(a) For many DMEPOS items, a specific CMN form is identified in the relevant rule in this chapter of the Administrative Code. Each identified CMN form bears the designation 'ODM' with a five-digit numeral. If no CMN form is identified, form ODM 01913, "Certificate of Medical Necessity / Request for Need Verification: General Medical Supplies and Equipment" , may be used.

(b) A CMN is not invalidated by a change in an individual's status from one medicaid eligibility category to another (e.g., from fee-for-service medicaid to medicaid managed care).

(3) "Coverage" is the principle that medicaid payment is routinely made for a particular medically necessary item or service. The department maintains several payment schedules of covered items and services, which are posted for reference on the department's web site. These schedules are neither all-inclusive nor exclusive. Neither the appearance of an item or service on a payment schedule nor its absence determines, in and of itself, coverage or non-coverage.

(4) "Date of service" is the date on which a DMEPOS service is furnished or a DMEPOS item is dispensed directly to an individual.

(a) For an item that is shipped directly to a medicaid-eligible individual, the date of service is either the shipping date or the delivery date. When the individual is to be discharged from a hospital or long-term care facility, the date of service is the date of discharge.

(b) For an item that needs multiple fittings and special construction, the date of service is the date of the first fitting.

(c) For items that are shipped on a reoccurring basis, such as enterals, supplies, or certain types of equipment, the date of service can fall within a thirty-day window using either the shipping or receiving date.

(5) "Department" is the Ohio department of medicaid or, when applicable, its designee. The address of the department's web site is http://medicaid.ohio.gov.

(6) "DMEPOS item" is a collective term for a covered durable medical equipment (DME) item, prosthetic device, orthotic device, or medical supply item furnished by an eligible provider to a medicaid-eligible individual.

(7) "DMEPOS provider" is a collective term for the following eligible providers:

(a) A basic DME supplier, which furnishes items other than life-sustaining or technologically sophisticated equipment in accordance with Chapter 4752. of the Revised Code;

(b) A specialized DME supplier, which furnishes life-sustaining or technologically sophisticated equipment in accordance with Chapter 4752. of the Revised Code; and

(c) An orthotics and prosthetics (O&P) supplier, which furnishes orthotic and prosthetic devices in accordance with section 4779.02 of the Revised Code.

(8) "DMEPOS service" is a covered service, such as labor for repair or replacement, that is furnished by an eligible provider and is related directly to a DMEPOS item.

(9) "Frequency limit" is the average expected useful life of a DMEPOS item. A frequency limit is not an absolute restriction but a general guideline and therefore may be exceeded with medical justification. For certain DMEPOS items that can be dispensed in multiple units (such as fasteners or items with left/right orientation), a frequency limit applies to each unit that is requested.

(10) "Long-term care facility (LTCF)" is a collective term for a nursing facility (NF), a skilled nursing facility (SNF), and an intermediate care facility for individuals with intellectual disabilities (ICFIID).

(11) "Medical supplies."

(a) For purposes of this chapter of the Administrative Code, this term applies to healthcare-related items delineated by the following criteria:

(i) They have a short useful life. They are expendable, disposable, or non-durable. They are intended either for a single use or for limited repeated use by one individual.

(ii) They are adjunctive in nature. They aid in the treatment or management of an illness, injury, or condition.

(iii) Their therapeutic effect is achieved through application to the body and not through ingestion.

(b) Medical supplies include but are not limited to the following non-exhaustive list of examples:

(i) Incontinence garments;

(ii) Syringes;

(iii) Wound dressings, including gauze;

(iv) Catheters and other urological items;

(v) Ostomy care items; and

(vi) Feeding bags.

(i) Enteral nutrition products; and

(ii) Parenteral nutrition products.

(d) The use of the term 'supply' meaning "quantity" (as in 'the supply of wheelchairs on hand' or 'a three-month supply') does not make the items in question medical supplies.

(e) This definition is useful only in the consideration of items for which no standard medicaid maximum payment amount has been established.

(12) "Need verification" is a process by which the department determines whether to make payment for a DMEPOS item or service that exceeds the established cost threshold or frequency guideline. Because need verification is applied only to items or services for which medical necessity has already been established or presumed, no extensive or in-depth clinical assessment is necessary (as it is with prior authorization). One purpose of need verification is to enable the department to consider whether the purchase of a new piece of DME might be more cost-effective than continued repair.

(13) "Prior authorization (PA)" has the same meaning as in rule 5160-1-31 of the Administrative Code.

(14) "Private residence" is a medicaid-eligible individual's place of residence other than a long-term care facility (LTCF).

(15) "Provider cost" is the amount paid for an item by a DMEPOS provider to a distributor or manufacturer after the application of any discounts, rebates, and adjustments that are available to the provider at the time of claim submission. Documentation of provider cost is subject to approval by the department; a figure that has been entered, superimposed, modified, obscured, or obliterated by the provider will not be accepted. Suitable documents for substantiating provider cost include but are not limited to the following examples:

(a) An invoice submitted by the distributor or manufacturer to the provider;

(b) A bona fide quotation (quote) submitted by the distributor or manufacturer to the provider; or

(16) "Starting date for dispensing" is the first date on which a DMEPOS item is anticipated to be dispensed on an ongoing basis. The date of signature does not determine the starting date for dispensing.

(1) In general, in accordance with Chapter 5160-3 of the Administrative Code, a LTCF is responsible for ensuring that a resident of the LTCF gets medically necessary DME items and medical supplies, either by providing such items and supplies itself or by paying a DMEPOS provider to dispense them. In turn, the LTCF receives medicaid per diem payment on the basis of its cost report. Therefore, claims submitted to ODM or its designee by a DMEPOS provider for such items or supplies furnished to LTCF residents will be denied. Any exceptions are set forth in other rules in this chapter of the Administrative Code.

(2) Separate payment may be made for a prosthesis or orthotic device supplied to a resident of a LTCF.

(3) A medically necessary DMEPOS item can be dispensed only by prescription. The following provisions apply:

(a) Eligible medicaid providers of the following types having prescriptive authority under Ohio law may prescribe a DMEPOS item:

(i) A physician;

(ii) A podiatrist;

(iii) An advanced practice registered nurse with a relevant specialty; or

(iv) A physician assistant.

(b) Before writing a prescription for certain DMEPOS items, a practitioner conducts a face-to-face encounter with the medicaid-eligible individual and documents it in the individual's medical record. Items for which an encounter is a prerequisite are listed on the web site of the centers for medicare and medicaid services (CMS) at http://www.cms.gov.

(c) A single encounter can serve for twelve months as the basis for a single prescription or for more than one prescription addressing the same medical condition for which a DMEPOS item is being prescribed.

(d) The prescribing practitioner needs to be actively involved in managing the medicaid-eligible individual's healthcare. The department may disallow a prescription written by a practitioner who has no professional relationship with the individual.

(e) There needs to be a direct relationship between the prescribed DMEPOS item and a medical condition of the medicaid-eligible individual that the practitioner evaluates, assesses, or actively treats during the encounter.

(f) Each prescription should specify a quantity (e.g., "TID," "thirty per month"). An unstated quantity is assumed to be one unit.

(g) Unless a law, regulation, rule, or the prescription itself states otherwise, a prescription is assumed to be valid for one year.

(4) DMEPOS items and services for which payment is subject to PA are so indicated in the applicable DMEPOS payment schedule.

(a) The following DMEPOS items are always subject to PA:

(i) A "not otherwise specified," "miscellaneous," or "unlisted" item or service; and

(ii) Used DME.

(b) When PA is given, it may specify a quantity, manufacturer, model, part number, or other information identifying a particular item. When such identifying information is present, a provider may supply and subsequently submit claims for the specified items only. No changes or substitutions are allowed without explicit authorization by the department.

(c) The department, on the basis of clinical indications, may grant PA for an item other than one that has been requested.

(5) If a medicaid-eligible individual dies after measurements for a prescribed custom item have been taken but before the item has been dispensed, then payment for the item may be made under the following conditions:

(a) The code set description for the item indicates that it is designed or intended for a specific individual;

(b) The item is substantially complete and cannot be modified for use by another individual;

(d) The provider can document the date of measurement; and

(e) On the claim, the provider reports the date of measurement as the date of service.

(6) Any request for a DMEPOS item or service needs to originate with an individual medicaid-eligible individual, the individual's authorized representative, or a medical practitioner acting as the prescriber with the individual's full knowledge and consent. A request that is determined by the department to have resulted from a mass screening or examination will be denied.

(7) When instruction in the safe and appropriate use of a particular DMEPOS item is indicated, it is the responsibility of the provider to ensure that the medicaid-eligible individual or someone authorized to assist the individual has received such instruction.

(8) Payment for repair of a DME item, prosthetic device, or orthotic device or for purchase of a related medical supply item or service can be made only if the medical necessity of the DME item, prosthetic device, or orthotic device itself has been established.

(a) The medical necessity of an item purchased by the department is established during the purchasing process.

(b) For an item not purchased by the department, medical necessity may be documented on an appropriate medicaid certificate of medical necessity, on a prescription that addresses all specified criteria, or on any other form that is acceptable to the department.

(d) The determination that an item not purchased by the department is medically necessary does not indicate that the item would be authorized for purchase.

(9) The initial payment for covered repair, maintenance, parts, accessories, or supplies for a DME item that is owned by an individual but has not been purchased by the department is subject to PA. Whether payment for subsequent items or services is subject to PA depends on the item or service.

(10) Proof is needed to show that a DMEPOS item has been delivered to the intended medicaid-eligible individual.

(a) Providers, their employees, and anyone else having a financial interest in the delivery of DMEPOS items are not permitted to accept delivery of an item on behalf of an individual.

(b) If a provider delivers directly to a medicaid-eligible individual, then acceptable proof of delivery includes the signature of the individual or the individual's authorized representative. For a DMEPOS item delivered to a resident of a LTCF, the LTCF is responsible for furnishing proof of delivery.

(c) If a provider uses a third-party shipper, then acceptable proof of delivery includes the shipper's tracking slip or a returned postage-paid delivery invoice.

(d) If a signature obtained physically at the time of delivery is not legible, then the provider or shipper records the name of the person accepting delivery and the relationship of the person to the medicaid-eligible individual. If the provider or shipper records such information for a particular person and maintains it in a readily accessible format, then on subsequent deliveries only the signature is needed.

(11) If more than one DMEPOS item or service will meet a medicaid-eligible individual's needs, then the maximum payment amount cannot exceed the least costly alternative, in accordance with rule 5160-1-01 of the Administrative Code.

(12) No separate payment will be made under this chapter of the Administrative Code for the following items or services:

(a) Items presumed to be non-medical in nature and for which no medical necessity can therefore be demonstrated, including but not limited to the following examples:

(i) Environmental control devices;

(ii) Items that are intended solely for the comfort or convenience of the user and have no medical benefit;

(iii) Physical fitness equipment;

(iv) Precautionary items (e.g., emergency alert systems);

(v) Training equipment (e.g., speech-teaching machines);

(vi) Communication aids, except as specified elsewhere in this chapter of the Administrative Code;

(vii) Educational aids; and

(viii) Hygiene equipment (e.g., bidets);

(b) Routine over-the-counter treatment supplies (e.g., adhesive bandages, antiseptic solutions, antibiotic ointments) and personal hygiene items (e.g., soap, diapers for children younger than three years of age);

(c) Medical supplies or DME items that are used during a visit with a healthcare practitioner (i.e., that are incidental to a professional service) in an appropriate healthcare setting or in the medicaid-eligible individual's private residence;

(d) Items or services that are covered under manufacturer or dealer warranty;

(e) Items or services for which full remuneration is made through other payment mechanisms;

(f) Costs of delivery (including postage), setup and assembly, pickup, and routine cleaning and maintenance associated with a covered DME item;

(g) Labor, measuring, casting, fitting, travel by the supplier, and shipping or mailing associated with a covered orthotic device or prosthesis;

(h) Maintenance and repair of DME during a rental period;

(i) Supporting wires, power supplies, cables, or attachment kits;

(j) Related supplies and accessories that are dispensed either during a rental period or with the dispensing or delivery of a purchased DME item and for which no payment amount exists for separate purchase or rental;

(k) A service call in addition to materials and labor;

(l) Repairs, adjustments, or modifications that are made within ninety days after delivery or during the total rental period, unless necessitated by major changes in the medicaid-eligible individual's condition;

(m) Instruction of the medicaid-eligible individual or the individual's authorized representative in the safe use of an item; and

(n) Education, training, instruction, counseling, or monitoring conducted in support of an individual's ordered treatment plan.

(13) The use of an item in conjunction with a piece of DME does not in itself make the item an accessory. A smart phone, for example, is not an accessory.

(14) Payment is not available for DMEPOS items that duplicate or conflict with another item currently in the medicaid-eligible individual's possession, regardless of payment or supply source. Providers are responsible for ascertaining whether duplication or conflict exists.

(15) Certain DMEPOS items may be dispensed on a recurring basis. A provider is to confirm a medicaid-eligible individual's current need before the next delivery. If DMEPOS items are routinely delivered without necessary confirmation of need, then any payment for excess quantities is subject to recovery.

(16) Most covered DME items are purchased and become the property of the medicaid-eligible individual. Some covered DME items that need ongoing servicing are rented exclusively. Some covered DME items may be rented on a short-term basis, purchased, or rented and then purchased.

(a) The short-term rental of a covered DME item other than a wheelchair is subject to PA, which may be given if rental is determined to be more cost-effective than purchase.

(b) Unless a different length of time is specified elsewhere in this chapter of the Administrative Code, the initial rental period does not exceed six months.

(d) Regardless of its authorized length, a rental period ends when the rented item is no longer medically necessary.

(e) A monthly rental payment secures the rented item for the entire calendar month.

(f) During a rental period and for ninety days afterward, the cumulative rental amounts paid for a particular "rental/purchase" DME item apply toward purchase.

(g) The department reserves the right to determine whether an item will be rented or purchased.

(17) Medical supply items such as gauze pads and wound fillers/packing are dispensed in bulk. No payment amount per unit has been established for such items; instead, an overall payment limit per period is specified. The charge submitted by the provider cannot exceed one hundred forty-seven per cent of the provider cost for the quantity of the item.

(18) The purchase of torsion cables may be authorized only for the treatment of children with neuromuscular diseases and related conditions. Requests for torsion cables to treat positional deformities will be denied because of anticipated resolution that occurs with maturation.

(19) A provider may furnish a DMEPOS item or service before obtaining a completed CMN but cannot submit a claim until the item or service has been furnished.

(20) A request for PA or need verification may be denied in cases involving malicious damage, neglect, culpable irresponsibility, or wrongful disposition.

(21) Only the department can determine coverage. Providers cannot decide on their own that an item or service is not covered or would not be covered with PA. Providers should submit a PA request to obtain an official decision.

(D) Documentation.

(1) When a request is made for PA, the following accompanying documentation is needed:

(a) A completed CMN:

(i) For a DMEPOS item that is dispensed once (such as a wheelchair), the provider submits one completed CMN; or

(ii) For a DMEPOS item that will be needed indefinitely, for a lifetime, or on a recurring or ongoing basis, the provider takes the following steps:

(a) The provider obtains and submits an initial completed CMN;

(b) Each year thereafter the provider obtains and submits an updated prescription no sooner than ninety days before the expiration of the current prescription; and

(c) If the updated prescription indicates a change in the need for a DMEPOS item, the provider obtains a new completed CMN;

(b) Related information, such as a full description of any similar item currently in possession of the medicaid-eligible individual or an explanation of a change in the individual's condition that warrants a change in equipment;

(c) For a preparatory prosthesis, the reason for the amputation, the date of the amputation, and an explanation of the benefit to be derived from having the medicaid-eligible individual use a preparatory prosthesis before a definitive prosthesis is designed;

(d) For a "not otherwise specified," "miscellaneous," or "unlisted" item, a complete description of the item (including, as applicable, the manufacturer, model or style, and size), a list of all bundled components, and an itemization of all charges; and

(e) Any other information requested by the department, as detailed in this chapter of the Administrative Code.

(2) A claim for an item or service that exceeds the specified maximum quantity or frequency but is not otherwise subject to PA is subject to need verification. Documentation of need may be made either on the CMN associated with the item or service or on form ODM 01913.

(3) For each claim, whether or not it is subject to PA or need verification, the provider cannot legitimately receive payment until necessary supporting documents have been obtained and placed in the provider's files. These documents include the prescription and any applicable items from the following non-exhaustive list of examples:

(a) A completed CMN;

(b) Practitioner orders or chart notes;

(d) Proof of delivery;

(e) Confirmation that the medicaid-eligible individual or the individual's authorized representative has been instructed in the safe use of the DMEPOS item;

(f) A copy of the manufacturer's or dealer's warranty; and

(g) A record of any repair or service that has been performed on equipment not paid for by medicaid.

(E) Claim payment.

(1) The payment amount specified in another rule in this chapter of the Administrative Code supersedes any payment amount established by provisions in this rule.

(2) For a covered DMEPOS item or service represented by a new or newly adopted healthcare common procedure coding system (HCPCS) procedure code, the initial maximum payment amount may be established in accordance with rule 5160-1-60 of the Administrative Code. New or newly adopted HCPCS codes are published in a separate table on the department's web site and remain there until the appropriate DMEPOS payment schedules can be updated.

(3) For any covered DMEPOS item or service not represented by a new or newly adopted HCPCS procedure code, the payment amount is the lesser of the submitted charge (which is to reflect any discounts or rebates available to the provider at the time of claim submission but need not reflect subsequent discounts or rebates) or the first applicable medicaid maximum from the following ordered list:

(a) The amount listed in the appendix to this rule;

(b) For a "by report" DMEPOS item or service, an amount determined on a case-by-case basis;

(i) A supply item, one hundred forty-seven per cent of the provider cost;

(ii) A wheelchair, wheelchair item, standing frame, gait trainer, or other DMEPOS item that incorporates complex rehabilitation technology, one hundred twenty per cent of the base invoice charge;

(iii) An enteral nutrition product, one hundred eighty-five per cent of the provider cost; or

(iv) Any other non-supply DMEPOS item or service, an amount determined on a case-by-case basis;

(d) For the authorized purchase of a DMEPOS item in used condition, eighty per cent of the payment amount for the item in new condition;

(e) For monthly payment for a "rental/purchase" DME item, ten per cent of the medicaid maximum specified for purchase; or

(f) For a professional service for which separate payment is made (such as an evaluation), the applicable amount listed in appendix DD to rule 5160-1-60 of the Administrative Code.

(4) In accordance with the principle stated in rule 5160-1-60 of the Administrative Code concerning correct coding, a "not otherwise specified," "miscellaneous," or "unlisted" procedure code of the appropriate DMEPOS type may be reported on a claim only if no other code listed on a payment schedule adequately represents the item or service. The department may deny a claim that omits necessary information or that includes a "not otherwise specified," "miscellaneous," or "unlisted" procedure code when an appropriate procedure-specific code is available.

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Last updated January 5, 2026 at 8:49 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-02 DMEPOS: repair.

(A) Definitions.

(1) "Major repair" is a repair for which the combined medicaid allowed amounts for materials and labor exceed one hundred twenty dollars for an orthotic or prosthetic device or one hundred dollars for any other item.

(2) "Minor repair" is a repair for which the combined medicaid allowed amounts for materials and labor do not exceed one hundred twenty dollars for an orthotic or prosthetic device or one hundred dollars for any other item. Reporting a major repair on a claim as a series of minor repairs is not permitted.

(B) Coverage.

(1) Provisions governing the repair of wheelchairs are set forth in rule 5160-10-16 of the Administrative Code.

(2) Need verification is necessary before payment can be made for the following repairs made to a particular item:

(a) The initial repair made to an item that was not purchased by the department;

(b) Major repairs; and

(3) The default form on which to submit a request for need verification (RNV) is the ODM 01904, "Request for Need Verification: Repair of Durable Medical Equipment (Other Than Wheelchairs), Prostheses, or Orthotic Devices" (rev. 7/2018). An RNV includes the following information:

(a) Specification of the item, including manufacturer, model, and serial number (if applicable);

(b) The date on which the item was originally purchased or dispensed or, if the date is not known, the approximate age of the item;

(d) A full description of the wear, damage, or malfunction;

(e) A full description of the repair;

(f) A description, with dates, of previous repairs (both major and minor);

(g) A complete itemization of parts; and

(h) An estimate of labor time needed.

(4) Providers should advise the department when, in their professional opinion, replacement of an item would be more cost-effective than repair.

(5) No separate payment will be made for the following items or services:

(a) Temporary replacement ("loaner") equipment provided while an individual's own equipment is being repaired;

(b) Repair of an item if within the preceding twelve months medicaid payment has been made for the repair of a duplicate or conflicting item currently in the individual's possession; or

Last updated January 2, 2024 at 8:56 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-06 DMEPOS: wearable cardioverter-defibrillators.

(A) Prescribing provider. Only a physician experienced in the management of patients at risk for sudden cardiac death (SCD), such as a cardiologist, electrophysiologist, or cardiac surgeon, may prescribe a wearable cardioverter-defibrillator (WCD).

(B) Coverage.

(1) Separate payment may be made for a WCD furnished to a resident of a long-term care facility (LTCF).

(2) Payment may be made for a WCD on a rental basis only.

(3) The default certificate of medical necessity (CMN) is form ODM 10275, "Certificate of Medical Necessity: Wearable Cardioverter-Defibrillators" (9/2021).

(4) A completed CMN confirms that the following criteria are met:

(a) The individual is at high risk of SCD, established by the occurrence or presence of medically indicated factors including but not limited to the following examples:

(i) A documented episode of ventricular fibrillation or sustained ventricular tachyarrhythmia lasting at least thirty seconds, either spontaneous or induced during an electrophysiologic (EP) study but not attributable to a transient or reversible cause and not occurring within the first forty-eight hours after an acute myocardial infarction;

(ii) Familial or hereditary conditions with a high risk of life-threatening ventricular tachyarrhythmia, such as long QT syndrome or hypertrophic cardiomyopathy; or

(iii) Recent myocardial infarction, dilated cardiomyopathy, newly diagnosed non-ischemic cardiomyopathy, coronary artery bypass graft (CABG), or percutaneous coronary intervention (PCI), with a left ventricular ejection fraction (measured during either the acute or post-acute phase) of not greater than thirty-five per cent; and

(b) Treatment of the individual with an implantable cardioverter-defibrillator (ICD) is precluded by any of the following considerations:

(i) A currently implanted ICD needs to be explanted;

(ii) An infection prevents initial implantation of an ICD; or

(iii) Some condition or circumstance, either temporary or permanent, contraindicates ICD implantation surgery.

(c) The individual is able to wear a properly fitted WCD at least ninety per cent of the time (an average total of at least twenty-one and a half hours per day).

(5) A WCD is generally covered for a period of ninety days at a time. Additional ninety-day coverage periods may be authorized if the provider submits documentation, such as a detailed statement signed by the treating physician that the WCD continues to be medically necessity and the individual continues to use it correctly. Authorization may be given for indefinite (lifetime) coverage if the provider submits appropriate documentation, such as a detailed statement signed by the treating physician and a description of the circumstances that preclude future implantation of an ICD.

(6) Rental payment includes necessary replacement of batteries, electrodes, and the cover garment.

Last updated September 1, 2021 at 8:28 AM

History

Effective: September 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-07 DMEPOS: bathing seats.

(A) Definitions and explanations.

(1) "Assistance," for purposes of this rule, is help with bathing-related tasks that individuals cannot accomplish by themselves, such as getting into and out of a bathing chair, moving in and out of the bathing area, or fastening and unfastening securements and positioners. The term does not include actual bathing (soaping, shampooing, scrubbing, rinsing).

(2) "Bathing seat" is a collective term for an item or device that enables an individual to sit securely and comfortably while taking a bath or shower.

(3) The primary healthcare purpose of a bathing seat is to promote cleanliness. Certain bathing seats can also function as commodes, and many commodes can be used as bathing seats. An item that functions equally well as a bathing seat and as a commode is deemed to be a commode for medicaid payment purposes.

(4) Prior authorization (PA) may be given only if a face-to-face evaluation of need has been performed not earlier than one hundred eighty days before the submission of the PA request.

(B) Providers.

(1) Prescribing providers. Eligible medicaid providers of the following types, acting within their scope of practice, may prescribe a bathing seat and may certify the medical necessity of a bathing seat when such certification is needed:

(a) A physician;

(b) An advanced practice registered nurse with a relevant specialty;

(d) A podiatrist.

(2) Evaluators. The following professionals may evaluate an individual's particular needs for a bathing seat:

(a) A physician, including a physiatrist, orthopedic surgeon, and neurologist;

(b) An advanced practice registered nurse with a relevant specialty;

(d) A podiatrist;

(e) A physical therapist; or

(f) An occupational therapist.

(3) Rendering providers. A medicaid provider enrolled as a basic durable medical equipment (DME) supplier may furnish a bathing seat, part, or accessory or may render a related service.

(4) Billing providers. A medicaid provider enrolled as a basic DME supplier may receive medicaid payment for submitting a claim for a bathing seat, part, accessory, or related service.

(1) Principles.

(a) If documentation of medical necessity is needed, the default certificate of medical necessity (CMN) is form ODM 10274, "Certificate of Medical Necessity: Bathing Seats" (rev. 7/2024).

(b) If more than one type of bathing seat will meet an individual's needs and satisfy the criteria of medical necessity, then the maximum payment amount is the lowest of the respective costs, regardless of which bathing seat is supplied.

(c) The provision of or payment for the purchase of a medically necessary bathing seat for a resident of a long-term care facility (LTCF) is the responsibility of the LTCF. Therefore, claims submitted to the department for bathing seats furnished to LTCF residents will be denied.

(d) Bathing seats on wheels are not to be used simply as transport chairs from which an individual then transfers to a bathtub, standard shower enclosure, or stationary bathing seat. A request for a bathing seat on wheels is therefore not appropriate if the individual does not have a roll-in shower enclosure.

(e) A back support for use in a bathtub is not a bathing seat.

(2) Classification. For purposes of this rule, bathing seats are classified into three categories (basic, intermediate, complex) and eleven total subcategories. The descriptions of the categories and subcategories given here are meant to be generally illustrative and neither all-inclusive nor exclusive.

(a) Basic bathing seats.

(i) Basic bath/shower chair.

(a) Appearance: it looks like a simple chair. It does not have wheels. It may have a back, armrests, or both. It may have any number of legs (including none). It is not wall-mounted.

(b) Construction: it is a standard off-the-shelf product.

(d) Independent use: the individual is able to use it without assistance.

(e) Commode capability: it cannot be used as a commode.

(f) Assessment and documentation: no face-to-face evaluation is needed. No PA is needed. No CMN is needed in addition to the prescription.

(ii) Basic bath/shower bench.

(a) Appearance: it looks like a simple bench. It does not have wheels. It may have a back, armrests, or both. It may have any number of legs (including none). It is not wall-mounted.

(b) Construction: it is a standard off-the-shelf product.

(d) Independent use: the individual is able to use it without assistance.

(e) Commode capability: it cannot be used as a commode.

(f) Assessment and documentation: no face-to-face evaluation is needed. No PA is needed. No CMN is needed in addition to the prescription.

(iii) Basic stationary transfer bath/shower bench.

(a) Appearance: it looks like a simple transfer bench, which straddles the side of the bathtub. It has a stationary seat. It does not have wheels. It may have a back, armrests, or both. It may have any number of legs (including none). It is not wall-mounted.

(b) Construction: it is a standard off-the-shelf product.

(d) Independent use: the individual is able to use it without assistance.

(e) Commode capability: it cannot be used as a commode.

(f) Assessment and documentation: no face-to-face evaluation is needed. No PA is needed. No CMN is needed in addition to the prescription.

(iv) Basic sliding transfer bath/shower bench.

(a) Appearance: it looks like a simple transfer bench, which straddles the side of the bathtub. It has a sliding seat, which may swivel. It does not have wheels. It may have a back, armrests, or both. It may have any number of legs (including none). It is not wall-mounted.

(b) Construction: it is a standard off-the-shelf product.

(d) Independent use: the individual is able to use it (and operate the sliding seat) without assistance.

(e) Commode capability: it cannot be used as a commode.

(f) Assessment and documentation: no face-to-face evaluation is needed. No PA is needed. No CMN is needed in addition to the prescription.

(v) Basic shower chair commode.

(a) Appearance: it looks like a standard wheelchair (two large rear wheels and two eight-inch front casters) or transport chair (four small casters or two small front casters and two slightly larger rear wheels). It generally has a back and may have footrests. It does not have a separate base.

(b) Construction: the frame may be made either of metal such as steel or aluminum or of a polymer such as polyvinyl chloride (PVC).

(d) Independent use: the individual is able to use it without assistance.

(e) Commode capability: it is used as a commode.

(f) Assessment and documentation: no face-to-face evaluation is needed. No PA is needed. No CMN is needed in addition to the prescription.

(b) Intermediate bathing seats.

(i) Intermediate non-assisted shower chair.

(b) Construction: the frame may be made of steel or aluminum but not PVC.

(c) Positioning: it may recline but does not have tilt-in-space capability. It may have basic securement straps and positioners.

(d) Independent use: the individual is able to use it without assistance.

(e) Commode capability: it should be used as a commode if a commode is needed. (A request for a separate commode will not be granted unless a medical reason contraindicates a bathing seat with a commode function.)

(f) Assessment and documentation: a face-to-face evaluation is needed. PA is needed. A CMN is needed in addition to the prescription.

(ii) Intermediate assisted multi-position beach style bathing chair.

(a) Appearance: it looks like a typical beach chair, sitting close to the ground (or floor) on short legs. It is intended for use only in a bathtub. It may have the capability to be used with a base, but any such base is a separate item.

(b) Construction: the frame may be made of steel or aluminum but not PVC.

(c) Positioning: it may recline in multiple positions. It may have a head support. It may have basic securement straps and positioners.

(d) Independent use: the individual needs assistance in using it.

(e) Commode capability: it cannot be used as a commode.

(f) Assessment and documentation: a face-to-face evaluation is needed. PA is needed. A CMN is needed in addition to the prescription.

(iii) Intermediate assisted single-position shower chair.

(a) Appearance: it looks like a transport chair (four small casters or two small front casters and two slightly larger rear wheels). It does not have a separate base.

(b) Construction: the frame may be made of steel or aluminum but not PVC.

(c) Positioning: it does not recline nor have tilt-in-space capability. It may have basic securement straps and positioners.

(d) Independent use: the individual needs assistance in using it.

(f) Assessment and documentation: a face-to-face evaluation is needed. PA is needed. A CMN is needed in addition to the prescription.

(iv) Intermediate assisted multi-position shower chair.

(a) Appearance: it looks like an examination or treatment chair on small wheels such as casters. It may have a separate base.

(b) Construction: the frame may be made of steel or aluminum but not PVC.

(c) Positioning: it may recline in multiple positions but does not have tilt-in-space capability. It may have basic securement straps and positioners. It may have a head support.

(d) Independent use: the individual needs assistance in using it.

(f) Assessment and documentation: a face-to-face evaluation is needed. PA is needed. A CMN is needed in addition to the prescription.

(i) Complex positioning shower chair.

(a) Appearance: it looks like a complex wheelchair. It has small wheels such as casters. It has no separate base.

(b) Construction: the frame may be made of steel or aluminum but not PVC.

(c) Positioning: it may recline in multiple positions. It generally has basic securement straps and positioners. It may have multiple support devices for the head, torso, arms, and legs.

(d) Independent use: the individual needs assistance in using it.

(f) Assessment and documentation: a face-to-face evaluation is needed. PA is needed. A CMN is needed in addition to the prescription.

(ii) Complex transfer bath/shower chair.

(a) Appearance: it consists of a rolling base with a chair seat and small wheels such as casters, a stationary base in the bathing area, and a connecting track or rail that permits the chair seat to slide from the rolling base to the stationary base (and thereby transfer the individual to the inside of the bathtub or shower enclosure).

(b) Construction: the frame may be made of steel or aluminum but not PVC.

(c) Positioning: it may recline in multiple positions and may have tilt-in-space capability. It generally has basic securement straps and positioners. It may have multiple support devices for the head, torso, arms, and legs.

(d) Independent use: the individual may need assistance in using it.

(f) Assessment and documentation: a face-to-face evaluation is needed. PA is needed. A CMN is needed in addition to the prescription. This type of bathing seat may be requested only when there is no other appropriate form of transfer in and out of the bathing space. Because the rolling base with chair seat functions as a transport chair, a request for a separate transport chair for travel to and from the bathing area will be denied.

(3) Purchase.

(a) Payment for intermediate and complex bathing seats is subject to prior authorization (PA), which may be given only if a face-to-face evaluation of need has been performed not earlier than one hundred eighty days before the submission of the PA request.

(b) The purchase of a bathing seat includes the bathing seat, delivery, setup, instruction and training in use, adjustments or minor modifications, and other parts or accessories (either substituted or added on). No separate payment is made for these items.

(4) Repair, including replacement of existing parts or accessories.

(a) The repair of an individual component is subject to need verification. No verification is needed for the repair of a wear item.

(b) For a bathing seat not purchased by the department, submission of documentation of the medical necessity of the bathing seat itself is needed for the initial repair but not for subsequent repairs. The determination that a bathing seat not purchased by the department is medically necessary does not indicate that the bathing seat itself would be authorized for purchase.

(c) Payment is not permitted for temporary replacement equipment (a "loaner bathing seat") provided while an individual's bathing seat is being repaired.

(d) No payment is made for routine maintenance.

(5) Evaluation and management.

(a) An evaluator may receive payment for determining an individual's needs for a bathing seat. Not more than one payment will be made per bathing seat per individual.

(b) Payment includes all services rendered by the evaluator, including evaluation, product selection, confirmation at delivery, and follow-up.

(6) Additional provisions and specifications.

(a) After delivery, the supplier needs to maintain documentary evidence that the following statements are true concerning a bathing seat and any related accessories:

(i) They were delivered to the individual for whom they were prescribed;

(ii) They are consistent with the items described in the CMN, if applicable; and

(iii) They correspond exactly to the items listed on the submitted claim.

(b) Claim payments for which there is insufficient documentation are subject to recovery.

(c) A PA request needs to specify all relevant information, such as procedure code, manufacturer, and model. A fully detailed PA request for repair (either of the entire bathing seat or of multiple components) includes the serial number of the equipment and a complete itemization of parts and estimated labor needed.

(d) When an authorization specifies a manufacturer, model, part number, or other information identifying a particular item, then a supplier may provide and subsequently submit claims only for the specified item.

(e) Payment will not be authorized for a bathing seat to be used by an individual younger than one year. For a child one year of age or older whose needs are not met by an adult-sized bathing seat, consideration for authorization will be given only to bathing seats that accommodate growth, unless there is a more appropriate, cost-effective, medically necessary alternative available. Payment may be made for additional parts needed to "grow" a bathing seat if the combined cost of the parts and related labor is less than the cost of a new bathing seat.

(f) A bathing seat purchased by medicaid is the property of the individual for whom it was prescribed.

Last updated July 2, 2024 at 10:44 AM

History

Effective: July 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-08 DMEPOS: high-frequency chest wall oscillation (HFCWO) devices.

(A) Coverage.

(1) Payment may be made for a high-frequency chest wall oscillation (HFCWO) device on a rental/purchase basis.

(2) Purchase of a HFCWO device will not be considered without an initial trial period lasting at least two months, excluding any portion that coincides with an inpatient hospital stay. Payment may be made for rental during this trial period.

(3) The default certificate of medical necessity (CMN) is form ODM 10229, "Certificate of Medical Necessity: High-Frequency Chest Wall Oscillation Devices" (7/2018). A CMN includes the following elements:

(a) Evidence of a respiratory condition for which a HFCWO device is an appropriate treatment, including but not limited to the following examples:

(i) A diagnosis of cystic fibrosis that has not been ameliorated by any other treatment;

(ii) A diagnosis of another respiratory condition that produces chronic, excessive, retained bronchopulmonary secretions; or

(iii) A medical history of chronic or recurrent respiratory infections that necessitate antibiotic treatment and multiple hospitalizations and are unresolved by other bronchial hygiene therapy;

(b) If applicable, documentation that other airway-clearance treatments are ineffective or contraindicated;

(d) If applicable, specification of other individuals (e.g., siblings) with whom equipment is to be shared.

(4) If use of the HFCWO device is to be continued in a residential setting after the initial trial period, the CMN is revised to include the following information:

(a) An attestation to the effectiveness of the device during the trial period and every previous rental period;

(b) If applicable, specification of a change in the duration or frequency of therapy; and

(B) Constraints and limitations.

(1) The need for a HFCWO device is not established if the condition diagnosed is not accompanied by such symptoms of respiratory distress as the accumulation of bronchopulmonary secretions or bronchopulmonary infection. Common diagnoses that by themselves do not establish need include but are not limited to the following examples:

(a) Amyotrophic lateral sclerosis;

(b) Asthma, uncomplicated;

(d) Cerebral palsy, any variety;

(e) Chronic obstructive pulmonary disease (COPD);

(f) Chronic respiratory failure, unspecified;

(g) Muscular dystrophy;

(h) Pneumonia, uncomplicated;

(i) Polyneuropathy; and

(j) Quadriplegia.

(2) Payment for a HFCWO device that has been dispensed on the basis of a diagnosis alone is subject to recovery.

Last updated January 2, 2024 at 8:57 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-09 DMEPOS: apnea monitors.

(A) Coverage.

(1) Initial payment may be made for rental of an apnea monitor for a period not to exceed four months, and after the first four months payment may be made either for additional rental or for purchase, only if the following conditions are satisfied:

(a) The monitoring unit meets current United States food and drug administration guidelines.

(b) The provider is capable of performing all of the following services:

(i) Arranging to have certified individuals provide infant cardiopulmonary resuscitation (CPR) training to caregivers;

(ii) Providing education and instruction on the mechanical aspects of monitors; and

(iii) Providing a technician twenty-four hours a day to service monitoring equipment;

(i) At least one clinical indication from the following list:

(a) The occurrence of at least one apparent life-threatening event (ALTE) requiring mouth-to-mouth resuscitation or vigorous stimulation;

(b) A need for active medical management of apnea of prematurity;

(d) A need for home oxygen therapy or ventilatory support (either invasive or non-invasive) and associated technology-dependence;

(e) Tracheotomy and associated technology-dependence;

(f) An abnormal pneumogram at discharge from a medical facility;

(g) Severe gastroesophageal reflux and associated apnea;

(h) Severe upper airway abnormality (e.g., achondroplasia, Pierre Robin syndrome); or

(i) Another, specified disorder necessitating close cardiorespiratory monitoring to facilitate a more timely discharge to home from a medical facility; and

(ii) An attestation that appropriate caregivers are capable of being trained to use the monitor properly; and

(d) For additional rental or purchase, the following information is recorded:

(i) An attestation by the prescriber to the need for continued home monitoring and supplies, including the following information pertinent to the child's circumstances:

(a) For a child who is technology-dependent, documentation that the equipment or service on which the child depends is still necessary and is still being used (evidenced, for example, by a copy of a recent clinician follow-up report or home health agency visit report noting equipment and services);

(b) For a child who is not technology-dependent, documentation of recent, clinically significant apnea or bradycardia (evidenced, for example, by a copy of recent monitor data or a recent pneumogram showing instances of apnea or bradycardia) or documentation of a recent emergency department visit or hospital admission for an ALTE; and

(c) For a child whose sibling died of SIDS, the birth and death dates of the sibling (for the purpose of indicating whether the child is currently younger than the sibling was at the time of death); and

(ii) Either a full report of the information recorded by the apnea monitor during the initial rental period or a summary of the information accompanied by a statement that a full report is available on request.

(2) Payment for an apnea monitor includes professional time, data recording, transmission or printing, maintenance, and supplies.

(3) The default certificate of medical necessity (CMN) form is the ODM 02900, "Certificate of Medical Necessity: Apnea Monitors" (rev. 7/2018).

(B) Constraints and limitations.

(1) The following diagnoses, conditions, or circumstances are not by themselves indications for monitoring:

(a) Seizures or seizure disorders in the absence of ALTEs;

(b) Uncomplicated hydrocephalus;

(d) Terminal illness;

(e) Congenital heart defect, with or without associated arrhythmia;

(f) History of apnea in immediate siblings;

(g) History of monitor use with immediate siblings;

(h) History of apnea or SIDS in family members other than immediate siblings;

(i) Parental anxiety or family request for a monitor; and

(j) Need to monitor blood oxygen saturation.

(2) Apnea monitoring in the home does not include pneumograms. A medically necessary pneumogram is ordered by a qualified prescriber and is based on the presence of appropriate symptoms or conditions. No payment will be made for a pneumogram that is used as a screening test in the absence of appropriate symptoms or conditions.

Last updated January 2, 2024 at 8:57 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-11 DMEPOS: hearing aids.

(A) Definition. "Basic hearing test" is an evaluation of an individual's ability to hear that includes the following components:

(1) Testing of air-conducted stimuli at thresholds of five hundred hertz (Hz), one thousand Hz, two thousand Hz, and four thousand Hz;

(2) Assessment of air-conducted speech awareness or speech reception threshold;

(3) Establishment of most comfortable and most uncomfortable listening levels;

(4) Pure-tone bone conduction audiometry (unless the individual's age or capability precludes such testing); and

(5) For an individual younger than twenty-one years of age, the following components:

(a) Tympanometry;

(b) Acoustic reflex battery; and

(B) Coverage.

(1) The default certificate of medical necessity (CMN) form is the ODM 01915, "Certificate of Medical Necessity: Hearing Aids" (rev. 7/2018).

(2) A completed CMN, signed and dated not more than ninety days before the requested dispensing date, is accompanied by a hearing evaluation report, compiled not more than six months before the requested dispensing date, made up of the following components:

(a) A detailed description of the hearing test, signed by the physician specializing in otology or otolaryngology, audiologist, or licensed hearing aid fitter who administered it;

(b) A copy of the hearing test results; and

(c) A written summation of the hearing test results, prepared and signed by a physician specializing in otology or otolaryngology or by an audiologist.

(3) Separate payment may be made for the hearing test itself, administered by authorized individuals working within their scope of practice and conducted in an appropriate sound environment in accordance with nationally accepted standards. Hearing tests should be performed on both ears; a detailed explanation is needed if bilateral testing cannot be done.

(4) The need for a hearing aid is demonstrated when the results of a basic hearing test performed on one ear indicate the following minimum best pure-tone average hearing loss:

(a) Thirty-one decibels (dB); or

(b) In an individual younger than twenty-one years of age, twenty-six dB.

(5) A claim for payment should be submitted only after the acceptability of the hearing aid has been confirmed, usually during a follow-up visit scheduled within thirty days after delivery. The individual may instead confirm acceptability by waiving the follow-up visit. In either case, the provider maintains relevant documentation. If the hearing aid is deemed unacceptable by either the provider or the individual, then payment is limited to the cost of the earmold insert and batteries. If payment has already been made for the hearing aid, then the claim is to be adjusted.

(6) The following warranty periods apply:

(a) For a covered hearing aid, it is the greater of the manufacturer's warranty period or one year from the date of delivery; and

(b) For an earmold insert, it is ninety days.

(7) A warranty comprehensively covers the following services:

(a) Repair, including labor and parts (except earmold inserts and batteries);

(b) Replacement necessitated by damage or loss; and

(c) Two adjustments per year for changes in hearing sensitivity or growth of the ear canal (after which additional adjustments made during the year will be treated as repairs).

(8) A programmable hearing aid, such as a hearing aid employing contralateral routing of signal (CROS) or binaural contralateral routing of signal (BiCROS), may be indicated if an individual has a documented need for such technology in noisy or otherwise adverse hearing environments.

(9) Separate payment may be made for the taking of an impression for an earmold insert (other than an insert dispensed with a hearing aid). Such payment is limited neither by the place of service nor by the individual's living arrangement.

(10) Regardless of how a hearing aid was purchased, payment may be made for necessary repair only if the following conditions are satisfied:

(a) The medical necessity of the hearing aid has been established;

(b) The repair is not covered by warranty or insurance; and

(1) The department may at any time ask a provider to produce a copy of the manufacturer's original cost estimate, a copy of the manufacturer's final invoice detailing discounts and shipping costs, and (if applicable) an explanation of any differences between the figures.

(2) No payment will be made for the following hearing aids:

(a) A disposable hearing aid; and

(b) A hearing aid that has been previously used by another individual.

(3) No payment (including payment of a deductible amount) will be made for replacement if either of the following conditions is satisfied:

(a) The hearing aid is covered by warranty or insurance; or

(b) Repair or reconditioning would be more cost-effective.

(4) Concurrent requests or claims for two separate hearing aids will be treated as a single request or claim for a binaural hearing aid.

(5) Payment for a hearing aid includes the following items:

(a) A cleaning kit;

(b) An initial earmold insert (applicable to behind-the-ear hearing aids); and

(6) Payment for hearing aid dispensing includes the following services:

(a) The taking of initial earmold impressions;

(b) Assistance with selection of the hearing aid;

(d) All visits (including travel) necessary for the dispensing and fitting of the hearing aid (regardless of place of service); and

(e) All service calls and follow-up visits during the warranty period.

(D) Claim payment.

(1) Payment for a hearing aid is the least of three figures:

(a) The medicaid maximum amount listed in the appendix to rule 5160-10-01 of the Administrative Code;

(b) The provider's acquisition cost, which is the sum of the manufacturer's final invoice price and shipping less any discounts received; or

(2) Payment for repair of a hearing aid is the submitted charge, which represents one of the following amounts:

(a) If the provider performed the repair, the total amount the provider customarily charges the general public; or

(b) If the provider subcontracted the repair, one hundred twenty-five per cent of the amount shown on the invoice sent to the provider.

Last updated January 2, 2024 at 8:57 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-13 DMEPOS: oxygen.

(A) Definitions.

(1) "Blood gas study" is the measurement of such characteristics of blood as the partial pressure of oxygen (PO2) or oxygen saturation. The term applies either to pulse oximetry or to an arterial blood gas (ABG) study.

(2) "Group I" and "group II" criteria are sets of clinical indicators used to determine the coverage of oxygen without prior authorization.

(a) Group I criteria.

(i) If the individual is tested while awake and at rest, either of the following measures applies:

(a) Arterial PO2 of fifty-five millimeters of mercury (mm Hg) or less; or

(b) Arterial oxygen saturation at or below eighty-eight per cent.

(ii) If the individual is tested while ambulating, either of the following measures applies:

(a) Arterial PO2 of fifty-five mm Hg or less during ambulation without oxygen, with documented improvement during ambulation with oxygen; or

(b) Arterial oxygen saturation at or below eighty-eight per cent during ambulation without oxygen, with documented improvement during ambulation with oxygen.

(iii) If the individual is tested while asleep, any of the following measures applies:

(a) Arterial PO2 of fifty-five mm Hg or less;

(b) Arterial oxygen saturation at or below eighty-eight per cent;

(c) A decrease in arterial PO2 of more than ten mm Hg, associated with symptoms of or signs reasonably attributable to hypoxemia; or

(d) A decrease in arterial oxygen saturation of more than five per cent, associated with symptoms of or signs reasonably attributable to hypoxemia.

(b) Group II criteria.

(i) Either of the following measures applies:

(a) Arterial PO2 of at least fifty-six mm Hg and not more than fifty-nine mm Hg; or

(b) Arterial oxygen saturation at or above eighty-nine per cent.

(ii) In addition, at least one of the following conditions applies:

(a) Dependent edema suggestive of congestive heart failure;

(b) Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or the presence of P pulmonale on an EKG; or

(3) "Group III criteria" is an informal designation for any other clinical indicators used to determine, through the prior authorization (PA) process, the medical necessity of oxygen. Such indicators include but are not limited to the following examples:

(a) Cluster headaches; or

(b) An illness for which a public health emergency has been declared.

(4) "Transfill unit" is a device that transfers oxygen from a source such as an oxygen concentrator to portable tanks.

(B) Providers.

(1) The following eligible medicaid providers may prescribe oxygen:

(a) A physician;

(b) An advanced practice registered nurse with a relevant specialty; or

(2) The following eligible medicaid providers may supply oxygen:

(a) A durable medical equipment (DME) provider;

(b) A pharmacy;

(d) An advanced practice registered nurse with a relevant specialty;

(e) A physician assistant; or

(f) An ambulatory health care clinic.

(3) The following eligible medicaid providers may receive medicaid payment for submitting a claim for oxygen:

(a) A DME provider;

(b) A pharmacy;

(d) An advanced practice registered nurse with a relevant specialty;

(e) A physician assistant;

(f) An ambulatory health care clinic; or

(g) A professional medical group.

(1) Payment for oxygen can be made only if a prescriber certifies that the oxygen is medically necessary for an individual. A completed certificate of medical necessity (CMN) needs to be signed and dated by the prescriber before a claim is submitted. The default form is the ODM 01909, "Certificate of Medical Necessity: Oxygen" (rev. 11/2024).

(2) On the CMN, the prescriber specifies an estimated length of need (certification period), which may range from one month to a lifetime.

(a) For an individual with a condition meeting group I criteria, each certification period is limited to a maximum of twelve months after the first date of service.

(b) For an individual with a condition meeting group II criteria, the certification period immediately following the first date of service is limited to a maximum of three months, and each certification period thereafter is limited to a maximum of twelve months.

(3) An initial CMN is used to document certification for new service.

(a) An initial CMN needs to be completed if oxygen has not been supplied under medicaid to an individual for at least two full calendar months.

(b) The individual needs to be seen and evaluated by a prescriber, and a blood gas study is needed.

(i) If the individual is a hospital inpatient or resident of a long-term care facility (LTCF), the most recent blood gas study performed within forty-eight hours before discharge is used.

(ii) Otherwise, the most recent blood gas study performed within the preceding twelve months may be used.

(4) A renewing CMN is used to extend certification.

(a) If the need for oxygen was established through a respiratory study in which a positive airway pressure device was shown to be effective only when supplemental oxygen was administered simultaneously, then the need for oxygen is presumed to last as long as the need for the positive airway pressure device, and no further respiratory study is needed to confirm a continued need for oxygen.

(b) Otherwise, the provider obtains a new prescription within ninety days before the end of the existing certification period (or, for lifetime certification, within ninety days before the expiration of the current prescription). No new blood gas study is needed.

(5) A revised CMN is used to modify an existing certification.

(a) The most recent blood gas study performed within thirty days before the revision date is used as the basis for any of the following modifications:

(i) The prescribed maximum flow rate has changed. If the new rate is greater than four liters per minute (LPM), then a new blood gas study needs to be performed while the individual is receiving four LPM.

(ii) Certification is being given for a portable oxygen delivery system to supplement a stationary system for which certification was previously given. If the most recent qualifying study was performed during sleep, then a new blood gas study needs to be performed while the individual is awake, either at rest or ambulating.

(b) No additional blood gas study is needed for the following modifications:

(i) There is a new prescriber, but the oxygen order is the same.

(ii) There is a new provider, and the new provider does not have the most recent CMN.

(D) Coverage.

(1) Payment may be made for oxygen supplied in the following forms:

(a) Stationary gaseous oxygen system (private residence only);

(b) Portable gaseous oxygen system (private residence only);

(d) Portable liquid oxygen system (private residence only);

(e) Oxygen contents, gaseous, including supplies (LTCF only);

(f) Oxygen contents, liquid, including supplies (LTCF only);

(g) Oxygen concentrator, single delivery port;

(h) Oxygen concentrator, dual delivery port;

(i) Portable oxygen concentrator (private residence only); and

(j) Transfill unit (private residence only).

(2) Separate payment for a portable oxygen delivery system may be made in addition to payment for a stationary system only if the following criteria are met:

(a) The individual has a demonstrable need for a separate portable system, either to maintain mobility in a private residence or to accomplish out-of-home activities;

(b) The individual's stationary oxygen delivery system cannot be used as a portable delivery system; and

(c) The prescribed oxygen flow is four LPM or less. If the prescribed oxygen flow is greater than four LPM, then no separate payment is made for the portable oxygen delivery system.

(3) PA is not needed when a supplier has obtained a properly completed CMN and furnishes oxygen to an individual either who has a condition that meets group I or group II criteria or who is a resident of a LTCF.

(4) PA is needed when a supplier has obtained a properly completed CMN and furnishes oxygen to an individual who has a condition that meets neither group I nor group II criteria and who is not a resident of a LTCF. If authorization is given, then the length of the authorization period will be based on medical necessity and cannot exceed the timeframe indicated by the prescriber. The PA request needs to include a copy of the completed CMN.

(5) Oxygen is not medically necessary if it is prescribed for any of the following conditions:

(a) Angina pectoris in the absence of hypoxemia;

(b) Dyspnea without cor pulmonale or evidence of hypoxemia;

(c) Severe peripheral vascular disease that results in clinically evident desaturation in one or more extremity but does not produce systemic hypoxemia; or

(d) A terminal illness that does not affect the respiratory system.

(E) Claim payment.

(1) Payment for oxygen is made on a monthly basis and includes the following related items and services:

(a) Setup and instruction on use;

(b) Equipment and supplies;

(c) Maintenance and repair, including the replacement of any part or attachment (such as tubing, cannula, mask, or filter) that is integral to the oxygen system or the operation of the system;

(d) Transportation or delivery charges;

(e) Emergency service, including the provision of backup equipment and supplies;

(f) Oxygen consumed (when applicable); and

(g) Equipment monitoring visits.

(2) The maximum payment for oxygen is the amount set forth in the appendix to this rule. When the prescribed oxygen flow is greater than four LPM, the payment amount is increased by fifty per cent.

Last updated November 4, 2024 at 8:43 AM

History

Effective: November 4, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-14 DMEPOS: compression garments.

(A) The default certificate of medical necessity (CMN) form is the ODM 01905, "Certificate of Medical Necessity: Compression Garments" (rev. 7/2024).

(B) Payment may be made only for compression garments generating a pressure of at least eighteen millimeters of mercury (mm Hg).

(C) For a gradient compression garment, the provider specifies at least one clinical indication such as but not limited to the conditions identified in the following list:

(1) Elephantiasis;

(2) Lymphedema;

(3) Milroy's disease;

(4) Orthostatic hypotension;

(5) Post-thrombotic syndrome;

(6) Stasis dermatitis;

(7) Stasis ulcers;

(8) Symptomatic chronic venous insufficiency (characterized by, for example, pain, swelling, ulcers, or severe varicose veins);

(9) Symptomatic venous insufficiency associated with pregnancy; or

(10) Thrombophlebitis.

(D) Payment for an anti-embolism compression garment may be limited to three months, because such garments are generally used for short-term treatment after surgery.

(E) Payment for a post-burn compression garment cannot be made if no burn injury has occurred.

(F) It is understood that because of the nature of certain applications, authorization for payment may be granted after an item has been dispensed.

Last updated July 2, 2024 at 10:45 AM

History

Effective: July 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-15 DMEPOS: transcutaneous electrical nerve stimulation (TENS) units.

(A) Definitions.

(1) "Accessories" is a collective term that encompasses but is not necessarily limited to the following items:

(a) Adapters;

(b) Clips;

(d) Carrying pouches; and

(e) Covers.

(2) "Supplies" is a collective term that encompasses but is not necessarily limited to the following items:

(a) Electrodes of any type;

(b) Lead wires;

(d) Adhesive;

(e) Adhesive remover;

(f) Skin preparation materials;

(g) Batteries; and

(h) Battery charger for rechargeable batteries.

(B) Coverage.

(1) Payment may be made for a TENS unit on a rental/purchase basis.

(2) The default certificate of medical necessity (CMN) form is the ODM 03402, "Certificate of Medical Necessity: Transcutaneous Electrical Nerve Stimulation (TENS) Units" (rev. 7/2018). The CMN includes one of the following statements of need:

(a) For neurogenic pain, the following information:

(i) An attestation that the individual is experiencing intractable, nerve-related pain that has lasted at least six months;

(ii) An appropriate supporting diagnosis; and

(iii) An attestation that the use of a comparable TENS unit for a trial period of at least thirty days produced substantial relief from pain and, if applicable, enabled a significant reduction in medication (e.g., muscle relaxants, narcotics, analgesics); or

(b) For post-operative pain, the following information:

(i) An attestation that treatment lasting no longer than thirty days is needed for acute pain following surgery; and

(ii) The date of surgery.

(3) Rental of a TENS unit to treat neurogenic pain is limited to four months.

(4) Rental of a TENS unit to treat post-operative pain is limited to a single thirty-day period and may not be extended.

(5) Payment may be made for the purchase of a TENS unit to treat neurogenic pain, either after a rental period or without a rental period, if the prescriber attests to the medical necessity of continued treatment.

(6) Separate payment may be made for repair of or supplies for a TENS unit owned by an individual. If the unit was not purchased through medicaid, such payment may be made only if the medical necessity of the unit has been established beforehand. Supplies are to be dispensed only when they are needed, at a frequency not to exceed once per month. The payment made for supplies is an all-inclusive lump sum and does not depend on the number or nature of items in a particular shipment. No separate payment is allowed for individual supply items.

(7) After a TENS unit has been purchased, no separate payment is allowed for accessories.

(1) A diagnosis of "chronic intractable pain" is not in itself sufficient to warrant coverage.

(2) The warranty period for a purchased TENS unit is two years from the date of delivery.

(3) Payment may be made for the rental or purchase of a used TENS unit only if the particular unit was previously used by the individual for whom it is currently prescribed.

(4) Payment for a TENS unit does not indicate or imply coverage of a conductive TENS garment.

(5) Payment is limited to the maximum amount for a two-lead unit unless the provider obtains and maintains documentation in the individual's file establishing the medical necessity of a four-lead unit.

(D) Claim payment. The lump-sum payment for TENS supplies is twenty-five dollars.

Last updated January 2, 2024 at 8:57 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-16 DMEPOS: wheelchairs.

(A) Definitions and explanations.

(1) "Basic equipment package" is the following standard set of parts and accessories that come with a wheelchair at the time of purchase:

(a) A sling or solid seat with back, a captain's chair, or a stadium-style seat;

(b) Standard casters or wheels with tires;

(d) Standard front rigging, such as non-elevating legrests with footrests or a footplate;

(e) Wheel locks or brakes;

(f) With a power mobility device, motors;

(g) With a power mobility device, a non-expandable controller;

(h) With a power mobility device, a battery charger;

(i) With a power wheelchair, a standard proportional joystick; and

(j) With a power-operated vehicle, batteries.

(2) "Complex rehabilitation technology (CRT)" is a categorization of wheelchair equipment items for which individual evaluation, fitting, configuration, adjustment, or programming is needed to meet the specific medical and functional needs of the user, as well as services related to those products. CRT includes, for example, customized seating systems, adaptive positioning devices, and alternative drive systems (directional interfaces other than a standard joystick).

(3) "Custom wheelchair" is a wheelchair that has a customized seating system. A custom wheelchair, therefore, cannot be easily used or adapted for use by another individual.

(4) "Customized seating system" is a wheelchair seat, wheelchair back, or combination of wheelchair seat and back that has been tailored specifically to the particular body shape and positioning needs of an individual user. Customization may be achieved by means of molding, contouring, carving, or other forms of fabrication or by the integration of prefabricated components into the wheelchair frame. Items such as seat cushions and other removable positioning aids do not by themselves constitute a customized seating system.

(5) "DMEPOS Fee Schedule" is a list of payment amounts for durable medical equipment, prostheses, orthoses, and supplies published by the centers for medicare and medicaid services (CMS); it is available at http://www.cms.gov. The January 2015 revision is the basis for the medicaid payment amounts described in paragraph (E) of this rule.

(6) "Individualized seating system" is a wheelchair seat, wheelchair back, or combination of wheelchair seat and back that has been tailored to the body shape and positioning needs of an individual user by means of installing and configuring prefabricated cushions or other removable positioning aids.

(7) "Medical necessity" is defined in rule 5160-1-01 of the Administrative Code. Wheelchairs and wheelchair parts and accessories need to meet additional criteria in order to be considered medically necessary:

(a) Wheelchairs and wheelchair parts and accessories are generally not necessary nor even useful in the absence of illness, injury, impairment, disability, or other condition that limits ambulation. Therefore, a wheelchair needs to provide mobility to an individual for whom ambulation is not possible, takes inordinate physical effort, or causes considerable physical discomfort.

(b) A wheelchair also needs to be suited to the purposes and daily routines of the individual using it.

(c) A manual wheelchair needs to provide a level of needed functionality that cannot be achieved with an assistive device such as a cane, a crutch or crutches, or a walker.

(d) A power mobility device (PMD) needs to provide a level of needed functionality that cannot be achieved with a manual wheelchair.

(e) A PMD needs to be functional in the environment in which it is used. The individual (or someone assisting the individual) needs to have the ability to take proper care of the PMD, the individual's place of residence needs to be accessible and have adequate electrical service, transportation of the PMD needs to be available as necessary, and there needs to be sufficient protection for the PMD from the elements. The place of residence is considered to be accessible only if the individual will be able to use the PMD without assistance to enter and leave the residence and to move easily about the main living space (which is used for purposes such as food preparation, eating, sleeping, personal hygiene, and relaxation).

(f) A customized seating system needs to enable an individual to sit (or recline, as appropriate) for long periods of time, provide postural support to permit functional activities, or reduce pressure on the body to a degree that cannot be achieved with items such as a standard wheelchair seat, an individualized seating system (e.g., a prefabricated seat cushion or other removable positioning aid or combination of positioning aids), or a spinal orthotic device.

(8) "Need verification" is a process, similar to prior authorization, by which the department determines whether to make payment for the repair of a wheelchair part or accessory that exceeds the established frequency guideline. One purpose of need verification is to enable the department to consider whether the purchase of a new piece of equipment might be more cost-effective than continued repair.

(9) "Power mobility device (PMD)" is a collective term for a power wheelchair or a power-operated vehicle (POV, commonly referred to as a "scooter"). Each PMD is classified on the basis of performance into one of eight groups developed under the auspices of CMS:

(a) Group one power-operated vehicles;

(b) Group two power-operated vehicles;

(d) Group two power wheelchairs;

(e) Group three power wheelchairs;

(f) Group four power wheelchairs;

(g) Group five power wheelchairs; and

(h) Power mobility devices not otherwise classified.

(10) "Routine maintenance" of a wheelchair is any upkeep that is necessary to maintain optimum functioning of the equipment and that does not need a skilled or trained technician to perform.

(11) "Wheelchair" is a collective term for a manual wheelchair or a power mobility device.

(B) Providers.

(1) Prescribing providers. Eligible medicaid providers of the following types, acting within their scope of practice, may certify the medical necessity of a wheelchair:

(a) A physician;

(b) An advanced practice registered nurse with a relevant specialty;

(d) A podiatrist.

(2) Evaluators. The following professionals may evaluate an individual's particular needs:

(a) For wheelchairs incorporating CRT, a physiatrist, orthopedic surgeon, neurologist, physical therapist, or occupational therapist; or

(b) For wheelchairs not incorporating CRT, a physician, physical therapist, or occupational therapist.

(3) Rendering providers. The following eligible providers may furnish a wheelchair, part, or accessory or may render a related service:

(a) For manual wheelchairs without CRT, a provider enrolled as a basic durable medical equipment (DME) supplier; or

(b) For PMDs and CRT, a provider enrolled as a specialized DME supplier.

(4) Billing providers. The following eligible providers may receive medicaid payment for submitting a claim for a wheelchair, part, accessory, or related service:

(a) For manual wheelchairs without CRT, a provider enrolled as a basic DME supplier; or

(b) For PMDs and CRT, a provider enrolled as a specialized DME supplier.

(1) Principles.

(a) The medical necessity of a wheelchair needs to be determined before the department will make payment. For a wheelchair purchased by the department, this necessity is documented on form ODM 03411, "Certificate of Medical Necessity: Wheelchairs" (rev. 7/2021). The medical necessity of a wheelchair that has not been purchased by the department is documented either on this certificate of medical necessity (CMN) or on an equivalent form.

(b) If more than one type of wheelchair will meet an individual's needs and satisfy the criteria of medical necessity, then the maximum payment amount is the lowest of the respective costs, regardless of which wheelchair is supplied.

(c) The provision of or payment for the purchase, repair, or rental of a medically necessary non-custom wheelchair for a resident of a long-term care facility (LTCF) is the responsibility of the LTCF. This responsibility holds even if the wheelchair incorporates CRT other than a customized seating system. In turn, the LTCF receives medicaid payment in accordance with Chapter 5160-3 of the Administrative Code. Therefore, claims submitted to the department by wheelchair suppliers for the purchase, repair, or rental of non-custom wheelchairs furnished to LTCF residents will be denied.

(2) Purchase.

(a) Custom wheelchairs for individuals living in a LTCF and wheelchairs for individuals not living in a LTCF. Prior authorization (PA) is needed, and a face-to-face evaluation of need has to be performed by a prescribing provider not earlier than one hundred eighty days before the submission of the PA request.

(b) Constraints and limitations.

(i) The purchase of a wheelchair includes the basic equipment package, delivery, setup, instruction and training in use, and adjustments or minor modifications. No separate payment is made for these items. Payment for other parts or accessories, either parts or accessories that are substituted for individual items in the basic equipment package or parts or accessories outside the basic equipment package that are added after a wheelchair is purchased, is subject to PA.

(ii) Authorization will not be given for the purchase of more than one wheelchair for concurrent use by an individual. An exception to this restriction may be made if it can be satisfactorily demonstrated that having a second wheelchair, such as a manual wheelchair in addition to a PMD, significantly improves an individual's mobility and is cost-effective.

(3) Repair, including replacement of existing parts or accessories.

(a) Custom wheelchairs for individuals living in a LTCF and wheelchairs for individuals not living in a LTCF. The repair of a component such as a frame, seating system, motor, drive system, or battery is subject to need verification. No verification is needed for the repair of a wear item, such as a caster bearing, tire, arm pad).

(b) Constraints and limitations.

(i) For a wheelchair not purchased by the department, submission of documentation of the medical necessity of the wheelchair itself is needed for the initial repair but not for subsequent repairs. The determination that a wheelchair not purchased by the department is medically necessary does not indicate that the wheelchair itself would be authorized for purchase.

(ii) Payment is not permitted for temporary replacement equipment (a "loaner wheelchair") provided while an individual's wheelchair is being repaired.

(iii) No payment is made for routine maintenance.

(4) Rental.

(a) Custom manual wheelchairs. PA is needed.

(b) Non-custom manual wheelchairs for individuals not living in a LTCF. No PA is needed for the first three months. PA is needed for rental periods after the first three months.

(d) Constraints and limitations.

(i) Payment will not be made for the rental of more than one wheelchair per month for an individual.

(ii) Payment for rental is all-inclusive; no separate payment is made for any other wheelchair-related items.

(iii) During a rental period and for ninety days afterward, all rental amounts paid are applied toward purchase. The total of the rental amounts cannot exceed the purchase amount.

(5) Evaluation and management.

(a) An evaluator may receive payment for determining an individual's needs for a wheelchair. Not more than one payment will be made per wheelchair per individual.

(b) Payment includes all services rendered by the evaluator, including evaluation, product selection, confirmation at delivery, and follow-up.

(D) Additional constraints and limitations.

(1) After delivery, the supplier needs to maintain documentary evidence that the following statements are true concerning a wheelchair and any related accessories:

(a) They were delivered to the individual for whom they were prescribed;

(b) They are consistent with the items described in the CMN; and

(2) Claim payments for which there is insufficient documentation are subject to recovery.

(3) A PA request needs to specify all relevant information (e.g., HCPCS code, manufacturer, model). A PA request for repair needs to include the serial number of the equipment and a complete itemization of parts and estimated labor needed.

(4) When an authorization specifies a manufacturer, model, part number, or other information identifying a particular item, then a supplier may provide and subsequently submit claims only for the specified item.

(5) Payment will not be authorized for a wheelchair to be used by an individual younger than one year. For a child one year of age or older whose needs are not met by an adult-sized wheelchair, consideration for authorization will be given only to wheelchairs that accommodate growth, unless there is a more appropriate, cost-effective, medically necessary alternative available. Payment may be made for additional parts needed to "grow" a wheelchair if the combined cost of the parts and related labor is less than the cost of a new wheelchair.

(6) Payment will not be authorized for wheelchairs, parts, accessories, or modifications whose primary application is leisure or recreational activities.

(7) Payment will not be authorized for a PMD intended exclusively for outdoor use.

(8) A wheelchair purchased by medicaid is the property of the individual for whom it was prescribed.

(E) Claim payment.

(1) As of the effective date of this rule, the payment amount is established as the lesser of the submitted charge or the applicable medicaid maximum from the following list:

(a) For purchase of a covered new wheelchair, part, or accessory, ninety per cent of the allowed amount listed for Ohio on the "DMEPOS Fee Schedule";

(b) For purchase of a covered group four power wheelchair for which there is no medicare allowed amount, one hundred ten per cent of the medicaid maximum payment amount allowed for purchase of the most closely corresponding covered group three power wheelchair;

(c) For purchase of any other covered wheelchair, new part, or new accessory for which there is no medicare allowed amount, payment by report;

(d) For purchase of a covered wheelchair, part, or accessory that has been previously used but remains in good working order, fifty per cent of the medicaid maximum payment amount allowed for purchase of a comparable new wheelchair, part, or accessory;

(e) For monthly rental of a covered wheelchair to which rental applies, ten per cent of the medicaid maximum payment amount allowed for purchase;

(f) For performance of an evaluation and related services, eighty per cent of the amount established by the medicare physician fee schedule; or

(g) For labor provided for a covered repair or covered maintenance, the result L obtained by the formula L = ([W + B] P + M) A 0.25.

(i) L is the medicaid maximum payment amount for labor, reported in fifteen-minute units.

(ii) W is the hourly median wage for medical equipment repairers in Ohio reported by the United States bureau of labor statistics (available at http://www.bls.gov/oes/). (The initial wage figure used was from May 2014.)

(iii) B is hourly employee-related expenses such as benefits, calculated as thirty-five per cent of wages.

(iv) P is a productivity adjustment factor, defined as the ratio of the number of total work hours per day (specified as eight) to the number of available productive work hours per day (specified as six and a half).

(v) M is an hourly mileage allowance, defined as the ratio of the daily mileage allowance to the number of available productive work hours per day. The daily mileage allowance is the product of the average travel speed (specified as thirty-five miles per hour), the average total travel time (specified as one hour and fifteen minutes), and the federal standard mileage rate for business (available at http://www.irs.gov). (The initial standard mileage rate used was for 2015.)

(vi) A is an administrative cost factor, specified as one hundred ten per cent.

(2) After the effective date of this rule, if the medicare amount for an item or service becomes less than the current medicaid maximum payment amount, then the medicaid maximum payment amounts related to that item or service are reestablished on the basis of the new medicare amount.

(3) After the effective date of this rule, if updates to the median hourly wage or the federal standard mileage rate would cause a variance of at least five per cent in the maximum payment amount for labor, then the maximum payment amount is reestablished on the basis of the updated figures.

(4) The payment provisions of this rule supersede entries in appendix DD to rule 5160-1-60 of the Administrative Code that pertain to wheelchairs, parts, accessories, or related services.

Last updated July 9, 2026 at 3:26 PM

History

Effective: July 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-17 DMEPOS: pneumatic compression devices and accessories.

(A) Payment may be made directly to a provider for a pneumatic compressor or a related appliance or accessory only if the following conditions are satisfied:

(1) The equipment is used to treat either lymphedema in the extremities or chronic venous insufficiency (CVI) with venous stasis ulcers; and

(2) The prescribing practitioner has determined either that there was no significant improvement or that significant symptoms persisted when one of the following treatments was applied:

(a) For lymphedema in the extremities, four weeks of therapy involving the use of an appropriate compression bandage system or compression garment (either prefabricated or custom-fabricated), exercise, and elevation of the limb; or

(b) For CVI, six months of therapy involving the use of an appropriate compression bandage system or compression garment, appropriate wound dressings, exercise, and elevation of the limb.

(B) Pneumatic compression devices to be used to treat conditions of the chest or trunk are not covered.

(C) The provider of the pneumatic compression device is expected to obtain from the prescribing practitioner brief documentation of the need for the device and to keep this documentation on file. Use of form ODM 02929 (rev. 7/2018) for this purpose is permitted but not obligatory. The documentation should include the following information as applicable:

(1) A statement that previous treatment produced no significant improvement or that significant symptoms persisted;

(2) The date of the most recent evaluation;

(3) Identification by diagnosis code of the condition or conditions necessitating a pneumatic compression device;

(4) The expected length of time (expressed as the number of months or as 'lifetime') during which the individual will need the pneumatic compression device;

(5) A listing of symptoms observed, measurements taken, and any other data that serve to establish the severity of the condition or conditions;

(6) Specification of the pneumatic compression device and any accessories to be supplied;

(7) Documentation of the individual's clinical response to treatment during evaluation (including changes in measurement results);

(8) A brief summary of the treatment plan, including the pressure to be used, the frequency and duration of use, and a provisional monitoring schedule;

(9) An assessment of the individual's capacity for tolerating the prescribed treatment; and

(10) A statement about the ability of the individual (or someone authorized to assist the individual) to use the device correctly and consistently.

(D) For a covered pneumatic compressor, payment may be made for short-term rental (repeated as necessary for not more than a total of ten months), for rental with subsequent purchase, or for purchase outright, as the prescribing practitioner determines to be appropriate. For a covered pneumatic appliance or accessory, payment is made for purchase.

Last updated January 2, 2024 at 8:58 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-18 DMEPOS: hospital beds, bed accessories, and pressure-reducing support surfaces.

(A) Definitions and explanations.

(1) "Group 1," "group 2," and "group 3" are classes of pressure-reducing support surface.

(a) Group 1 surfaces are generally non-powered pads or overlays that are designed to be placed on top of a hospital bed or standard mattress. They achieve their effect through the application of, for example, a gel layer, air pressure, natural lamb's wool, or synthetic sheepskin. Group 1 may also include some powered systems (alternating pressure or low air loss) that are not classified as group 2.

(b) Group 2 surfaces generally encompass powered air flotation beds, powered air mattresses, and non-powered advanced overlays that are designed to be placed on top of a hospital bed frame or standard bed frame.

(c) Group 3 surfaces are generally air-fluidized beds, which simulate the characteristics of fluid by circulating air through a medium such as silicone-coated ceramic beads. They are used for the treatment of stage III or stage IV pressure sores.

(2) "Stage I," "stage II," "stage III," and "stage IV" are classes of tissue breakdown associated with pressure sores.

(a) Stage I is characterized by erythema (redness lasting at least fifteen minutes after pressure is removed), warmth, tenderness, and sometimes blistering. The affected area is usually located over a bony prominence. Further breakdown may be occurring if erythema fails to dissipate when pressure is removed; however, stage I is usually considered a transient circulatory disturbance, and the affected area generally returns to normal within twenty-four hours.

(b) Stage II involves actual tissue damage and appears as a shallow, open ulcer with a red or pink wound bed without slough or as an intact or ruptured serum-filled blister. It is characterized by a distinct break in epidermal integrity (which may extend into the dermis), erythema, disturbance in skin temperature, tenderness, local swelling or edema, and sometimes drainage. (This stage should not be confused with skin tears, tape burns, perineal dermatitis, maceration, or excoriation.) Stage II tissue damage generally heals quickly and easily.

(c) Stage III is characterized by epidermal and dermal destruction that penetrates subcutaneous tissue, infection, cellulitis, eschar, pain, and drainage. Subcutaneous fat may be visible; however, bone, tendon, and muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. There may be undermining and tunneling of surrounding subcutaneous tissue. With proper attention under optimal conditions, a stage III wound can heal in two to four weeks.

(d) Stage IV is characterized by destruction of the epidermis and dermis, penetration of the deep subcutaneous layers, exposure of subcutaneous structures, destruction of muscle or bone, and possible undermining of surrounding subcutaneous tissue. Slough or eschar may be present.

(B) Coverage of hospital beds.

(1) Payment may be made for a hospital bed on a rental/purchase basis.

(2) The default certificate of medical necessity (CMN) form is the ODM 02910, "Certificate of Medical Necessity: Hospital Beds and Bed Accessories" (rev. 7/2018). The CMN includes an attestation that at least one of the following criteria is met:

(a) The individual's condition (e.g., congestive heart failure, chronic obstructive pulmonary disease, problems with aspiration, disease aggravated by excessive body weight) necessitates elevation of the head or upper body to at least thirty degrees, and such elevation cannot be achieved with pillows or wedges in a standard bed;

(b) The individual uses or will use traction equipment that can be attached only to a hospital bed;

(d) The elevating functions of a hospital bed will facilitate frequent intervention by an assistant or caregiver to alleviate pain or prevent pressure sores.

(3) Documentation of medical necessity is needed for any additional feature that is requested (e.g., powered elevation, powered height adjustment, heavy-duty or extra-heavy-duty construction, extra width).

(a) A heavy-duty hospital bed may be indicated for an individual weighing more than three hundred fifty pounds.

(b) An extra-heavy-duty hospital bed may be indicated for an individual weighing more than six hundred pounds.

(1) The default form is the ODM 02910.

(2) Payment may be made for an accessory to be used with a hospital bed only if the medical necessity of the hospital bed has been established.

(D) Coverage of pressure-reducing support surfaces.

(1) The default CMN form is the ODM 02904, "Certificate of Medical Necessity: Pressure-Reducing Support Surfaces" (rev. 7/2018).

(2) For a group 1 surface, the CMN includes an attestation that at least one of the following criteria is met:

(a) The individual cannot make changes in body position without assistance;

(b) The individual cannot independently make changes in body position sufficient to alleviate pressure;

(d) The individual's circulation is compromised.

(3) For a group 2 surface, the CMN includes the following information:

(a) If the individual underwent a surgical procedure involving the closure of a wound with a skin graft or skin flap within the thirty days preceding placement of the surface, an attestation to the surgery;

(b) An attestation that at least one of the following criteria is met:

(i) The individual has a stage III or stage IV pressure sore on the trunk;

(ii) The individual has multiple stage II wounds;

(iii) The individual has third-degree burns (irrespective of whether grafting has been performed); or

(iv) Within the sixty days preceding placement of the surface or (if applicable) submission of the request for prior authorization, the individual underwent a surgical procedure involving the closure of a wound with a skin graft or skin flap; and

(4) For a group 3 surface, the following information is included on the CMN directly or by attachment:

(a) An attestation that the individual is being treated for a stage III or stage IV wound;

(b) A detailed description of the wound, prepared by a qualified health practitioner within the twenty-one days preceding placement of the surface, that specifies location, length, width, depth, and overall appearance and characteristics;

(c) A record of the individual's body weight taken intermittently over a period of at least sixty days preceding placement of the surface;

(d) The results of blood tests performed within the twenty-one days preceding placement of the surface, including the following levels:

(i) Serum protein;

(ii) Serum albumin or prealbumin;

(iii) Hemoglobin; and

(iv) Hematocrit; and

(e) A current, comprehensive nutritional assessment of the individual, performed by a registered dietitian or licensed dietitian.

(5) The department may determine the length of an initial rental period and any subsequent rental periods.

(E) Constraints and limitations.

(1) A bed does not qualify as a hospital bed if it has no elevating function or if its elevating function is not needed.

(2) Prior authorization of payment for a group 3 support surface may be denied if its use is contraindicated by factors such as but not limited to the following examples:

(a) Treatment protocols that involve significant quantities of moisture;

(b) Inability of the individual or an assistant to operate the equipment safely;

(d) Insufficient electrical supply.

Last updated January 2, 2024 at 8:58 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-19 DMEPOS: positive airway pressure devices.

(A) Definition. "Apnea-hypopnea index (AHI)" is the mean number of episodes of apnea or hypopnea per hour recorded over a period of at least two hours without the use of a positive airway pressure device, reported by polysomnogram. Extrapolation or projection of the AHI is not permitted.

(B) Coverage.

(1) The default certificate of medical necessity (CMN) form is the ODM 01903, "Certificate of Medical Necessity: Positive Airway Pressure Devices" (rev. 7/2021). The CMN includes the following information:

(a) A diagnosis of obstructive sleep apnea or other condition for which positive airway pressure is an appropriate treatment;

(b) The results of a respiratory study; and

(2) A respiratory study may be performed with a positive airway pressure device that records relevant data automatically.

(3) Payment for a positive airway pressure device may be made only if the following criteria are met:

(a) In the absence of positive airway pressure, the respiratory study yields the following results:

(i) An AHI of at least fifteen; or

(ii) An AHI of at least five coupled with documented evidence of any of the following conditions:

(a) Excessive sleepiness during waking hours;

(b) Insomnia;

(d) Impaired cognition;

(e) Hypertension;

(f) Ischemic heart disease; or

(g) A history of stroke.

(b) When positive airway pressure is applied, the respiratory study yields the following results:

(i) A decrease in the number of airway obstructions per hour; and

(ii) At least one of the following indications of effectiveness:

(a) An absolute increase in oxygen saturation to at least eighty-nine per cent;

(b) A relative increase in oxygen saturation of at least fifteen per cent; or

(4) A need for oxygen is established if a positive airway pressure device is effective during a respiratory study only when supplemental oxygen is administered simultaneously. That need for oxygen is presumed to last as long as the need for the positive airway pressure device, and no further respiratory study is necessary to confirm a continued need for oxygen.

(5) Payment for a variable or bilevel positive airway pressure device (i.e., a positive airway pressure device that produces different inspiratory and expiratory pressure levels) may be made only if the following criteria are met:

(a) A positive airway pressure device that produces a single pressure level has been tried and found to be ineffective; and

(b) Evidence gathered during the respiratory study or during a one-week trial period indicates that a variable or bilevel positive airway pressure device is effective.

(6) The provider of a positive airway pressure device cannot perform the qualifying respiratory study.

Last updated August 4, 2025 at 7:40 AM

History

Effective: August 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-21 DMEPOS: incontinence garments and related supplies.

(A) Coverage.

(1) Payment for quantities of incontinence garments or incontinence supplies that exceed the indicated limit is subject to prior authorization (PA). The default certificate of medical necessity (CMN) form is the ODM 02912, "Certificate of Medical Necessity: Incontinence Items" (rev. 7/2024). The CMN includes the following elements:

(a) An indication that the individual is at least thirty-six months of age;

(b) The applicable diagnosis of the specific disease, injury, developmental delay, or developmental disability causing the incontinence;

(d) The type and quantity of incontinence garments or incontinence supplies being prescribed.

(2) An increase in the prescribed quantity of an incontinence item is subject to PA, as is a change in the type of incontinence item. (No additional authorization is needed for a decrease in quantity.)

(3) Similar types of incontinence garments (e.g., briefs/diapers and underwear/pull-ons) may be dispensed together without PA if the aggregate quantity does not exceed the prescribed quantity or indicated limit for any of the individual items.

(B) Constraints and limitations.

(1) Payment cannot be made for items related to stress incontinence to which no specific physiological, psychological, or physiopsychological cause can be attributed.

(2) PA cannot be granted for longer than twelve months at a time.

(3) Incontinence items are dispensed in quantities representing one month's supply. A provider is expected to verify and document an individual's current need before dispensing additional items. Medicaid payment for excessive quantities of items is subject to recovery.

(4) Payment will not be made for more incontinence items than are prescribed or authorized.

Last updated July 2, 2024 at 10:45 AM

History

Effective: July 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-22 DMEPOS: ventilators.

(A) Condition of provider participation. A provider of in-home use ventilators needs to have a licensed respiratory care professional (LRCP) available twenty-four hours a day to provide respiratory care, technical support, and clinical ventilator services and to perform emergency servicing of equipment on two-hour notice.

(B) Coverage.

(1) Separate payment may be made for a ventilator furnished to a resident of a long-term care facility (LTCF).

(2) Payment may be made for a ventilator on a rental basis only. The default certificate of medical necessity (CMN) form is the ODM 01902, "Certificate of Medical Necessity: Ventilators."

(3) For the rental of a primary ventilator, a CMN includes the following information:

(a) Diagnosis;

(b) Specification of the condition or conditions for which ventilatory support is needed;

(d) The continuity of ventilatory support needed (constant, during the day, at night, for sleep only);

(e) The ventilator type, mode, and settings or parameters;

(f) A list of other respiratory equipment in use; and

(g) If applicable, documentation showing that the individual is being weaned.

(4) For the rental of a second ventilator, the CMN includes appropriate attestation to at least one of the following statements:

(a) The individual cannot maintain spontaneous respiration for at least four hours;

(b) Because of regular activities outside the home such as school or outpatient therapy), the individual needs a second ventilator with a suitable power source;

(d) The individual requires one type of ventilator (e.g., a negative pressure ventilator with a chest shell) for part of the day and another type of ventilator (e.g., positive pressure ventilator with a nasal mask) during the rest of the day; or

(e) An individual confined to a wheelchair requires a ventilator mounted on the wheelchair for use during the day and needs another ventilator of the same type for use while in bed.

(5) A multi-function ventilator is an all-in-one device that also has the capability to perform the functions of other respiratory equipment such as an oxygen concentrator, a nebulizer, a suction device, or a cough-assist device. A device that may serve either as a ventilator or as a positive airway pressure device but not as both simultaneously is not a multi-function ventilator.

(a) Payment may be made for a multi-function ventilator only if at least one additional function ("ventilator plus one") is used.

(b) For each additional function, whether included when the unit is first dispensed or activated later, the appropriate CMN applies. A prescription is sufficient when no CMN is specified for a particular function.

(1) A ventilator with an invasive interface is covered only if it includes backup power capability and alarms indicating disconnection, high pressure, low pressure, and power loss.

(2) Rental of a ventilator includes the following items and services:

(a) Ventilator accessories, including inlet ventilator filters, permanent or reusable ventilator circuits, whisper swivels, exhalation ports, tracheostomy tube elbows, and circuit extensions and adapters;

(b) Accessories necessary for the oxygen and ventilator functions of a multi-function ventilator;

(d) Humidifier bacteria filters;

(e) Tubing to connect the humidifier to the ventilator;

(f) Evaluation of the individual's residence to ensure compatibility with the equipment and to forestall problems with its use; and

(g) In person visits made at an appropriate frequency determined by a LRCP in consultation with the individual's prescribing practitioner, at least one visit during the first week, at least one visit per month for the first six months, and at least one visit every sixty days thereafter.

(3) No separate payment is made to a provider for keeping a LRCP on call or for performing emergency servicing of equipment.

Last updated September 1, 2026 at 8:00 AM

History

Effective: September 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-23 DMEPOS: pulse oximeters.

(A) Coverage.

(1) Payment may be made only for a pulse oximeter that meets the following criteria:

(a) It is correctly calibrated, preset, and sealed such that its settings cannot be adjusted by the average user; and

(b) It is capable either of converting data (e.g., number of sampling hours, oxygen saturation level, aggregated results) directly to electronic or printed form or of recording and storing data for later conversion.

(2) Payment may be made for a pulse oximeter on a rental/purchase basis. The default certificate of medical necessity (CMN) form is the ODM 03401, "Certificate of Medical Necessity: Pulse Oximeters" (rev. 7/2018). The CMN includes an attestation by a prescriber that a need exists either for diagnostic monitoring or for continuous monitoring:

(a) For diagnostic monitoring undertaken in response to an acute clinical event or the exacerbation of an existing condition, the prescriber includes the following information:

(i) An attestation that at least one of the following two criteria has been met:

(a) The individual was currently being weaned or was about to be weaned from an oxygen supply; or

(b) The individual was oxygen-dependent and was in a clinically unstable condition; and

(ii) Any previously recorded oximeter data accompanied by an assessment of the resulting impact on the management of the individual's care.

(b) For continuous monitoring twenty-four hours per day, the prescriber attests to three statements:

(i) The individual exhibits clinical instability (evidenced by chronically compromised respiration and frequently varying oxygen requirements);

(ii) The individual is at risk for critical fluctuations in oxygen saturation (e.g., hyperoxia, hypoxia), and

(iii) At least one of the following conditions is present:

(a) Frequent bradycardia;

(b) Frequent oxygen desaturation;

(d) Ventilator-dependency;

(e) Poor growth and development suggesting inadequate oxygenation; or

(f) Another specific risk factor that causes sudden, critical fluctuations in oxygen saturation.

(3) The rental or purchase of a pulse oximeter includes the following items and services:

(a) Service calls;

(b) Supplies and accessories (e.g., cable, printer, printer tape, carrying case); and

(4) Separate payment may be made for probes.

(B) Constraints and limitations.

(1) It is understood that because of the nature of diagnostic monitoring, authorization for payment can generally be granted only after the service has been provided.

(2) No single rental period can be longer than three months.

Last updated January 2, 2024 at 8:58 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-24 DMEPOS: speech-generating devices.

(A) Coverage.

(1) Separate payment may be made for a speech-generating device (SGD) furnished to a resident of a long-term care facility (LTCF).

(2) The default certificate of medical necessity (CMN) form is the ODM 02924, "Certificate of Medical Necessity: Speech-Generating Devices" (rev. 7/2018). The CMN includes the following elements:

(a) A formal, written report of a face-to-face evaluation of the individual's communication abilities performed by a speech-language pathologist (SLP);

(b) Exact specifications for a SGD and the rationale for selection;

(c) Clinical documentation that the individual's cognitive and physical abilities will enable effective use of the specified SGD;

(d) Full disclosure of any SGD equipment currently in the individual's possession and an explanation of why that equipment does not meet the individual's needs;

(e) Documentation of the medical necessity of any accessory or add-on equipment, supplies, or SGD features being requested; and

(f) An explanation of the necessity or functional benefit of any requested upgrade, modification, or replacement.

(3) The formal, written evaluation report includes all of the following components:

(a) A description of the individual's current communication impairment, including the type, severity, and prognosis;

(b) An assessment of the individual's speech skills and capacity for receptive and expressive language;

(c) An explanation, as applicable, of how the individual's cognition, emotions, physical abilities, and behaviors affect the communication of basic needs;

(d) Identification of the persons with whom the individual communicates most frequently and any associated limitations and needs;

(e) Identification of the environments in which the individual communicates most frequently (including vocational and educational settings);

(f) A description of the types of messages the individual generally needs to convey and the range of vocabulary used;

(g) An assessment of the extent to which the individual's daily communication needs could be met by a SGD incorporating less complex technology or by a means of communication other than a SGD;

(h) A description of the functional communication goals expected to be achieved with a SGD;

(i) Recommendations for the following SGD features and functions:

(i) Representational systems (symbols);

(ii) Vocabulary encoding (e.g., icon, level-plus-location, traditional orthography);

(iii) Vocabulary expandability and message generation (e.g., programmed or programmable words or parts of sentences, additional memory);

(iv) Rate-enhancement techniques (e.g., simple symbol selection, symbol sequencing, key linking, dynamic display, abbreviation-expansion, word lists, word prediction, icon prediction, macros);

(v) Access techniques and strategies;

(vi) Keyboard organization (e.g., key size and spacing, overlay size and number, key guard);

(vii) Device output modes (e.g., speech synthesis, printed output, character display, auditory and visual prompting, auditory and visual feedback); and

(viii) Portability;

(j) A description of a comprehensive treatment plan that includes a training schedule for the selected SGD; and

(k) The signature and license number of the SLP and any other member of the evaluation team.

(4) Payment will not be made for a SGD until the individual has used the device for a period of at least four weeks, during which the prescriber determines that the device satisfactorily meets the individual's needs. If the device does not meet the individual's needs, then the provider may choose to submit a request for payment of one month's rental.

(5) The department will consider coverage of SGDs in any of several forms, including but not limited to the following examples:

(a) A standalone unit running dedicated, proprietary software;

(b) Commercially available software and, if necessary, hardware to run it (e.g., a portable or tablet computer);

(d) A combination of components that provides functionality for the user.

(6) Separate payment may be made for the following items and services:

(a) A face-to-face evaluation performed by a SLP;

(b) Brackets and mounting hardware; and

(c) An adaptive interface or other accessory if the evaluating SLP provides documentation that the item is necessary for the independent use of a SGD by a particular individual.

(7) Payment for the upgrade, modification, or replacement of a fully functional SGD during its useful life may be made only if the SGD no longer meets the individual's basic communication needs.

(a) Replacement during the useful life of a SGD will be considered only when it is more cost-effective than modification.

(b) Repair does not extend the useful life of a SGD.

(B) Constraints and limitations.

(1) Payment may be made only for the type of SGD prescribed. Substitution (e.g., provision of a tablet instead of a standalone unit running proprietary software) requires the approval of the prescriber.

(2) Payment for a SGD includes the following items and services:

(a) Supplies, equipment (e.g., interface, printer, cables, adapters, connectors), and any standard component or requested accessory that is dispensed with a SGD; and

(b) All professional, technical, and administrative services performed by the provider in relation to a SGD.

(3) No separate payment will be made for any of the following items:

(a) A second SGD used concurrently by an individual;

(b) Additional software, applications, accessories, components, peripheral devices, or pieces of hardware that are not related to the main purpose of the SGD;

(c) Purchase, rental, lease, subscription, or maintenance associated with a cellular phone, even if the cellular phone has the capability to perform SGD functions; or

(d) Features that may be added on to some models of SGD but have been integrated into the particular SGD under consideration.

(1) The payment amount for a portable/tablet computer with software, for portable/tablet computer software, or for an accessory (e.g., mounting bracket, adaptive interface) is determined through the prior authorization (PA) process.

(2) Payment for a face-to-face evaluation is the lesser of the submitted charge or the amount listed in appendix DD to rule 5160-1-60 of the Administrative Code.

Last updated January 2, 2024 at 8:59 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-25 DMEPOS: lactation pumps.

(A) Definitions and explanations.

(1) "Multiple-user lactation pump" is a lactation pump that is safe for sequential use by multiple individuals. (The term "hospital-grade," which is often applied to such a pump, is not recognized by the United States food and drug administration.) A multiple-user lactation pump comes with a separate set of accessories (e.g., breast shields, tubing) for each individual, which reduces the risk of contamination. It generally features adjustable suction pressure and adjustable pumping speed. It is intended only for temporary, short-term use.

(2) The prescriber of a lactation pump may be involved in the care of the individual woman, of the infant, or of both.

(B) Coverage.

(1) Payment may be made for either or both of the following purposes:

(a) Purchase of a single-user manual or electric lactation pump as a medical supply item and purchase of any necessary replacement supplies; or

(b) Rental of a multiple-user lactation pump.

(2) For a single-user manual or electric lactation pump, a prescription is sufficient. No separate certificate of medical necessity (CMN) is needed.

(3) For a multiple-user lactation pump, the default CMN form is the ODM 01901, "Certificate of Medical Necessity: Multiple-User Lactation Pumps" (rev. 1/2022).

(a) On the CMN, the prescriber explains and attests to the medical necessity of the pump.

(b) On the CMN, the prescriber specifies the expected number of ninety-day rental periods. If additional rental periods are needed, the prescriber may either revise the existing CMN or complete a new CMN.

(1) The warranty period for a covered single-user manual or electric lactation pump is one year from the date of delivery.

(2) When a manual lactation pump is supplied as part of a pump accessory kit, separate payment will not be made for the manual lactation pump, nor will separate payment be made for an additional manual lactation pump.

(3) Payment for the rental of a multiple-user lactation pump includes all accessories, supplies, and cleaning.

(4) ODM is not responsible for failure to return a multiple-user lactation pump in working order.

Last updated January 3, 2022 at 9:50 AM

History

Effective: January 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-26 DMEPOS: nutrition products.

(A) Coverage.

(1) Enteral and parenteral nutrition.

(a) The default certificate of medical necessity (CMN) form is the ODM 01907, "Certificate of Medical Necessity: Enteral and Parenteral Nutrition" (rev. 7/2024). The CMN includes the following information:

(i) Attestation to one of the following statements:

(a) The individual is able to ingest food but cannot derive sufficient energy and nutrients from ordinary food, even if the food is prepared in a liquefied, puréed, or blended form;

(b) The individual is unable to ingest food safely but can digest it; or

(ii) For an individual who has difficulty in maintaining weight, a current weight history; and

(iii) For an individual who needs a daily intake of more than two thousand calories, an explanation of the need.

(b) A new prescription is needed for a change in the type or increase in the quantity of an item.

(c) Substitutions are permitted, so long as the substituted product is correctly formulated to meet the needs of the individual and the prescriber is notified before the supplier dispenses the product.

(d) Payment will not be made for quantities that exceed one month's supply.

(e) Suppliers may dispense items up to one week before the scheduled dispensing date.

(f) Payment includes dispensing and either shipping or delivery.

(2) Provision of donor human milk.

(a) Payment can be made only to a medicaid-enrolled provider that is a member in good standing of the human milk banking association of North America.

(b) The provider keeps on file the following documents:

(i) An explanation by a prescriber of the medical necessity of human milk for the recipient;

(ii) An attestation that the prescriber has given the recipient's parent or guardian information about human milk (e.g., nutrients, growth factors, shelf life, the effects of pasteurization, the possibility of disease transmission) and the donation process (e.g., donor screening, pasteurization, storage, transport), which may be in the form of educational material obtained from the provider; and

(iii) A consent form, signed and dated by the recipient's parent or guardian, indicating that the parent or guardian has been made aware of the benefits and risks of using banked donor human milk.

(c) Payment to a provider for supplying donor human milk in a hospital setting is made in accordance with Chapter 5160-2 of the Administrative Code.

(d) For donor human milk supplied in a non-hospital setting, payment includes processing, additives, and either shipping or delivery; no payment is made for the milk itself.

(B) Constraints and limitations. Separate payment will not be made for the following items as medical supplies:

(1) Ordinary prepared food;

(2) Commercial products that serve as ordinary food (e.g., shakes, smoothies, energy bars, vitamin or mineral supplements, baby food);

(3) Food products to be eaten as part of a diet related to diabetes, obesity, gastric bypass, or bariatric surgery;

(4) Food products for which a provider receives medicaid per diem payment; and

(5) Standard infant formula (not used to treat errors of metabolism) for which payment may be made through a program other than medicaid.

Last updated July 2, 2024 at 10:45 AM

History

Effective: July 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-27 DMEPOS: continuous passive motion (CPM) devices.

(A) Coverage.

(1) No particular form or format is specified for the certification of medical necessity.

(2) Payment may be made for the rental of a continuous passive motion (CPM) device to be used in a personal residence, beginning within forty-eight hours after total knee replacement surgery or the surgical revision of a total knee replacement, for a period not to exceed twenty-one days. On the prescription for the device, the first date and last date of use are indicated.

(3) Separate payment may be made for the purchase of one complete set of accessories (e.g., pads, straps, hook-and-loop closures) if the individual does not already have such accessories as a result of previous use of a CPM device.

(B) Constraints and limitations. No payment is made for a CPM device in any of the following circumstances:

(1) The device is used on a joint other than the knee;

(2) The device is used as a substitute for conventional physical therapy; or

(3) Neither the individual nor anyone assisting the individual is able to operate the device or is willing to follow the necessary post-surgery rehabilitation regimen.

Last updated January 2, 2024 at 8:59 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-28 DMEPOS: osteogenesis stimulators.

(A) Coverage.

(1) Payment may be made for the purchase only of a noninvasive osteogenesis stimulator.

(2) The default certificate of medical necessity (CMN) form is the ODM 07134, "Certificate of Medical Necessity: Osteogenesis Stimulators" (rev. 7/2024). The CMN includes an attestation that appropriate coverage criteria are met.

(3) Payment may be made for a spinal electrical osteogenesis stimulator only if at least one of the following criteria is met:

(a) The individual has undergone multilevel spinal fusion surgery;

(b) The individual has undergone spinal fusion surgery that has failed, and at least nine months have elapsed since the most recent operation; or

(c) The individual has undergone spinal fusion surgery, and previous attempts at spinal fusion at the same site have failed.

(4) Payment may be made for a non-spinal electrical osteogenesis stimulator only if at least one of the following criteria is met:

(a) The fracture is in a long bone and has failed to unite for at least three months, which the provider substantiates with the following documentation:

(i) At least two sets of images including multiple views of the fracture site, the first and last of which were taken at least ninety days apart; and

(ii) A written statement by a qualified interpreting practitioner that there has been no clinically significant evidence of fracture healing during the period when the images were taken.

(b) The individual has congenital pseudarthrosis; or

(c) The individual has undergone joint fusion surgery that has failed, and at least nine months have elapsed since the most recent operation.

(5) Payment may be made for an ultrasonic osteogenesis stimulator only if all of the following criteria are met:

(a) The fracture is in a bone other than the skull or a vertebra;

(b) The fracture is not tumor-related; and

(c) The fracture has failed to unite for at least three months, which the provider substantiates with the following documentation:

(i) At least two sets of images including multiple views of the fracture site, the first and last of which were taken at least ninety days apart; and

(ii) A written statement by a qualified interpreting practitioner that there has been no clinically significant evidence of fracture healing during the period when the images were taken.

(6) Payment may be made for either an electrical or an ultrasonic osteogenesis stimulator for an individual who is younger than twenty-one years of age only if all of the following additional criteria are also met:

(a) There is radiological documentation that skeletal maturity has been attained;

(b) The fracture gap is not greater than one half of the diameter of the bone to be treated; and

(B) Constraints and limitations.

(1) Possible contraindications to treatment include but are not limited to the following non-exhaustive list of examples:

(a) Fracture of a short bone, a flat bone, or an epiphysis;

(b) Fracture that results from cancer;

(d) Fracture with post-reduction displacement of greater than fifty per cent;

(e) Fracture gap greater than one centimeter or greater than one half of the diameter of the bone;

(f) Avascularity, vascular insufficiency, or other vascular problems (e.g., thrombophlebitis);

(g) Severe osteoporosis;

(h) The taking of medication that may interfere with or alter bone metabolism and healing;

(i) Paget's disease, renal disease, or diabetes;

(j) Sensory paralysis; or

(k) Synovial pseudarthrosis.

(2) Payment will not knowingly be made for an electrical osteogenesis stimulator used in proximity to vital equipment, such as a pacemaker, that may be adversely affected by changes in electromagnetic fields.

(3) Separate payment will not be made for the concurrent use of more than one osteogenesis stimulator on the same fracture site.

Last updated July 2, 2024 at 10:46 AM

History

Effective: July 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-29 DMEPOS: insulin pumps.

(A) Definitions.

(1) "Sensor-augmented insulin pump system" is an insulin infusion pump equipped with a continuous glucose monitoring (CGM) sensor. The pump uses the glucose readings taken by the CGM sensor to modify the amount of insulin infused.

(2) "Insulin pump," for purposes of this rule, is a collective term encompassing a portable external insulin infusion pump and a sensor-augmented insulin pump system.

(B) Coverage.

(1) Payment may be made for a portable external insulin infusion pump on a rental/purchase basis. The initial rental period is limited to three months.

(2) The default certificate of medical necessity (CMN) form is the ODM 07136, "Certificate of Medical Necessity: Insulin Pumps" (rev. 7/2021). The CMN includes an attestation that appropriate documentation is kept in the individual's medical record to demonstrate that the following criteria are met:

(a) The individual has type 1 or insulin-dependent type 2 diabetes mellitus;

(b) The individual has at least one of the following symptoms or conditions:

(i) Glycated hemoglobin level (HbA1c) greater than seven per cent;

(ii) A history of recurring hypoglycemia;

(iii) Wide fluctuations in blood glucose before mealtime;

(iv) A marked early-morning increase in fasting blood sugar (the "dawn phenomenon"), in which the glucose level frequently exceeds two hundred milligrams per deciliter; or

(v) A history of severe glycemic excursions;

(d) The individual has been on a maintenance program for at least six months involving at least three injections of insulin per day and frequent self-adjustments of insulin dosage;

(e) The individual has performed glucose self-testing at least four times per day on average during the preceding month; and

(f) The individual is at high risk for preventable complications of diabetes, early signs of which include micro-albuminuria and persistent difficulty in controlling blood sugar levels despite good compliance with an intensive multiple-injection regimen.

(3) After the first three months, payment may be made for the purchase of an insulin pump. During the initial rental period, the provider obtains a revised copy of the previously completed CMN, on which the prescriber attests that the individual (or someone assisting the individual) is capable of managing the pump and that the desired improvement in metabolic control can be achieved.

(1) The use of an insulin pump is contraindicated by either of the following conditions or circumstances:

(a) The individual has end-stage complications such as renal failure; or

(b) Neither the individual nor anyone assisting the individual is able to operate a pump or to perform frequent blood glucose monitoring.

(2) The following insulin-delivery devices are not covered:

(a) A portable external insulin infusion pump that is requested purely as a matter of convenience or individual preference;

(b) Surgically implanted infusion devices or systems;

(d) Devices associated with chronic intermittent intravenous insulin therapy (CIIIT), or

(e) Devices associated with pulsatile intravenous insulin therapy (PIVIT).

(3) The warranty period for a covered insulin pump is at least one year from the date of purchase authorization.

(4) No payment can be made for the purchase of an insulin pump that has been previously used by another individual.

Last updated May 8, 2026 at 12:24 PM

History

Effective: July 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-30 DMEPOS: ambulation aids.

(A) Definitions.

(1) "Ambulation aid" is a collective term for a cane, crutch, or walker.

(2) "Ambulatory limitation" is an impediment to walking that has either of two effects:

(a) It prevents an individual from completing activities of daily living within a reasonable time (or at all); or

(b) It places an individual at a demonstrably higher risk of injury, exacerbation of illness, or death when activities of daily living are performed.

(B) Coverage.

(1) No particular form or format is specified for the certification of medical necessity.

(2) Payment may be made for a covered ambulation aid if all of the following criteria are met:

(a) The individual has an ambulatory limitation that is documented in the individual's medical record;

(b) The ambulation aid has been prescribed by a qualified practitioner;

(d) The ambulation aid reduces the ambulatory limitation enough to permit the individual to complete activities of daily living in a reasonable amount of time and with a reasonable degree of safety.

(3) Additional coverage criteria are specific to particular ambulation aids:

(a) For a heavy-duty walker, the individual weighs at least three hundred pounds.

(b) For a heavy-duty walker with multiple braking system and variable wheel resistance (a four-wheeled walker having at least two wheels with hand-operated brakes that can be independently adjusted and lock the wheels when either or both hand levers are released), the individual both weighs at least three hundred pounds and is unable to use a standard heavy-duty walker because the use of one hand is restricted.

(c) For an enclosed-frame walker, the prescriber describes and attests in writing to the medical necessity, and the provider keeps a copy of this document in the individual's file.

(d) For a trunk-support walker, the prescriber describes and attests in writing to the medical necessity, and the provider keeps a copy of this document in the individual's file.

(e) For walker leg extensions, the individual stands at least six feet tall.

(f) For a white cane that is to be used as a mobility aid, the provider maintains documentation that the individual cannot obtain an equivalent cane free of charge (e.g., from a source such as the "Free White Cane Program" administered by the national federation of the blind, http://nfb.org).

Last updated January 2, 2024 at 8:59 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-31 DMEPOS: footwear and foot orthoses.

(A) Orthopedic shoes.

(1) No particular form or format is specified for the certification of medical necessity.

(2) Payment may be made for an orthopedic shoe only if at least one of the following conditions is met:

(a) The shoe is an integral part of an orthotic device (brace);

(b) The shoe has been molded specifically for the individual;

(d) The shoe is used to treat talipes equino varus (club foot);

(e) For an individual younger than eight years of age, the shoe is used independently of an orthotic device for one of the following purposes:

(i) Treatment of metatarsus adductus, femoral torsion, tibial torsion, vertical talus, fracture of a major bone, or osteochondrosis; or

(ii) Post-surgical control;

(f) For an individual eight years of age or older, the shoe is used for treatment of moderate or severe peripheral neuropathy or peripheral arterial disease; or

(g) A modification or addition to the shoe is medically necessary and has been prescribed by a physician, an advanced practice registered nurse, or a physician assistant.

(3) Greater frequency of shoe replacement may be allowed for individuals younger than eight years of age. Payment for shoe replacement beyond an established frequency for individuals younger than twenty-one years of age is subject to prior authorization (PA).

(4) No payment is made for an orthopedic shoe that is to be worn over a prosthesis.

(5) Payment for a foot orthosis includes the acquisition (by casting or other means) of the model on which the orthosis is constructed.

(B) Specialized non-orthopedic shoes. Payment may be made for a specially constructed non-orthopedic shoe for an individual younger than twenty-one years of age only if both of the following conditions are met:

(1) The shoe is to be worn over an orthotic device; and

(2) Commercially available shoes that fit over the orthotic device would be unacceptably long or otherwise ill-suited to ambulation.

(1) The default certificate of medical necessity (CMN) form is the ODM 01912, "Certificate of Medical Necessity: Therapeutic Footwear for Individuals with Diabetes" (rev. 7/2018). The CMN includes an attestation that all of the following statements are true:

(a) The individual has diabetes mellitus;

(b) The conditions of coverage are met;

(d) Therapeutic footwear is medically necessary for the individual because of diabetes; and

(e) All relevant information is documented in the individual's medical record.

(2) Therapeutic footwear may be prescribed only by a podiatrist, pedorthist, orthotist, prosthetist, or other qualified practitioner who manages the individual's diabetes.

(3) Therapeutic footwear may be fitted and dispensed only by a podiatrist, pedorthist, orthotist, or prosthetist.

(4) Payment may be made for therapeutic footwear (shoes, inserts, or shoe modifications) only if the individual has diabetes mellitus and at least one of the following conditions is met:

(a) Either an entire foot or part of either foot has been amputated; or

(b) In either foot, the individual has a history of ulceration, pre-ulcerative calluses, peripheral neuropathy with evidence of callus formation, foot deformity, or poor circulation.

(5) Payment may be made for a custom-molded shoe only if the individual has a foot deformity that cannot be accommodated by a depth shoe. The nature and severity of the deformity is to be well documented in the provider's records. If there is insufficient evidence of need for a custom-molded shoe, then payment will be limited to the cost of the least expensive medically appropriate alternative.

(6) No payment is made for the following items:

(a) Inserts that are compression-molded to the foot over time by the heat and pressure of being worn inside a shoe;

(b) Inserts used in noncovered shoes; and

(7) Payment for a therapeutic shoe includes fitting, necessary inserts, and any necessary modification. Separate payment may be made for inserts if the provider confirms in writing that the individual has appropriate footwear meeting the industry definition of a depth or custom-molded shoe, into which the insert can be placed.

Last updated January 2, 2024 at 8:59 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-32 DMEPOS: ostomy supplies and urological supplies.

(A) No particular form or format is specified for the certification of medical necessity.

(B) Stoma maintenance supplies. If more than one type of supply serve the same function, then payment may be made only for the dispensing of one type at a time (e.g., skin barrier applied as a liquid, in a spray, or with a wipe or swab; drainage management with a stoma cap, a stoma plug, or gauze pads).

(1) Indwelling catheters.

(a) Frequency limits imposed on catheter replacement may be exceeded without prior authorization (PA) for reasons including but not limited to the following examples:

(i) Accidental removal of a catheter;

(ii) Malfunction of a catheter;

(iii) Obstruction of a catheter by encrustation, mucus plug, or blood clot; or

(iv) A history of recurrent obstruction or infection, as a precaution against which the prescriber has specified more frequent changing of the catheter.

(b) Additional documentation of medical necessity is needed for either of the following items:

(i) A specialty indwelling catheter or all-silicone catheter used in lieu of a standard coated Foley catheter; or

(ii) A three-way indwelling catheter used either alone or with other components.

(2) Supplies for intermittent irrigation of indwelling catheters.

(a) Payment may be made for either an irrigation tray or an irrigation syringe used on an as-needed basis to clear an obstruction from an indwelling catheter by irrigation.

(b) Payment may be made for sterile water or saline solution for irrigation. No additional payment is made if the irrigation solution contains acetic acid or hydrogen peroxide. No payment is made for an irrigation solution containing antibiotics or chemotherapeutic agents.

(c) No payment is made for supplies used for the irrigation of an indwelling catheter at predetermined intervals (routine irrigation).

(3) Supplies for continuous irrigation of indwelling catheters.

(a) Payment may be made for an irrigation tubing set, as well as for a three-way Foley catheter, if there is a history of catheter obstruction and catheter patency cannot be maintained by intermittent irrigation and necessary changing of the catheter.

(d) Additional documentation is needed to establish the medical necessity of continuous irrigation used instead of intermittent irrigation. This documentation is to indicate the rate of administration and the duration of need.

(e) Additional documentation is needed to establish the medical necessity of continuous irrigation lasting more than two weeks.

(4) Intermittent catheters and related supplies.

(a) Payment may be made for a sterile intermittent catheter and related supplies (or a catheter kit) rather than a clean intermittent catheter and related supplies if sterile catheterization is medically necessary. Sterile intermittent catheterization is presumed to be medically necessary if the individual experiences any of the following conditions:

(i) Immunosuppression, without regard to cause;

(ii) Both neurogenic bladder dysfunction and pregnancy;

(iii) Documented vesicoureteral reflux; or

(iv) At least two distinct urinary tract infections within the preceding year.

(b) Additional documentation is needed to establish the medical necessity of a coudé catheter used instead of a straight catheter. The use of a coudé catheter by a female is rarely necessary.

(5) External urinary collection devices.

(a) Payment may be made for a medically necessary external urinary collection device (e.g., a condom-style catheter for a male, a meatal cup or a pouch for a female) as an alternative to an indwelling catheter for an individual who has permanent urinary incontinence.

(b) Payment will not be made for the concurrent dispensing of both an external urinary collection device and an indwelling catheter.

(c) Additional documentation is needed to establish the medical necessity of a specialty external urinary collection device (e.g., an inflatable condom-style catheter, a pouch with a faceplate).

(6) Urinary drainage systems.

(a) Payment may be made for the routine changing of a urinary drainage system.

(b) Payment will not be made for the concurrent dispensing of a vinyl and a latex bag.

(7) Miscellaneous supplies.

(a) Payment may be made for cleaner for a urinary collection device or drainage system only if the individual is using the collection device or drainage system.

(b) Payment may be made for a medically necessary adhesive anchoring device used to secure an indwelling urethral catheter, a suprapubic catheter, or a nephrostomy tube.

Last updated January 2, 2024 at 9:00 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-34 DMEPOS: wound dressings and related supplies.

(A) Coverage.

(1) No particular form or format is specified for the certification of medical necessity.

(2) Payment may be made for wound dressings and related supplies as long as medical necessity exists.

(3) Payment may be made for dressings placed over a percutaneous catheter or tube as long as the catheter or tube remains in place and after removal until the insertion point heals.

(4) Clinical indications, contraindications, and application guidelines for certain types of wound dressing are summarized in the appendix to this rule.

(B) Documentation.

(1) A prescription for a wound dressing or related supply is necessarily based on an evaluation of the wound performed by a qualified healthcare provider. Frequent evaluation is expected if a wound is heavily draining or infected. Each evaluation report, which will be made available to the department on request, includes the wound type; wound location; wound length, width, and depth; the amount of drainage; and any other relevant clinical information.

(2) The provider keeps the prescription for dressings or related supplies on file. The prescription includes the following clinical information, which can be no older than one year:

(a) The type and number of wounds;

(b) The type, size, and quantity of each dressing;

(c) The purpose of each dressing (e.g., primary or secondary covering for a surgical or debrided wound, wound cleansing);

(d) The quantity to be applied at one time (if more than one unit);

(e) The frequency of dressing change; and

(f) The expected duration of need.

(3) A prescription is valid for not longer than three months. A new prescription is needed for the addition of a dressing or for an increase in the quantity of a dressing already prescribed. (No new prescription is needed for a decrease in quantity.)

(1) Providers should not dispense dressings that will be used together but have conflicting characteristics (e.g., a hydrating dressing with an absorptive dressing, a primary dressing that must be changed daily with a secondary dressing that needs to be changed less frequently).

(2) The use of more than one type of wound filler or more than one type of wound cover on a single wound is rarely medically necessary. (An additional, dry wound cover is not incompatible, however, with an alginate or other fiber-gelling dressing or saline-, water-, or hydrogel-impregnated gauze.)

(3) Providers should gauge the quantity of dressings actually being used by an individual and adjust the dispensing of dressings accordingly. Not more than one month's supply of dressings may be dispensed at one time.

(4) No payment is made for gauze impregnated with water or normal saline, because there is no medical necessity for it. Standard gauze may instead be moistened with bulk saline or sterile water.

View Appendix

Last updated January 2, 2024 at 9:00 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-35 DMEPOS: cranial remolding devices.

(A) No particular form or format is specified for the certification of medical necessity.

(B) Payment may be made only for a cranial remolding device that meets the standards established by the United States food and drug administration for a class II medical device.

(C) Payment may be made for the purchase of a cranial remolding device to treat any of the following conditions if the associated criteria are met.

(1) Positional (non-synostotic) plagiocephaly:

(a) The individual is at least three months old but not older than eighteen months;

(b) Any of the following asymmetries is present:

(i) A right/left discrepancy in the skull base of at least six millimeters, measured subnasally to the tragus;

(ii) A right/left discrepancy in the cranial vault of at least ten millimeters, measured from the frontozygomaticus point to the euryon; or

(iii) A right/left discrepancy in the orbitotragial distances of at least four millimeters; and

(c) The asymmetry has not substantially improved after two months of conservative cranial repositioning therapy or physical therapy.

(2) Positional (non-synostotic) braciocephaly: The cephalic index (the ratio of the maximum width of the head to its maximum length) is greater than ninety-one per cent.

(3) Positional (non-synostotic) scaphocephaly: The cephalic index is less than seventy-five per cent.

(4) Synostotic deformity:

(a) The individual is not older than eighteen months;

(b) Premature closing of the cranial structures has been documented; and

Last updated January 2, 2024 at 9:00 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-36 DMEPOS: continuous glucose monitors.

(A) Definition. "Continuous glucose monitor (CGM)" is a device that can constantly measure glucose levels in interstitial body fluid. The sensor, transmitter, and receiver may be separate parts or may be combined. The receiver may have the capacity to record data.

(B) Coverage.

(1) This rule does not apply to either of the following items:

(a) An insulin infusion pump into which a continuous glucose monitoring sensor is integrated, coverage and payment policies for which are addressed in rule 5160-10-29 of the Administrative Code; or

(b) A disposable tubeless subcutaneous insulin administration device, which is covered as a pharmacy benefit in accordance with Chapter 5160-9 of the Administrative Code.

(2) Payment may be made for the purchase of a CGM and for the periodic purchase of replaceable CGM components.

(3) The default certificate of medical necessity (CMN) form is the ODM 10277, "Certificate of Medical Necessity: Continuous Glucose Monitors" (10/2022). The CMN includes the following information, for which appropriate documentation is kept in the individual's medical record.

(a) A condition for which continuous glucose monitoring is indicated for the individual, such as diabetes mellitus or hypoglycemia;

(b) The intended length of monitoring, either short-term (from three to seven consecutive days, once or twice a year) or long-term; and

(c) A brief explanation of why the use of a CGM is indicated, including contributing conditions and symptoms such as are specified in the following non-exhaustive list:

(i) Unexplained hypoglycemic episodes (generally, excessively low blood glucose levels despite appropriate modifications in insulin therapy);

(ii) HbA1c level consistently outside the target range for the individual;

(iii) Hypoglycemic unawareness (the inability to recognize hypoglycemic events consistently and reliably), evidenced in extreme cases by seizures or loss of consciousness;

(iv) The presence of microvascular complication (e.g., vasculopathy, retinopathy);

(v) A treatment regimen that necessitates either of the following activities:

(a) Frequent adjustments to insulin dosage throughout the day; or

(b) Insulin pump therapy;

(vi) A coexistent condition (e.g., uncontrolled epilepsy) that may make hypoglycemia management difficult;

(vii) Evidence of fasting or postprandial hyperglycemia; or

(viii) Recurrent diabetic ketoacidosis.

(1) No payment will be made for a CGM if neither the individual nor anyone assisting the individual is able to operate it.

(2) Payment for a CGM includes related software.

(3) Even if a CGM has the capability to use a cellular phone as a receiver, no payment will be made for purchase, rental, lease, subscription, or maintenance associated with a cellular phone.

(4) The warranty period for a CGM receiver is at least one year from the dispensing date.

(5) No payment may be made for the purchase of a CGM that has been previously used by another individual.

(6) Replacement components are dispensed in units representing the quantity an individual is expected to use in one month. Before dispensing additional units, the provider makes contact, either verbally or in writing, with the individual (or the individual's authorized representative) to verify the current need. The provider keeps on file a summary of this contact. If the individual has one unit or less, the provider may dispense up to three units.

Last updated October 17, 2022 at 8:44 AM

History

Effective: October 15, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-10-38 DMEPOS: respiratory assist devices.

(A) Terminology.

(1) The following abbreviations are used in this rule:

(a) "AHI" stands for "apnea-hypopnea index."

(b) "CAHI" stands for "central apnea-central hypopnea index."

(d) "CSA" stands for "central sleep apnea."

(e) "FEV1" stands for "forced expiratory volume in one second."

(f) "FIO2" stands for "fractional concentration of oxygen delivered for inspiration."

(g) "FVC" stands for "forced vital capacity."

(h) "LPM" stands for "liters per minute."

(i) "OSA" stands for "obstructive sleep apnea."

(j) "PaCO2" stands for "partial pressure of carbon dioxide." The measurement can be expressed in millimeters of mercury (mm Hg).

(k) "PAPD" stands for "positive airway pressure device," "PAPD-W" stands for "positive airway pressure device with backup rate," and "PAPD-WO" stands for "positive airway pressure device without backup rate."

(l) "RAD" stands for "respiratory assist device," "RAD-W" stands for "respiratory assist device with backup rate," and "RAD-WO" stands for "respiratory assist device without backup rate."

(2) The policy provisions in this rule depend on the following definitions:

(a) Apnea is a breathing disorder characterized by the cessation of airflow for at least ten seconds. Hypopnea is a reduction in airflow of more than thirty per cent.

(i) OSA is the obstruction or collapse, either total or partial, of the airways during sleep.

(ii) CSA is an interruption of breathing caused by a brief lack of communication between the brain and the muscles that control breathing. CSA is characterized by the following symptoms:

(a) An AHI of five or greater with no evidence of diurnal or nocturnal hypoventilation;

(b) A CAHI of five or greater;

(d) The presence of at least one of the following symptoms:

(i) Sleepiness;

(ii) Difficulty initiating or maintaining sleep, frequent waking, or non-restorative sleep;

(iii) Shortness of breath on waking;

(iv) Snoring; or

(v) Witnessed episodes of apnea.

(b) CompSA is a form of CSA characterized by all of the following symptoms:

(i) After resolution of obstructive events, episodes of central apnea and central hypopnea make up more than half of all episodes of apnea and hypopnea;

(ii) When a PAPD-WO is used and episodes of obstructive apnea or hypopnea have been resolved, episodes of central apnea or hypopnea persist or emerge; and

(iii) The CAHI is five or greater.

(i) AHI is the mean number of episodes per hour of apnea or hypopnea, either obstructive or central, without the use of a PAPD or a RAD, reported by polysomnogram.

(ii) CAHI is the mean number of episodes per hour of central apnea and central hypopnea, reported by polysomnogram. For CSA, the CAHI is determined without the use of a PAPD; for CompSA, the CAHI is determined with the use of a PAPD after resolution of obstructive events.

(iii) Calculation of the AHI or CAHI is normally based on at least two hours of continuous recorded sleep. However, if the threshold number (e.g., ten recorded events in two hours) is reached before the allotted time has elapsed, sleep may be discontinued.

(d) Prescribed FIO2 is the oxygen concentration an individual normally breathes in the absence of testing.

(i) For an individual who normally uses supplemental oxygen, the prescribed FIO2 is the supplemental oxygen concentration, expressed in LPM.

(ii) For an individual who does not normally use supplemental oxygen, the prescribed FIO2 is the oxygen concentration in the surrounding air.

(B) Coverage.

(1) The default certificate of medical necessity (CMN) form is the ODM 01910, "Certificate of Medical Necessity: Respiratory Assist Devices." The CMN includes the following information:

(a) A diagnosis of a condition for which a RAD is an appropriate treatment, including but not limited to the disorders specified in the following list:

(i) Restrictive thoracic disorders (i.e., neuromuscular diseases or severe thoracic cage abnormalities);

(ii) Severe chronic obstructive pulmonary disease (COPD);

(iii) CSA or CompSA; or

(iv) Hypoventilation syndrome;

(b) The results of a respiratory study; and

(2) For treatment of the following conditions, payment for the indicated type of RAD may be made only if the associated criteria are met:

(a) Restrictive thoracic disorders, RAD:

(i) COPD does not contribute significantly to the individual's pulmonary limitation; and

(ii) One of the following conditions is met:

(a) Arterial blood gas PaCO2, tested while the individual is awake and breathing oxygen at the prescribed FIO2, is forty-five mm Hg or greater;

(b) Sleep oximetry demonstrates that oxygen saturation falls to eighty-eight per cent or less while the individual is breathing oxygen at the prescribed FIO2; or

(c) For a neuromuscular disease, either the maximal inspiratory pressure is less than sixty centimeters of water (cm H20) or the FVC is less than fifty per cent of the predicted volume.

(b) Severe COPD, RAD-WO:

(i) Arterial blood gas PaCO2, tested while the individual is awake and breathing oxygen at the prescribed FIO2, is fifty-two mm Hg or greater;

(ii) Sleep oximetry demonstrates that oxygen saturation falls to eighty-eight per cent or less while the individual is breathing oxygen at the greater of two LPM or the prescribed FIO2; or

(iii) Treatment with a continuous positive airway pressure (CPAP) device has been considered and ruled out, either by sleep testing or by evidence, documented in the medical record, that sleep apnea (OSA, CSA, or CompSA) is the predominant cause of oxygen desaturation.

(i) Arterial blood gas PaCO2, tested while the individual is awake and breathing oxygen at the prescribed FIO2, varies more than seven mm Hg from the reference measurement of fifty-two mm Hg; and

(ii) Oxygen saturation is eighty-eight per cent or less while the individual is using a RAD-WO and the AHI is less than five.

(d) Severe COPD, RAD-W, not sooner than sixty-one days after initial use of a RAD-WO:

(i) Arterial blood gas PaCO2, tested while the individual is awake and breathing oxygen at the prescribed FIO2, remains at fifty-two mm Hg or greater; and

(ii) Oxygen saturation is eighty-eight per cent or less while the individual, using a RAD-WO, is breathing oxygen at the greater of two LPM or the prescribed FIO2.

(e) Central sleep apnea or complex sleep apnea, RAD:

(i) CSA or CompSA has been diagnosed and documented; and

(ii) There is significant improvement of sleep-associated hypoventilation while the individual, using either a RAD-WO or RAD-W adjusted to the settings that will be prescribed for initial use at home, is breathing oxygen at the prescribed FIO2.

(f) Hypoventilation syndrome, RAD-WO:

(i) Arterial blood gas PaCO2, tested while the individual is awake and breathing oxygen at the prescribed FIO2, is forty-five mm Hg or greater;

(ii) The FEV1/FVC ratio is seventy per cent or greater; and

(iii) One of the following conditions is met:

(a) Arterial blood gas PaCO2, tested either while the individual is asleep or immediately upon waking, varies more than seven mm Hg from the reference measurement of forty-five mm Hg; or

(b) Oxygen saturation is eighty-eight per cent or less and the AHI is less than five.

(g) Hypoventilation syndrome, RAD-W:

(i) The individual is using a RAD-WO; and

(ii) The criteria for initial use of a RAD-WO are still met.

(3) When the FEV1/FVC ratio is less than seventy per cent, the criteria for COPD are applied to hypoventilation syndrome.

(4) A need for oxygen is established if a RAD is effective during a respiratory study only when supplemental oxygen is administered simultaneously. That need for oxygen is presumed to last as long as the need for the RAD, and no further respiratory study is necessary to confirm a continued need for oxygen.

(5) The provider of a RAD cannot perform the qualifying respiratory study.

Last updated August 4, 2025 at 7:40 AM

History

Effective: August 1, 2025
Promulgated Under: 119.03

Chapter 5160-11 Independent Laboratory and X-Ray Services

Ohio Adm.Code 5160-11-11 Laboratory services.

(A) Definitions and explanations that apply to this chapter of the Administrative Code.

(1) "Clinical consultation" is the formal evaluation by a physician or other qualified healthcare professional, performed on the written order of a treating practitioner, of test results that appear to be abnormal. Payment for the clinical consultation is based on the physician fee schedule relative value file published by the centers for medicare and medicaid services (CMS). (The procedure code used for clinical consultation is different and separate from the procedure code for the test whose results are being evaluated.)

(2) "Clinical pathology interpretation" is the interpretation, performed on the written order of a treating practitioner by another practitioner, of the results of any of a certain group of clinical diagnostic procedures that are distinguished by three shared traits:

(a) Separate payment may be made for interpretation;

(b) Payment for the clinical diagnostic procedures themselves is based on the clinical laboratory fee schedule published by CMS; and

(c) Payment for the clinical pathology interpretation is based on the physician fee schedule relative value file published by CMS. (The procedure code for the clinical pathology interpretation consists of a professional component modifier appended to the relevant clinical diagnostic procedure code.)

(3) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code.

(4) "Global procedure" or "total procedure" is a procedure, in its entirety, that comprises both a technical component (the part of a laboratory procedure that relies on the technical skill of a trained individual to secure a specimen and prepare it for analysis) and a professional component (the part of a laboratory procedure that relies on the professional skill or training of a physician or other qualified healthcare professional to analyze the results produced by the technical component and to provide a written report of findings).

(5) "Independent" means separate from an attending or consulting practitioner's office or group practice, an ambulatory surgery center, a hospital, or a nursing facility. A laboratory facility under the ownership and direction of an individual practitioner or group practice is considered to be independent if it is represented to other practitioners that both the owners and directors and the facility itself are available for the performance of procedures.

(6) "Routine procedure" is a procedure for which no separate payment is made for either of two reasons:

(a) It is very common and is performed only in connection with another procedure (e.g., the collection of a clean-catch urine sample or a throat swab); or

(b) It is included in a treatment protocol for which a composite payment amount has been established (e.g., a specific laboratory test performed for an individual receiving dialysis, the reading by automated glucose monitor of blood samples taken from nursing facility residents who have diabetes).

(7) For purposes of medicaid, most covered laboratory procedures fall into two main categories.

(a) For the performance of clinical diagnostic procedures, no highly specialized skill is needed (such as the knowledge and training of a physician or other qualified healthcare professional).

(i) Clinical diagnostic procedures have no separate professional and technical components.

(ii) Performance of these procedures is generally predicated on certification of the laboratory provider under the "Clinical Laboratory Improvement Amendments of 1988" (CLIA, Pub. L. No. 100-578, 42 U.S.C. 263a as in effect on January 1, 2021).

(iii) Payment for these procedures is based on the clinical laboratory fee schedule published by CMS.

(b) The performance of professional procedures relies on the skill and training of a physician or other qualified healthcare professional, usually a pathologist or a hematologist.

(i) Pathology procedures have both a professional component and a technical component. In most instances, these components are distinguished on claims by the inclusion of a modifier along with the procedure code. (The professional and technical components of a few procedures may be represented by separate procedure codes.) The professional component of a pathology procedure represents the professional services a practitioner renders in the performance of the procedure. It does not represent the simple reading of test results, which is included in the associated originating service (e.g., office visit or surgery).

(ii) Some procedures are exclusively professional in nature and have no technical component.

(iii) Only an eligible practitioner or an independent laboratory submitting claims on behalf of its eligible practitioners may receive payment for a professional procedure (or a professional component of a procedure).

(iv) Payment for pathology procedures and for other professional procedures or components of procedures is based on the physician fee schedule relative value file published by CMS. (There are a very few exclusively technical procedures for which payment is also based on the physician fee schedule relative value file.)

(B) Providers.

(1) Providers. An entity may enroll in medicaid as a laboratory provider only if the following conditions are satisfied:

(a) The entity holds appropriate certification under CLIA; and

(b) The laboratory procedures it performs are within its usual scope.

(2) A facility that only collects or prepares specimens or that functions only as a mailing service and does not perform testing is not considered to be a laboratory.

(1) Payment is made in accordance with Chapter 5160-2 of the Administrative Code for the following services, which in a hospital setting are treated not as laboratory services but rather as hospital services:

(a) A clinical diagnostic procedure performed for a hospital inpatient; and

(b) The technical component of a pathology procedure performed for a hospital inpatient.

(2) Payment can be made only for a laboratory service or procedure that, in accordance with Chapter 5160-1 of the Administrative Code, is medically necessary or is medically indicated when performed in conjunction with a covered preventive health service.

(3) A laboratory provider obtains and maintains appropriate documentation.

(a) A laboratory service may be rendered on the verbal order of a physician or other qualified healthcare professional. Unless an exception is stated in this rule, the laboratory provider may submit a claim only after it has obtained a written order. A written order may consist of an entry in a person's medical records (e.g., in an individual practitioner's office, a group practice, or a hospital). A written order includes the following information:

(i) The name of the medicaid-eligible individual;

(ii) Contact information for the practitioner ordering the service;

(iii) Specification of the service (e.g., procedure code, description, number of units);

(iv) At least one appropriate diagnosis code;

(v) The date of the order;

(vi) The names of the relevant persons or entities involved in providing the service (e.g., referring laboratory, reference laboratory, interpreting practitioner, radiographer); and

(vii) Any additional information necessary to ensure accurate and timely testing or reporting (e.g., for a Pap test, the beginning date of the individual's last menstrual period, the individual's age or date of birth, an indication of previous abnormal results and subsequent actions).

(b) A written order may be given in any industry-recognized format, such as handwriting, typed text, or electronic transmission.

(c) No separate written order is needed for a medically necessary follow-up procedure (e.g., a quantitative test performed in response to a positive qualitative test result) so long as the procedure is performed in accordance with appropriate standard practices and is included in the laboratory provider's written protocols. A written order is needed for any additional procedure that is based solely on a laboratory provider's internal protocols.

(d) A laboratory provider is to keep the following records for the period of time specified in rule 5160-1-17.2 of the Administrative Code:

(i) A copy of each written order for a procedure or service (clinical diagnostic procedure, pathology procedure, consultation, or interpretation);

(ii) A copy of any clinical diagnostic procedure result for which consultation or interpretation was ordered; and

(iii) A copy of any written narrative report prepared by the consulting or interpreting practitioner.

(4) Payment may be made to a physician or other qualified healthcare professional (such as a pathologist or a hematologist) for the following professional laboratory services:

(a) The professional component of a pathology procedure;

(b) A global pathology procedure that was performed in the practitioner's own full-service, in-office laboratory (certified for the performance of the technical component) on a specimen obtained from an individual who was not a hospital patient;

(d) The professional administration of a testing device, isotope, or other material.

(5) Specific coverage provisions apply to certain groups of services and procedures.

(a) Referred procedures.

(i) In general, payment for a clinical diagnostic procedure may be made only to the laboratory provider that actually performs the procedure. Payment may be made to a referring provider for a clinical diagnostic procedure performed by a reference laboratory only if all of the following conditions are satisfied:

(a) The reference laboratory has the appropriate CLIA certification to perform the procedure;

(b) One of the following two sets of criteria is met:

(i) Either the referring provider is a FQHC or RHC or the reference laboratory is a hospital, and the referring provider and the reference laboratory are related in one of three ways:

(A) The referring provider is wholly owned by the reference laboratory;

(B) The reference laboratory is wholly owned by the referring provider; or

(ii) The referring laboratory is a hospital that performs clinical diagnostic procedures, the procedure is performed for a hospital outpatient or hospital emergency department patient, and the referring laboratory provider and the reference laboratory provider have a written agreement that specifies which provider is exclusively permitted to submit claims to the department for clinical diagnostic procedures.

(c) At the request of the department, the referring provider discloses to the department in writing the following information and any changes made to it:

(i) The name, address, and CLIA number of the reference laboratory;

(ii) A delineation of the relationship between the referring provider and the reference laboratory; and

(iii) A list of all the clinical diagnostic procedures it routinely refers to the reference laboratory.

(ii) In the event that the department issues payment to both a referring provider and a reference laboratory for the same clinical diagnostic procedure, the expenditure subject to recovery is assumed to be the payment issued to the reference laboratory.

(b) Procedures bundled into a panel.

(i) Altered descriptions of a particular panel are not to be used in place of the official description established by a national authority such as the American medical association or the centers for medicare and medicaid services.

(ii) When a provider performs all of the constituent procedures of a covered panel (and all of the constituent procedures are medically necessary or medically indicated), the entire panel is reported on a claim rather than the separate constituent procedures.

(iii) When a provider performs some but not all of the constituent procedures of a panel, the separate constituent procedures are reported on a claim.

(iv) When a provider performs more procedures than are included in a panel, both the panel and the additional procedures are reported on a claim.

(i) Specimen collection performed in a nursing facility, skilled nursing facility, or intermediate care facility for individuals with intellectual disabilities is not a laboratory service.

(ii) Payment as laboratory services may be made only for the following specimen collection procedures:

(a) Collection of a blood specimen by venipuncture;

(b) Collection of a blood specimen by capillary puncture that has the same diagnostic value as a specimen collected by venipuncture;

(d) Collection of a blood specimen from an established central or peripheral venous catheter.

(iii) The collection of multiple specimens is considered to be a single procedure in either of the following circumstances:

(a) The specimens are collected in a single encounter from a single body site; or

(b) The specimens are needed for a single test (e.g., a glucose tolerance test).

(iv) Only the eligible provider that performs a specimen collection may receive payment for it.

(v) Payment for specimen collection includes costs for handling and shipping.

(vi) Payment for specimen collection is independent of payment for the laboratory procedure performed on the specimen.

(vii) No payment is made for the following specimen collection services:

(a) Collection of a blood specimen by capillary puncture when the collection is part of a test procedure (e.g., bleeding time);

(b) Collection of a specimen for a Papanicolaou test (Pap test, Pap smear) or of a tissue specimen for which there is no discrete procedure code; and

(d) Evocation/suppression testing.

(i) Only the laboratory provider performing the technical evocation/suppression test (the actual measurement of the chemical constituents) may receive payment for it.

(ii) Separate payment may be made to a physician or other qualified healthcare professional for identifiable evaluation and management services rendered on the same date of service as an evocation/suppression test. Such services include supervision and monitoring of the individual during testing, intermittent or continual attendance during the administration of the evocation/suppression agent, and interpretation of the test results in relation to the individual's condition.

(iii) Separate payment may be made in accordance with Chapter 5160-4 of the Administrative Code for an evocation/suppression testing agent administered to an individual who is not a hospital patient. Such payment includes costs for the agent itself and for administration of the agent, which may be intradermal, subcutaneous, intramuscular, intraarterial, or intravenous (injection by syringe, intravenous push injection, or intravenous infusion of short duration).

(iv) Separate payment may be made to a physician or other qualified healthcare professional for prolonged infusion services rendered for an individual who is not a hospital patient. Such payment includes costs for additional supplies used in the prolonged administration of the evocation/suppression testing agent.

(e) Neonatal diagnostic screening. Payment for neonatal diagnostic screening may be made to a physician laboratory provider, a professional medical group laboratory provider, a hospital laboratory provider, or a clinic laboratory provider if both of the following conditions are satisfied:

(i) The procedure was performed with a prefabricated laboratory kit purchased from the Ohio department of health (ODH) laboratory and used for screening a newborn infant for genetic, endocrine, or metabolic disorders listed in Chapter 3701-55 of the Administrative Code; and

(ii) The kit was used for an initial screening, a repeat screening, or a follow-up screening in accordance with Chapter 3701-55 of the Administrative Code.

(f) Urine drug screening.

(i) The performance of drug screening by urinalysis is subject to the following frequency limits, which may be exceeded with prior authorization:

(a) For presumptive screens, thirty dates of service per benefit year; and

(b) For definitive tests, twelve dates of service per benefit year.

(ii) Prior authorization is needed for a definitive drug test involving twenty-two or more drug classes on a single date of service.

(6) Non-covered laboratory services.

(a) No payment is made for the following services:

(i) Laboratory services exceeding the provisions set forth in this chapter for which no prior authorization has been given;

(ii) Routine laboratory or screening procedures;

(iii) Laboratory services for which a laboratory provider is not appropriately certified under CLIA;

(iv) Laboratory services rendered in conjunction with those non-covered services that are delineated in rule 5160-1-61 of the Administrative Code; and

(v) Laboratory services rendered for forensic investigation, autopsy, or paternity testing.

(b) Although certain provisions in Chapter 5160-1 of the Administrative Code allow an eligible provider to seek payment directly from a medicaid-eligible individual for services that are not covered by the medicaid program, no laboratory provider may seek payment for any laboratory service for which it lacks the necessary CLIA certification.

(D) Claim payment.

(1) When submitting a claim to the department, a laboratory provider is to use the code that describes the procedure in the most detail.

(a) Analytic procedures can be listed by analyte (the substance or material being measured), by method, by both analyte and method, or by specimen type (e.g., urine, blood). Many laboratory procedures, especially drug tests, have synonyms. Care therefore needs to be taken in the selection of the most appropriate procedure code.

(b) A "not otherwise specified," "miscellaneous," or "unlisted" procedure code in the appropriate area of specialty may be used only if no other code accurately corresponds to a procedure. For such a service, the laboratory provider submits a claim "by report" in accordance with rule 5160-1-60.4 of the Administrative Code and notes the analyte, the specimen type, and the method in the claim. The department may deny a claim that omits necessary information or that includes a "not otherwise specified," "miscellaneous," or "unlisted" procedure code when an appropriate procedure-specific code is available.

(2) When a laboratory provider uses the Ohio department of health (ODH) laboratory to perform a covered laboratory procedure for a medicaid-eligible individual, the laboratory provider prepares specimens and completes necessary paperwork in accordance with all applicable ODH rules and practices. The laboratory provider is exempt from paying the ODH laboratory for the service; instead, the department will pay the ODH laboratory. Claims for such procedures are not to be submitted to the department.

(3) For a covered laboratory service represented by a new healthcare common procedure coding system (HCPCS) procedure code, the initial maximum payment amount is established in accordance with rule 5160-1-60 of the Administrative Code.

(4) For any other covered laboratory service (global procedure, professional component, or technical component), the initial payment amount is the lesser of the submitted charge or the applicable medicaid maximum from the following list:

(a) For a service that is payable under the clinical laboratory fee schedule published by CMS, seventy-five per cent of the Ohio-specific medicare allowed amount for that service; or

(b) For a service that is payable under the medicare physician fee schedule, seventy-five per cent of the Ohio-specific medicare allowed amount for that service.

(5) If the medicare amount for a service becomes less than the current medicaid maximum payment amount, then the medicaid maximum payment amount for that service is reestablished on the basis of the new medicare amount:

(a) For a service that is payable under the clinical laboratory fee schedule published by CMS, it is seventy-five per cent of the Ohio-specific medicare allowed amount for that service; or

(b) For a service that is payable under the medicare physician fee schedule, it is seventy-five per cent of the Ohio-specific medicare allowed amount for that service.

(6) Both the medicare physician fee schedule and the clinical laboratory fee schedule are available from CMS, http://www.cms.gov.

(7) For convenience, a list of medicaid maximum payment amounts and additional claim-related information for clinical diagnostic procedures, molecular pathology procedures, and pathology procedures is available on the department's 'Fee Schedule and Rates' web page, which may be accessed through the department's main web page (http://medicaid.ohio.gov).

Last updated December 16, 2025 at 11:17 AM

History

Effective: January 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-11-21 Portable x-ray supplier services.

(A) Providers. An entity may enroll in medicaid as a portable x-ray supplier only if it complies with the conditions set forth in 42 C.F.R. part 486 subpart C (October 1, 2025).

(B) Coverage.

(1) The radiology procedures performed by a portable x-ray supplier have both a professional component and a technical component.

(a) In general, a portable x-ray supplier performs the technical component of a procedure.

(b) A portable x-ray supplier may receive payment for the technical component alone if it performs only the technical component and the professional component is performed by a physician or other qualified healthcare professional not associated with the portable x-ray supplier by ownership, employment, or contract (e.g., interpretation of an x-ray is performed by an individual's treating practitioner).

(c) A portable x-ray supplier may receive payment for a global procedure if it performs both the professional and the technical components and the professional component is performed by a physician or other qualified healthcare professional who owns, is employed by, or is under contract with the portable x-ray supplier.

(d) A portable x-ray supplier cannot receive payment for the professional component alone.

(2) For payment purposes, only the following radiology procedures are considered to be portable x-ray services:

(a) Skeletal imaging involving the extremities, pelvis, vertebral column, and skull;

(b) Chest imaging;

(d) Diagnostic mammography if the provider meets the conditions set forth in 21 C.F.R. part 900 subpart B (October 1, 2025).

(3) Provisions affecting payment for radiology services are set forth in rule 5160-4-25 of the Administrative Code.

(4) No payment is made for the following procedures when they are performed by a portable x-ray supplier:

(a) Procedures involving fluoroscopy;

(b) Procedures involving the use of a contrast medium;

(c) Procedures involving the administration of a substance to the individual, the injection of a substance into the individual, or special manipulation of the individual;

(d) Procedures involving special medical skill or knowledge possessed by a physician or other qualified healthcare professional or the exercise of medical judgment;

(e) Procedures involving special technical competency or special equipment or materials not ordinarily needed for radiography;

(f) Routine screening procedures; and

(g) Procedures that are not of a diagnostic nature.

(5) Payment is available for the one-way transportation of portable x-ray equipment to a medicaid-eligible individual's place of residence. For each visit, only one equipment transportation charge is allowed, regardless of the number of persons served.

(C) Claim payment. For a covered global radiology procedure and its professional and technical components and for covered transportation of portable x-ray equipment, the medicaid maximum payment amounts are indicated in appendix DD to rule 5160-1-60 of the Administrative Code.

Last updated March 9, 2026 at 11:02 AM

History

Effective: March 9, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-11-31 Independent diagnostic testing facility (IDTF) services.

(A) Providers.

(1) An entity may enroll in medicaid as an independent diagnostic testing facility (IDTF) only if it meets the following criteria:

(a) It meets all standards set forth in and provide services in accordance with 42 C.F.R. 410.33 (October 1, 2025);

(b) It takes the following measures to establish accountability:

(i) It ensures that each supervising practitioner attests in writing, at the time of the initial application and at each renewal of the Ohio medicaid provider agreement, that one of two statements is true:

(a) The practitioner owns the facility, in whole or in part, and employs the operating personnel; or

(b) The practitioner works for the facility either as an employee (full-time or part-time) or under contract and has responsibilities that include:

(i) Checking the procedure and quality control manuals;

(ii) Observing the performance of operators or technicians;

(iii) Verifying that the equipment and personnel meet applicable conditions for federal, state, and local licensure and registration; and

(iv) Ensuring that safe operating procedures and quality control procedures are used;

(ii) It maintains and updates procedure and quality control manuals; and

(iii) It keeps all records of quality control as specified in rule 5160-1-17.2 of the Administrative Code; and

(c) It performs only procedures that are not subject to the "Clinical Laboratory Improvement Amendments of 1988" (CLIA, Pub. L. No. 100-578, 42 U.S.C. 263a as in effect on January 1, 2021).

(2) An entity that owns both an IDTF and an independent laboratory should enroll them as discrete Ohio medicaid providers.

(3) An entity may enroll in medicaid as a mammography supplier (a facility or an entity established solely for the provision of mammography services) only if it meets the following criteria:

(a) It participates in medicaid as an IDTF; and

(b) It complies with the conditions set forth in 42 C.F.R. 410.34 (October 1, 2025).

(B) Coverage. Provisions affecting payment for radiology services are set forth in rule 5160-4-25 of the Administrative Code.

(1) No separate payment is made to an IDTF that performs a procedure in a hospital setting. Instead, the provider makes payment arrangements directly with the participating hospital.

(2) For a covered global radiology procedure and its professional and technical components, the medicaid maximum payment amounts are indicated in appendix DD to rule 5160-1-60 of the Administrative Code.

Last updated March 9, 2026 at 11:02 AM

History

Effective: March 9, 2026
Promulgated Under: 119.03

Chapter 5160-12 Ohio Medicaid State Plan Home Health and Nursing Services

Ohio Adm.Code 5160-12-01 Home health services: provision requirements, coverage and service specification.

(A) "Home health services" includes home health nursing, home health aide services and skilled therapies.

(B) Home health services are reimbursable only if a qualifying treating physician, advance practice nurse or physician assistant certifying the need for home health services documents that he or she had a face-to-face encounter with the individual within ninety days prior to the start of care date, or within thirty days following the start of care date. To be a qualifying treating physician, the physician will be a doctor of medicine or osteopathy legally authorized to practice medicine and surgery as authorized under Chapter 4731. of the Revised Code. Advanced practice registered nurses in accordance with rule 5160-4-04 of the Administrative Code or a physician assistant in accordance with rule 5160-4-03 of the Administrative Code have the authority to conduct the face-to-face encounter. The face-to-face encounter with the individual will occur independent of any provision of home health services to the individual. The face-to-face encounter may be completed using telehealth. The face-to-face encounter will be documented as follows:

(1) For home health services unrelated to an inpatient hospital stay, the face-to-face encounter will be documented by the qualifying treating physician, advance practice nurse or physician assistant using:

(a) The ODM 07137 "Certificate of Medical Necessity for Home Health Services and Private Duty Nursing Services" (rev. 2/2016) or

(b) The individual's plan of care if all of the data elements specified for home health services unrelated to an inpatient hospital stay on the ODM 07137 are included and the plan of care contains the signature, credentials and the date of the signature of the qualifying treating physician, advance practice nurse or physician assistant.

(2) For post hospital home health services, the face-to-face encounter will be documented by the clinician using the ODM 07137.

(3) For an individual dually eligible for medicare and medicaid, the face-to-face encounter will be documented by the treating clinician using the ODM 07137 if supporting documents are attached, or using the individual's plan of care pursuant to paragraph (B)(1)(b) of this rule when the face-to-face encounter date for medicare home health services falls within ninety days prior to the medicaid home health services start of care date, or within thirty days following the medicaid start of care date.

(1) No more than a combined total of eight hours per day of home health nursing, home health aide, and skilled therapies except as specified in paragraph (H) of this rule;

(2) No more than a combined total of fourteen hours per week of home health nursing and home health aide services except as specified in paragraphs (D) and (H) of this rule or as prior authorized by ODM or its designee; and

(3) Visits are not more than four hours. Nursing visits over four hours may qualify for coverage in accordance with rule 5160-12-02 of the Administrative Code.

(D) A combined total of twenty-eight hours per week of home health nursing and home health aide services is available to an individual for up to sixty consecutive days from the date of discharge from an inpatient hospital stay if all of the following are met as certified by the qualifying treating clinician using the ODM 07137:

(1) The individual is discharged from a covered inpatient hospital stay of three or more days, with the discharge date recorded on form ODM 07137. It is considered one inpatient hospital stay when an individual is transferred from one hospital to another hospital, either within the same building or to another location. The sixty days will begin once the individual is discharged to their place of residence or to a nursing facility from the last inpatient stay in an inpatient hospital or inpatient rehabilitation unit of a hospital.

(2) The individual has a comparable level of care as evidenced by either:

(a) Enrollment in a home and community based services (HCBS) waiver; or

(b) A medical condition that temporarily meets the criteria for an institutional level of care as described in rule 5160-3-08 of the Administrative Code or as defined in rule 5123:2-8-01 of the Administrative Code. In no instance does this requirement constitute the determination of a level of care for waiver eligibility status, or admission into a medicaid covered long term care institution.

(3) The individual requires home health nursing, or a combination of private duty nursing, home health nursing, or waiver nursing and/or skilled therapy services at least once per week and the services are medically necessary in accordance with rule 5160-1-01 of the Administrative Code.

(4) The individual has had a covered inpatient hospital stay of three or more days, with the discharge date recorded on form ODM 07137.

(E) Home health services may only be provided by a medicare certified home health agency (MCHHA) that meets the requirements in accordance with rule 5160-12-03 of the Administrative Code. In order for home health services to be covered, MCHHAs must:

(1) Provide home health services only if the clinician has documented a face-to-face encounter with the individual as specified in paragraph (B) of this rule.

(2) Provide home health services that are appropriate given the individual's diagnosis, prognosis, functional limitations and medical conditions as ordered by the individual's treating clinician for the treatment of the individual's condition, illness or injury.

(3) Provide home health services as specified in the individual's plan of care in accordance with rule 5160-12-03 of the Administrative Code. Home health services not specified in a plan of care are not reimbursable. Additionally the plan of care must provide the amount, scope, duration, and type of home health service as:

(a) Documented on the person-centered services plan as defined in rule 5160-45-01 of the Administrative Code that is prior approved by the Ohio department of medicaid (ODM) or designee when an individual is enrolled on an ODM administered HCBS waiver. Home health services that are not identified on the person-centered services plan are not reimbursable; or

(b) Documented on the services plan when an individual is enrolled on an Ohio department of aging (ODA) or Ohio department of developmental disabilities (DODD) administered HCBS waiver. Home health services that are not documented on the services plan are not reimbursable.

(4) Provide the home health services in any setting in which normal life activities take place, other than a hospital, nursing facility; intermediate care facility for individuals with intellectual disabilities; or any setting in which payment is or could be made under medicaid for inpatient services that include room and board.

(5) Not provide home health nursing and home health aide services for the provision of habilitative care, or respite care, and not provide skilled therapies for the provision of maintenance care, habilitative care or respite care.

(a) "Maintenance care" is the care given to an individual for the prevention of deteriorating or worsening medical conditions or the management of stabilized chronic diseases or conditions. Services are considered maintenance care if the individual is no longer making significant improvement in his or her medical condition.

(b) "Habilitative care" is the care provided to assist individuals in acquiring, retaining, and improving the self-help, socialization, and adaptive skills necessary to reside successfully in home and community based settings.

(c) "Respite care" is the care provided to an individual unable to care for himself or herself because of the absence or need for relief of those persons normally providing care.

(6) Bill for provided home health services in accordance with visit policy rule 5160-12-04 of the Administrative Code.

(7) Bill for provided home health services using the appropriate procedure code and applicable modifiers in accordance with rule 5160-12-05 of the Administrative Code.

(8) Bill after all documentation is completed for the services rendered during a visit in accordance with rule 5160-12-03 of the Administrative Code.

(F) Individuals who receive home health services will:

(1) Participate in a face-to-face encounter as specified in paragraph (B) of this rule for the purpose of certifying their medical need for home health services.

(2) Be under the supervision of a clinician who is providing care and treatment to the individual. The clinician will not be a clinician whose sole purpose is to sign and authorize plans of care or who does not have direct involvement in the care or treatment of the individual. A treating clinician may be a clinician who is substituting temporarily on behalf of a treating clinician.

(3) Participate in the development of a plan of care along with the treating clinician and the MCHHA.

(4) Access home health services in accordance with the program for the all-inclusive care of the elderly (PACE) when the individual participates in the PACE program.

(5) Access home health services in accordance with the individual's provider of hospice services when the individual has elected the hospice benefit.

(6) Access home health services in accordance with the individual's managed care plan when the individual is enrolled in a medicaid managed care plan.

(G) Covered home health services:

(1) "Home health nursing" is a nursing service that requires the skills of and is performed by a registered nurse, or a licensed practical nurse at the direction of a registered nurse. The nurse performing the home health service must possess a current, valid and unrestricted license with the Ohio board of nursing and must be employed or contracted by a MCHHA that has an active medicaid provider agreement. A service is not considered a nursing service merely because it is performed by a licensed nurse.

(a) Nursing tasks and activities that shall only be performed by an RN include, but are not limited to, the following:

(i) Intravenous (IV) insertion, removal or discontinuation;

(ii) IV medication administration;

(iii) Programming of a pump to deliver medications including, but not limited to, epidural, subcutaneous and IV (except routine doses of insulin through a programmed pump);

(iv) Insertion or initiation of infusion therapies;

(v) Central line dressing changes; and

(vi) Blood product administration.

(b) Home health nursing services performed by an RN and/or an LPN will be:

(i) Performed within the nurse's scope of practice as defined in Chapter 4723. of the Revised Code and rules adopted thereunder.

(ii) Provided and documented in accordance with the individual's plan of care in accordance with rule 5160-12-03 of the Administrative Code.

(iii) Provided during an in-person visit or using telehealth if clinically appropriate given the needs of the individual, the nature of the service, and the technology that is available.

(iv) Medically necessary in accordance with rule 5160-1-01 of the Administrative Code to care for the individual's illness or injury.

(i) A visit when the sole purpose is for the supervision of the home health aide.

(ii) RN assessment services as defined in rule 5160-12-08 of the Administrative Code.

(iii) RN consultation services as defined in rule 5160-12-08 of the Administrative Code.

(2) "Home health aide services" are services that use the skills of and are performed by a home health aide employed or contracted by the MCHHA providing the service. Home health aide services:

(a) Are performed within the home health aide's scope of practice as defined in 42 C.F.R. 484.36 (October 1, 2016). The home health aide cannot be the parent, step-parent, foster parent or legal guardian of an individual who is under eighteen years of age, or the individual's spouse.

(b) Are provided and documented in accordance with the individual's plan of care in accordance with rule 5160-12-03 of the Administrative Code.

(c) Are provided during an in-person visit or using telehealth if clinically appropriate given the needs of the individual, the nature of the service, and the technology that is available.

(d) Must be medically necessary in accordance with rule 5160-1-01 of the Administrative Code to care for the individual's illness or injury.

(e) Must be necessary to assist the nurse or therapist in the care of the individual's illness or injury, or help the individual maintain a certain level of health in order to remain in a home and community based setting.

(f) Include health related services including but not limited to:

(i) Bathing, dressing, grooming, hygiene, including shaving, skin care, foot care, ear care, hair, nail and oral care, that are needed to facilitate care or prevent deterioration of the individual's health, and including changing bed linens of an incontinent or immobile individual.

(ii) Feeding, assistance with elimination including administering enemas (unless the skills of a home health nurse are required), routine catheter care, routine colostomy care, assistance with ambulation, changing position in bed, and assistance with transfers.

(iii) Performing a selected nursing activity or task as delegated in accordance with Chapter 4723-13 of the Administrative Code, and performed as specified in the plan of care.

(iv) Assisting with activities such as routine maintenance exercises and passive range of motion as specified in the plan of care. These activities are directly supportive of skilled therapy services but do not require the skills of a therapist to be safely and effectively performed. The plan of care is developed by either a licensed therapist or a licensed registered nurse within their scope of practice.

(v) Performing routine care of prosthetic and orthotic devices.

(g) May include incidental services, as long as they do not substantially extend the time of the visit.

(i) Incidental services are necessary household tasks that must be performed by someone to maintain a home and can include light chores, laundry, light house cleaning, preparation of meals, and taking out the trash.

(ii) The main purpose of a home health aide visit cannot be solely to provide these incidental services since they are not health related services.

(iii) Incidental services are to be performed only for the individual and not for other people in the individual's place of residence.

(3) "Skilled therapies" is defined as physical therapy, occupational therapy, and speech-language pathology services that require the skills of and are performed by skilled therapy providers to meet the individual's medical needs, promote recovery, and ensure medical safety for the purpose of rehabilitation.

(a) "Skilled therapy providers" are licensed physical therapists, occupational therapists, speech-language pathologists, licensed physical therapy assistants (LPTA) under the direction of a physical therapist, or certified occupational therapy assistants (COTA) under the direction of a licensed occupational therapist who are contracted or employed by a MCHHA.

(b) "Rehabilitation" is the care of an individual with the intent of curing the individual's disease or improving the individual's condition by the treatment of the individual's illness or injury, or the restoration of a function affected by illness or injury.

(i) Must be provided to the individual within the therapist's or therapy assistant's scope of practice in accordance with sections 4755.44, 4755.07, and 4753.07 of the Revised Code.

(ii) Must be medically necessary in accordance with rule 5160-1-01 of the Administrative Code to care for the individual's illness or injury.

(iii) Must be provided and documented in the individual's plan of care in accordance with rule 5160-12-03 of the Administrative Code.

(iv) Must be reasonable in their amount, frequency, and duration. Treatment must be considered to be safe and effective treatment for the individual's condition according to the accepted standards of medical practice.

(v) Are provided with the expectation of the individual's rehabilitation potential according to the treating clinician's prognosis of illness or injury. The expectation of the individual's rehabilitation potential is that the condition of the individual will measurably improve within a reasonable period of time or the services are necessary to the establishment of a safe and effective maintenance program.

(vi) May include treatments, assessments and/or therapeutic exercises but cannot include activities that are for the general welfare of the individual, including motivational or general activities for the overall fitness of the individual.

(vii) Are provided during an in person visit or using telehealth if clinically appropriate given the needs of the individual, the nature of the service, and the technology that is available.

(H) An individual who meets the requirements in this paragraph may qualify for increased home health services. The MCHHA must assure and document that the individual meets all requirements in this paragraph prior to increasing services. The U5 modifier must be used when billing in accordance to rule 5160-12-05 of the Administrative Code. The use of the U5 modifier indicates that all conditions of this paragraph were met. The individual who meets the following requirements may receive an increase of home health services if he or she:

(1) Is under age twenty-one and requires services for treatment in accordance with Chapter 5160-14 of the Administrative Code for the healthchek program.

(2) Needs more than, as ordered by the treating clinician:

(a) Eight hours per day of any home health service, or a combined total of fourteen hours per week of home health aide and home health nursing as specified in paragraph (C) of this rule; or

(b) A combined total of twenty-eight hours per week of home health nursing and home health aide for sixty days as specified in paragraph (D) of this rule.

(3) Has a comparable level of care as evidenced by either:

(a) Enrollment in a HCBS waiver; or

(b) A level of care evaluated initially and annually by ODM or its designee for an individual not enrolled in a HCBS waiver. The criteria for an institutional level of care, including a nursing facility-based level of care as defined in rule 5160-3-08 of the Administrative Code or an ICF-IID level of care as defined in rule 5123:2-8-01 of the Administrative Code. In no instance does this constitute the determination of a level of care for waiver eligibility purposes, or admission into a medicaid covered long term care institution; and

(4) Needs home health nursing or a combination of PDN, home health nursing, waiver nursing, and skilled therapy visits at least once per week that is medically necessary in accordance with rule 5160-1-01 of the Administrative Code as ordered by the treating clinician.

(I) Individuals subject to decisions regarding home health services made by ODM or its designee pursuant to this rule will be afforded notice and hearing rights to the extent afforded in division 5101:6 of the Administrative Code.

History

Effective: March 7, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-12-02 Private duty nursing services: provision requirements, coverage and service specification.

(A) "Private duty nursing (PDN)" is a continuous nursing service that requires the skills of and is performed by either a registered nurse (RN) or a licensed practical nurse (LPN) at the direction of a registered nurse. A service is not considered a PDN service merely because it was performed by a licensed nurse. A covered PDN visit must meet the definition in paragraph (A) of rule 5160-12-04 of the Administrative Code and be more than four hours in length but less than or equal to twelve hours in length per nurse, on the same date or during a twenty-four hour time period, unless:

(1) An unforseen event causes a medically necessary scheduled visit to end at four or less hours, or extend beyond twelve hours, up to and including, but no more than sixteen hours; or

(2) Less than a two hour lapse between visits has occurred and the length of the PDN service requires an agency to provide a change in staff; or

(3) Less than a two hour lapse between visits has occurred and the PDN service is provided by more than one non-agency provider.

(B) For PDN to be covered, the service:

(1) Must be performed within the nurse's scope of practice as defined in Chapter 4723. of the Revised Code and rules adopted thereunder;

(2) Must be provided and documented in accordance with the individual's plan of care in accordance with rule 5160-12-03 of the Administrative Code;

(3) Must be medically necessary in accordance with rule 5160-1-01 of the Administrative Code to care for the individual's condition, illness or injury; and

(4) Must be provided in person in the individual's place of residence unless it is medically necessary for a nurse to accompany the individual in the community. The individual's place of residence is wherever the individual lives, whether the residence is the individual's own dwelling, assisted living facility, a relative's home, or other type of living arrangement. The place of residence cannot include a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities (ICF-IID). The place of service in the community cannot include the residence or business location of the provider of PDN. The residence of the provider is not excluded when the residence of the provider is the same as the individual and all other requirements of Chapter 5160-12 of the Administrative Code are met.

(1) Intravenous (IV) insertion, removal or discontinuation;

(2) IV medication administration;

(3) Programming of a pump to deliver medications including, but not limited to, epidural, subcutaneous and IV (except routine doses of insulin through a programmed pump);

(4) Insertion or initiation of infusion therapies;

(5) Central line dressing changes; and

(6) Blood product administration.

(D) PDN services do not include:

(1) Services provided for the provision of habilitative care in accordance with 42 U.S.C 1396n (c)(5).

(2) RN assessment services as defined in rule 5160-12-08 of the Administrative Code.

(3) RN consultation services as defined in rule 5160-12-08 of the Administrative Code.

(E) The providers of PDN include a medicare certified home health agency (MCHHA) that meets the requirements in accordance with rule 5160-12-03 of the Administrative Code, an otherwise accredited agency that meets the requirements in accordance with rule 5160-12-03.1 of the Administrative Code, and a non-agency nurse that meets the requirements in accordance with rule 5160-12-03.1 of the Administrative Code. In order for PDN to be covered, these providers must:

(1) Provide PDN that is appropriate given the individual's diagnosis, prognosis, functional limitations and medical conditions as documented by the individual's treating physician, physician's assistant or advance practice nurse.

(2) Provide PDN as specified in the plan of care in accordance with rule 5160-12-03 of the Administrative Code. PDN services not specified in a plan of care are not reimbursable. Additionally, for individuals enrolled on a home and community based services (HCBS) waiver, the providers of PDN services must provide the amount, scope, duration, and type of PDN service within the plan of care as:

(a) Documented on the all services plan that is approved by (ODM) or its designee when an individual is enrolled on an ODM administered HCBS waiver. PDN services not identified on the all services plan are not reimbursable; or

(b) Documented on the services plan when an individual is enrolled on an Ohio department of aging (ODA) administered or an Ohio department of developmental disabilities (DODD) administered HCBS waiver. PDN services not documented on the services plan are not reimbursable.

(3) Bill for provided PDN services using the appropriate procedure code and applicable modifiers in accordance with rule 5160-12-06 of the Administrative Code.

(4) Bill for provided PDN services in accordance with the visit policy in rule 5160-12-04 of the Administrative Code, except as provided for in paragraph (A) of this rule.

(5) Bill after all documentation is completed for services rendered during a visit in accordance with rule 5160-12-03 of the Administrative Code.

(F) In case of an emergency, PDN authorization may be requested and approved in accordance with paragraph (E) of rule 5160-12-02.3 of the Administrative Code, after the delivery of PDN services when:

(1) The provider has an existing prior authorization to provide PDN to the individual;

(2) PDN services are medically necessary in accordance with rule 5160-1-01 of the Administrative Code; and

(3) PDN services are deemed necessary to protect the health and welfare of the individual.

(G) Individuals who receive PDN must:

(1) Be under the supervision of a treating physician, physician's assistant or advance practice nurse who is providing care and treatment to the individual. The treating physician, physician's assistant or advance practice nurse is not a physician, physician's assistant or advance practice nurse whose sole purpose is to sign and authorize plans of care or who does not have direct involvement in the care or treatment of the individual. A treating physician, physician's assistant or advance practice nurse may be a physician, physician's assistant or advance practice nurse who is substituting temporarily on behalf of a treating physician.

(2) Participate in the development of a plan of care with the treating physician, physician's assistant or advance practice nurse and the MCHHA or other accredited agencies or non-agency registered nurse. An authorized representative may participate in the development of the plan of care in lieu of the individual.

(3) Access PDN in accordance with the program for the all-inclusive care of the elderly (PACE) if the individual participates in the PACE program.

(4) Access PDN in accordance with the individual's provider of hospice services if the individual has elected hospice.

(5) Access PDN in accordance with the individual's managed care plan's process if the individual is enrolled in a medicaid managed care plan.

(H) Post hospital PDN:

(1) Any individual receiving medicaid, whether adult or child, may receive PDN services up to fifty-six hours per week, and up to sixty consecutive days from the date of discharge from an inpatient hospital stay of three or more covered days in accordance with rule 5160-2-03 of the Administrative Code. For purposes of this rule, a covered inpatient hospital stay is considered one hospital stay when an individual is transferred from one hospital to another hospital, either within the same building or to another location.

(a) The sixty days will begin when the individual is discharged from the hospital to the individual's place of residence as defined in paragraph (B)(5) of this rule, from the most recent inpatient stay in an inpatient hospital or inpatient rehabilitation unit of a hospital.

(b) The sixty days will begin when the individual is discharged from a hospital to a nursing facility. PDN is not available while residing in a nursing facility.

(2) The treating physician, physician's assistant, or advance practice nurse will certify the medical necessity of PDN services using the ODM 07137 "Certificate of Medical Necessity for Home Health Services and Private Duty Nursing Services" (rev. 7/2014). PDN is available to individuals only if they have a medical need comparable to a skilled level of care as evidenced by a medical condition that temporarily reflects the skilled level of care as defined in rule 5160-3-08 of the Administrative Code. In no instance do these requirements constitute the determination of a level of care for waiver eligibility purposes, or admission into a medicaid covered long-term care institution.

(3) The PDN service must not be for the provision of maintenance care. "Maintenance care" is the care given to an individual for the prevention of deteriorating or worsening medical conditions or the management of stabilized chronic diseases or conditions. Services are considered maintenance care if the individual is no longer making significant improvement in his or her medical condition.

(4) Individuals who require additional PDN beyond the post hospitalization service may access PDN through either paragraph (I) or (J) of this rule.

(I) A child may qualify for additional PDN services if:

(1) The individual is under age twenty-one and requires services for treatment in accordance with Chapter 5160-14 of the Administrative Code for the healthchek program, and

(2) Needs, as ordered by the treating physician, physician's assistant, or advance practice nurse, continuous nursing services, including the provision of on-going maintenance care. Services for habilitative care as defined in paragraph (D)(1) of this rule are inappropriate, and

(3) Has a comparable level of care as evidenced by either:

(a) Enrollment on a HCBS waiver; or

(b) For a child not enrolled on a HCBS waiver, a comparable institutional level of care, including a nursing facility-based level of care pursuant to rule 5160-3-08 of the Administrative Code, or an ICF-IID level of care pursuant to 5123:2-8-01 of the Administrative Code, as evaluated initially and annually by ODM or its designee. In no instance do these criteria constitute the determination of a level of care for waiver eligibility purposes, or admission into a medicaid covered long-term care institution.

(4) The provider of PDN services ensures and documents the child meets all requirements in paragraph (I) of this rule prior to providing and billing for the PDN services.

(5) The child has a PDN authorization obtained in accordance with rule 5160-12-02.3 of the Administrative Code to establish medical necessity and the child's comparable level of care. Except as noted in paragraph (G)(5) of this rule, a request for additional, recertification, and/or a change of PDN authorization is made as follows:

(a) For a child not enrolled on a HCBS waiver, the provider of PDN shall submit the request to ODM or its designee. Any documentation required by ODM or its designee for the review of medical necessity shall be provided by the provider of PDN services. ODM or its designee will notify the provider of the amount, scope and duration of services authorized.

(b) For a child enrolled on a DODD administered waiver, the provider of PDN must submit the request to the case manager of the HCBS waiver, who will forward the request to DODD. Any documentation required by DODD for the review of medical necessity shall be provided by the provider of PDN services. DODD will notify the provider and the case manager of the amount, scope and duration of services authorized.

(c) For a child enrolled on an ODM administered waiver, the ODM case manager will authorize PDN services through the person-centered services plan.

(J) An adult may qualify for additional PDN services if he or she meets the following requirements:

(1) The adult is age twenty-one or older;

(2) The adult needs, as ordered by the treating physician, physician's assistant or advance practice nurse, continuous nursing including the provision of on-going maintenance care. Services cannot be for habilitative care;

(3) The adult has a comparable level of care as evidenced by either:

(a) Enrollment on a HCBS waiver; or

(b) A comparable institutional level of care, including a nursing facility-based level of care as evaluated initially and annually by ODM or its designee for an adult not enrolled on a HCBS waiver. The criteria for a nursing facility-based level of care are defined in rule 5160-3-08 of the Administrative Code or ICF-IID level of care as defined in rule 5123:2-8-01 of the Administrative Code. In no instance does this constitute the determination of a level of care for waiver eligibility purposes, or admission into a medicaid covered long term care institution;

(4) The provider of PDN services ensures and documents the adult meets all requirements in paragraph (J) of this rule prior to providing PDN.

(5) The adult must have a PDN authorization obtained in accordance with rule 5160-12-02.3 of the Administrative Code and approved by ODM or its designee to establish medical necessity and the adult's level of care. ODM or its designee will conduct an in-person visit and/or review of documentation. In an emergency, PDN services may be delivered when the provider has an existing authorization to provide PDN services to the adult and PDN authorization obtained after the delivery of services when the services are medically necessary in accordance with rule 5160-1-01 of the Administrative Code, and the services are required to protect the health and welfare of the individual. Except as noted in paragraph (G)(5) of this rule, a request for additional PDN authorization is made as follows:

(a) For an adult not enrolled on a HCBS waiver, the provider of PDN shall submit the request to ODM or its designee. Any documentation required by ODM or its designee for the review of medical necessity shall be provided by the provider of PDN services. ODM or its designee will notify the provider of the amount, scope and duration of services authorized.

(b) For an adult enrolled on a DODD administered waiver, the provider of PDN must submit the request to the county board of DD who will forward the request to DODD. Any documentation required by DODD for the review of medical necessity shall be provided by the provider of PDN services. DODD will notify the provider and the county board of DD of the amount, scope and duration of services authorized.

(c) For an adult enrolled on an ODA administered waiver, the provider of PDN shall submit the request to the case manager of the ODA waiver, who will forward the request to ODM or its designee. Any documentation required by ODM or its designee for the review of medical necessity must be provided by the provider of PDN services. ODM or its designee will notify the provider and the case manager of the amount, scope and duration of services authorized.

(d) For an adult enrolled on an ODM administered waiver, the case manager will authorize PDN services through the person-centered services plan.

(K) Individuals subject to decisions regarding PDN services made by ODM or its designee pursuant to this rule will be afforded notice and hearing rights to the extent afforded in division 5101:6 of the Administrative Code.

History

Effective: March 7, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-12-02.3 Private duty nursing: procedures for service authorization.

(A) The process of submitting a request for PDN or a change in the amount, scope, or duration of authorized PDN services is dependent on the individual's home and community-based services (HCBS) waiver enrollment and service payer, as follows:

(1) For individuals in fee for service, who are not enrolled on an HCBS waiver, a request for PDN is submitted to ODM using the ODM 02374, "Private Duty Nursing (PDN) Services Request," along with supporting documentation requested by ODM.

(2) For individuals enrolled on the Ohio department of aging (AGE) preadmission screening system providing options and resources today (PASSPORT) waiver, a request for PDN is submitted to ODM using the ODM 02374, "Private Duty Nursing (PDN) Services Request," along with supporting documentation requested by ODM.

(3) For individuals enrolled on an Ohio department of developmental disabilities (DODD) HCBS waiver, they will need to request a referral be made through their county board of developmental disabilities services and support administrator (SSA), along with supporting documentation requested by DODD.

(4) For individual enrolled on an Ohio home care waiver, they will request a referral be made through their waiver case manager, along with any additional supporting documentation requested by ODM.

(5) For individuals enrolled in a MCO, the provider will follow submission procedures designated by the individual's MCO.

(B) ODM or its designee will conduct an in-person assessment or perform a desk review to determine if the individual has needs that necessitate PDN services or PDN services are in accordance with rule 5160-12-02 of the Administrative Code. The assessor will notify the referral source or individual in writing of the outcome of the eligibility determination.

(1) Service approval will include authorized amount, scope, andd duration of PDN services and the PDN authorization number.

(2) Service denial will include a denial notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

(C) If the individual disagrees with the authorized amount, scope or duration of PDN services, the individual may request a hearing in accordance with division 5101:6 of the Administrative Code.

(D) Additional PDN services beyond what ODM or its designee has authorized may be provided to an individual in an emergency when the provider has an existing PDN authorization to provide PDN services to that individual. For the purposes of this rule, emergency services are provided outside of normal state of Ohio office hours when prior authorization cannot be obtained.

(1) PDN services may be delivered in an emergency and a new PDN authorization obtained after the delivery of services. The PDN services have to be medically necessary in accordance with rule 5160-1-01 of the Administrative Code, and the services need to be necessary to protect the health and welfare of the individual. If the individual disagrees with the authorized amount, scope and/or duration of PDN.

(2) The provider will notify ODM or its designee when emergency PDN services are delivered. Notification is immediate when possible, or no later than the first business day following the emergency provision of PDN services.

Last updated September 3, 2026 at 8:18 AM

History

Effective: September 3, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-12-03 Home health service providers.

(A) Home health services are provided by medicare certified home health agencies (MCHHA). MCHHAs must:

(1) Be certified for medicare participation by the centers for medicare and medicaid services.

(2) Be licensed by the Ohio department of health (ODH) in accordance with Chapter 3701-60 of the Administrative Code.

(3) Meet the conditions of participation in accordance with 42 C.F.R. part 484 (October 1, 2014).

(B) When terminating a service, providers of home health services need to submit written notification to the individual at least thirty days prior to the last date of service, unless:

(1) The individual's treating physician has discontinued home health services

(2) The treating physician has been notified that goals have been met;

(3) The individual no longer resides at their known place of residence or their whereabouts are unknown;

(4) The individual or another person has harmed or threatened to harm staff of the MCHHA;

(5) The individual has had a change in payor.

(6) Services are no longer authoized.

(C) Providers of home health services will maintain documentation on all aspects of services provided in accordance with this chapter. All documentation should be complete prior to billing for services provided and is subject to monitoring by ODM in accordance with rule 5160-1-27 of the Administrative Code. This includes, but is not limited to:

(1) Clinical records, including all signed orders; and

(2) Time keeping records that indicate the date and time span of the services provided during each visit, and the type of services provided.

(D) The MCHHA will notify the individual prior to a scheduled visit when unable to provide scheduled services.

(E) If home health services are being provided to an individual enrolled in a home and community-based services (HCBS) waiver, the services will be coordinated with the waiver administrator and documented in their person-centered care plan.

Last updated September 3, 2026 at 8:18 AM

History

Effective: September 3, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-12-03.1 Private duty nursing providers.

(A) Medicare certified home health agencies" (MCHHAs), "non-agency nurses," and "otherwise-accredited agencies" who meet the qualifications and conditions of this rule can provide private duty nursing (PDN) in accordance with rule 5160-12-02 of the Administrative Code.

(B) MCCHAs will:

(1) Be certified for medicare participation by the centers for medicare and medicaid services.

(2) Be licensed by the Ohio department of health (ODH) in accordance with Chapter 3701-60 of the Administrative Code.

(3) Meet the conditions of participation in accordance with 42 C.F.R. part 484 (October 1, 2024).

(C) A "non-agency nurse" that meets the requirements in accordance with this rule is eligible to participate in the Ohio medicaid program upon execution of a provider agreement. A non-agency nurse is mandated to:

(1) Be a registered nurse or licensed practical nurse at the direction of a registered nurse practicing within the scope of his or her nursing license pursuant to Chapter 4723. of the Revised Code as an independent provider.

(2) Not be the parent, step-parent, foster parent, legal guardian of an individual who is under eighteen years of age, or the individual's spouse.

(D) "Otherwise-accredited agencies" will:

(1) Have and maintain accreditation by a national accreditation organization for the provision of home health services, private duty nursing, personal care services, and support services. The accreditation can be granted by the accreditation commission for health care (ACHC), the community health accreditation program (CHAP), or the joint commission.

(2) Be licensed by the Ohio department of health (ODH) in accordance with Chapter 3701-60 of the Administrative Code.

(E) Providers of PDN services who are also providers of waiver services to an individual enrolled on a home and community based services (HCBS) waiver should comply with all applicable conditions. Services will also be coordinated with the waiver administrator and documented in their person-centered services plan.

(F) Providers of PDN services will maintain documentation on all aspects of services provided in accordance with this chapter. All documentation should be complete prior to billing for services provided and is subject to monitoring by ODM in accordance with rule 5160-1-27 of the Administrative Code. This includes:

(1) Clinical records, including all signed orders; and

(2) Time keeping records that indicate the date and time span of the services provided during each visit, and the type of services provided.

(G) Providers of PDN services will notify the individual when the regularly scheduled staff cannot or do not meet their obligation to provide services.

Last updated September 3, 2026 at 8:30 AM

History

Effective: September 3, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-12-04 Home health and private duty nursing: visit policy.

(A) Reimbursement of home health or private duty nursing (PDN) services in accordance with this chapter are on a per visit basis. A "visit" is the duration of time that a covered home health service or private duty nursing (PDN) service is provided during an in-person or telehealth encounter to one or more individuals receiving medicaid at the same residence on the same date during the same time period.

(1) A visit begins with the provision of a covered service and ends when the in-person or telehealth encounter ends.

(2) A visit must have a lapse of time of two or more hours between any previous or subsequent visit for the provision of the same covered service unless the length of a private duty nursing visit requires an agency to provide a change in staff.

(3) A visit must have a lapse of two or more hours between the provision of home health nursing and PDN service.

(4) A visit must be verified using an ODM-approved electronic visit verification (EVV) system in accordance with rule 5160-1-40 of the Administrative Code.

(B) When an individual is enrolled in a home and community based services (HCBS) waiver and is receiving consecutive home health or PDN service(s) with waiver service(s) that have the same scope of service, there must be a lapse of time of two or more hours between the services. A "scope" of a service includes the definition of the service and the conditions that apply to its provision and the provider who renders the service(s).

(C) Each covered visit must be billed as a separate line item. The number of lines /procedure codes must reflect the number of visits provided with one line equaling one visit.

(D) A "group visit" is a visit where the service(s) is provided to more than one person. During a group visit:

(1) The ratio of provider to the individuals being served may never exceed one to three.

(2) An entire visit is considered a group visit even if only a portion of the visit met the definition of a group visit.

(3) A modifier HQ must be used when billing to identify each group setting in accordance with rule 5160-12-05 of the Administrative Code.

(E) A "multiple visit" is when the provision of the same home health service or PDN by the same provider occurs on the same date of service for the same individual separated by a lapse of two hours. Multiple visits must be medically necessary in accordance with rule 5160-1-01 of the Administrative Code due to the functional limitations and/or medical condition of the individual as documented in the plan of care, and if the individual is enrolled in HCBS waiver, the services plan or all services plan. Documentation must support the medical need for multiple visits. After the initial visit, multiple visits must either be billed with a U2 modifier for the second visit or U3 for the third or any subsequent visit.

History

Effective: March 7, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-12-05 Reimbursement: home health services.

(A) Definitions of terms used for billing home health services rates set forth in appendix A to this rule are:

(1) "Base rate," as used in this rule and appendix A to this rule, means the amount reimbursed by Ohio medicaid:

(a) For the initial thirty-five to sixty minutes of home health aide service delivered;

(b) For the initial thirty-five to sixty minutes of home health nursing service delivered; or

(2) "Unit rate," as used in this rule and appendix A to this rule, means the amount reimbursed by Ohio medicaid for each fifteen minutes of service delivered when the initial visit is:

(a) Greater than sixty minutes in length for any home health service delivered; or

(b) Less than or equal to thirty-four minutes in length for home health aide and/or home health nursing service delivered.

(B) Home health services are delivered and billed in accordance with this chapter by medicare certified home health agencies (MCHHA).

(C) The amount of reimbursement for a home health visit will be the lesser of the provider's billed charge or the medicaid maximum rate. The medicaid maximum rate is determined by using a combination of the base rate and/or unit rate found in appendix A as applicable to this rule using the number of units of service that were provided during a visit in accordance with this chapter as follows:

(1) Each visit will be less than or equal to four hours.

(2) For a home health aide and/or a home health nursing visit that is less than thirty-five minutes in total, Ohio medicaid will reimburse a maximum of only one unit if the service is equal to or less than fifteen minutes in length, and a maximum of two units if the service is sixteen through thirty-four minutes in length.

(3) For a home health aide and/or a home health nursing visit thirty-five minutes to one hour in length in total, the medicaid maximum is the amount of the base rate.

(4) For a home health aide, home health nursing, or home health skilled therapy visit in length beyond the initial hour of service, the base rate plus the rate amount for each unit over the initial one hour may be claimed, not to exceed four hours.

(D) The amount of reimbursement for a visit will be the lesser of the provider's billed charge or seventy-five per cent of the total medicaid maximum as specified in paragraph (C) of this rule when billing with the modifier HQ "group setting" for group visits conducted in accordance with rule 5160-12-04 of the Administrative Code.

(E) The modifiers set forth in appendix B to this rule will be used to provide additional information in accordance with this chapter. A visit made for the purpose of home infusion therapy in accordance with 5160-12-01 of the Administrative Code will be billed using the U1 modifier.

(F) The "place of service" code "02" will be used to indicate a visit was completed using telehealth.

(G) A visit conducted by a registered nurse (RN) for the provision of home health nursing services will be billed to Ohio medicaid using the billing code G0299 as found in appendix A to this rule. A visit conducted by a licensed practical nurse (LPN) for the provision of home health nursing services will be billed to Ohio medicaid using the billing code G0300 as found in appendix A to this rule.

(H) An MCHHA will not be reimbursed for home health services provided to an individual that duplicates same or similar services already paid by medicaid or another funding source. For example, if the facility/home where a residential state supplement recipient or individual receiving medicaid resides, such as an adult foster home, adult family home, adult group home, residential care facility, or other facility is paid to provide personal care or nursing services, home health services are not reimbursable by medicaid.

(I) An MCHHA may be reimbursed for home health services provided to an individual residing in a facility/home if the provider has written documentation from the facility/home stating that it is not responsible for providing the same or similar home health services to the individual.

(J) Home health services provided to an individual enrolled on an assisted living home and community based services waiver in accordance with rule 5160-1-06 and Chapter 173-39 of the Administrative Code do not constitute a duplication of services.

View AppendixView Appendix

Last updated January 2, 2024 at 9:00 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-12-06 Reimbursement: private duty nursing services.

(A) Definitions of terms used for billing private duty nursing services (PDN) rates set forth in appendix A to this rule are:

(1) "Base rate," as used in this rule and appendix A to this rule, means the amount reimbursed by Ohio medicaid for the initial thirty-five to sixty minutes of service delivered.

(2) "Unit rate," as used in this rule and appendix A to this rule, means the amount reimbursed by Ohio medicaid for each fifteen minute units of service delivered when the initial visit is:

(a) Greater than sixty minutes in length; or

(b) Less than or equal to thirty-four minutes in length.

(B) PDN services are delivered and billed as PDN visits in accordance with rules 5160-12-02, 5160-12-2.3 and 5160-12-04 of the Administrative Code. The services will be provided by medicare certified home health agencies, "otherwise accredited agencies," or "non-agency nurses." PDN service rates are identified in appendix A to this rule.

(C) The amount of reimbursement for a PDN visit will be the lesser of the provider's billed charge or the medicaid maximum rate. The medicaid maximum rate is determined by using a combination of the base rate and unit rate found in appendix A to this rule using the number of units of service that were provided during a visit in accordance with this chapter.

(D) The amount of reimbursement for a PDN visit will be the lesser of the provider's billed charge or seventy-five per cent of the total medicaid maximum as specified in paragraph (C) of this rule when billing with the modifier HQ "group setting" for group visits conducted in accordance with rule 5160-12-04 of the Administrative Code.

(E) The modifiers set forth in appendix B to this rule will be used to provide additional information in accordance with this chapter. A visit made for the purpose of home infusion therapy in accordance with 5160-12-02 of the Administrative Code will be billed using the U1 modifier.

(F) A visit conducted by a registered nurse (RN) for the provision of PDN servcies will be billed to Ohio medicaid using the TD modifier. A visit conducted by a licensed practical nurse (LPN) for the provision of PDN services will be billed to Ohio medicaid using the TE modifier.

(G) Providers of PDN will not be reimbursed for PDN services provided to an individual that duplicate services already paid by medicaid or another funding source. For example, if the facility/home where a residential state supplemental recipient or individual receiving medicaid resides, such as an adult foster home, adult family home, adult group home, residential care facility, or other facility is paid to provide nursing services, PDN services are not reimbursable by medicaid.

(H) Providers of PDN may be reimbursed for PDN services provided to an individual who resides in a facility/home if the provider has written documentation from a facility/home stating that the facility/home is not responsible for providing the same or similar PDN services to the individual.

(I) PDN services provided to the individual enrolled in the assisted living home and community based services waiver in accordance with rule 5160-1-60 and Chapter 173-39 of the Administrative Code do not constitute a duplication of services.

View AppendixView Appendix

Last updated January 2, 2024 at 9:00 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-12-07 Reimbursement: exceptions.

Home health, RN assessment, RN consultation, and private duty nursing (PDN) service providers may be reimbursed when any of the exceptions set forth in this rule apply through no fault of the provider:

(A) Requirements of paragraphs (D)(2) of rule 5160-12-01 and (E)(2) of rule 5160-12-02 of the Administrative Code are not met due to any of the following:

(1) Services are not identified on the all services plan when the individual is enrolled on an Ohio department of medicaid (ODM)-administered waiver, and the provider has documented attempts to work with the case manager and the case manager's supervisors to identify the services on the all services plan. Documentation shall include written proof of the provider's attempts to obtain the all services plan that identifies the services. This exception does not extend to instances in which the provider disagrees with the amounts of service identified on the all services plan.

(2) Services are not documented on the service plan or individual service plan when the individual is enrolled on an Ohio department of aging (ODA) or department of developmental disabilities (DODD)-administered waiver, and the provider has documented attempts to work with the case manager and the case manager's supervisors to identify the services on the service plan. Documentation shall include written proof of the provider's attempts to obtain the service plan that identifies the services. This exception does not extend to instances in which the provider disagrees with the amounts of service identified on the service plan.

(3) The provider verified and documented before providing services that either:

(a) The individual was not enrolled on a home and community-based services (HCBS) waiver at the initiation of services and every six months thereafter, and the case manager cannot produce documentation that the provider was notified that the individual had become enrolled on an HCBS waiver; or

(b) The individual was not enrolled on a HCBS waiver and subsequently, at any point during the delivery of services, the provider became aware of the individual's enrollment and the provider notified the case manager and requested that the services be identified on the plan. And the case manager cannot produce documentation that the provider was notified that the individual had become enrolled on a HCBS waiver.

(B) Requirements of paragraphs (H) of rule 5160-12-05 and (H) of rule 5160-12-06 of the Administrative Code are not met due to either of the following:

(1) The provider has written documentation from a facility/home (i.e., an adult foster home, adult family home, adult group home, residential care facility, or other facility) stating that the facility/home is not responsible for providing the same or similar home health or PDN services to the individual; or

(2) Home health and/or PDN services provided to the individual enrolled on the assisted living HCBS waiver in accordance with rule 5160-1-06 and Chapter 173-39 of the Administrative Code do not constitute a duplication of services.

(C) For services to be reimbursed by Ohio medicaid or its designee, the provider shall document all efforts to meet the requirements set forth in Chapter 5160-12 of the Administrative Code which includes maintaining a written record of the provider's effort to obtain missing information from case managers and other service related professionals. Provider documentation must include the date and time of each contact and attempted contact, contact's information (i.e., contact's title, telephone number, fax number, email address, and/or mailing address), and the nature of the provider's communication with the contact.

History

Effective: July 1, 2015
Promulgated Under: 119.03

Ohio Adm.Code 5160-12-08 Registered nurse assessment and registered nurse consultation services.

(A) For the purpose of this rule:

(1) A "plan of care" is the medical treatment plan that is established, approved, and signed by a treating physician, advance practice nurse or physician's assistant in accordance with the Coronavirus Aid, Relief, and Economic Security (CARES) Act, S.3548 (2020), prior to a provider requesting reimbursement for a service. The plan of care has the same meaning as set forth in rule 5160-51-01 of the Administrative Code and is not the same as an all services plan, individual service plan, or helping Ohioans move expanding choice (HOME choice) service plan.

(2) A "registered nurse (RN) assessment" is the medicaid service performed by an RN pursuant to paragraphs (B) and (D) of this rule. It may include a recommendation subject to orders written by the treating physician, but not a determination of the amount or duration of nursing services. The RN assessment may be completed using telehealth.

(3) An "RN consultation" is a face-to-face or telephone contact between a directing RN and a licensed practical nurse (LPN) pursuant to paragraphs (C) and (D) of this rule, when an individual experiences a significant change that necessitates a change in the existing interventions the LPN must perform during a nursing service visit, and that will result in a change in the individual's plan of care. RN consultation does not replace routine direction and supervision provided by an RN to an LPN where evidence of significant change does not exist and/or does not necessitate a change in the LPN's intervention or the individual's plan of care.

(4) A "significant change" is a change experienced by an individual that warrants an RN assessment. Significant changes may include, but are not limited to, a change in health status, caregiver status, location/residence, referral to or active involvement on the part of a protective service agency, and/or institutionalization.

(5) A "nursing service visit" is the duration of time that a nurse provides covered medicaid services, face to face, to an individual at the individual's residence on the same date during the same time period.

(B) RN assessment service.

(1) An RN assessment service shall be performed on an individual participating in the medicaid program prior to the individual receiving the following services for the first time, prior to any change being made to an individual's current package of the following services, and any time the RN is informed that the individual receiving the following services has experienced a significant change, including an improvement or a decline in condition:

(a) State plan home health services as set forth in rule 5160-12-01 of the Administrative Code;

(b) Private duty nursing services as set forth in rule 5160-12-02 of the Administrative Code;

(c) Waiver nursing services as set forth in rules 5160-46-04, 5160-50-04, 5123:2-9-59 and 173-39-02.22 of the Administrative Code;

(d) Personal care aide services furnished by a medicare-certified home health agency or an otherwise accredited agency as set forth in rules 5160-46-04, 5160-50-04, and 5123:2-9-56 of the Administrative Code; and/or

(e) HOME choice nursing services as set forth in rule 5160-51-04 of the Administrative Code.

(2) An RN performing an RN assessment service shall:

(a) Possess a current, valid and unrestricted license with the Ohio board of nursing.

(b) Only provide services within the RN's scope of practice as set forth in Chapter 4723. of the Revised Code and Administrative Code rules adopted thereunder.

(d) Be either:

(i) Employed by a medicare-certified home health agency when identifying an individual's need for state plan home health services as set forth in rule 5160-12-01 of the Administrative Code;

(ii) Employed by medicare-certified home health agency or an otherwise accredited agency when identifying an individual's need for personal care aide services as set forth in rules 5160-46-04, 5160-50-04, and 5123:2-9-56 of the Administrative Code;

(iii) Employed by a medicare-certified home health agency or an otherwise accredited agency, or be an non-agency RN when identifying an individual's need for private duty nursing services as set forth in rule 5160-12-02 of the Administrative Code;

(iv) Employed by a medicare-certified home health agency or an otherwise accredited agency, or be a non-agency RN when identifying an individual's need for waiver nursing services as set forth in rules 5160-46-04, 5160-50-04, 5123:2-9-59 and 173-39-02.22 of the Administrative Code; or

(v) Employed by a medicare-certified home health agency or an otherwise accredited agency, or be a non-agency RN when identifying an individual's need for HOME choice nursing services as set forth in rule 5160-51-04 of the Administrative Code.

(3) The RN assessment service shall:

(a) Provide the basis for the RN to make independent decisions and nursing diagnoses, plan nursing interventions and evaluate the need for other interventions, develop the plan of care and assess the need to communicate and, as applicable, consult with other team members as defined in rule 5160-45-01 of the Administrative Code.

(b) Include a face-to-face interview with, and observation of, the individual in his or her place of residence or through telehealth. Place of residence has the same meaning as defined in rule 5160-12-01 of the Administrative Code. During the interview, the RN will assess the individual's verbal and nonverbal communication abilities, medical and social history, medications, living arrangements, supportive assistance equipment needs, and any other information available and relevant to the development of the individual's plan of care. At a minimum, the RN should capture the following information relative to the individual's health status:

(i) The physical condition of the individual including vital signs, skin color and condition, motor and sensory nerve function, cognitive status, respiratory status, and the nutritional, rest, sleep, activity, elimination habits and consciousness of the individual; and

(ii) The social and emotional condition of the individual, including religious preference, if any, occupation, mood, emotional state, and family ties and responsibilities.

(i) An LPN and/or home health aide is providing state plan home health services pursuant to rule 5160-12-01 of the Administrative Code;

(ii) An LPN is providing private duty nursing services pursuant to rule 5160-12-02 of the Administrative Code;

(iii) An LPN is providing waiver nursing services pursuant to rules 5160-46-04, 5160-50-04, 5123:2-9-59 and 173-39-02.22 of the Administrative Code;

(iv) An LPN is providing HOME choice nursing services pursuant to rule 5160-51-04 of the Administrative Code;

(v) A home health aide is providing state plan home health services pursuant to rule 5160-12-01 of the Administrative Code;

(4) Reimbursement for an RN assessment service.

(a) RN assessment services shall be reimbursed in accordance with the rates set forth in appendix A to this rule.

(b) The non-agency provider's, medicare-certified home health agency's or otherwise accredited agency's name and national provider identifier (NPI) number must be identified on the claim.

(c) When an individual is enrolled on an ODM-administered waiver, RN assessment services performed by a non-agency RN, or a medicare-certified home health agency or otherwise accredited agency must be prior-approved by ODM and be specified on the individual's service plan.

(d) When an individual is participating in the HOME choice program, RN assessment services performed by a non-agency RN or a medicare-certified home health agency or otherwise accredited agency must be prior-approved and be specified on the individual"s HOME choice service plan.

(e) An RN may be reimbursed for an RN assessment service no more than once every sixty days per individual receiving services unless the RN is informed that the individual receiving services experienced a significant change, including an improvement or a decline in condition, and therefore a subsequent RN assessment is required.

(f) RN assessments are reimbursable when sequentially, but not concurrently, performed with any other service during a visit in which the RN is furnishing billable home health, PDN, waiver nursing, or any other service that is reimbursable through the Ohio medicaid program.

(5) The RN assessment service code may be billed by an RN when the RN is performing a home care attendant service (HCAS) RN visit required by rules 5160-46-04.1, 5160-50-04.1 and 173-39-02.24, as applicable, and pursuant to rules 5160-46-06.1, 5160-50-06.1 and 173-39-02.24 of the Administrative Code as applicable.

(6) RN assessment services are not reimbursable when performed in conjunction with nursing delegation tasks as set forth in Chapter 4723-13 of the Administrative Code.

(7) RN assessments must be verified using an ODM-approved electronic visit verification (EVV) system in accordance with rule 5160-1-40 of the Administrative Code.

(1) An RN consultation service shall be performed as required by rule 5160-12-01 of the Administrative Code for state plan home health nursing services, rule 5160-12-02 of the Administrative Code for PDN services, rules 5160-46-04, 5160-50-04, 173-39-02.22 and 5123:2-9-59 of the Administrative Code for waiver nursing services and rule 5160-51-04 of the Administrative Code for HOME choice nursing services.

(2) An LPN shall seek the guidance of the directing RN when the individual receiving services from the LPN experiences a significant change in condition that may necessitate a change in the individual's plan of care and the interventions being provided by the LPN.

(3) An RN consultation service must be conducted between the directing RN and LPN either face-to-face or over the telephone.

(4) RN consultation services shall be reimbursed in accordance with the rates set forth in appendix A to this rule.

(5) RN consultation services are not reimbursable when performed in conjunction with nursing delegation services provided under a DODD-administered waiver program, or for consultations between RNs.

(D) If an individual selects multiple non-agency LPNs to furnish PDN services, waiver nursing, or HOME choice nursing services, the individual may designate a single RN to provide RN assessment and/or RN consultation services. Such designation shall be identified on the individual's service plan, as applicable, or the case manager, if one is assigned to the individual, shall develop a plan for the coordination of non-agency nursing services.

(E) Record keeping for RN assessment and RN consultation services.

(1) All RNs providing RN assessment and RN consultation services must maintain a clinical record for each individual receiving the medicaid covered services.

(2) Maintenance of the record shall be in a manner that protects the confidentiality of the record.

(3) Agency providers must maintain the clinical records at their place of business. The provider shall also maintain a file in the individual's place of residence containing a copy of the individual's medication profile, if one exists. The file may also include, but not be limited to the individual's medication administration record, treatment administration record, aide assignment, all services plan and plans of care. The individual shall identify a location in his or her residence where a copy of the clinical record will be safely maintained. Storage shall be in the manner that protects the confidentiality of the file, and for the purpose of contributing to the continuity of the individual's care.

(4) Non-agency providers must maintain the clinical records at their place of business and a copy at the home of the individual receiving the services. The individual shall identify a location in his or her residence where a copy of the clinical record will be safely maintained. Storage shall be a manner that protects the confidentiality of the record, and for the purpose of contributing to the continuity of the individual's care.

(5) At a minimum, the record must contain the following information:

(a) The name, address, age, date of birth, sex, race, marital status, significant phone numbers and health insurance identification numbers of the individual receiving the services;

(b) The medical history of the individual receiving the services;

(c) If the RN performing RN assessment services and/or RN consultation services is employed by an agency, the RN's name and contact information, the agency's contact information, and the agency's national provider identifier (NPI) number and medicaid provider number;

(d) If the RN performing RN assessment services and/or RN consultation services is a non-agency provider, his or her name, contact information, medicaid provider number and NPI number;

(e) If an LPN, being directed by an RN, is providing services and is employed by an agency, the LPN's name and contact information and the agency's NPI number and medicaid provider number;

(f) If an LPN, being directed by an RN, is providing services and is a non-agency provider, the LPN's name, contact information, NPI number and medicaid provider number;

(g) The name of and contact information for the treating physician of the individual receiving the services;

(h) A copy of the initial and all subsequent all services plans, individual service plans or HOME choice service plans, as applicable, for the individual receiving the services;

(i) A copy of the initial and all subsequent plans of care for the individual receiving the services;

(j) Documentation that the RN has reviewed the plans of care with the LPN when services are performed by an LPN at the direction of an RN;

(k) Documentation that the plan of care was recertified by the treating physician at least every sixty days;

(l) Documentation of any change of orders by the treating physician subsequent to the certified plan of care that altered the plan of care;

(m) Documentation of each instance in which the treating physician gave verbal orders to the RN or LPN, including what the physician ordered and the date and time the orders were given by the physician to the RN or LPN nurse, followed by the nurse's signature;

(n) A copy of the treating physician's signed and dated written verification of the verbal orders given to the nurse;

(o) In all instances in which a non-agency LPN has provided services, clinical notes that are signed and dated by the LPN, documentation of all RN consultation services occurring between the LPN and the directing RN, documentation of all face-to-face visits between the LPN and the directing RN, and documentation of the face-to-face visits between the LPN, the directing RN, and the individual receiving the services;

(p) A copy of all advance directives, including a "do not resuscitate" (DNR) order or medical power of attorney, if they exist;

(q) Documentation of all drug and food interactions, allergies and dietary restrictions;

(r) Clinical notes and other documentation of tasks performed or not performed;

(s) Documentation of the arrival and departure times of the RN assessment service provider with the dated signatures of the provider and the individual receiving the services verifying the service delivery upon completion of the service delivery and verifying the arrival and departure times. The signature method of choice of the individual receiving the services shall be documented in the clinical record. The signature method of choice shall include, but not be limited to any of the following: a handwritten signature, initials, a stamp or mark, or an electronic signature;

(t) Documentation of the date, start time and end time of the RN consultation service including the RN consultation provider's dated signature upon completion of the service;

(u) Clinical notes signed and dated by the RN and LPN documenting all communications with the treating physician and other members of the team selected by the individual receiving the services if the individual has team members;

(v) Documentation of face-to-face HCAS RN visits that must occur, every ninety days pursuant to rules 5160-46-04.1, 5160-50-04.1 and 173-39-02.24 of the Administrative Code, and any resulting activities; and

(w) A discharge summary signed and dated by the directing RN, at the point the RN is no longer going to provide assessment and consultation services to the individual or when the individual no longer needs services from the supervising RN. The summary should include information regarding the progress made toward goal achievement and indicate any recommended follow-ups or referrals.

View Appendix

Last updated November 29, 2021 at 9:48 AM

History

Effective: November 28, 2021
Promulgated Under: 119.03

Chapter 5160-13 Ambulatory Health Care Clinic Services

Ohio Adm.Code 5160-13-01 Clinic services.

(A) Unless otherwise noted, any limitations or requirements specified in the Revised Code or in agency 5160 of the Administrative Code apply to services addressed in this rule.

(B) This rule does not apply to federally qualified health centers (FQHCs) nor to rural health clinics (RHCs), policies for which are set forth in Chapter 5160-28 of the Administrative Code.

(1) It renders healthcare services on an outpatient basis under the direction of a physician or dentist.

(2) It operates from a fixed location, a specifically designed mobile unit, or both.

(3) It is freestanding administratively, organizationally, and financially independent of an institution such as a hospital or long-term care facility. It may be physically located in a hospital or long-term care facility so long as it remains independent.

(4) It does not provide overnight accommodations.

(D) The following entities that meet the definition of a clinic may enroll with the Ohio department of medicaid (ODM) as a clinic provider:

(1) A dialysis center, defined as a "dialysis facility" in 42 C.F.R. 494.10 (October 1, 2022), that meets the following criteria:

(a) It is recognized by medicare as a dialysis facility;

(b) It operates in accordance with Chapter 3701-83 of the Administrative Code or, if it is located outside of Ohio, operates in accordance with its respective state's authority; and

(2) A family planning clinic that meets the following criteria:

(a) It is a public or nonprofit organization;

(b) It complies with federal guidelines set forth in 42 C.F.R. Part 59 (October 1, 2022);

(c) It is qualified to receive funding for pregnancy prevention services through Title X of the Public Health Services Act; and

(d) It provides pregnancy prevention services in accordance with Chapter 5160-21 of the Administrative Code;

(3) An outpatient rehabilitation clinic that delivers rehabilitation services at a medicare-certified rehabilitation agency, defined in 42 C.F.R. 485.703 (October 1, 2022), or at a medicare-certified comprehensive outpatient rehabilitation facility (CORF), defined in 42 C.F.R. 485.51 (October 1, 2022);

(4) A primary care clinic that meets either of the following criteria:

(a) It receives state or federal grant funds for the provision of health services; or

(b) It is an accredited provider of primary care services as recognized by one of the following entities:

(i) The joint commission;

(ii) The accreditation association for ambulatory health care (AAAHC);

(iii) The healthcare facilities accreditation program of the American osteopathic association (AOA); or

(iv) The community health accreditation program (CHAP);

(5) A professional dental school clinic associated with an accredited dental school;

(6) A professional optometry school clinic associated with an accredited optometry school;

(7) A public health department clinic that meets the following criteria:

(a) It has legal status as a local health department created by a city health district, a general health district, or a combined health district in accordance with Chapter 3709. of the Revised Code; and

(b) It meets the standards set forth under the authority of section 3701.342 of the Revised Code; or

(8) A speech-language-audiology clinic that specializes in and provides speech, language, or audiology services delivered by professionals who meet the American speech-language-hearing association (ASHA) certification standards as determined by ASHA.

(E) Payment for a covered service furnished in a clinic is made in accordance with the chapter or rule of agency 5160 of the Administrative Code that pertains to that service.

Last updated April 11, 2023 at 8:14 AM

History

Effective: April 10, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-13-02 Dialysis services rendered by a dialysis center.

(A) Coverage and limitations.

(1) Payment may be made for dialysis performed for the treatment of kidney dysfunction resulting from conditions such as end-stage renal disease (ESRD) or acute kidney injury (AKI).

(2) If an individual is eligible for both medicare and medicaid, then coverage by medicaid as the primary payer continues only until medicare coverage begins.

(3) Payment may be made for hemodialysis (HD) or for any of three types of peritoneal dialysis: intermittent peritoneal dialysis (IPD), continuous ambulatory peritoneal dialysis (CAPD), or continuous cycling peritoneal dialysis (CCPD).

(4) CAPD or CCPD is peritoneal dialysis normally performed in a setting other than a dialysis center.

(5) Dialysis self-care training is instruction of the individual or a caregiver on how to perform self-dialysis with little or no professional assistance. It is customarily provided in conjunction with a session of dialysis treatment.

(6) The following frequency limits apply:

(a) HD - one session per day, three sessions per week;

(b) IPD, CAPD, or CCPD - one session per day, seven sessions per week;

(c) HD self-care training - a total of twenty-five sessions to be conducted within a period not to exceed ninety-one days;

(d) IPD self-care training - a total of twelve sessions to be conducted within a period not to exceed twenty-eight days; and

(e) CAPD or CCPD self-care training - a total of fifteen sessions.

(7) Frequency limits may be exceeded only if the medical necessity of the additional service is documented in the medical record by the practitioner who is primarily responsible for the dialysis services.

(B) Payment.

(1) Medicaid payment for a covered dialysis service rendered by a dialysis center is made as a per-visit payment amount (PVPA). This medicaid PVPA includes all applicable related services, tests, equipment, supplies, and incidental instruction furnished on the same date. A list of these related items, designated by medicare as items that are "subject to consolidated billing," is published by the centers for medicare and medicaid services (CMS) in the end-stage renal disease (ESRD) section of its website, http://www.cms.gov.

(2) PVPAs for covered dialysis services are listed in the appendix to this rule.

(3) Payment separate from the PVPA may be made for the following items and services:

(a) Covered professional dialysis services provided by a medical practitioner, addressed in rule 5160-4-14 of the Administrative Code; and

(b) Covered laboratory services and pharmaceuticals, addressed in Chapter 5160-11 of the Administrative Code, that are not designated by medicare as "subject to consolidated billing."

(4) Nothing in this rule precludes a medicaid managed care organization (described in Chapters 5160-26 and 5160-58 of the Administrative Code) from paying amounts other than those listed in the appendix to this rule.

View Appendix

Last updated January 2, 2024 at 9:01 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-13-08 Dialysis center services: add-on payment for nursing facility-based hemodialysis furnished by a dialysis center.

(A) The following definitions apply to this rule:

(1) "Dialysis center" means as defined in rule 5160-13-01 of the Administrative Code.

(2) "Nursing facility" means as defined in rule 5160-3-02.3 of the Administrative Code.

(3) "Nursing facility-based hemodialysis" means hemodialysis (HD) furnished by a dialysis center on the premises of a nursing facility.

(B) Add-on payment.

(1) Beginning on the effective date of this rule, the Ohio department of medicaid (ODM) pays an add-on amount of one hundred ten dollars per treatment for nursing facility-based HD furnished by a dialysis center, in addition to the HD per-visit payment amount listed in the appendix to rule 5160-13-02 of the Administrative Code.

(2) The add-on payment is claimed using the designated HD revenue center code listed in the appendix to rule 5160-13-02 of the Administrative Code along with an ODM-specified modifier.

(1) The add-on payment described in this rule is available only if all the following conditions are met:

(a) The nursing facility-based HD was rendered by the dialysis center during state fiscal year (SFY) 2027;

(b) The dialysis center is already furnishing nursing facility-based HD on or before the effective date of this rule; and

(c) Total expenditures have not reached the budgeted amount of two million one hundred thousand dollars, after which no additional add-on payments are made.

(2) If an individual is eligible for both medicare and medicaid, the add-on payment is discontinued when medicare coverage begins.

Last updated July 1, 2026 at 8:41 AM

History

Effective: July 1, 2026
Promulgated Under: 119.03

Chapter 5160-15 Healthcare-Related Transportation

Ohio Adm.Code 5160-15-01 Transportation: definitions.

(A) Provisions in this chapter do not necessarily apply to transportation furnished in accordance with other chapters of agency 5160 of the Administrative Code.

(B) The following definitions apply to this chapter:

(1) Terms that have the same meaning as in 42 C.F.R. 414.605 (October 1, 2020) include the following items:

(a) "Advanced life support, level 1 (ALS1)";

(b) "Advanced life support, level 2 (ALS2)";

(d) "EMT-basic," "EMT-intermediate, and "EMT-paramedic" (collectively, "advanced life support (ALS) personnel");

(e) "Fixed wing air ambulance";

(f) "Rotary wing air ambulance"; and

(g) "Specialty care transport (SCT)."

(2) "Ambulance" is a collective term for air ambulance and ground ambulance.

(a) "Air ambulance" is a collective term for "fixed wing air ambulance" and "rotary wing air ambulance."

(b) "Ground ambulance" is a collective term for land ambulance and water ambulance.

(3) "Attendant" is an individual employed by a transportation provider, in addition to the minimum crew of a wheelchair van or a ground ambulance, who aids in the non-emergency transportation of medicaid-eligible individuals who need extra assistance.

(4) "County department of job and family services (CDJFS)" is an entity established under section 329.01 of the Revised Code or a group of such entities acting together under a formal collaborative agreement.

(5) "Documentation" is information recorded in an appropriate medium for the purpose of substantiating an assertion. Information that is not relevant to a situation or does not support a statement about a situation is not documentation.

(6) "Eligible provider" has the same meaning as in Chapter 5160-1 of the Administrative Code.

(7) "Emergency" is a situation that calls for an immediate response for the provision of medical treatment, particularly a situation in which the sudden onset of a medical condition manifests itself in acute symptoms so severe that the absence of immediate medical attention could reasonably be expected to result in serious harm to an individual's health, significant impairment of a body function, or failure of a body organ or part. An ambulance service may be considered to be of an emergency nature when an individual, at the time of transport, needs health-related assistance including but not limited to the following services:

(a) Immediate medical attention for a serious injury, an acute illness, or the sudden instability of a physical condition;

(b) Prophylactic immobilization; or

(8) "Emergency medical technician (EMT)" is a collective term for EMT-basic, EMT-intermediate, and EMT-paramedic.

(9) "Loaded mileage" is the distance traveled to or from a medicaid-coverable service with a medicaid-eligible individual in the vehicle. Air ambulance mileage is expressed in statute miles.

(10) "Long-term care facility" is a collective term for intermediate care facility for individuals with intellectual disabilities (ICFIID), nursing facility (NF), and skilled nursing facility (SNF). Neither an assisted living facility nor a group home is an LTCF.

(11) "Manual review" is the examination of a claim by an employee of the department for the purpose of determining whether it meets criteria for payment.

(12) "Medicaid-eligible individual" is an individual who meets eligibility criteria of the medicaid program.

(13) "Medicaid-coverable service" is a service or procedure, exclusive of the transportation services specified in this chapter, that either is itself payable under the Ohio medicaid program in accordance with agency 5160 of the Administrative Code or is intrinsically related to a payable service or procedure.

(14) "Mobility-related assistive device" (or "mobility device") is a piece of equipment that is intended primarily to facilitate human locomotion and cannot be classified as a motor vehicle, common carrier, or similar conveyance. For purposes of this chapter, a mobility device is a manual wheelchair, power wheelchair, power-operated vehicle (scooter), or wheelbench (a device, similar in function to a wheelchair, that is used by a person in a recumbent position).

(15) "Non-emergency" is a situation for which immediate response is not needed for the provision of medical treatment.

(16) "Personal assistant" is an individual who accompanies and provides necessary assistance to a medicaid-eligible individual during non-emergency transport that has been arranged through a county department of job and family services.

(17) "Point of transport" is the terminus of a trip, either the place of origin or the destination.

(18) "Signature" is a distinctive mark (usually taking the form of a name) that is made in order to indicate a person's responsibility for a document or other material. A signature may be written in someone's own hand or produced in any other legally valid manner.

(19) "Transportation provider" is an eligible provider that furnishes wheelchair van or ambulance services and meets the minimum criteria specified or referenced in this chapter. For purposes of this chapter, a vendor under contract with a CDJFS to transport medicaid-eligible individuals is not considered to be a medicaid transportation provider.

(20) "Wheelchair van" is a vehicle that meets the definition of "ambulette" set forth in section 4766.01 of the Revised Code, meets the standards and conditions for licensure specified in Chapter 4766. of the Revised Code, and meets standards specified in Chapter 4766-3 of the Administrative Code.

Last updated May 26, 2026 at 3:55 PM

History

Effective: July 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-15-10 Transportation: non-emergency services through a CDJFS.

(A) Pursuant to 42 C.F.R. 431.53, the Ohio department of medicaid (ODM) is obligated to ensure necessary transportation for medicaid-eligible individuals to and from providers of covered healthcare services. ODM fulfills this obligation in large measure through three-way subgrant agreements with the Ohio department of job and family services (ODJFS) and with each county department of job and family services (CDJFS). This rule sets forth the responsibilities and expectations placed by ODM on each CDJFS in the administration of this medicaid-funded non-emergency transportation assistance benefit. In signing a subgrant agreement, a CDJFS agrees to be bound by this rule and by any other applicable provision of the Administrative Code.

(B) For each individual to whom non-emergency transportation assistance is provided, a CDJFS is expected to select the type of assistance that is most cost-effective, is suitable to the individual's needs and circumstances, and enables timely access. If one type of assistance proves infeasible, a CDJFS may select another type.

(1) A CDJFS may decline to provide medicaid-funded non-emergency transportation assistance to a medicaid-eligible individual under this rule if either of the following criteria is met:

(a) The associated healthcare service is not part of the individual's medicaid benefit package; or

(b) The requested non-emergency transportation assistance is not necessary for any of the following reasons:

(i) A medicaid managed care organization (MCO) is obligated to furnish transportation to the individual under its provider agreement with ODM;

(ii) The individual is a resident of a long-term care facility (nursing facility, skilled nursing facility, or intermediate care facility for individuals with intellectual disabilities), for whom transportation is provided in accordance with Chapter 5160-3 or Chapter 5123:2-7 of the Administrative Code;

(iii) A medicaid hospice provider is obligated to provide or arrange transportation that is necessary for the individual to receive care related to a terminal illness;

(iv) Suitable transportation is available free of charge to the general public; or

(v) Failure to provide the requested assistance will have no effect on the individual's ability to obtain the healthcare service.

(2) A request made on behalf of a minor child for non-emergency transportation assistance entails additional considerations.

(a) Responsibility for transporting a child normally falls to a parent or guardian. In reviewing a request, a CDJFS should take into account the impact, if any, of the following factors:

(i) Whether a family member or friend is available to provide transportation;

(ii) Whether the family has ready access to a reliable vehicle;

(iii) Whether the family has sufficient financial resources (including any adoption or foster care subsidy); and

(iv) Whether another entity such as a school system is or should be involved.

(b) A request for non-emergency transportation assistance to enable another person, such as a parent, to be with a child in a healthcare facility may be approved if two criteria are met:

(i) The presence of the other person is needed for an identifiable healthcare purpose that will benefit the child; and

(ii) The other person lacks the resources necessary to make the trip (or trips).

(3) A CDJFS may temporarily restrict or suspend a particular type of non-emergency transportation assistance or non-emergency transportation assistance in general for an individual for reasons including but not limited to the following examples:

(a) Misuse by the individual, as determined by the CDJFS;

(b) Dangerous, threatening, or disruptive behavior on the part of the individual; or

(c) Presence in the individual of a communicable disease or condition (other than a mild endemic illness such as the common cold) that constitutes a danger to public health.

(4) A CDJFS is to provide a notice of state hearing rights whenever it proposes to withhold, reduce, suspend, or terminate the medicaid-funded non-emergency transportation assistance benefit or whenever a medicaid-eligible individual formally expresses disagreement with an action or lack of action taken by the CDJFS on a request for non-emergency transportation assistance. The following examples, however, do not constitute restrictions by the CDJFS of the medicaid benefit and are not subject to state hearing:

(a) The refusal of a request for a specific trip, particularly because of factors beyond the control of the CDJFS such as a scheduling conflict, lack of sufficient advance notice, or adverse weather conditions; and

(b) Failure to provide further non-emergency transportation assistance when all options have been exhausted.

(C) The community service area of a CDJFS is the geographical area within which medicaid-eligible individuals and the general population in the county routinely access healthcare services.

(1) The community service area comprises at least the county or counties served by the CDJFS, and it may also include specific locations in contiguous Ohio counties, non-contiguous Ohio counties, and bordering states.

(2) It is expected that medicaid-eligible individuals will access covered healthcare services within the community service area. If a covered healthcare service can be obtained only outside the community service area, the CDJFS may choose to provide assistance sufficient to enable travel only to or from the nearest location, unless a documented consideration other than distance overrides such a limitation.

(D) Every CDJFS may offer a variety of transportation assistance options.

(1) These options include the following examples:

(a) Contracted livery service;

(b) Payment for fixed-route or demand-response transportation;

(d) Prepayment of fares;

(e) Prepayment for fuel;

(f) Transportation by a CDJFS staff member in a CDJFS vehicle;

(g) Payment of mileage reimbursement;

(h) Reimbursement for travel-related expenses that represent a necessary out-of-pocket cost to a medicaid-eligible individual;

(i) Transportation, or payment for transportation, of a parent or legal guardian accompanying a medicaid-eligible individual who is younger than twenty-one years of age; and

(j) Other services approved in advance by ODM.

(2) The types of non-emergency transportation assistance offered by a CDJFS generally reflect the resources available within its community service area. In a large metropolitan area with an extensive public transit system and numerous taxicab and transportation network companies, for example, the CDJFS may choose to offer rides rather than payment of vehicle costs; in a very rural area with no public transit and few livery options, the CDJFS may choose to offer fuel subsidy as its main form of assistance. Every CDJFS, however, regardless of community service area, is expected to develop a process for identifying transportation sources and to make a good-faith effort to secure rides for individuals who need actual transportation.

(E) Each CDJFS shares basic information about its administration of the transportation assistance benefit by submitting form ODM 10241, "Medicaid County Transportation Profile" (rev. 4/2021), to ODM and revising the document whenever changes are made but not less often than every twelve months.

(F) Of all the records created in the course of administering medicaid-funded non-emergency transportation assistance, ODM expects a CDJFS to collect the following types for purposes of data analysis and program integrity:

(1) Documentation of each request for non-emergency transportation assistance, maintained in such a manner that ODM can readily verify the following information:

(a) The individual's medicaid identification number;

(b) The date on which the request for transportation assistance was made;

(d) The trip date or dates requested;

(e) The number of one-way trips involved;

(f) The type of transportation assistance provided or the reason why transportation assistance was not provided;

(g) The name of the transportation vendor, when applicable;

(h) The scheduled pick-up and drop-off times and the actual pick-up and drop-off times, when applicable; and

(i) The name of the medicaid program area (such as pregnancy-related services, healthchek/EPSDT, or general non-emergency transportation) to which the cost should be allocated;

(2) Results of criminal background checks and database searches conducted in accordance with rule 5160-15-14 of the Administrative Code; and

(3) Complaints and suggestions received from passengers and, if applicable, from vendors.

Last updated May 26, 2026 at 3:55 PM

History

Effective: July 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-15-14 Transportation: non-emergency services through a CDJFS: program integrity provisions.

(A) Definitions.

(1) "Private transportation vendor (PTV)" is an entity that meets the following criteria:

(a) It seeks to establish or to maintain a contract with a county department of job and family services (CDJFS) to supply transportation service to medicaid recipients in accordance with rule 5160-15-10 of the Administrative Code; and

(b) It is not a government agency, transit authority, public transportation system, or other quasi-governmental organization.

(2) "PTV owner/manager" is a person having an ownership or control interest in the PTV, as defined in 42 C.F.R. 455.101 (October 1, 2020).

(3) "Related enterprise" is any other business in which a PTV owner/manager has an ownership or control interest.

(4) "Direct-service PTV employee" is a PTV employee who provides direct services to medicaid recipients.

(B) A CDJFS may hold a contract with a PTV only if the following conditions are met:

(1) All applicable disclosure provisions set forth in 42 C.F.R. Part 455, Subpart B (October 1, 2020) are satisfied;

(2) Whenever a contract between the CDJFS and the PTV is established or renewed and whenever the PTV is considering an applicant for a position as a direct-service PTV employee, the following four conditions are met:

(a) Each driver holding or applying for a position with the PTV has a valid driver's license;

(b) For each driver holding or applying for a position with the PTV, a certified driving record history is obtained from the bureau of motor vehicles of the Ohio department of public safety and provided to the CDJFS;

(c) A criminal background check performed in accordance with section 109.572 of the Revised Code on each direct-service PTV employee or applicant returns one of two results:

(i) The direct-service PTV employee or applicant has never been convicted of or pleaded guilty to an offense listed in divisions (A)(3)(a) to (A)(3)(e) of section 109.572 of the Revised Code (a disqualifying offense); or

(ii) The direct-service PTV employee or applicant has been convicted of or pleaded guilty to a disqualifying offense and one of the following criteria is met:

(a) The individual has satisfied the conditions associated with any applicable exclusionary periods set forth in rule 5160-1-17.8 of the Administrative Code; or

(b) The individual has obtained a certificate of qualification for employment in accordance with section 2953.25 of the Revised Code or an equivalent certification issued by another state or federal jurisdiction; and

(d) A search substantiates that no PTV, PTV owner/manager, or direct-service PTV employee or applicant is currently listed as sanctioned or excluded in either of the following databases:

(i) The system for award management (SAM) maintained by the United States general services administration; or

(ii) The list of excluded individuals and entities (LEIE) maintained by the office of inspector general in the United States department of health and human services.

(C) Not later than thirty calendar days either after a contract period has started or after a criminal background check and database search have been performed for an applicant, the CDJFS documents and submits to the department or its designee the relevant information indicated in paragraph (B) of this rule, in the format specified by the department or its designee.

Last updated March 22, 2024 at 10:33 AM

History

Effective: July 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-15-21 Transportation: services from an eligible provider: conditions of provider participation.

(A) Definition. "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code.

(B) Transportation-specific criteria. For each entity enrolled as an eligible provider of transportation services, the following conditions are met:

(1) The entity, each crew member, and each attendant comply with all applicable local, state, and federal laws, regulations, and rules, including all applicable provisions developed in accordance with Chapter 4765. or Chapter 4766. of the Revised Code;

(2) Each vehicle meets all applicable permit provisions developed in accordance with Chapter 4766. of the Revised Code; and

(3) If the entity provides ground ambulance services, it is also enrolled in medicare as an ambulance service provider or supplier.

(1) A wheelchair van provider;

(2) An ambulance provider;

(3) A hospital; or

(4) A provider under contract with a medicaid managed care organization.

(D) Billing ("pay to") provider. The following eligible providers may receive medicaid payment for submitting a claim for a transportation service:

(1) A wheelchair van provider;

(2) An ambulance provider;

(3) A hospital; or

(4) A provider under contract with a medicaid managed care organization.

(E) Prescribing or referring provider.

(1) The following practitioners may certify the necessity of either a wheelchair van service or an ambulance service:

(a) An advanced practice registered nurse;

(b) A doctor of medicine, osteopathy, or podiatric medicine;

(d) Any other professional recognized by the department as having prescriptive authority.

(2) The following practitioners may certify the necessity of a wheelchair van service:

(a) A chiropractor;

(b) A licensed practical nurse or registered nurse;

(d) A psychologist;

(e) A certified rehabilitation counselor; or

(f) Any other professional recognized by the department as having the qualifications necessary to determine whether an individual needs a mobility device.

Last updated July 10, 2026 at 11:24 AM

History

Effective: July 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-15-22 Transportation: services from an eligible provider: wheelchair van services.

(A) Payment may be made for the following wheelchair van services:

(1) Transport by wheelchair van;

(2) Mileage, wheelchair van; and

(3) Attendant services, wheelchair van.

(B) Payment may be made only if all the conditions in this paragraph are met.

(1) The necessity of the wheelchair van service is established. A necessary wheelchair van service is presumed to satisfy the criteria for medical necessity set forth in rule 5160-1-01 of the Administrative Code.

(a) The transfer by wheelchair van of a medicaid-eligible individual from one hospital to a second hospital is deemed to be necessary if two conditions apply:

(i) Both of the criteria listed in paragraph (B)(1)(b) of this rule are met; and

(ii) The services provided at the second hospital are coverable by medicaid.

(b) The necessity of all other wheelchair van services is determined by two criteria:

(i) The medicaid-eligible individual needs to be accompanied by a mobility-related assistive device from the point of pick-up to the point of drop-off. This need is demonstrated by the following indicators:

(a) The mobility device is dropped off or picked up along with the medicaid-eligible individual at the location where the medicaid-coverable service is obtained; and

(b) The medicaid-eligible individual rides in or on the mobility device when moving between the wheelchair van and the location where the medicaid-coverable service is obtained.

(ii) Transportation of the medicaid-eligible individual by standard passenger vehicle or common carrier is precluded or contraindicated. (Note: The use of a portable device such as a cane, crutch, or walker does not in and of itself preclude or contraindicate transportation by standard passenger vehicle or common carrier.)

(2) The transport vehicle is one of two types:

(a) A wheelchair van; or

(b) A ground ambulance used only under the following conditions:

(i) The transportation provider is an eligible provider of both wheelchair van services and ground ambulance services;

(ii) No wheelchair van is available for one of three reasons:

(a) A wheelchair van was originally scheduled for the transport but has been rendered inoperative or unavoidably delayed, and the transportation provider cannot substitute another wheelchair van within a reasonable time;

(b) The wheelchair vans operated by the transportation provider cannot accommodate the medicaid-eligible individual's mobility device; or

(c) The medicaid-eligible individual (or the medicaid-eligible individual's representative) requested a ground ambulance, and the ambulance crew discovered on arrival that wheelchair van service was needed;

(iii) The medicaid-eligible individual's mobility device can be safely transported with the medicaid-eligible individual in the ground ambulance;

(iv) The medicaid-eligible individual does not refuse the transport; and

(v) On the claim submitted for payment of wheelchair van service, the transportation provider indicates the use of a ground ambulance.

(3) The medicaid-eligible individual is transported either to or from a medicaid-coverable service.

(4) The medicaid-eligible individual is transported both to and from a recognized or approved point of transport.

(5) The services of an attendant are used only when such services are necessary for the safe transport of a medicaid-eligible individual, and the transportation provider maintains documentation of such necessity.

Last updated July 10, 2026 at 11:24 AM

History

Effective: July 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-15-23 Transportation: services from an eligible provider: ground ambulance services.

(A) Payment may be made for the following ground ambulance services:

(1) Basic life support, provided in a non-emergency (BLS non-emergency);

(2) Basic life support, provided in an emergency (BLS emergency);

(3) Advanced life support, level 1, provided in a non-emergency (ALS1 non-emergency);

(4) Advanced life support, level 1, provided in an emergency (ALS1 emergency);

(5) Advanced life support, level 2 (ALS2);

(6) Specialty care transport (SCT);

(7) Mileage, ground ambulance; and

(8) Attendant services, ground ambulance.

(B) Payment may be made only if all the requirements in this paragraph are met.

(1) The necessity of ground ambulance service is established.

(a) Emergency ground ambulance services are deemed to be necessary. BLS emergency, ALS1 emergency, and associated loaded mileage are emergency services by definition. ALS2, specialty care transport, and associated loaded mileage are treated as emergency services.

(b) The non-emergency transfer by ground ambulance of a medicaid-eligible individual from one hospital to a second hospital is deemed to be necessary if two conditions apply:

(i) At least one of the criteria listed in paragraph (B)(1)(c) of this rule is met; and

(ii) The services provided at the second hospital are coverable by medicaid.

(c) Any other non-emergency ground ambulance service is determined to be necessary if the individual needs at least one of the following services during transport:

(i) Medical treatment or continuous supervision by an EMT;

(ii) The administration or regulation of oxygen by another person; or

(iii) Supervised protective restraint.

(2) The transport vehicle is a ground ambulance.

(3) The medicaid-eligible individual is transported either to or from a medicaid-coverable service.

(4) The medicaid-eligible individual is transported both to and from a recognized or approved point of transport.

(5) The services of an additional attendant are used only when such services are necessary for the safe transport of a medicaid-eligible individual, and the transportation provider maintains documentation of such necessity.

(C) A hospital that is an eligible provider may submit a claim for ground ambulance services on behalf of another entity if two conditions apply:

(1) The other entity is an eligible provider of ground ambulance services; and

(2) The hospital and the other entity have entered into an appropriate agreement or contract.

Last updated July 10, 2026 at 11:24 AM

History

Effective: July 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-15-24 Transportation: services from an eligible provider: air ambulance services.

(A) Payment may be made for the following air ambulance services:

(1) Ambulance transport, fixed wing;

(2) Ambulance transport, rotary wing;

(3) Mileage, fixed wing ambulance; and

(4) Mileage, rotary wing ambulance.

(B) Payment may be made only if all the requirements in this paragraph are met.

(1) The necessity of air ambulance service is established.

(a) Air ambulance services are deemed to be necessary when two criteria are met:

(i) Emergency ambulance service is necessary because the medicaid-eligible individual is critically ill or has critical injuries; and

(ii) It is estimated that transporting the medicaid-eligible individual by ground ambulance to the nearest appropriate treatment facility will take more than thirty minutes.

(b) The necessity of other air ambulance services is determined by two criteria:

(i) The criteria have been met for determining the necessity of transport by ground ambulance in accordance with rule 5160-15-23 of the Administrative Code; and

(ii) At least one of the following conditions applies:

(a) The point of pick-up is inaccessible by ground ambulance;

(b) The additional time needed for transport by ground ambulance would endanger the life or health of the medicaid-eligible individual;

(c) The time saved by air transport would significantly increase the chances of survival or reduce the risk of further injury or impairment; or

(d) The closest appropriate treatment facility is at least one hundred eighty miles from the point of pick-up.

(2) The transport vehicle is an air ambulance.

(3) The medicaid-eligible individual is transported either to or from a medicaid-coverable service.

(4) The medicaid-eligible individual is transported both to and from a recognized or approved point of transport.

(C) A hospital that is an eligible provider may submit a claim for air ambulance services on behalf of another entity if two conditions apply:

(1) The other entity is an eligible provider of air ambulance services; and

(2) The hospital and the other entity have entered into an appropriate agreement or contract.

(D) Separate payment may be made for critical care services, the provision of which is delineated in Chapter 5160-4 of the Administrative Code.

Last updated July 10, 2026 at 11:24 AM

History

Effective: July 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-15-25 Transportation: services from an eligible provider: points of transport.

(A) For purposes of this chapter, medicaid recognizes the following twelve points of transport, which represent the origin or destination of a discrete one-way trip:

(1) Ten points of transport recognized by the centers for medicare and medicaid services (CMS):

(a) A diagnostic or therapeutic site other than a practitioner's office or a hospital, such as an alcohol and drug rehabilitation center, an ambulatory surgery center, an independent diagnostic testing facility, or a medical equipment supplier;

(b) A residential, domiciliary, or custodial facility that is not a skilled nursing facility;

(d) A hospital;

(e) A site of transfer between modes of transport, such as an airstrip or a helipad;

(f) A dialysis facility not located in a hospital;

(g) A skilled nursing facility;

(h) A practitioner's office, which includes but is not limited to the office of an individual health professional, the office of a group of health professionals, or a clinic;

(i) A residence other than a residential, domiciliary, or custodial facility; and

(j) The scene of an accident or an acute event;

(2) A workplace; and

(3) A school.

(B) On each claim for a transportation service provided by wheelchair van or by ambulance, the origin and the destination are specified in accordance with current claim-submission instructions.

(1) A claim submitted for a wheelchair van service or an ambulance service is subject to manual review unless the combination of origin and destination has been exempted. A list of the exempted combinations for each service is shown in the appendix to rule 5160-15-28 of the Administrative Code.

(2) Transportation providers may request manual review of claims for services involving non-exempted combinations of origins and destinations. Transportation providers may also request manual review of a claim for a service involving an origin or destination not listed in paragraph (A) of this rule if they indicate that fact explicitly on the claim.

(3) A request for manual review of a claim for a transportation service includes the following information:

(a) A completed practitioner certification form when the claim does not concern emergency ambulance service;

(b) A complete description of the service requested, the date of service, the trip origin and destination, a description of any special services involved, and a justification for the use of an attendant (when applicable); and

Last updated May 11, 2026 at 1:01 PM

History

Effective: July 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-15-26 Transportation: services from an eligible provider: service limitations and allowances.

(A) No payment can be made for the following services and associated costs:

(1) Transportation services for an individual who is not medicaid-eligible at the time of transport;

(2) Transportation of a medicaid-eligible individual for a purpose other than the receipt of medicaid-coverable services;

(3) Transportation of a medicaid-eligible individual to or from a service provided outside the limits of the individual's medicaid benefit package;

(4) Transports during which there is no medicaid-eligible individual in the vehicle;

(5) Services that are available to the general public without charge;

(6) Excessive mileage resulting from the use of unnecessarily indirect routes;

(7) The service of hospital staff members as attendants during transportation to or from a hospital (which is treated as an inpatient or outpatient hospital service);

(8) Transportation of any person other than the medicaid-eligible individual and an attendant who accompanies the medicaid-eligible individual; and

(9) Duplicate attendant services provided by the same individual simultaneously to more than one passenger.

(B) Travel to the point of pick-up or from the point of drop-off is considered to be intrinsic to the transportation service. No separate payment is made for the cost of such travel, nor can it be billed to the medicaid-eligible individual.

(C) An entity that furnishes transportation to a medicaid-eligible individual but is not an eligible provider at the time of transport may submit a claim for that service in accordance with Chapter 5160-1 of the Administrative Code after it has become an eligible provider of transportation services.

(D) Certain coverage limitations are based on the length of a transport.

(1) Mileage payment for a non-emergency transport (either by wheelchair van or by ground ambulance) that is longer than fifty miles from the point of pick-up will be limited to fifty miles unless a transportation provider maintains additional documentation that justifies the distance.

(2) Claims for transportation by wheelchair van or by ground ambulance from an origin or to a destination that is not in Ohio nor in one of the states contiguous to Ohio are subject to manual review.

(E) Claims for loaded mileage are to represent, individually and collectively, only the distance that was actually traveled. When more than one medicaid-eligible individual is transported at the same time, then loaded mileage for the shared portion of the trip should be allocated in a reasonable, consistent manner.

(F) Payment may be made for the transport of a medicaid-eligible individual to or from a medicaid-coverable service that is canceled (or otherwise becomes unavailable before the medicaid-eligible individual arrives) if the following conditions apply:

(1) The transport was provided in accordance with all applicable requirements of this chapter;

(2) The transportation provider received no prior notice of the cancellation or unavailability of the medicaid-coverable service either from the provider of the medicaid-coverable service or from the medicaid-eligible individual;

(3) The cancellation or unavailability of the medicaid-coverable service was not the result of any action or inaction on the part of the transportation provider;

(4) Before submitting a claim, the transportation provider obtains the following items from the provider of the medicaid-coverable service:

(a) The business name, address, and telephone number of the provider of the medicaid-coverable service;

(b) The scheduled date and time of the medicaid-coverable service that was canceled or became unavailable;

(d) A statement that the provider of the medicaid-coverable service was unable to give notice of the cancellation or unavailability of the medicaid-coverable service before the medicaid-eligible individual was en route; and

(e) The printed name and the signature of an authorized representative of the provider of the medicaid-coverable service; and

(5) On the claim for both the transport and the actual loaded mileage, the transportation provider indicates that the medicaid-coverable service was canceled or became unavailable.

(G) No payment can be made for services provided to an individual who has already died. The coverage of ambulance services is therefore affected by the time of pronouncement of death, which can be made only by someone who is licensed to do so under Ohio law.

(1) If a medicaid-eligible individual is pronounced dead either before an ambulance is called or while arrangements for an ambulance can still be canceled, then no payment is made.

(2) If a medicaid-eligible individual is pronounced dead after an ambulance is called and either the ambulance has not yet begun transport or arrangements for the ambulance can no longer be canceled, then payment may be made for the transport but not for loaded mileage.

(a) If the vehicle is a ground ambulance, then payment may be made for BLS (either emergency or non-emergency). Payment may be made instead for ALS1 or ALS2, with manual review, if there is documentation that the ambulance crew provided a corresponding level of service at the scene.

(b) If the vehicle is an air ambulance, then payment may be made for the appropriate air transport.

(3) If a medicaid-eligible individual is pronounced dead in the ambulance en route to the destination, then payment is made as if the death of the medicaid-eligible individual had not occurred.

(H) Claims for ambulance services provided to medicaid-eligible individuals who also have medicare coverage are paid in accordance with Chapter 5160-1 of the Administrative Code. On claims for services provided to such dually eligible individuals, medicaid does not make separate payment for mileage beyond the closest appropriate facility.

(I) Wheelchair van service is always of a non-emergency nature and does not involve medical treatment. No part of a trip (transport, loaded mileage, or attendant services) can be claimed as wheelchair van service if there is an expectation in advance that the transportation provider will provide medical treatment to a medicaid-eligible individual en route.

Last updated May 11, 2026 at 1:01 PM

History

Effective: July 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-15-27 Transportation: services from an eligible provider: documentation.

(A) Certification is needed to confirm the necessity of wheelchair van services and most non-emergency ambulance services. No certification is needed for transportation services furnished by an eligible provider that are automatically deemed to be necessary in accordance with rule 5160-15-22, 5160-15-23, or 5160-15-24 of the Administrative Code. A medicaid managed care organization (MCO) is not obliged to use the practitioner certification process described in paragraph (B) of this rule to certify the necessity of a transportation service furnished to a medicaid-eligible individual enrolled in the MCO.

(B) For transportation services that need certification but are not furnished to a medicaid-eligible individual enrolled in an MCO, a practitioner certification form is used.

(1) The nature of the practitioner certification form depends on the type of transportation service.

(a) For wheelchair van services, an ODM 03452, "Certification of Necessity for Transportation by Wheelchair Van," is used.

(b) For non-emergency ground ambulance services, documents required by the primary payer of the claim are acceptable; if medicaid is the primary payer, then an ODM 01960, "Certification of Necessity for Non-Emergency Transportation by Ground Ambulance," is used.

(c) For air ambulance services, any document that includes the information specified in paragraph (B)(1)(b) of rule 5160-15-24 of the Administrative Code is acceptable.

(2) If practitioner certification for a transportation service is needed, then the transportation provider obtains a completed, signed, and dated practitioner certification form before submitting a claim.

(a) The date shown on the form is the actual date of signature.

(b) The date of signature cannot be more than one hundred eighty days after the latter of two dates:

(i) The first date of service; or

(ii) The date on which the transportation provider learns of the individual's medicaid eligibility.

(c) In no case does the date of signature on the practitioner certification form extend the limits specified in Chapter 5160-1 of the Administrative Code for the timely filing of claims.

(d) Persons who sign on behalf of the certifying practitioner, with proper authority or the approval of the certifying practitioner, are to add the practitioner's name as well as their own signature and professional designation (such as MD, DO, DPM, RN, APN, PA, LSW).

(e) A photocopy, an electronic copy, or a facsimile transmittal of the completed, signed, and dated practitioner certification form is as valid as the original for documentation purposes.

(3) Certification cannot create a conflict of interest for the practitioner. No person employed by, under contract with, serving in a volunteer capacity for, or otherwise associated with a transportation provider can certify the necessity of a service furnished by that provider.

(4) A transportation provider may submit a claim to the Ohio department of medicaid (ODM) for a specific one-way or round-trip transport after having obtained an incomplete practitioner certification form if the following conditions apply:

(a) The transportation provider has made three attempts to obtain the completed form;

(b) The transportation provider has allowed no fewer than thirty calendar days for receipt of a reply after each attempt; and

(5) For wheelchair van services and non-emergency ground ambulance services, a practitioner may designate one of two certification periods, each of which begins on the earlier of the date of signature or the first date of service:

(a) Temporary certification for up to ninety days; or

(b) Ongoing certification for one year.

(6) If a change in a medicaid-eligible individual's status renders the current practitioner certification form obsolete, then a new form is to be completed.

(7) No payment is to be made for transportation services provided during the certification period that do not meet the certification criteria. For example, payment cannot be made for a transport by wheelchair van provided during the certification period if no mobility device is involved.

(8) A patently incorrect practitioner certification form is invalid, even if it is signed.

(9) False certification constitutes medicaid fraud. The following examples illustrate false certification:

(a) For transport by wheelchair van, certification that a medicaid-eligible individual must be accompanied by a mobility device is false if the medicaid-eligible individual in fact has no need for and never uses a mobility device.

(b) For non-emergency transport by ground ambulance, certification that a medicaid-eligible individual requires medical treatment or continuous supervision by an EMT during transport is false if such treatment or supervision could reasonably and appropriately be supplied by someone who has not had training to the level of an EMT.

(10) Certification is not transferrable between medicaid-eligible individuals or transportation providers.

(C) Each transportation provider is expected to maintain documentation that fully accounts for the services provided. No payment is to be made for a service for which a transportation provider fails to obtain necessary documentation before submitting a claim to ODM or to an MCO. All records and documentation related to transportation services are subject to retention provisions set forth in Chapter 5160-1 of the Administrative Code.

(D) Each transportation provider is to maintain the following records:

(1) Copies of all certification or licensure documents required for crew members and attendants, which must be current at the time of the transport;

(2) Completed practitioner certification forms, when applicable;

(3) Copies of completed requests for manual review, when applicable;

(4) The relevant trip information specified in agency 4766 of the Administrative Code; and

(5) The following medicaid-specific trip information:

(a) Identification of the particular vehicle used;

(b) The name of each wheelchair van attendant, when applicable;

(d) For non-emergency trips, the signature of each medicaid-eligible individual transported.

Last updated August 3, 2026 at 8:16 AM

History

Effective: August 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-15-28 Transportation: services from an eligible provider: payment.

(A) The amount of payment for a transportation service furnished by an eligible provider on a fee-for-service basis is the lesser of either the provider's submitted charge or the medicaid maximum payment amount for the date of transport. The medicaid maximum payment amounts for transportation services are listed in the appendix to this rule.

(B) The amount of payment for a transportation service furnished by an eligible provider under an arrangement with a medicaid managed care organization (MCO) is determined by the provider agreement established in accordance with section 5167.10 of the Revised Code.

View Appendix

Last updated August 3, 2026 at 8:16 AM

History

Effective: August 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-15-30 Transportation: services from an eligible provider: supplemental payment for ground emergency medical transportation service providers.

(A) Purpose. This rule implements section 5164.96 of the Revised Code regarding supplemental medicaid payments to eligible emergency medical services organizations operated by a government entity.

(B) Definitions applicable to this rule.

(1) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code.

(2) "Ground ambulance transport" comprises the following service categories:

(a) Basic life support, provided in an emergency (BLS emergency);

(b) Basic life support, provided in a non-emergency (BLS non-emergency);

(d) Advanced life support, level 1, provided in a non-emergency (ALS1 non-emergency);

(e) Advanced life support, level 2 (ALS2);

(f) Specialty care transport (SCT);

(g) Ground mileage; and

(h) Extra ambulance attendant.

(3) "Ground emergency medical transportation service provider" is an emergency medical service organization that renders emergency medical services in ground ambulance vehicles.

(4) "Qualified ambulance provider (QAP)" is a ground emergency medical transportation service provider that is operated by a government entity and is enrolled in medicaid as an eligible provider.

(1) Each QAP seeking to participate in the supplemental payment program submits the following documents and information:

(a) A voluntary election to participate on form ODM 10378, "Application for Supplemental Medicaid Payment to a Government-Operated Emergency Medical Service (EMS) Provider";

(b) An agreement with the Ohio department of medicaid that sets forth the responsibilities of the parties with respect to the supplemental payment program; and

(2) For the budget biennium beginning on July 1, 2025, the submission deadline for the documents and information listed in paragraphs (C)(1)(a) to (C)(1)(c) of this rule is the first business day after the thirtieth calendar day following the effective date of this rule. For each subsequent budget biennium, the submission deadline is one year before the start of the biennium.

Last updated April 7, 2025 at 8:10 AM

History

Effective: April 7, 2025
Promulgated Under: 119.03

Chapter 5160-17 Abortions

Ohio Adm.Code 5160-17-01 Abortions.

(A) Reimbursement for abortion services, other than those identified in paragraph (D) of this rule, is restricted to the following circumstances when the appropriate certification in paragraph (B) of this rule is made:

(1) Instances in which the woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed; or

(2) Instances in which the pregnancy was the result of an act of rape and the patient, the patient's legal guardian, or the person who made the report to the law enforcement agency, certifies in writing that a report was filed, prior to the performance of the abortion, with a law enforcement agency having the requisite jurisdiction, unless the patient was physically unable to comply with the reporting requirement and that fact is certified by the physician performing the abortion; or

(3) Instances in which the pregnancy was the result of an act of incest and the patient, the patient's legal guardian, or the person who made the report certifies in writing that a report was filed, prior to the performance of the abortion, with either a law enforcement agency having the requisite jurisdiction, or, in the case of a minor, with a county children services agency established under Chapter 5153. of the Revised Code, unless the patient was physically unable to comply with the reporting requirement and that fact is certified by the physician performing the abortion.

(B) Certification.

(1) Before reimbursement for an abortion can be made, the physician performing the abortion must certify that one of the three circumstances in paragraph (A) of this rule has occurred. The certification must be made on the Ohio department of job and family services "Abortion Certification Form" JFS 03197, contained in appendix A of this rule. The physician's signature must be in the physician's own handwriting. All certifications must contain the name and address of the patient. The certification form must be attached to the billing invoice.

(2) The certification must be as follows:

I certify that, on the basis of my professional judgment, this service was necessary because:

(a) The woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed; or

(b) The pregnancy was the result of an act of rape and the patient, the patient's legal guardian, or the person who made the report to the law enforcement agency certified in writing that a report was filed, prior to the performance of the abortion, with a law enforcement agency having the requisite jurisdiction; or

(c) The pregnancy was the result of an act of incest and the patient, the patient's legal guardian, or the person who made the report certified in writing that a report was filed, prior to the performance of the abortion, with either a law enforcement agency having the requisite jurisdiction, or, in the case of a minor, with a county children services agency established under Chapter 5153. of the Revised Code; or

(d) The pregnancy was the result of an act of rape and in my professional opinion the recipient was physically unable to comply with the reporting requirement; or

(e) The pregnancy was a result of an act of incest and in my professional opinion the recipient was physically unable to comply with the reporting requirement.

(3) Reimbursement will not be made for associated services such as anesthesia, laboratory tests, or hospital services if the abortion service itself cannot be reimbursed. All abortion services for the purposes of paragraph (A) of this rule must be submitted to the department on a hard copy billing invoice.

(C) Documentation that supports the certification made by the physician must be maintained by the physician in the recipient's medical record. When the physician certifies that paragraph (B)(2)(b) or (B)(2)(c) of this rule is true, a copy of a signed statement by the patient, the patient's legal guardian, or the person who made the report must be maintained in the patient's medical record.

(D) Nothing in this rule shall be construed to deny reimbursement for drugs or devices to prevent implantation of the fertilized ovum, or for medical procedures for the termination of an ectopic pregnancy. The requirements stated in this rule do not apply to those abortions that are treatments for incomplete, missed, or septic abortions.

History

Effective: March 1, 2005
Promulgated Under: 119.03

Chapter 5160-18 Freestanding Birth Center Services

Ohio Adm.Code 5160-18-01 Freestanding birth center services.

(A) Definitions.

(1) "Freestanding birth center (FBC)" is an entity defined in 42 U.S.C. 1396d(l)(3)(B) (in effect as of January 1, 2023) that is operated in conformity with rules 3701-83-33 to 3701-83-42 of the Administrative Code.

(2) "Independent practitioner" and "non-independent practitioner" have the same meaning as in rule 5160-4-02 of the Administrative Code.

(3) "Low-risk expectant mother" has the same meaning as in rule 3701-83-33 of the Administrative Code.

(B) Coverage. Payment may be made for covered services provided to a low-risk expectant mother.

(1) Facility services. A single "bundled" payment is made to an FBC for all covered obstetrical care (antepartum, delivery, postpartum, and newborn care services), including healthcare services listed in rule 3701-83-36 of the Administrative Code. If delivery does not occur at the FBC, payment is made for the discrete covered services.

(2) Professional services. Additional professional payment is also made to an independent practitioner, or to an FBC on behalf of either an independent practitioner or a non independent practitioner, for the performance of discrete covered services including but limited to the following examples:

(a) Antepartum services;

(b) Intrapartum services, delivery, postpartum, and newborn care services listed in rule 3701-83-36 of the Administrative Code;

(d) The administration of a pharmaceutical;

(e) Reproductive health services (including the provision of contraceptive supplies); or

(f) The professional component of a covered service comprising both professional and technical components.

(C) Claim payment. The maximum payment for a covered item or service in the following list is established in accordance with the indicated rules of the Administrative Code:

(1) "Bundled" or discrete covered services payment made to an FBC appendix DD to rule 5160-1-60;

(2) Professional payment:

(a) Medical or radiological service Chapter 5160-4, for which maximum payment amounts are published in appendix DD to rule 5160-1-60;

(b) Immunization, injection or infusion (including trigger-point injection), skin substitute, or provider-administered pharmaceutical rule 5160-4-12;

(d) Laboratory service rule 5160-11-11; or

(e) Reproductive health service Chapter 5160-21, for which maximum payment amounts are published in appendix DD to rule 5160-1-60.

Last updated January 3, 2023 at 9:22 AM

History

Effective: January 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-18-02 Pediatric recovery centers (PRCs).

(A) This rule defines coverage and payment for providers who meet the provisions in sections 5103.60, 5103.602, 5103.603, 5103.6010, 5103.6011, 5103.6017 and 5103.6018 of the Revised Code and the provisions described in this rule.

(B) Definitions. For the purpose of this rule the following definitions apply:

(1) "Clinical Director" is a practitioner of physician services who supervises day-to-day clinical operations of the pediatric recovery center (PRC) including clinical practice standards and quality improvement in collaboration with the medical director. The clinical director will also be responsible for coordinating outreach and education to referring entities.

(2) "Direct care costs" are costs for services delivered to an infant treated at a PRC through a PRC employee or contractual arrangement with a PRC. Direct care costs include wages, supervision, staff development, contracting, and consulting services.

(3) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code.

(4) "Medical Director" means a practitioner of physician services who assumes responsibility for administering all medical services performed by the PRC, either by performing them directly or by delegating specific responsibility to authorized program physicians and health care professionals functioning under the medical director's supervision. The medical director will have hospital admitting privileges.

(5) "Non-pharmacological care" means evidence-based treatment, excluding the use of pharmacological interventions, for withdrawal that is recognized by the American academy of pediatrics or another nationally recognized organization with expertise in withdrawal treatment.

(6) "Pediatric recovery center (PRC)" has the same meaning as "residential infant care center" in section 5103.60 of the Revised Code.

(7) "Pharmacological care" means the use of prescribed medications indicated to relieve moderate to severe signs of withdrawal and to prevent complications such as fever, weight loss, and seizures that is recognized by the American academy of pediatrics or another nationally recognized organization with expertise in withdrawal treatment.

(1) Billing ("pay-to") provider. The following eligible providers may receive medicaid payment for submitting a claim for a covered PRC service:

(a) PRCs.

(b) Professional medical groups with a PRC specialty.

(D) Staffing:

(1) In addition to the operational requirements in section 5103.6010 of the Revised Code, a PRC will employ or contract with the following providers:

(a) Medical director with hospital admitting privileges; and

(b) Clinical director to establish, supervise and evaluate clinical services.

(2) The PRC will ensure all clinical and professional staff who provide direct care to or interact with patients and families complete training in trauma-informed care annually and for new employees within thirty calendar days of start date.

(E) Coverage:

(1) Payment may be made only for a PRC service for which the following conditions are met:

(a) The service is medically necessary in accordance with rule 5160-1-01 of the Administrative Code.

(b) For admission to a PRC, the following criteria are met:

(i) The infant is recommended or referred by a practitioner of physician services, a public children services agency, a parent, guardian, or legal custodian.

(ii) The infant is considered medically stable as determined by hospital or other facility discharge; and

(iii) The infant's parent or caregiver would benefit from additional education and support services regarding care for the patient.

(c) The PRC develops and implements a program for parents and caregivers of the infant, either individually or in a group setting to address:

(i) Activities to encourage caregiver-infant bonding.

(ii) Advising on caring for infants with physical withdrawal symptoms.

(iii) Referrals for services and counseling; and

(iv) Training on caring for infants.

(F) Payment:

(1) The medicaid base per diem rate includes medically necessary PRC services provided to the infant during their stay at the PRC for up to thirty consecutive days.

(2) PRC per diem payments in excess of thirty days may be made through the prior authorization (PA) process described in rule 5160-1-31 of the Administrative Code. If treatment goals are not accomplished within a consecutive thirty day timeframe, it is the PRC's responsibility to justify why a longer stay is needed.

(a) The justification for a continued stay should be directly related to the physical withdrawal symptoms of the infant which have not improved and should include the following:

(i) A documented medical diagnosis related to significant substance exposure resulting in withdrawal.

(ii) A description of the infant's condition including on-going physical withdrawal symptoms and additional unimproved symptoms requiring medically necessary care in this setting; and

(iii) A detailed care plan with the anticipated period of time for treatment goals to be met.

(b) A lack of post-discharge options alone will not be considered a valid basis for a continued stay at a PRC.

(3) The per diem rate includes the following:

(a) Activities to encourage caregiver-infant bonding.

(b) Advising on caring for infants with physical withdrawal symptoms.

(d) Direct care costs.

(e) Discharge planning.

(f) Non-pharmacological care for infants with significant substance exposure resulting in withdrawal.

(g) Pediatric medical services including but not limited to prescribing medication, administering rectal or intravenous medication, outpatient laboratory services, sick visits, and onsite well child exams.

(h) Pharmacological care for infants with significant substance exposure resulting in withdrawal; and

(i) Training on caring for infants.

(4) Services not included in the PRC per diem reimbursement rate for which a separate medicaid payment may be made include, but are not limited to:

(a) Direct services provided to medicaid eligible parents or caregivers.

(b) Healthcare-related transportation services defined in Chapter 5160-15 of the Administrative Code.

(d) Other services specifically authorized in rule promulgated under agency 5160 of the Administrative Code.

(5) For any covered PRC service, payment is the lesser of the provider's submitted charge or the maximum amount specified in appendix DD to rule 5160-1-60 of the Administrative Code.

Last updated July 1, 2025 at 8:06 AM

History

Effective: July 1, 2025
Promulgated Under: 119.03

Chapter 5160-19 Patient-Centered Medical Homes

Ohio Adm.Code 5160-19-01 Comprehensive primary care (CPC) program: eligible providers.

(A) For the purpose of rules 5160-19-01 and 5160-19-02 of the Administrative Code, the following definitions apply:

(1) "Attribution" is the process through which medicaid recipients are assigned to specific primary care practitioners (PCPs) who are able to participate in the medicaid program in accordance with rule 5160-1-17.2 of the Administrative Code. The Ohio department of medicaid (ODM) is responsible for attributing fee-for-service recipients; medicaid managed care organizations (MCOs) are responsible for attributing their enrolled recipients. CPC entities who are not able to participate in accordance with rule 5160-1-17.2 of the Administrative Code at the time of attribution or during the prospective payment period are not eligible for payment until the next attribution period following the provider's reinstatement. The following hierarchy will be used in assigning recipients to PCPs under the CPC and CPC for kids program:

(a) The recipient's choice of provider.

(b) Claims data concerning the recipient.

(2) "Baseline year" is a twelve month calendar year, typically two years preceding the performance period unless otherwise specified by ODM. More information about baseline years can be found at www.medicaid.ohio.gov."

(3) "CPC attributed medicaid individuals" are Ohio medicaid recipients for whom PCPs have accountability under a CPC entity. A PCP's attributed medicaid individuals are determined by ODM or the MCOs. All medicaid recipients are attributed. The following attributed individuals are excluded from CPC program quality and efficiency metrics, total cost of care calculations, and per member per month payments:

(a) Recipients dually enrolled in both medicare and Ohio medicaid.

(b) Recipients not eligible for the full range of medicaid benefits.

(c) Recipients with third party benefits as defined in rule 5160-1-08 of the Administrative Code except for recipients with exclusively third party dental or third party vision coverage.

(d) Recipients enrolled in a prepaid inpatient health plan, as defined in 42 C.F.R. 438.2 (as in effect on October 1, 2025), under contract with ODM.

(4) "Convener" is the practice responsible for acting as the point of contact for ODM and the practices who form a practice partnership.

(5) "CPC entity" is a single practice or a practice partnership participating in CPC.

(6) "CPC for kids" program is a voluntary enhancement to the CPC program focused on attributed pediatric medicaid covered individuals under twenty-one years of age.

(7) "Eligible provider" is as defined in rule 5160-1-17 of the Administrative Code.

(8) "A Patient-centered medical home (PCMH)" is a team-based care delivery model led by PCPs who comprehensively manage the health needs of individuals. Provider enrollment in ODM's PCMH program, known as the CPC program is voluntary. A CPC entity may be a single practice or a practice partnership.

(9) "Performance period" is the twelve month calendar year period of participation in the CPC program by an enrolled CPC entity. An enrolled CPC entity's first performance period begins the first of January after their enrollment in the program.

(10) "Population health management" is an approach to maintain and improve physical and psychosocial well-being and address differences in health outcomes among communities through cost-effective, person-centered health solutions that address members' health needs in multiple settings at all points along the continuum of care.

(11) "Practice Partnership" is a group of practices participating as a CPC entity whose performance will be evaluated as a whole. The practice partnership has to meet the following provisions:

(a) Each member practice will have a minimum of one hundred fifty attributed medicaid individuals determined using claims-only data.

(b) Member practices will have a combined total of five hundred or more attributed individuals determined using claims-only data at each attribution period.

(d) Each member practice will acknowledge to ODM its participation in the partnership.

(e) Each member practice will agree that summary-level practice information will be shared by ODM among practices within the partnership.

(B) The following eligible providers may participate in ODM's CPC program through their contracts with MCOs or provider agreements for participation in medicaid fee-for-service in accordance with rule 5160-1-17.2 of the Administrative Code:

(1) Individual physicians and practices.

(2) Professional medical groups.

(3) Rural health clinics.

(4) Federally qualified health centers.

(5) Primary care clinics.

(6) Public health department clinics.

(7) Professional medical groups billing under hospital provider types.

(C) The following eligible providers may participate in the delivery of primary care activities or services in the CPC program:

(1) Medical doctor (MD) or doctor of osteopathy (DO) as defined in section 4731.14 of the Revised Code with any of the following specialties or sub-specialties:

(a) Family practice.

(b) General practice.

(d) Internal medicine.

(e) Pediatric.

(f) Public health.

(g) Geriatric.

(2) Clinical nurse specialist, certified nurse midwife, or certified nurse practitioner as defined in section 4723.41 of the Revised Code and has any of the following specialties:

(a) Pediatric.

(b) Adult health.

(d) Family practice.

(3) Physician assistant as defined in section 4730.11 of the Revised Code.

(D) To be eligible for enrollment in the CPC program, the CPC will have at least five hundred attributed medicaid individuals determined using claims-only data, and attest that it will continue to meet all of the provisions described in paragraph (F) of this rule as of the first day of January in the program year.

(E) To be eligible for enrollment in the CPC for kids program, the CPC entity will:

(1) Be a CPC entity that participates in ODM's CPC program for the same performance period.

(2) Have at least one hundred fifty attributed pediatric medicaid individuals determined using claims-only data.

(F) It is the responsibility of an enrolled CPC entity to complete population health activities within the time frames stated in this rule and have written policies where specified. Further descriptions of these activities can be found on the ODM website, www.medicaid.ohio.gov. Upon enrollment and on an annual basis, the CPC entity is expected to attest that it will:

(1) Complete the "twenty-four-seven and same-day access to care" activities in which the CPC entity will:

(a) Offer at least one alternative to traditional office visits to increase access to the patient care team and clinicians in ways that best meet the needs of the population. This may include, but is not limited to, e-visits, phone visits, group visits, home visits, alternate location visits, or expanded hours in the early mornings, evenings, and weekends.

(b) Provide twenty-four-seven and same-day access to a PCP with access to the attributed medicaid individual's medical record.

(c) Make clinical information of the attributed medicaid individual available through paper or electronic records, or telephone consultation to on-call staff, external facilities, and other clinicians outside the practice when the office is closed.

(2) Complete the "risk stratification" activities in which the CPC entity will have a developed method for documenting patient risk level that is integrated within the attributed medicaid individual's record and has a clear approach to implement this across the practice's entire patient panel.

(3) Complete the "population health management" activities in which the CPC entity will identify attributed medicaid individuals, in groups or segments by using practice-defined common characteristics, in need of preventive or chronic services and outreach to schedule applicable appointments or identify additional services needed to meet the needs and improve the health of the identified group or segment of attributed medicaid individuals.

(4) Complete the "continuous quality improvement" activities in which the CPC entity will demonstrate regular and ongoing quality improvement through the use of quality improvement projects, quality goals for outcome metrics, quality improvement education for staff, quality improvement committees, or other quality improvement activities that also includes the voice of the patient and the provider to continuously improve the quality of care for attributed medicaid individuals.

(5) Complete the "care coordination" activities in which the CPC entity will identify and close gaps in care and refer attributed medicaid individuals for further intervention as needed, including referrals to MCOs or community resources as appropriate.

(6) Complete the "follow-up after hospital discharge" activities in which the CPC entity will have established relationships with all emergency departments and hospitals from which it frequently receives referrals and has an established process to ensure a reliable flow of information.

(7) Complete the "tests and specialist referrals" activities in which the CPC entity will have established bi-directional communication with specialists, pharmacies, laboratories, and imaging facilities necessary for tracking referrals.

(8) Complete the "patient, CPC entity staff, and provider experience" activities in which the CPC entity will:

(a) Orient all attributed medicaid individuals to the practice and incorporate patient preferences in the selection of a PCP to build continuity of attributed medicaid individual relationships throughout the entire care process.

(b) Ensure all staff who provide direct care or otherwise interact with attributed medicaid individuals complete cultural competency training, as deemed acceptable by ODM, within six months of program enrollment and annually thereafter.

(c) Ensure that new staff who will provide direct care or otherwise interact with attributed medicaid individuals complete cultural competency training within thirty days of their start date.

(d) Routinely assess demographics and adapt training needs based on demographics.

(e) Assess its approach to attributed medicaid individual experience and cultural competency at least once annually through the use of the patient and family advisory council (PFAC) or other quantitative and qualitative means, such as focus groups or a patient survey, that covers access to care, communication, coordination, whole person care, and self-management support.

(f) Use the information collected pursuant to paragraph (F)(8)(e) of this rule to identify and act on opportunities to improve attributed medicaid individual experience and reduce differences in health outcomes among communities, including differences in the identification, treatment, and outcomes related to chronic conditions such as asthma, diabetes, and cardiovascular health. The CPC entity will report findings and opportunities to attributed medicaid individuals, the PFAC, payers, and ODM.

(g) Demonstrate a means of assessing staff and provider satisfaction at least once annually by using resources such as meeting minutes, surveys, or a comment box.

(9) Complete the "community services and supports integration" activities in which the CPC entity will identify medicaid covered individuals in need of community services and supports and maintain a process to connect attributed medicaid individuals to necessary services.

(10) Complete the "behavioral health integration" activities in which the CPC entity will use screening tools to identify attributed medicaid individuals in need of behavioral health services, track and follow up on behavioral health service referrals, and have a planned improvement strategy for behavioral health outcomes.

(11) Cooperate with and grant access to ODM or its designee for the purpose of conducting activity requirement evaluations.

(12) Participate in learning activities as determined by ODM or its designee.

(13) Share all requested data with ODM and its contracted MCOs.

(14) Conduct outreach and deliver primary care services to attributed medicaid individuals who are not current patients.

(15) Actively use an electronic health record (EHR) in clinical services.

(G) It is the responsibility of a CPC entity to pass the following efficiency metrics representing at least fifty per cent of applicable metrics, to be evaluated annually at the end of each performance period. Further details regarding these metrics can be found on the ODM website, www.medicaid.ohio.gov.

(1) Inpatient admission for ambulatory care sensitive conditions (ACSCs).

(2) Emergency room visits per one thousand.

(3) Behavioral health related inpatient admissions per one thousand.

(4) Adherence to the single preferred drug list.

(H) It is the responsibility of a CPC entity to pass a number of the following clinical quality metrics representing at least fifty per cent of applicable metrics, to be evaluated annually at the end of each performance period. Further details regarding these metrics can be found on the ODM website, www.medicaid.ohio.gov.

(1) Well-child visits in the first fifteen months of life.

(2) Child and adolescent well-child visits for members who are three to eleven years of age.

(3) Child and adolescent well-child visits for members who are twelve to seventeen years of age.

(4) Weight assessment and counseling for nutrition and physical activity for children and adolescents. Body mass index (BMI) assessment for children and adolescents.

(5) Timeliness of prenatal care.

(6) Live births weighing less than two thousand five hundred grams.

(7) Postpartum care.

(8) Chlamydia screening for women.

(9) Cervical cancer screening.

(10) Controlling high blood pressure.

(11) Asthma medication ratio.

(12) Statin therapy for attributed medicaid individuals with cardiovascular disease.

(13) Glycemic status assessment for patients with diabetes.

(14) Comprehensive diabetes care: blood pressure control.

(15) Comprehensive diabetes care: eye exam.

(16) Follow up after emergency department (ED) visit for mental illness.

(17) Follow-up after hospitalization for mental illness.

(18) Preventive care and screening: tobacco use, screening and cessation intervention.

(19) Initiation and engagement of alcohol and other drug dependence treatment.

(20) Well visits for members who are eighteen to twenty-one years of age.

(21) Well visits for members who are fifteen to thirty months of age.

(22) Follow up after ED visit for substance use.

(I) It is the responsibility of a CPC entity participating in CPC for kids to also pass at least fifty per cent of the applicable metrics from the following list of clinical quality metrics, to be evaluated annually at the end of each performance period. Further details regarding these metrics can be found on the ODM website, www.medicaid.ohio.gov.

(1) Lead screening in children.

(2) Childhood immunization status.

(3) Immunizations for adolescents.

(4) Well-child visits in the first fifteen months of life.

(5) Child and adolescent well-child visits for members who are three to eleven years of age.

(6) Child and adolescent well-child visits for members who are twelve to seventeen years of age.

(7) Weight assessment and counseling for nutrition and physical activity for children and adolescents. BMI assessment for children and adolescents.

(8) Well visits for members who are eighteen to twenty-one years of age.

(9) Well visits for members who are fifteen to thirty months of age.

(10) Oral evaluation, dental services.

(J) It is the responsibility of a CPC entity participating in CPC for kids to also pass at least one of the following clinical quality metrics when applicable, to be evaluated annually at the end of each performance period. Further details regarding these metrics can be found on the ODM website, www.medicaid.ohio.gov.

(1) Lead screening in children.

(2) Childhood immunization status.

(3) Immunizations for adolescents.

(K) A CPC entity may utilize reconsideration rights as stated in rules 5160-70-01 and 5160-70-02 of the Administrative Code to challenge a decision of ODM concerning CPC or CPC for kids program enrollment or eligibility.

Last updated January 5, 2026 at 8:49 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-19-02 Comprehensive primary care (CPC) program: payments.

(A) A comprehensive primary care (CPC) entity has to be enrolled and meet the provisions set forth in rule 5160-19-01 of the Administrative Code to be eligible for patient centered medical home (PCMH) payments.

(B) A CPC entity participating in the CPC for kids program has to be enrolled as a CPC entity and meet all provisions set forth in rule 5160-19-01 of the Administrative Code to be eligible for CPC for kids payments.

(1) The "CPC per-member-per-month (PMPM)" is a payment to support the CPC entity.

(a) Payment is in the form of a prospective risk-adjusted PMPM payment that is calculated for each attributed medicaid individual except for individuals attributed to other population health alternative payment models administered by the Ohio department of medicaid (ODM) under Chapter 5160-19 of the Administrative Code. Further detail regarding risk-adjustment can be found on the ODM website, www.medicaid.ohio.gov.

(b) Payment begins following enrollment and in accordance with the payment schedule determined by the Ohio department of medicaid (ODM).

(2) The "CPC for kids enhanced PMPM" is a payment to support the CPC entities participating in the CPC for kids program.

(a) Payment is in the form of a prospective flat PMPM payment per attributed medicaid pediatric individual except for those excluded in rule 5160-19-01 of the Administrative Code.

(b) Payment begins following CPC entity enrollment in CPC for kids and in accordance with the payment schedule determined by ODM.

(3) The "CPC shared savings payment" is a payment for a CPC entity to reward total cost of care savings.

(a) To be eligible for the CPC shared savings payment, the CPC entity has to meet the following:

(i) The CPC entity has to meet quality, efficiency, and financial outcomes outlined in rule 5160-19-01 of the Administrative Code;

(ii) The CPC entity has at least sixty thousand member months in the performance period;

(iii) The CPC entity achieves savings on its total cost of care during the performance period compared to its own baseline total cost of care performance by performing in the top decile of all CPC entities based on total cost of care performance. The total cost of care for a CPC entity is calculated by summing all claims for a given patient, plus any PMPM payment that the CPC entity has received through the CPC program, minus the following exclusions and taking into account the overall risk status of the population. Baseline total cost of care calculations may be adjusted mid-performance year as necessary to reflect factors such as population acuity shifts. The following categories of expenditures are excluded:

(a) All expenditures for waiver services.

(b) All expenditures for dental, vision, and transportation services.

(c) All expenditures in the first year of life for attributed medicaid individuals with a neonatal intensive care unit (NICU) level three or four stay.

(d) All expenditures for outliers within each risk tier as determined by statistical methods described on the ODM website, www.medicaid.ohio.gov.

(e) All expenditures for individuals with more than ninety consecutive days in a long-term care facility.

(b) The CPC shared savings payment consists of the following:

(i) An annual retrospective payment equivalent to a percentage of the savings on total cost of care over the course of the performance period. The percentage is determined by the CPC entity's total cost of care for its attributed medicaid individuals as defined in rule 5160-19-01 of the Administrative Code.

(ii) An annual retrospective bonus payment based on total cost of care for CPC entities in the top-performing decile, to be determined annually by ODM and not to exceed one million dollars.

(4) The "CPC for kids bonus payment" is an annual retrospective payment for the highest performing CPC entities participating in the CPC for kids program that meet quality and efficiency outcomes and perform additional bonus activities focused on improving pediatric care.

(a) To be eligible for the CPC for kids bonus payment, the CPC entity has to be a high performing CPC relative to other CPC entities participating in the CPC for kids program based on performance of risk-adjusted scoring of the following pediatric bonus activities, which will be determined by ODM and evaluated annually during each performance period. More information on the CPC for kids program can be found on the ODM website, www.medicaid.ohio.gov.

(i) Additional supports for children in the custody of a title IV-E agency.

(ii) Integration of behavioral health services.

(iii) School-based health care linkages.

(iv) Transitions of care.

(v) Oral evaluation, dental services.

(b) In the event of a tied score on the pediatric bonus activities, the CPC entity will be ranked for bonus payment based upon the percent of applicable quality and efficiency metrics passed. If there is a tie, then the following will be applied:

(i) The CPC entities are ranked based upon the highest average point performance over threshold across all applicable quality and efficiency metrics, rounded to the nearest percent. If additional ties persist then.

(ii) Bonus payment will be split equally among each CPC entity in the tie group.

(D) Payment and program participation conditions.

(1) A CPC entity has to continue completing activities annually as defined in rule 5160-19-01 of the Administrative Code. If activities are not completed upon evaluation, program participation and payment under this rule terminates.

(2) A CPC entity has to continue to meet efficiency and clinical quality metrics defined in rule 5160-19-01 of the Administrative Code. If any of these metrics are not met in a program year, a warning will be issued. After two consecutive program years of a metric not being met, entity participation in the program and payment under this rule will be terminated.

(3) A CPC entity participating in CPC for kids has to continue to meet clinical quality metrics defined in rule 5160-19-01 of the Administrative Code. If any of these provisions are not met, a warning will be issued. After two consecutive program years of a metric not being met, the CPC for kids entity participation in the program and payments under this rule will be terminated.

(4) ODM may recoup payments if it is discovered that the CPC entity has failed to meet other program provisions defined in rule 5160-19-01 of the Administrative Code.

(E) A CPC entity may utilize reconsideration rights as stated in rules 5160-70-01 and 5160-70-02 of the Administrative Code to challenge decisions by ODM to terminate payments described in this rule.

Last updated January 5, 2026 at 2:50 PM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-19-03 Comprehensive maternal care program.

The "comprehensive maternal care (CMC) program" is a maternal and infant support program that utilizes a comprehensive care coordination and service model incorporating supportive services for expectant and postpartum women to reduce adverse birth and infant outcomes.

(A) For purposes of Chapter 5160-19 of the Administrative Code, the following definitions apply:

(1) "Attribution" is the process through which the Ohio department of medicaid (ODM) or its designee assigns eligible individuals to a specific CMC entity.

(2) "CMC attributed medicaid individuals" are the eligible pregnant and postpartum women for whom an entity eligible under this rule has accountability for coordinating and ensuring the delivery of CMC program activities. All eligible individuals will be attributed except for:

(a) Individuals who are currently receiving another care coordination service that substantially duplicates those activities provided under this program.

(b) Individuals with a limited medicaid benefit plan other than presumptive eligibility for pregnant women.

(d) Individuals with third party benefits as defined in rule 5160-1-08 of the Administrative Code except for those with exclusively dental or vision coverage.

(3) "CMC enrollment lookback period" includes review of final paid or denied professional, medical, and outpatient claims with dates of service from August first of the prior year through July thirty first of the year in which CMC enrollment occurs for the following program year to identify pregnant and postpartum women who have received prenatal and postpartum services.

(4) "CMC entity" is the primary entity which meets the criteria described in this rule and is responsible for meeting CMC program activities for attributed medicaid individuals. The following medicaid providers are eligible to participate and receive payment under this rule:

(a) Professional medical groups as defined in Chapter 5160-1 of the Administrative Code.

(b) Federally qualified health centers (FQHC) and rural health clinics (RHC) as defined in Chapter 5160-28 of the Administrative Code.

(d) Professional medical groups billing under hospital provider types.

(5) "Electronic perinatal risk assessment form" (e-PRAF) is the electronic version of ODM form 10207 "perinatal risk assessment form" (PRAF) that is submitted through the web portal designated by ODM.

(6) "Electronic report of pregnancy" (e-ROP) is the electronic version of ODM form 10257, "report of pregnancy" (ROP) that is submitted through the web portal designated by ODM.

(7) "Eligible provider" is as defined in rule 5160-1-17 of the Administrative Code.

(B) To be eligible and remain eligible for enrollment and participation as a CMC entity for payment in each program year, the CMC entity will:

(1) Have an active Ohio medicaid provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code;

(2) Have provided prenatal and perinatal services to at least one hundred fifty pregnant and postpartum women under the same tax identification number during the CMC enrollment lookback period, as identified through ODM data sources; and

(3) Apply to become a CMC entity. ODM reserves the right to deny any enrollment application it determines is not in compliance with the activities in this rule. An applicant may seek reconsideration pursuant to rule 5160-70-02 of the Administrative Code if ODM has denied a CMC program enrollment application.

(C) At the time of enrollment, the applicant attests that for the duration of its participation, it will do all of the following:

(1) Perform the activities identified in this rule.

(2) Have at least one practitioner from each of the following categories on staff or contracted with the entity:

(a) A practitioner with prescribing authority in the state of Ohio;

(b) A registered nurse (RN) or licensed practical nurse (LPN); and

(c) A case manager to lead the care coordination relationship and serve as the primary point of contact for the attributed medicaid individual.

(3) Demonstrate organizational commitment to integration of physical and behavioral health care by meeting one of the following:

(a) Employ or have under contract one or more licensed behavioral health care clinicians;

(b) Have an integrated care agreement such as a contract or memorandum of understanding with a behavioral health care entity;

(c) Have an ownership or membership interest in a provider organization where primary and behavioral health care services are integrated within the facility structure or entity, and are readily available to attributed medicaid individuals; or

(d) Have accreditation by a national accrediting entity as an integrated primary care-behavioral health provider.

(4) Integrate services of community resources and other practitioners including non-physician licensed or certified behavioral health practitioners described in rule 5160-8-05 of the Administrative Code.

(5) Conduct the following cultural competency activities to advance health and population-based opportunity:

(a) Ensure all clinical and professional staff who provide direct care to or interact with patients complete cultural competency training, meeting criteria established by ODM within six months of program enrollment and annually thereafter and for new employees within thirty calendar days of start date; and

(b) At least annually, assess the demographics of patients served, including race, ethnicity, and language, and adapt training needs for staff based on the results of the assessment.

(6) In the delivery of the CMC program activities, ensure appropriate measures are taken to protect the safety and confidentiality of attributed medicaid individuals in accordance with all state and federal regulations.

(7) Establish or adapt a patient and family advisory council to include members who reflect the demographics of the attributed medicaid individuals served.

(8) Participate in learning activities as determined by ODM or its designee and share data with ODM and contracted managed care organizations (MCOs).

(9) Review reports as specified by ODM.

(10) Actively use an electronic health record (EHR) in clinical services.

(11) Have the ability to share, receive, and use electronic data from a variety of sources with other health care providers, ODM, and the MCOs.

(12) Have the ability to submit prescriptions electronically.

(13) Ensure that an e-PRAF is submitted for every pregnant woman.

(D) Attribution.

(1) The following hierarchy will be used in attributing individuals to a CMC entity:

(a) The eligible individual's choice of provider identified through the completion of the PRAF or e-PRAF.

(b) Pregnancy or postpartum related claims data concerning the eligible individual.

(d) Other data concerning the eligible individual such as geographic location.

(2) All pregnant and postpartum women will be assigned to either of the following risk tiers:

(a) Pregnant or postpartum women who:

(i) Are at risk of pre-term birth based on having had a prior pre-term birth or a shortened cervix as evidenced by vital statistics data or claims history;

(ii) Live in an area determined to have the least access to critical services according to the most recent Ohio opportunity index (OOI); or

(iii) Are considered medically complex as evidenced by claim history indicating substance use disorder, asthma, diabetes, lupus, chronic kidney disease, advanced maternal age (individuals over forty years of age), or cardiovascular disease.

(b) Pregnant or postpartum women up to three months postpartum who do not qualify under the previous tier.

(3) At any time, the eligible individual may choose a specific CMC entity or request to be re-attributed to a different CMC entity by submitting a request to the MCO, ODM or its designee.

(4) Eligible individuals may opt-out of the CMC program and may opt-in at any time by making a request to the MCO, ODM, or its designee.

(E) It is the responsibility of the CMC entity, upon enrollment and on an annual basis, to attest that it will meet the following provisions:

(1) Risk stratification. It is the responsibility of the CMC entity to:

(a) Use risk stratification information from multiple sources (including payers, e-PRAF, screenings tools, electronic health records, and patient history) to risk stratify patients and integrate this information into clinical records and care plans; and

(b) Perform maternal depression screens and use screening tools such as social determinants of health, screenings, brief intervention, and referral to treatment (SBIRT) at routine intervals to identify patients in need of, and connect them to, community services and supports.

(2) Enhanced access. It is the responsibility of the CMC entity to:

(a) Expedite the first prenatal visit by:

(i) Offering appointments within seven calendar days of the patient's initial request; and

(ii) Establishing a process to reduce the gestational age at the first prenatal appointment with the overall goal of achieving the first appointment by the ninth week of gestation.

(b) Offer at least one alternative to traditional office visits to increase access to the patient care team and clinicians in ways that best meet the needs of the population. This may include e-visits, telehealth, phone visits, group visits, home visits, alternate location visits, or expanded hours in the early mornings, evenings, or weekends;

(c) Within one business day of initial request, provide access to a maternal care provider with access to the patient's medical record; and

(d) Make patient clinical information available through paper or electronic records, or telephone consultation to on-call staff, external facilities, and other clinicians outside the entity when the office is closed.

(3) Patient engagement. It is the responsibility of the CMC entity to:

(a) Implement strategies to engage patients early in their care and encourage them to be active participants in their care delivery;

(b) Implement specialized outreach strategies for pregnant women who are attributed to, but have not been seen by, the CMC;

(c) Deliver services in a manner that addresses the social, cultural, and linguistic needs of patients with specific attention to populations with high rates of infant and maternal mortality;

(d) Implement procedures that acknowledge patient consent and choice regarding referrals for needed treatment, community, and other supports;

(e) Assure patient consents are obtained to support exchange of information in compliance with state and federal regulations; and

(f) Establish partnerships with primary care practitioners and payers in order to strengthen the referral process of the CMC entity.

(4) Team based care delivery. It is the responsibility of the CMC entity to:

(a) Define care team members, roles, and qualifications with specific input from the patient regarding team composition (e.g., obstetricians, primary care, behavioral health, pediatricians, doulas, midwives, community workers, care managers, payers and community partners, as applicable);

(b) Establish care team meetings and planned, formal communication (including sharing of care plan documentation) among team members for highest risk patients;

(c) Have a process during the individual's prenatal period to assemble a team of providers who will care for the individual and baby during the postpartum period;

(d) Have active relationships with providers and community resources based on patient population needs; and

(e) Provide various care management strategies in partnership with payers, ODM and other providers, as applicable.

(5) Care management. It is the responsibility of the CMC entity to:

(a) Create, maintain, and update care plans and clinical documentation such as progress notes for the highest risk pregnant women which includes necessary key elements including integrated behavioral health elements, as applicable; and

(b) Identify key activities that need action or follow up by care team members.

(6) Patient, CMC entity staff, and provider experience. It is the responsibility of the CMC entity to:

(a) Have a process to ensure continuity in relationships and care throughout the entire care process including:

(i) A plan to transition patients to appropriate providers and resources as they move through the care continuum; and

(ii) A process to complete a transfer of care (in person or by telephone) with the CMC entity, the patient and members of the care team, specifically the individual's primary care practitioner, pediatric primary care for the baby, behavioral health provider, and community partners as appropriate.

(b) Assess its approach to improving the patient experience at least once annually through quantitative and qualitative means, including the patient and family advisory council, covering such topics as access to care, cultural competence, holistic care, and effective communication;

(c) Use the collected information to identify and act on opportunities to improve patient experience and reduce differences in health outcomes; and

(d) Report findings and opportunities for improvement to patients, patient and family advisory council, payers, and ODM.

(e) Demonstrate a means of assessing and improving staff and provider satisfaction at least once annually by using resources such as meeting minutes, surveys, or a comment box.

(7) Follow-up after hospital discharge. It is the responsibility of the CMC entity to:

(a) Establish relationships with emergency departments (EDs) and hospitals from which it frequently sends and receives referrals and has an established process to ensure a reliable flow of information;

(b) Proactively and consistently obtain patient discharge summaries from hospitals and other facilities, and connect information from discharge summaries to broader entity systems for highest risk tier patients; and

(c) Track patients receiving care at hospitals and EDs, proactively contact patients for appropriate follow-up care given the cause of admission within an appropriate period following a hospital admission or emergency department visit.

(8) Community integration. It is the responsibility of the CMC entity to:

(a) Identify local entities that can help address social and emotional needs of patients and integrate them into activities described in paragraph (F) of this rule, as appropriate;

(b) Participate directly or indirectly in state and local infant and maternal mortality efforts; and

(c) Integrate community services and supports into broader entity systems, including risk stratification, care management plan, and population health management.

(d) Allow patients to have a doula of their choice at any pregnancy related service or appointment. Patients that procure or request the assistance of a doula as part of their prenatal, birth, or postpartum care will be supported by the practice in receiving doula services.

(9) Population health management. It is the responsibility of the CMC entity to:

(a) Identify individuals in need of medical, behavioral, or community support services to drive best-evidence care using multifaceted outreach efforts;

(b) Track and follow up on referrals to medical, behavioral health, and community service providers and ensure no gaps in care;

(d) Have a planned strategy to improve maternal and infant health outcomes segmented by high risk subpopulations, including a planned strategy to reduce differences in outcomes.

(F) It is the responsibility of the CMC entity to pass at least fifty percent of the following clinical quality measures, to be evaluated annually at the end of each performance period. Further details regarding these metrics can be found on the ODM website, www.medicaid.ohio.gov.

(1) Hepatitis B screening.

(2) Maternal primary care visit.

(3) HIV screening.

(4) TDAP vaccine.

(5) Tobacco cessation.

(6) Postpartum care.

(7) Maternal behavioral health screenings (i.e., depression, anxiety, substance use disorder, etc.)

(8) Preterm birth.

(G) The CMC entity may qualify to access the following payments:

(1) The CMC per-member-per-month (PMPM) is a payment to support the CMC entity. Payment is in the form of a prospective PMPM payment that will be calculated for each attributed medicaid individual using ODM's risk tier file to categorize individuals in one of the two risk tiers. Specific information about this payment can be found on the ODM website, www.medicaid.ohio.gov.

(2) The CMC quality add-on payment is made to the CMC entities who meet mandatory quality outcomes. Specific information about this payment can be found on the ODM website, www.medicaid.ohio.gov.

(H) Penalties.

(1) It is the responsibility of the CMC entity to continue meeting all provisions as defined in this rule, including those contained in the described attestations. If these provisions are not met, payment under this rule is subject to termination.

(2) It is the responsibility of the CMC entity to continue meeting mandatory clinical quality measures defined in this rule. If any of these provisions are not met in a program year, a warning will be issued. After two consecutive program years of a metric not being met, payment under this rule will be terminated.

(3) ODM may recoup payments if it is discovered that the CMC entity has failed to meet other program provisions outlined in this rule.

(4) A CMC entity may seek reconsideration pursuant to rule 5160-70-02 of the Administrative Code to challenge decisions by ODM to terminate payment described in this rule.

Last updated January 5, 2026 at 9:36 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Chapter 5160-20 Coordinated Services Program

Ohio Adm.Code 5160-20-01 Coordinated services program: definitions.

The following definitions apply to rule 5160-20-04 of the Administrative Code

(A) "Abuse" means recipient practices that result in unnecessary cost to the medicaid program as defined in rule 5160-26-01 of the Administrative Code.

(B) "Abuse potential drug" means any drug that contains substances which have a potential for abuse because of depressant or stimulant effects on the central nervous system or hallucinogenic effects. Abuse potential drugs include any drug that is reportable to the Ohio automated RX reporting system (OARRS) as described in rules 4729:8-2-01 and 4729:8-2-02 of the Administrative Code, in addition to muscle relaxants and other non-controlled drugs as determined by ODM. Drugs used for medication assisted treatment (MAT) are excluded from consideration.

(C) "Assigned provider" means a pharmacy provider that is authorized to and is not excluded from receiving reimbursement for health care services rendered to an individual. The assigned pharmacy provider is selected to serve as the pharmacy provider for an individual enrolled in the coordinated services program (CSP).

(D) "Coordinated services program" is a program required by section 5164.758 of the Revised Code.

(E) "Fraud" for the purpose of this rule, includes but is not limited to, forged prescriptions, possession and use of multiple medicaid cards, card loaning, and sharing of drugs or other supplies obtained through medicaid.

(F) "Managed care entity" (MCE) means defined in rule 5160-26-01 of the Administrative Code.

(G) "Managed care organization (MCO)" means as defined in rule 5160-26-01 of the Administrative Code.

(H) "Medicare" means defined in rule 5160-1-05 of the Administrative Code.

(I) "Medication Assisted Treatment" (MAT) means as defined in rule 5160-1-73 of the Administrative Code.

(J) "Polypharmacy" for the purpose of this chapter means that a recipient utilized three or more pharmacies, within ninety calendar days, throughout a twelve-month overall period, to fill abuse potential drugs. MAT drugs are excluded from consideration. Individual pharmacies are determined by the national provider identification (NPI) number. Consideration of pharmacy types should be examined as a recipient may need to use multiple pharmacies for specialty services.

(K) "Polyprescriber" for the purpose of this chapter means that a recipient obtained prescriptions for abuse potential drugs from four or more prescribers, within ninety calendar days, throughout a twelve-month overall period. MAT drugs are excluded from consideration. Affiliated prescribers with a shared business structure, including prescribers serving in rural health centers, federally qualified health centers, and group practices are considered a single prescriber for CSP purposes. Prescriber identification numbers are used for the determination of multiple prescriber use.

(L) "Polyprescription" for the purpose of this chapter means that a recipient obtained four or more distinct (defined as having different active ingredients or dosage forms) OARRS reportable drugs or muscle relaxants, within ninety calendar days, throughout a twelve-month overall period. MAT drugs are excluded from consideration.

(M) "Single pharmacy benefit manager (SPBM)" means as defined in rule 5160-26-01 of the Administrative Code.

(N) "Waste" means receipt of or the attempt to obtain items or services when there may be no intent to deceive or misrepresent, but poor treatment or care coordination methods result in unnecessary costs.

Last updated February 2, 2026 at 8:12 AM

History

Effective: February 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-20-04 Coordinated services program: enrollment and operation.

(A) The coordinated services program (CSP) provides continuity of care, helps reduce inappropriate or unnecessary utilization of pharmacy services, fraud, and excessive use, waste, or abuse of prescribed abuse potential drugs. A recipient enrolled in CSP remains eligible for all medically-necessary medicaid-covered services, but is assigned a designated pharmacy provider through which pharmacy services are received. Only controlled substances, as defined in 21 U.S.C. 801 as in effect July 6, 2025, are to be received from a designated pharmacy provider. Drugs used for medication assisted treatment (MAT) are excluded.

(B) CSP enrollment criteria. The enrollment criteria of this rule are based upon available utilization data within the past twelve rolling calendar months, referrals received for fraud, waste, or abuse activities, or self-reported referrals from the recipient. A recipient who self refers, is referred for abuse, fraud, or waste, or who meets three or more of the enrollment criteria will be enrolled unless the recipient meets a specific exclusion criteria.

(1) Self-referral criteria:

A recipient elects to refer oneself to the coordinated services program.

(2) Referrals to the CSP can come from the Ohio department of medicaid (ODM) if a recipient is suspected of or was verified to be involved in practices consistent with "abuse," "fraud," and "waste," as defined in rule 5160-20-01 of the Administrative Code.

(3) Enrollment criteria:

(a) Polypharmacy as defined in rule 5160-20-01 of the Administrative Code;

(b) Polyprescriber as defined in rule 5160-20-01 of the Administrative Code;

(d) Combinations of abuse potential drugs, as identified by ODM and available on the ODM website, that are duplicative, contraindicative, or which when combined may cause negative health outcomes.

(1) The recipient is enrolled in both the medicare and medicaid programs.

(2) The recipient has been identified as having cancer within the last twelve months.

(3) The recipient is receiving services through hospice.

(4) It is determined to be inappropriate to enroll the recipient in CSP based on clinical evidence reviewed by ODM, managed care organization (MCO), or single pharmacy benefit manager (SPBM) clinical staff.

(D) Initial enrollment, continued enrollment, and disenrollment procedures.

(1) Initial enrollment. If a recipient is selected for enrollment in CSP using criteria from paragraph (B) of this rule, the recipient is enrolled in CSP for twenty-four months, which begin at the effective date of enrollment.

(a) A recipient proposed for enrollment in CSP receives the "Notice of Proposed Enrollment in the Coordinated Services Program (CSP)" (ODM 01717), including the effective date of enrollment, from the MCO in accordance with division 5101:6 of the Administrative Code.

(b) If a recipient enrolled in CSP becomes ineligible for medicaid, then resumes eligibility for medicaid within the initial enrollment period, the recipient is reinstated into CSP until the initial enrollment period is exhausted.

(2) Continued enrollment. If after the initial enrollment period, ODM or the MCO determines a recipient's service utilization continues to support the reasons for enrollment in the CSP program described in paragraph (B) of this rule, the recipient continues enrollment in CSP for an additional twenty-four months. There is no limit to the number of times a recipient may be selected for continued enrollment in CSP.

(a) ODM notifies the recipient of the continued enrollment by issuing the "Notice of Continued Enrollment in the Coordinated Services Program (CSP)" (ODM 01705) in accordance with division 5101:6 of the Administrative Code.

(b) (b) If a recipient enrolled in CSP becomes ineligible for medicaid, then resumes eligibility for medicaid within a continued enrollment period, the recipient is reinstated into CSP until the continued enrollment period is exhausted.

(3) Disenrollment. If a recipient enrolled in CSP meets any of the criteria described in paragraph (C) of this rule, the recipient is disenrolled from CSP.

(E) Pharmacy provider assignment and changes. A recipient enrolled in CSP may request an assigned pharmacy provider within thirty days of the mailing date on the initial or continued enrollment notification. This pharmacy provider serves as the recipient's assigned pharmacy provider as defined in rule 5160-9-01 of the Administrative Code.

(1) The MCO or the SPBM selects an assigned pharmacy provider for the recipient for any of the following reasons:

(a) The recipient does not select an assigned pharmacy provider within thirty calendar days of the mailing date on the initial enrollment notification;

(b) The recipient's selected assigned pharmacy provider is denied by the MCO, or the SPBM; or

(2) A recipient may request to change an assigned pharmacy provider, or ODM, the MCO, or the SPBM may direct a recipient to make an alternative selection of an assigned pharmacy provider if:

(a) The assigned pharmacy provider closes or relocates;

(b) The recipient moved or is unable to travel to the pharmacy provider;

(d) The assigned pharmacy provider chooses not to provide services to the recipient.

(3) If the MCO denies the recipient's request to change the assigned provider, the recipient is notified by issuance of the "Notice of Denial of Assigned Provider or Pharmacy in the Coordinated Services Program (CSP)" (ODM 01718) in accordance with division 5101:6 of the Administrative Code.

(4) Secondary assignments are allowed if the recipient needs to utilize a secondary pharmacy provider for specialty medications, compounding, risk evaluation and mitigation system (REMS) program, or limited distribution network.

Last updated February 2, 2026 at 8:13 AM

History

Effective: February 1, 2026
Promulgated Under: 119.03

Chapter 5160-21 Reproductive Health Services

Ohio Adm.Code 5160-21-02 Reproductive health services: pregnancy prevention.

(A) Principles.

(1) Medicaid-eligible individuals have access to medicaid-covered pregnancy prevention services. This access is not restricted by factors including but not limited to religion, race, color, national origin, disability, age, sex, sexual orientation, gender identity, gender expression, military status, health status, number of pregnancies, or marital status.

(2) Medicaid-eligible individuals can obtain medicaid-covered pregnancy prevention services voluntarily, free from coercion or pressure and free to choose the type or method of service to be used.

(3) The receipt of pregnancy prevention services cannot be made a prerequisite to eligibility for, receipt of, or participation in any other services offered by a provider.

(4) Medicaid-eligible individuals cannot be denied other medicaid-covered medically necessary services on the basis of fertility or infertility.

(B) Coverage. Payment may be made for the following pregnancy prevention services:

(1) Temporary pregnancy prevention, including the following services:

(a) Evaluation and management services (office visits) and consultations for either or both of two purposes:

(i) Contraceptive management; or

(ii) Pregnancy examination and testing, with either a negative or an inconclusive result, that includes provision of information about pregnancy prevention; and

(b) Individual preventive medicine counseling and health education on topics including but not limited to fertility awareness, natural family planning (the use of fertility awareness to track ovulation), and risk factor reduction;

(2) Permanent pregnancy prevention, including the following services:

(a) Sterilization performed in accordance with rule 5160-21-02.2 of the Administrative Code; and

(b) Hysterectomy performed in accordance with rule 5160-21-02.2 of the Administrative Code;

(3) Associated medical or surgical services;

(4) Associated laboratory tests or procedures performed in accordance with Chapter 5160-11 of the Administrative Code, including but not limited to the following services:

(a) Screening, diagnostic, and counseling services for the detection of genetic anomalies or hereditary metabolic disorders including but not limited to the following conditions:

(i) Chromosomal anomalies (in non-pregnant patients) that have neonatal implications;

(ii) Sickle cell and other abnormal hemoglobin syndromes;

(iii) Metabolic disorders such as phenylketonuria (PKU), galactosemia, or homocystinuria; and

(iv) Cystic fibrosis (carrier status); and

(b) Screening, diagnosis, and treatment services for sexually transmitted diseases and infections;

(5) Associated drugs prescribed in accordance with Chapter 5160-9 of the Administrative Code or administered in accordance with Chapter 5160-4 of the Administrative Code; and

(6) Associated medical supplies provided in accordance with Chapter 5160-10 of the Administrative Code.

(1) Infertility treatment, including but not limited to the following modalities:

(a) Assisted reproductive technologies (ART);

(b) In vitro fertilization;

(d) Surgery to promote or restore fertility, including procedures for the reversal of voluntary sterilization; and

(e) Drugs for the treatment of infertility, even if they are prescribed in accordance with Chapter 5160-9 of the Administrative Code or administered in accordance with Chapter 5160-4 of the Administrative Code; or

(2) Hysterectomy that would not have been performed except for the purpose of rendering the individual permanently incapable of reproduction.

Last updated November 1, 2021 at 2:05 AM

History

Effective: November 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-21-02.2 Medicaid covered reproductive health services: permanent contraception/sterilization services and hysterectomy.

(A) Definitions.

(1) For the purposes of this rule, "hysterectomy" means, in accordance with 42 C.F.R. 441.251 (October 1, 2010 edition), a medical procedure or operation for the purpose of removing the uterus.

(2) For the purposes of this rule, "institutionalized individual" means, in accordance with 42 C.F.R. 441.251 (October 1, 2010 edition), an individual who is:

(a) Involuntarily confined or detained, under a civil or criminal statute, in a correctional or rehabilitative facility, including a mental hospital or other facility for the care and treatment of mental illness; or

(b) Confined, under a voluntary commitment, in a mental hospital or other facility for the care and treatment of mental illness.

(3) For the purposes of this rule, "mentally incompetent individual" means, in accordance with 42 C.F.R. 441.251 (October 1, 2010 edition), an individual who has been declared mentally incompetent by a federal, state, or local court of competent jurisdiction for any purpose, unless the individual has been declared competent for purposes which include the ability to consent to sterilization.

(4) For the purposes of this rule, "sterilization" means, in accordance with 42 C.F.R. 441.251 (October 1, 2010 edition), any medical procedure, treatment, or operation for the purpose of rendering an individual permanently incapable of reproducing.

(5) For the purposes of this chapter, "permanent pregnancy prevention" has the same meaning as "sterilization."

(B) Sterilization.

(1) Medicaid covered sterilization services include:

(a) Management and evaluation (office) visits and consultations for the purpose of providing sterilization services;

(b) Health education and counseling visits for the purpose of providing sterilization services;

(c) Medical/surgical services/procedures covered in accordance with appendix DD to rule 5101:3-1-60 of the Administrative Code and provided in association with the provision of sterilization services;

(d) Laboratory tests and procedures provided in accordance with Chapter 5101:3-11 of the Administrative Code and in association with the provision of sterilization services;

(e) Drugs administered in accordance with Chapter 5101:3-4 of the Administrative Code and in association with the provision of sterilization services; and

(f) Supplies provided in accordance with appendix A to rule 5101:3-10-03 of the Administrative Code and associated with the provision of sterilization services.

(2) The department will reimburse medicaid providers for sterilization services only if all the requirements of this rule and 42 C.F.R. part 441 subpart F (October 1, 2010 edition), are met:

(a) The individual is at least twenty-one years old at the time consent is obtained;

(b) The individual is not a mentally incompetent individual;

(d) The individual has voluntarily given informed consent in accordance with paragraph (B)(3) of this rule;

(e) At least thirty days, but not more than one hundred eighty days, have passed between the date of the informed consent and the date of the sterilization, except in the case of premature delivery or emergency abdominal surgery. An individual may consent to be sterilized at the time of a premature delivery or emergency abdominal surgery, if at least seventy-two hours have passed since he or she gave informed consent for the sterilization. In the case of premature delivery, the informed consent must have been given at least thirty days before the expected date of delivery; and

(f) The medicaid provider requesting payment for the sterilization submits to the department a copy of the consent form, completed in accordance with paragraph (B)(3) of this rule.

(3) Informed consent for sterilization.

(a) For the purposes of this rule, an individual has given informed consent only if:

(i) The person who obtained consent for the sterilization procedurehas:

(a) Offered to answer any questions the individual to be sterilized may have had concerning the procedure;

(b) Provided a copy of one of the following to the individual to be sterilized:

(i) "Consent for Sterilization," HHS-687 (5/2010), available at www.hhs.gov/forms/HHS-687.pdf;

(ii) "CONSENTIMIENTO PARA LA ESTERILIZACIN," HHS-687-1 (11/2006), available at www.hhs.gov/forms/HHS-687-1.pdf;

(iii) "Consent for Sterilization Form," JFS 03198 (rev. 7/2009), available at www.odjfs.state.oh.us/forms/inter.asp, which may be used for consent forms signed during the period from July 1, 2009 through June 30, 2012 by the individual to be sterilized; or

(iv) "Consent for Sterilization Form," JFS 03198 (rev. 2/2003), which may be used for consent forms signed before July 1, 2010 by the individual to be sterilized, if the person obtaining consent has copies of this form available.

(i) Advice that the individual is free to withhold or withdraw consent to the procedure at any time before the sterilization without affecting the right to future care or treatment and without loss or withdrawal of any federally-funded program benefits to which the individual might be otherwise entitled;

(ii) A description of available alternative methods of family planning and birth control;

(iii) Advice that the sterilization procedure is considered to be irreversible;

(iv) A thorough explanation of the specific sterilization procedure to be performed;

(v) A full description of the discomforts and risks that may accompany or follow the performance of the procedure, including an explanation of the type and possible effects of any anesthetic to be used;

(vi) A full description of the benefits or advantages that may be expected as a result of the sterilization; and

(vii) Advice that the sterilization will not be performed for at least thirty days, except under the circumstances specified in paragraph (B)(2)(e) of this rule;

(ii) Suitable arrangements were made to insure that the information specified in paragraph (B)(3)(a)(i) of this rule was effectively communicated to any individual who is blind, deaf, or otherwise handicapped;

(iii) An interpreter was provided if the individual to be sterilized did not understand the language used on the consent form or the language used by the person obtaining consent;

(iv) The individual to be sterilized was permitted to have a witness of his or her choice present when consent was obtained;

(v) The consent form requirements of this rule and of 42 C.F.R. 441.258 (October 1, 2010 edition) were met; and

(vi) Any additional requirement of state or local law for obtaining consent, except a requirement for spousal consent, was followed.

(b) For the purposes of this rule, informed consent may not be obtained while the individual to be sterilized is:

(i) In labor or childbirth; or

(ii) Seeking to obtain or obtaining an abortion; or

(iii) Under the influence of alcohol or other substances that affect the individual's state of awareness.

(i) The consent form must be signed and dated by:

(a) The individual to be sterilized;

(b) The interpreter, if one was provided;

(d) The physician who performed the sterilization procedure.

(ii) The person securing the consent must certify, by signing the consent form, that:

(a) Before the individual to be sterilized signed the consent form, he or she advised the individual to be sterilized that no federal benefits may be withdrawn because of the decision not to be sterilized;

(b) He or she explained orally to the individual to be sterilized the requirements for informed consent as set forth in this rule and on the consent form; and

(c) To the best of his or her knowledge and belief, the individual to be sterilized appeared to the person securing the consent to be mentally competent and knowingly and voluntarily consented to be sterilized.

(iii) The physician performing the sterilization must certify, by signing the consent form, that:

(a) Shortly before the performance of sterilization, he or she advised the individual to be sterilized that no federal benefits may be withdrawn because of the decision not to be sterilized;

(b) He or she explained orally to the individual to be sterilized the requirements for informed consent as set forth in this rule and on the consent form;

(c) To the best of his or her knowledge and belief, the individual to be sterilized appeared to the physician to be mentally competent and knowingly and voluntarily consented to be sterilized; and

(d) In the case of premature delivery or emergency abdominal surgery (except for induced abortion in the first trimester of pregnancy) performed within thirty days of consent, the physician must certify that the sterilization was performed less than thirty days, but not less than seventy-two hours after informed consent was obtained because of premature delivery or emergency abdominal surgery and:

(i) In the case of premature delivery, must state the expected date of delivery; or

(ii) In the case of abdominal surgery, must describe the emergency.

(iv) If an interpreter is provided, the interpreter must certify that he or she translated the information and advice presented orally and read the consent form and explained its contents to the individual to be sterilized and that, to the best of the interpreter's knowledge and belief, the individual understood what the interpreter told him or her.

(1) The department will not reimburse medicaid providers for hysterectomy if:

(a) The hysterectomy was performed solely for the purpose of rendering an individual permanently incapable of reproducing;

(b) There was more than one purpose to the hysterectomy, and it would not have been performed but for the purpose of rendering the individual permanently incapable of reproducing; or

(2) The department will reimburse medicaid providers for hysterectomy only if:

(a) All the requirements of this rule and 42 C.F.R. part 441 subpart F (October 1, 2010 edition) are met; and

(b) The medicaid provider requesting payment for the hysterectomy submits a copy of the JFS 01399, completed in accordance with paragraph (C)(3) of this rule, with the claim to the department.

(c) For a hysterectomy performed during a period of an individual's retroactive medicaid eligibility, the physician who performed the hysterectomy certifies in writing that:

(i) The individual was informed before the operation that the hysterectomy would make her permanently incapable of reproducing; or

(ii) The conditions of paragraph (C)(3)(a)(ii) of this rule were met.

(3) Informed consent for hysterectomy.

For the purposes of this rule, an individual has given informed consent only if:

(a) The person who secures authorization to perform the hysterectomy has:

(i) Informed the individual and her representative, if any, orally and in writing that the hysterectomy will make the individual permanently incapable of reproducing;

(ii) Offered to answer any questions the individual to have the hysterectomy may have concerning the procedure;

(iii) Offers the individual to have the hysterectomy a copy of one of the following:

(a) "Acknowledgement of Hysterectomy Information," JFS 03199 (rev. 04/2011), available at www.odjfs.state.oh.us/forms/inter.asp, which may be used for consent forms signed by the individual on or after January 1, 2012;

(b) "Acknowledgement of Hysterectomy Information," JFS 03199 (rev. 7/2009), which may be used for consent forms signed by the individual on and after July 1, 2009 but before June 30, 2012 if the person obtaining consent has copies of this form available; or

(c) "Acknowledgement of Hysterectomy Information," JFS 03199 (rev. 7/2003), which may be used for consent forms signed by the individual before July 1, 2010 if the person obtaining consent has copies of this form available; and

(b) The individual to have the hysterectomy or her representative, if any, has signed the JFS 01399 as a written acknowledgment of receipt of the information specified in paragraph (C)(3)(a)(i) of this rule unless the individual:

(i) Was already sterile before the hysterectomy; or

(ii) Requires a hysterectomy because of a life-threatening emergency situation in which the physician determines that prior acknowledgement is not possible.

(D) Claims.

(1) Claims for sterilization and hysterectomy procedures must be submitted to the department with either an original or a copy of the appropriate consent form.

For dual eligibles, the JFS 03199 must not be attached to the medicare claim, but must be forwarded separately to the department. If the claim is rejected by medicare, the provider should submit a separate invoice to the department with the medicare rejection attached. The date that the JFS 03199 form was sent to the department should be entered in the provider remarks section of the medicaid claim.

(2) The department will not reimburse medicaid providers for services, procedures, and supplies associated with the provision of sterilization or hysterectomy services that do not meet the requirements of this rule.

Last updated September 1, 2023 at 1:09 PM

History

Effective: January 1, 2012
Promulgated Under: 119.03

Ohio Adm.Code 5160-21-04 Reproductive health services: pregnancy-related services.

(A) Coverage.

(1) Unless a different time period is specified, services described in this rule are covered through the pregnancy and the delivery.

(2) Basic pregnancy-related services include but are not limited to antepartum care, delivery, outpatient postpartum care, and family planning services.

(a) Antepartum care. Payment for a visit may be made for either of two purposes:

(i) Basic care (including the taking and subsequent updating of a medical history, physical examination, the recording of vital signs, and routine chemical urinalysis) provided monthly up to twenty-eight weeks' gestation, biweekly thereafter up to thirty-six weeks' gestation, and weekly thereafter until delivery; or

(ii) Initial establishment of a relationship with a certified nurse-midwife, pediatrician, or other primary care provider who will subsequently furnish early and continuous well-child and primary care for the newborn and will discuss care of the infant with the woman and, as appropriate, the woman's family.

(b) Delivery. Payment may be made for admission to a facility (hospital or freestanding birth center), the taking of a medical history during admission, physical examinations, the management of labor (intrapartum management), and either vaginal delivery (with or without episiotomy and with or without forceps) or delivery by cesarean section.

(i) Separate payment may be made for intrapartum management and for delivery performed as distinct procedures by different providers who are not part of the same practice.

(ii) Additional payment may be made for multiple-birth delivery.

(iii) Additional payment may be made for evaluation and management (E&M) services or medical services rendered for the diagnosis and treatment of medical conditions that complicate labor and delivery management.

(iv) No additional payment will be made for complex delivery nor for additional professional services (e.g., assistance by a second practitioner during delivery).

(c) Outpatient postpartum care. Payment may be made for hospital and office visits involving routine, uncomplicated follow-up care rendered during the postpartum period specified in rule 5160:1-2-16 of the Administrative Code. Postpartum care rendered prior to discharge from the facility is considered incidental to the delivery.

(d) Family planning services. Policies governing payment for these services are set forth in rules 5160-21-02 and 5160-21-02.2 of the Administrative Code.

(3) Payment may be made for one report of a pregnancy that is diagnosed in conjunction with an E&M service not associated with a normal obstetrics/gynecology visit, submitted on either form ODM 10257, "Report of Pregnancy (ROP)," or its web-based equivalent. This payment is separate from the payment for the E&M service (or the encounter or visit of which the E&M service is part).

(4) A perinatal risk assessment may be used to screen a woman for medical and social factors that may place that woman at risk for adverse pregnancy or postpartum outcomes and to substantiate the woman's need for enhanced pregnancy-related services and other support services during this period. Payment may be made for up to six such assessments, performed during antepartum and postpartum visits and submitted on either form ODM 10207, "Perinatal Risk Assessment," or its web-based equivalent.

(a) If a woman is determined to be at risk and the practitioner obtains the woman's informed consent, then the practitioner sends to the entity responsible for managing the woman's pregnancy-related care a report with recommendations, in the form and format specified by the entity.

(b) If the woman needs additional support services during the course of pregnancy or the postpartum period, then (with the woman's informed consent) the practitioner may relay that information to the entity responsible for managing the woman's pregnancy-related care.

(5) Enhanced pregnancy-related services promote general health, improve the quality of life, and produce better outcomes for a pregnant woman or a fetus during pregnancy or the postpartum period. Such services include but are not limited to the following examples:

(a) High-risk patient monitoring (the additional monitoring of a woman who has been determined to be at risk for a preterm birth) performed by a healthcare professional qualified to identify the signs of preterm labor, which has three components:

(i) Counseling and education to assist the woman in identifying and reducing the risk of preterm labor;

(ii) Regular contact with the woman, either in person or by telecommunication, to identify signs of preterm labor; and

(iii) Ready access to the provider in the event the woman begins to show signs of preterm labor;

(b) Group pregnancy education (the face-to-face presentation by a medical professional to a group of two or more participants but not more than twenty) in classes, consisting of one or more sessions, that meet at least one of the following sets of criteria:

(i) The classes cover subjects related to pregnancy, including but not limited to the following topics:

(a) Childbirth preparation (e.g., Lamaze);

(b) Childbirth refresher;

(d) Parenting; and

(e) Infant safety; or

(ii) The classes are drawn from an evidence-based or evidence-informed curriculum that has been demonstrated to result in improved health outcomes, improved health equity, or both for pregnant and postpartum women and their infants;

(c) Individual counseling and education, given during an antepartum visit, that entails a face-to-face encounter of at least fifteen minutes in which the primary focus is the specific needs of the woman;

(d) Medical nutrition therapy in accordance with rule 5160-8-41 of the Administrative Code;

(e) Family planning-related services in accordance with rule 5160-21-02 of the Administrative Code; and

(f) Tobacco cessation counseling and treatment.

(B) Claim payment.

(1) Payment for covered antepartum care provided in a federally qualified health center (FQHC) or rural health clinic (RHC) is determined in accordance with Chapter 5160-28 of the Administrative Code.

(2) The maximum payment amount for a covered evaluation and management service reported as antepartum care provided in a setting other than an FQHC or RHC is the lesser of the following two figures:

(a) The provider's submitted charge; or

(b) The product of the amount specified in appendix DD to rule 5160-1-60 of the Administrative Code and any applicable place-of-service multiplier.

(3) The maximum payment amount for covered delivery is the lesser of the following two figures:

(a) The provider's submitted charge; or

(b) The product of the amount specified in appendix DD to rule 5160-1-60 of the Administrative Code, any applicable place-of-service multiplier, and the relevant percentage from the following list:

(i) For a single delivery or the first delivery of a multiple birth, one hundred per cent;

(ii) For the second delivery of a multiple birth, fifty per cent;

(iii) For the third delivery of a multiple birth, twenty-five per cent; or

(iv) For each additional delivery of a multiple birth, zero.

(4) Payment for a report of pregnancy or a perinatal risk assessment is the amount specified in appendix DD to rule 5160-1-60 of the Administrative Code.

(5) Payment of all other claims is made in accordance with the applicable rule of the Administrative Code.

Last updated September 17, 2026 at 1:57 PM

History

Effective: April 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-21-05 Nurse home visiting services.

(A) Unless otherwise noted, any limitations or conditions specified in the Revised Code or in agency 5160 of the Administrative Code apply to services addressed in this rule.

(B) Definitions.

(1) "Advanced practice registered nurse (APRN)" has the same meaning as in Chapter 4723-08 of the Administrative Code.

(2) "Registered nurse (RN)" has the same meaning as in Chapter 4723. of the Revised Code.

(3) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code.

(4) "Home visiting" has the same meaning as in Chapter 5180-8 of the Administrative Code.

(5) "Nurse home visiting" is home visiting provided by an APRN or RN. Within the package of home visiting services, emphasis is placed on the following services performed within the scope of the practitioner:

(a) Prenatal visits;

(b) Postpartum visits;

(d) Nursing examinations, which focus on assessment of social determinants of health, on education, and on emotional support;

(e) Health education;

(f) Maternal depression screening; and

(g) Lactation counseling.

(1) Rendering provider. Medicaid payment may be made for a covered nurse home visiting service rendered by an eligible provider.

(2) Billing ("pay-to") provider. The following eligible providers may receive medicaid payment for submitting a claim for a covered nurse home visiting service:

(a) An ambulatory health care clinic as defined in Chapter 5160-13 of the Administrative Code;

(b) A federally qualified health center (FQHC);

(d) A professional medical group.

(D) Coverage.

(1) Payment may be made only for a nurse home visiting service for which the following criteria are met:

(a) The service is medically necessary in accordance with rule 5160-1-01 of the Administrative Code;

(b) The individual receiving the service has at least one of the following medically complex conditions that may put an individual at a high risk for preterm birth:

(i) Asthma;

(ii) Diabetes;

(iii) Cardiovascular disease;

(iv) Chronic mental health condition;

(v) Substance use disorder; or

(vi) History of pre-term birth.

(c) The individual is not currently receiving another service that substantially duplicates a nurse home visiting service.

(2) No payment is made for a separate evaluation and management service in addition to a nurse home visiting service rendered by the same provider to the same individual on the same day.

(E) Claim payment.

(1) For a covered nurse home visiting service rendered by an FQHC or RHC, payment is made in accordance with Chapter 5160-28 of the Administrative Code.

(2) For a covered nurse home visiting service rendered at any other valid place of service, payment is the lesser of the provider's submitted charge or the maximum amount specified in appendix DD to rule 5160-1-60 of the Administrative Code.

Last updated January 5, 2026 at 8:56 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-21-06 Family connects.

(A) Unless otherwise noted, any limitations or conditions specified in the Revised Code or in agency 5160 of the Administrative Code apply to services addressed in this rule.

(B) Definitions applied to this rule.

(1) "Eligible provider" has the same meaning as defined in rule 5160-1-17 of the Administrative Code.

(2) "Family connects" is an evidence-based home visiting model that provides treatment, education, home visits, and training to a postpartum individual to facilitate better birth outcomes and to improve child health and development. family connects comprises of the following services performed within the scope of the practitioner:

(a) Training in pediatric care;

(b) Nursing examinations, which focus on assessment of social determinants of health, on education, and on emotional support;

(d) Maternal depression screening; and

(e) Lactation counseling.

(3) "Registered nurse (RN)" has the same meaning as in Chapter 4723. of the Revised Code.

(1) Rendering provider. The following eligible provider may render a covered family connects service: an RN who is a home visitor as defined in rule 5180-8-01 of the Administrative Code.

(2) Billing ("pay-to") provider. The following eligible providers may receive medicaid payment for submitting a claim for a covered family connects service:

(a) An ambulatory health care clinic as defined in Chapter 5160-13 of the Administrative Code;

(b) A federally qualified health center (FQHC);

(d) A professional medical group.

(D) Coverage.

(1) Payment may be made only for a family connects service for which the following criteria are met:

(a) The service is medically necessary in accordance with rule 5160-1-01 of the Administrative Code;

(b) The individual is not currently receiving another service that substantially duplicates a nurse home visiting service.

(2) For a family connects service, the practitioner order specified in rule 5160-1-17 of the Administrative Code is waived.

(3) Payment may be made for a total of three visits.

(E) Claim payment.

(1) For a covered family connects service rendered at an FQHC or RHC, payment is made in accordance with Chapter 5160-28 of the Administrative Code.

(2) For a covered family connects service rendered at any other valid place of service, payment is the lesser of the provider's submitted charge or the maximum amount specified in appendix DD to rule 5160-1-60 of the Administrative Code.

Last updated July 1, 2025 at 8:06 AM

History

Effective: July 1, 2025
Promulgated Under: 119.03

Chapter 5160-22 Ambulatory Surgery Center Services

Ohio Adm.Code 5160-22-01 Ambulatory surgery center (ASC) services: coverage and reimbursement.

Effective for dates of service on or after the effective date of this rule, eligible ambulatory surgery centers, as defined in paragraphs (A)(1) and (B) of this rule, are subject to the enhanced ambulatory patient grouping system (EAPG) and prospective payment methodology utilized by the Ohio department of medicaid (ODM) as described in this rule.

(A) Definitions, for the purposes of this rule, the following meanings apply.

(1) An "ambulatory surgery center (ASC)" is any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization.

(2) "ASC claim" encompasses the ASC services rendered to one eligible medicaid beneficiary on one date of service at an ASC facility.

(3) "ASC charge factor" is a factor specific to ASCs that is used to calculate reimbursement for pharmaceutical procedure codes described in paragraph (F)(1)(c) of this rule.

(4) "ASC EAPG base rate" is the dollar value that is multiplied by the final EAPG relative weight for each EAPG listed on a claim to determine the total allowable medicaid payment.

(5) "ASC facility services" are items and services furnished by an ASC in connection with covered ASC surgical procedure(s).

(6) "ASC invoice" is a bill submitted to ODM in accordance with Chapter 5160-1 of the Administrative Code for services rendered to one eligible medicaid recipient on one or more date(s) of service. For an invoice encompassing more than one date of service, each date will be processed separately as an individual claim.

(7) "Default EAPG settings" are the default EAPG grouper options for each version of the core grouping software by "Solventum" or its successors.

(8) "Diagnosis code" is the international classification of diseases (ICD) diagnosis code as identified in rule 5160-1-19 of the Administrative Code.

(9) "Discounting factor" is a factor applicable for multiple significant procedures or repeated ancillary services designated by default EAPG settings or both. The appropriate percentage (fifty or one hundred per cent) will be applied to the highest weighted of the multiple procedures or ancillary services payment group.

(a) "Full payment" is the EAPG payment with no applicable discounting factor.

(b) "Consolidation factor" is a factor of zero per cent, applicable for services designated with a same procedure consolidation flag or clinical procedure consolidation flag by the EAPG grouper under default EAPG settings.

(c) "Packaging factor" is a factor of zero per cent applicable for services designated with a packaging flag by the EAPG grouper under default EAPG settings.

(10) "EAPG grouper" is the software provided by "Solventum" or its successors to group outpatient claims based on services performed and resource intensity.

(11) "Enhanced ambulatory patient grouping (EAPG)" is a group of outpatient procedures, encounters, or ancillary services that reflect similar patient characteristics and resource utilization and incorporate the use of international classification of diseases (ICD) diagnosis codes, current procedural terminology (CPT) procedural codes, and healthcare common procedure coding system (HCPCS) procedure codes.

(12) "Procedure code" is a CPT code or HCPCS code, as identified in rule 5160-1-19 of the Administrative Code.

(13) "Relative weight" is a factor specific to each EAPG that represents the EAPG's relative cost compared to an average case.

(B) ASC providers will bill in accordance with rule 5160-1-19 of the Administrative Code. ODM will reimburse an ASC for properly submitted claims for facility services furnished in connection with covered surgical procedures when the services are provided by an eligible ASC provider to an eligible medicaid recipient. Reimbursement for covered ASC facility services will be paid in accordance with paragraph (D) of this rule.

(1) Services include but are not limited to:

(a) Nursing, technician, and related services;

(b) Use of the ASC facilities;

(c) Drugs, biologicals (e.g., blood), surgical dressings, splints, casts and appliances, and equipment directly related to the provision of a surgical procedure;

(d) Diagnostic or therapeutic services or items directly related to the provision of a surgical procedure;

(e) Administrative, record keeping, and housekeeping items and services;

(f) Materials for anesthesia;

(g) Intraocular lenses; and

(h) Supervision of the services of an anesthetist by the operating surgeon.

(2) Prior authorization (PA) is necessary for certain surgical CPT codes. The services needing PA are published in accordance with section 5160.34 of the Revised Code.

(D) EAPG payment formula.

(1) Total EAPG payment is the sum of all paid line items on an ASC claim.

(2) The payment for a paid line item on a claim is calculated as follows, except as described in paragraph (E) or (F) of this rule:

(a) The ASC EAPG base rate, multiplied by

(b) The ASC EAPG relative weight for which the service was assigned by the EAPG grouper; then rounded to the nearest whole cent.

(c) The product of paragraphs (D)(2)(a) and (D)(2)(b) of this rule is multiplied by applicable discounting factor(s), as defined in paragraph (A)(9) of this rule, and the result is rounded to the nearest whole cent.

(E) Payment for laboratory services, radiological services, and diagnostic and therapeutic procedures.

An ASC may be reimbursed in addition to the facility fee for covered laboratory services, radiological services, and diagnostic and therapeutic procedures provided in connection with a covered ASC surgical procedure.

(1) Payment for laboratory services.

(a) An ASC may be reimbursed for covered laboratory services.

(b) An ASC should not bill separately for the professional component of an anatomic pathology procedure.

(c) Laboratory services will be reimbursed the lesser of billed charges or the result of paragraph (D)(2)(c) of this rule.

(2) Payment for radiological services.

(a) An ASC may be reimbursed for covered radiological services.

(b) An ASC should not bill separately for the professional component of a radiological service.

(c) Radiological services will be reimbursed the lesser of billed charges or the result of paragraph (D)(2)(c) of this rule.

(3) Payment for diagnostic and therapeutic procedures.

(a) An ASC may be reimbursed for the provision of diagnostic and therapeutic procedures.

(b) An ASC should not bill separately for the professional component of a diagnostic and therapeutic procedure.

(4) An ASC may also be reimbursed for laboratory services, radiological services, and diagnostic and therapeutic procedures when performed in the ASC in conjunction with covered services not eligible for an ASC facility payment.

(F) Items which may be paid outside of EAPG.

(1) Pharmaceuticals.

(a) Payments for covered pharmaceuticals will be made in accordance with the discounting factors as determined by the EAPG grouper. If no consolidation or packaging factors are assigned, then the pharmaceutical line is separately payable and will pay according to paragraphs (F)(1)(b) and (F)(1)(c) of this rule.

(b) Reimbursement for separately payable covered pharmaceuticals will be the lesser of billed charges or the payment amounts in the provider administered pharmaceutical fee schedule, as published on ODM's web site, http://medicaid.ohio.gov/, at the rate in effect on the date of service.

(c) If a HCPCS J-code or Q-Code, that is covered for ASC facilities and separately payable, is listed as "by report" in the provider administered pharmaceutical fee schedule, the line will be paid in accordance with paragraph (F)(1)(d) of this rule..

(d) Procedure codes described in paragraph (F)(1)(c) of this rule will be reimbursed the allowed charges for the detail line multiplied by sixty per cent of the ASC charge factor; then rounded to the nearest whole cent.

(2) Durable medical equipment (DME).

(a) Additional payments may be made for line items grouping to a DME EAPG type.

(b) Reimbursement for DME will be the lesser of billed charges or the payment amounts in the DME payment schedule, as published on ODM's web site, http://medicaid.ohio.gov/, at the rate in effect on the date of service.

(3) Dental services.

Reimbursement for ASC claims assigned to a dental service EAPG type will be paid as follows:

(a) Reimbursement for dental services will be one thousand four hundred thirty dollars.

(b) Payments for dental services will be made in accordance with the discounting factors as determined by the EAPG grouper.

(G) Risk corridors.

(1) Effective for dates of service on or after January 1, 2024, ODM will apply the following to ASC EAPG relative weights as described in paragraph (A)(13) of this rule:

(a) The ASC EAPG relative weights were calculated to result in an increase of at least five per cent in payments compared to the prior prospective payment system; or

(b) The ASC EAPG relative weights were calculated to result in no more than a fifteen per cent increase in payments compared to the prior prospective payment system.

(2) Effective January 1, 2026, the relative weights for ASCs are increased by 11.6 per cent.

Last updated January 15, 2026 at 3:42 PM

History

Effective: January 10, 2026
Promulgated Under: 119.03

Chapter 5160-26 Managed Care Programs

Ohio Adm.Code 5160-26-01 Managed care: definitions.

As used in Chapter 5160-26 of the Administrative Code:

(A) "Abuse" means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the medicaid program.

(B) "Advance directive" means written instructions such as a living will or durable power of attorney for health care relating to the provision of health care when an adult is incapacitated.

(1) Denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit;

(2) Reduction, suspension, or termination of services prior to the member receiving the services previously authorized by the MCE;

(3) Failure to provide services in a timely manner as specified in rule 5160-26-03.1 of the Administrative Code;

(4) Failure to act within the resolution time frames specified in rule 5160-26-08.4 of the Administrative Code;

(5) Denial of a member's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance and other member financial liabilities, if applicable; or

(6) Denial, in whole or part, of payment for a service. A denial, in whole or in part, of a payment for a service solely because the claim does not meet the definition of a "clean claim" as defined in 42 C.F.R. 447.45(b) (October 1, 2021) is not an adverse benefit determination.

(D) "Appeal" is the member's request for an MCE to review an adverse benefit determination.

(E) "Authorized representative" has the same meaning as in rule 5160:1-1-01 of the Administrative Code.

(F) "Care management system" means the system established by the Ohio department of medicaid (ODM) in accordance with section 5167.03 of the Revised Code.

(G) "Consumer contact record (CCR)" means the record containing demographic health-related information provided by an eligible individual, managed care member, or ODM that is used by the Ohio medicaid consumer hotline to process membership transactions.

(H) "Coordination of benefits (COB)" means a procedure establishing the order in which health care entities pay their claims as described in rule 5160-26-09.1 of the Administrative Code.

(I) "Covered services" means those medical services set forth in rule 5160-26-03 of the Administrative Code or a subset of those medical services.

(J) "Eligible individual" means any medicaid recipient who is a legal resident of the managed care service area and is in one of the categories specified in rule 5160-26-02 of the Administrative Code.

(K) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the following: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.

(L) "Emergency services" means covered inpatient services, outpatient services, or medical transportation services that are provided by a qualified provider and are needed to evaluate, treat, or stabilize an emergency medical condition. As used in this chapter, providers of emergency services also include physicians or other health care professionals or health care facilities not under employment or under contractual arrangement with an MCE.

(M) "Explanation of benefits (EOB)," otherwise known as "explanation of payment (EOP)," or "remittance advice (RA)," means the information sent to providers and/or members by any other third party payer, or MCE, to explain the adjudication of a claim.

(N) "Federally qualified health center (FQHC)" has the same meaning as in rule 5160-28-01 of the Administrative Code.

(O) "Fraud" means any intentional deception or misrepresentation made by an individual or entity with the knowledge that the deception could result in some unauthorized benefit to the individual, the entity, or some other person. This includes any act that constitutes fraud under applicable federal or state law. Member fraud means the altering of information or documents in order to fraudulently receive unauthorized benefits or to knowingly permit others to use the member's identification card to obtain services or supplies.

(P) "Grievance" is the member's expression of dissatisfaction about any matter other than an adverse benefit determination. Grievances may include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the member's rights regardless of whether remedial action is requested. Grievance includes a member's right to dispute an extension of time proposed by an MCE to make an authorization decision.

(Q) "Healthchek" services, otherwise known as early and periodic screening, diagnostic, and treatment (EPSDT) services, are comprehensive preventive health services available to individuals under twenty-one years of age who are enrolled in medicaid as those services are described in rule 5160-1-14 of the Administrative Code.

(R) "Hospital" means an institution located at a single site that is engaged primarily in providing to inpatients, by or under the supervision of an organized medical staff of physicians licensed under Chapter 4731. of the Revised Code, diagnostic services and therapeutic services for medical diagnosis and treatment or rehabilitation of injured, disabled, or sick persons. "Hospital" does not mean an institution that is operated by the United States government.

(S) "Hospital services" means those inpatient and outpatient services that are generally and customarily provided by hospitals.

(T) "Inpatient facility" means an acute or general hospital.

(U) "Intermediate care facility for individuals with intellectual disabilities (ICF/IID)" has the same meaning as in section 5124.01 of the Revised Code.

(V) "Managed care" means a health care delivery system operated by the state in accordance with 42 C.F.R. part 438 (October 1, 2021).

(W) "Managed care entity (MCE)" means a managed care organization, the single pharmacy benefit manager, a MyCare Ohio plan as defined in rule 5160-58-01 of the Administrative Code, and the OhioRISE plan as defined in rule 5160-59-01 of the Administrative Code.

(X) "Managed care organization (MCO)" has the same definition as in 42 C.F.R 438.2 (October 1, 2021) and is a health insuring corporation (HIC) licensed in the state of Ohio that enters into a managed care provider agreement with ODM.

(Y) "Medicaid" means medical assistance as defined in section 5162.01 of the Revised Code.

(Z) "Medicaid fraud control unit (MCFU)" means an identifiable entity of state or federal government charged with the investigation and prosecution of fraud and related offenses within medicaid.

(AA) "Medically necessary," or "medical necessity," has the same meaning as in rule 5160-1-01 of the Administrative Code.

(BB) "Medicare" means the federally financed medical assistance program defined in 42 U.S.C. 1395 (as in effect July 1, 2022).

(CC) "Member" means a medicaid recipient who has selected or been assigned to an MCE for the purpose of receiving health care services.

(DD) "Network provider" means any provider, group of providers, or entity that has a network provider contract with the MCE in accordance with rule 5160-26-05 of the Administrative Code and receives medicaid funding directly or indirectly to order, refer, or render covered services as a result of the MCE's provider agreement or contract with ODM.

(EE) "Non-contracting provider" means any provider with an ODM provider agreement who does not contract with an MCE, but delivers health care services to an MCE's members.

(FF) "Non-contracting provider of emergency services" means any person, institution or entity that does not contract with an MCE, but provides emergency services to an MCE's members, regardless of whether that provider has an ODM provider agreement.

(GG) "Notice of action (NOA)" is the written notice an MCE provides to members when an adverse benefit determination has occurred or will occur.

(HH) "Nursing facility" has the same meaning as in section 5165.01 of the Revised Code.

(II) "Ohio medicaid consumer hotline" means the managed care enrollment broker and customer service agent for individuals receiving Ohio medicaid services.

(JJ) "Oral interpretation services" means services provided to a limited-reading proficient eligible individual or member to ensure that he or she receives MCE information in a format and manner that is easily understood by the eligible individual or member.

(KK) "Oral translation services" means services provided to a limited-English proficient eligible individual or member to ensure that he or she receives MCE information translated into the primary language of the eligible individual or member.

(LL) "Pending member" means an eligible individual who has selected or been assigned to an MCE but whose membership in the MCE is not yet effective.

(MM) "Post-stabilization care services" means covered services related to an emergency medical condition that a treating provider views as medically necessary after an emergency medical condition has been stabilized in order to maintain the stabilized condition, or under the circumstances described in 42 C.F.R. 422.113 (October 1, 2021) to improve or resolve the member's condition.

(NN) "Premium" means the monthly payment amount per member to which the MCO is entitled as compensation for performing its obligations in accordance with Chapter 5160-26 of the Administrative Code and/or the provider agreement with ODM.

(OO) "Primary care provider (PCP)" means an individual physician (M.D. or D.O.), a physician group practice, an advanced practice registered nurse as defined in section 4723.01 of the Revised Code, an advanced practice nurse group practice within an acceptable specialty, or a physician assistant who meets the requirements of rule 5160-4-03 of the Administrative Code contracting with an MCO to provide services as specified in rule 5160-26-03.1 of the Administrative Code. Acceptable PCP specialty types include family/general practice, internal medicine, pediatrics, and obstetrics/gynecology (OB/GYNs).

(PP) "Protected health information (PHI)" means information received from or on behalf of ODM that meets the definition of PHI as defined by 45 C.F.R. 160.103 (October 1, 2021).

(QQ) "Provider" means a hospital, health care facility, physician, dentist, pharmacy, or otherwise licensed or certified appropriate individual or entity that is authorized to or may be entitled to reimbursement for health care-related services rendered to an MCE's member.

(RR) "Provider agreement" means a formal agreement between ODM and an MCO for the provision of medically necessary services to medicaid recipients who are enrolled in the MCO.

(SS) "Provider network" or "network," means an MCE's contracted providers available to the MCE's members.

(TT) "Qualified family planning provider (QFPP)" means any public or nonprofit health care provider that complies with guidelines/standards set forth in 42 U.S.C. 300 (as in effect July 1, 2022), and receives either Title X funding or family planning funding from the Ohio department of health.

(UU) "Respite services" are services that provide short-term, temporary relief to the informal unpaid caregiver of a managed care member in order to support and preserve the primary care giving relationship.

(VV) "Risk" or "underwriting risk" means the possibility that an MCO may incur a loss because the cost of providing services may exceed the payments made by ODM to the contractor for services covered under the provider agreement.

(WW) "Rural health clinic (RHC)" has the same meaning as in rule 5160-28-01 of the Administrative Code.

(XX) "Self-referral" means the process by which an MCO member may access certain services without prior approval from the PCP or the MCO.

(YY) "Service area" means the geographic area specified in the MCO's provider agreement where the MCO agrees to provide Medicaid services to members residing in those areas.

(ZZ) "Single case agreement" means a contract with an out-of-network provider to provide services to an MCE's member on a one-time, individual, or limited basis.

(AAA) "Single pharmacy benefit manager (SPBM)" is a prepaid ambulatory health plan as defined in 42 C.F.R. 438.2 (October 1, 2021) and the state pharmacy benefit manager selected under section 5167.24 of the Revised code which is responsible for processing all pharmacy claims under the care management system. The SPBM service area is statewide.

(BBB) "SPBM contract" means a formal agreement between ODM and the SPBM for the provision of medically necessary pharmacy services to medicaid recipients who are enrolled in the SPBM.

(CCC) "State cut-off" means the eighth state working day prior to the end of a calendar month.

(DDD) "State hearing" means the process set forth in 42 C.F.R 431, Subpart E (October 1, 2021) and division 5101:6 of the Administrative Code.

(EEE) "Subcontract" means a written contract between an MCE and a third party, including the MCE's parent company or any subsidiary corporation owned by the MCE's parent company, or between the third party and a fourth party, or between any subsequent parties, to perform a specific part of the obligations specified under the MCO's provider agreement or the SPBM's contract with ODM.

(FFF) "Subcontractor" means an individual or entity that has entered into a subcontract with an MCE to perform a specific part of the obligations specified under the MCO's provider agreement or the SPBM's contract with ODM. A provider or network provider is not a subcontractor by virtue of the provider's contract with an MCE.

(GGG) "Third party" means the same as in section 5160.35 of the Revised Code.

(HHH) "Third party administrator" means any entity used in accordance with the provisions of this chapter to manage or administer a portion of services in fulfillment of the provider agreement with ODM.

(III) "Third party benefit" means any health care service(s) available to members through any medical insurance policy or through some other resource that covers medical benefits and the payment for those services is either completely the obligation of the third party payer (TPP) or in part the obligation of the member, the TPP, and/or the MCE.

(JJJ) "Third party claim" or "COB claim" means any claim submitted to an MCE for reimbursement after all TPPs have met their payment obligations. In addition, the following will be considered third party claims by an MCE:

(1) Any claim received by the MCE that shows no prior payment by a TPP, but the MCE's records indicate that the member has third party benefits.

(2) Any claim received by the MCE that shows no prior payment by a TPP, but the provider's records indicate that the member has third party benefits.

(KKK) "Third party liability (TPL)" means the payment obligations of the TPP for health care services rendered to a member when the member also has third party benefits as described in paragraph (EEE) of this rule.

(LLL) "Third party payer (TPP)" means an individual, an entity, or a program responsible for adjudicating and paying claims for third party benefits rendered to an eligible member.

(MMM) "Title X services" means services and supplies allowed under 42 U.S.C. 300 (as in effect July 1, 2022), and provided by a qualified family planning provider.

(NNN) "Tort action," or "subrogation," means the right of ODM to recover payment received from a third party payer who may be liable for the cost of medical services and care arising out of an injury, disease, or disability to the member.

(OOO) "Waste" means payment for or the attempt to obtain payment for items or services when there may be no intent to deceive or misrepresent, but poor or inefficient billing or treatment methods result in unnecessary costs.

Last updated July 18, 2022 at 8:17 AM

History

Effective: July 18, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-26-02 Managed care: eligibility and enrollment.

(A) This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code.

(B) Eligibility for managed care organization (MCO) enrollment.

(1) Except as specified in paragraphs (B)(3) to (B)(5) of this rule, in mandatory service areas as permitted by 42 C.F.R. 438.52 (October 1, 2021), an individual must be enrolled in an MCO if he or she has been determined medicaid eligible in accordance with division 5160:1 of the Administrative Code.

(2) MCO enrollment is mandatory for the following individuals:

(a) Children receiving Title IV-E federal foster care maintenance;

(b) Children receiving Title IV-E adoption assistance:

(d) Children receiving services through the Ohio department of health's bureau for children with medical handicaps (BCMH) or any other family-centered, community-based, coordinated care system that receives grant funds under Section 501(a)(1)(D) of Title V of the Social Security Act, 42 U.S.C. 701(a)(1)(D) (July 1, 2022) and is defined by the state in terms of either program participation or special health care needs.

(e) Individuals who meet the criteria specified in rule 5160-59-04 of the Administrative Code and receive services through the OhioRISE home and community based services (HCBS) waiver administered by the Ohio department of medicaid (ODM).

(3) Medicaid eligible individuals may voluntarily choose to enroll in an MCO if they are:

(a) Indians who are members of federally recognized tribes; or

(b) Individuals diagnosed with a developmental disability who have a level of care that meets the criteria specified in rule 5123-8-01 of the Administrative Code and receive services through a HCBS waiver administered by the Ohio department of developmental disabilities (DODD).

(4) Except for individuals receiving medicaid in the adult extension category under section 1902(a)(10)(A)(i)(VIII) of the Social Security Act 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) (July 1, 2022), and individuals who meet the criteria in paragraphs (B)(2)(e) and (B)(3)(b) of this rule, medicaid eligible individuals are excluded from MCO enrollment if they:

(a) Reside in a nursing facility; or

(b) Receive medicaid services through a medicaid waiver component, as defined in section 5166.02 of the Revised Code.

(5) The following individuals are excluded from MCO enrollment.

(a) Inmates of public institutions as defined in 42 C.F.R. 435.1010 (October 1, 2021) unless otherwise specified by ODM;

(b) Dually eligible individuals enrolled in both the medicaid and medicare programs;

(c) Individuals receiving services in an intermediate care facility for individuals with intellectual disabilities (ICF-IID) or a developmental center as defined in rule 5123-9-30 of the Administrative Code;

(d) Individuals enrolled in the program of all-inclusive care for the elderly (PACE);

(e) Individuals who are determined to be presumptively eligible and receive temporary, time-limited medical assistance as described in rule 5160:1-2-13 of the Administrative Code;

(f) Individuals who receive alien emergency medical assistance in accordance with rule 5160:1-5-06 of the Administrative Code;

(g) Individuals who receive refugee medical assistance in accordance with rule 5160:1-5-05 of the Administrative Code; and

(h) Non-citizen victims of trafficking as set forth in rule 5160:1-5-08 of the Administrative Code.

(6) Nothing in this rule shall be construed to limit or in any way jeopardize an eligible individual's basic medicaid eligibility or eligibility for other non-medicaid benefits to which he or she may be entitled.

(C) Upon implementation of the single pharmacy benefit manager (SPBM), any individual enrolled in an MCO as specified in paragraph (B) of this rule will be mandatorily enrolled in the SPBM.

(D) Enrollment and commencement of coverage in an MCO or the SPBM.

(1) The MCO and the SPBM must accept eligible individuals without regard to race, color, religion, gender, gender identity, sexual orientation, age, disability, national origin, military status, genetic information, ancestry, health status or need for health services. The MCO and the SPBM will not use any discriminatory policy or practice in accordance with 42 C.F.R. 438.3(d) (October 1, 2021).

(2) The MCO and the SPBM must accept eligible individuals who request MCO enrollment without restriction.

(3) If a member loses managed care eligibility and is disenrolled from the MCO and the SPBM, and subsequently regains eligibility, his or her enrollment in the same MCO and the SPBM may be reinstated back to the date eligibility was regained in accordance with procedures established by ODM.

(4) ODM shall confirm the eligible individual's MCO and SPBM enrollment via the ODM-produced Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant 834 daily and monthly enrollment files of new members, continuing members and terminating members.

(5) The MCO and SPBM shall not be required to provide coverage until MCO or SPBM enrollment is confirmed via the ODM-produced HIPAA compliant 834 daily or monthly enrollment files except as provided in paragraph (D)(6) of this rule or upon mutual agreement between ODM and the MCO.

(6) Infants born to mothers enrolled in an MCO are enrolled in an MCO from their date of birth through at least the end of the month of the child's first birthday, or until such time that the MCO is notified of the child's disenrollment via the ODM-produced HIPAA compliant 834 daily or monthly enrollment files. This does not include infants placed for adoption or legally placed in the custody of an Ohio county public children's serivces agency (PCSA).

(7) Coverage of MCO and SPBM members will be effective on the first day of the calendar month specified on the ODM-produced HIPAA compliant 834 daily and monthly enrollment files to the MCO and SPBM, except as specified in paragraph (D) of this rule.

Last updated July 18, 2022 at 8:17 AM

History

Effective: July 18, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-26-02.1 Managed care: termination of enrollment.

(B) The Ohio department of medicaid (ODM) will terminate a member from enrollment in a managed care organization (MCO) for any of the following reasons:

(1) The member's permanent place of residence is moved outside the MCO service area. When this occurs, termination of MCO enrollment takes effect on the last day of the month in which the member moved from the service area.

(2) The member becomes ineligible for medicaid. When this occurs, termination of MCO enrollment takes effect on the last day of the month in which the member became ineligible.

(3) The member dies, in which case MCO enrollment ends on the date of death.

(4) The member is not receiving medicaid in the adult extension category under section 1902(a)(10)(A)(i)(VIII) of the Social Security Act, 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) (July 1, 2022), is authorized for nursing facility services, and the following criteria are met:

(a) The MCO has authorized nursing facility services for no less than the month of nursing facility admission and for two complete consecutive calendar months thereafter;

(b) For the entire period in paragraph (B)(4)(a) of this rule, the member has remained in the nursing facility without any admission to an inpatient hospital or long-term acute care facility;

(c) The member's discharge plan documents that nursing facility discharge is not expected in the foreseeable future and the member has a need for long-term nursing facility care;

(d) For the entire period in paragraph (B)(4)(a) of this rule, the member is not using hospice services; and

(e) The MCO has requested disenrollment, and ODM has approved the request.

(f) The member is found by ODM to meet the criteria for the developmental disabilities level of care as specified in rule 5123-8-01 of the Administrative Code and resides in an intermediate care facility for individuals with intellectual disabilities (ICF-IID). Following MCO notification to ODM and written approval by ODM, termination of MCO membership takes effect on the last day of the month preceding the individual's stay in the ICF-IID.

(5) The member has third party coverage, and ODM determines that continuing MCO enrollment may not be in the best interest of the member. This determination may be based on the type of coverage the member has, the existence of conflicts between provider networks, or access requirements. When this occurs, the effective date of termination of MCO enrollment shall be determined by ODM but in no event shall the termination date be later than the last day of the month in which ODM approves the termination.

(6) The member is not eligible for MCO enrollment for one of the reasons set forth in rule 5160-26-02 of the Administrative Code.

(7) The provider agreement between ODM and the MCO is terminated.

(C) Upon implementation of the single pharmacy benefit manager (SPBM), ODM will terminate a member from enrollment in the SPBM when a member is terminated from enrollment in an MCO as specified in paragraph (B) of this rule or if the contract between ODM and the SPBM is terminated.

(D) All of the following apply when enrollment in an MCO or the SPBM is terminated for any of the reasons set forth in paragraph (B) or (C) of this rule:

(1) Such terminations may occur either in a mandatory or voluntary service area.

(2) All such terminations occur at the individual level.

(3) Such terminations do not require completion of a consumer contact record (CCR).

(4) If ODM fails to notify the MCO or the SPBM of a member's termination from an MCO or the SPBM, ODM shall continue to pay the MCO or the SPBM the applicable monthly capitation rate for the member. The MCO or the SPBM shall remain liable for the provision of covered services as set forth in rule 5160-26-03 of the Administrative Code, until such time as ODM provides the MCO or the SPBM with documentation of the member's termination.

(5) ODM shall recover from the MCO or the SPBM any capitation paid for retroactive enrollment termination occurring as a result of paragraph (B) or (C) of this rule.

(6) A member may lose medicaid eligibility during an annual open enrollment period, and thus become unable to change to a different MCO. If the member then regains medicaid eligibility, the member may request to change plans within thirty days following reenrollment in the MCO.

(E) Member-initiated MCO terminations.

(1) An MCO member who qualifies as a mandatory managed care enrollment population as specified in rule 5160-26-02 of the Administrative Code may request a different MCO as follows:

(a) From the date of enrollment through the initial three months of MCO enrollment;

(b) During an open enrollment month for the member's service area as described in paragraph (G) of this rule;

(c) At any time, if the member is a child receiving Title IV-E federal foster care maintenance or is in foster care or other out of home placement. The change must be initiated by the local public children's services agency (PCSA) or the local Title IV-E juvenile court; or

(d) At any time, if the just cause request meets one of the reasons for just cause as specified in paragraph (E)(3)(f) of this rule;

(2) An MCO member who qualifies as a voluntary managed care enrollment population as specified in rule 5160-26-02 of the Administrative Code may request a different MCO, if available, or be returned to medicaid fee-for-service (FFS) as follows:

(a) From the date of enrollment through the initial three months of MCO enrollment;

(b) During an open enrollment month for the member's service area as described in paragraph (G) of this rule; or

(c) At any time, if the just cause request meets one of the reasons for just cause as specified in paragraph (E)(3)(f) of this rule;

(3) The following provisions apply when a member either requests a different MCO or, if applicable, requests to be returned to medicaid FFS:

(a) The request may be made by the member, or by the member's authorized representative.

(b) All member-initiated changes or terminations must be voluntary. The MCO is not permitted to encourage members to change or terminate enrollment due to a member's age, gender, gender identity, sexual orientation, disability, national origin, race, color, religion, military status, ancestry, genetic information, health status or need for health services. The MCO may not use a policy or practice that has the effect of discrimination on the basis of the criteria listed in this rule.

(c) If a member requests disenrollment because he or she meets the requirements of paragraph (B)(3) of rule 5160-26-02 of the Administrative Code, the member will be disenrolled after the member notifies the Ohio medicaid consumer hotline.

(d) Disenrollment will take effect on the last day of the calendar month in which the request for disenrollment was made.

(e) In accordance with 42 C.F.R. 438.56(d)(2) (October 1, 2021), a change or termination of MCO enrollment may be permitted for any of the following just cause reasons:

(i) The member moves out of the MCO's service area and a non-emergency service must be provided out of the service area before the effective date of the member's termination as described in paragraph (B)(1) of this rule;

(ii) The MCO does not, for moral or religious objections, cover the service the member seeks;

(iii) The member needs related services to be performed at the same time; not all related services are available within the MCO's network, and the member's PCP or another provider determines that receiving services separately would subject the member to unnecessary risk;

(iv) The member has experienced poor quality of care and the services are not available from another provider within the MCO's network;

(v) The member cannot access medically necessary medicaid-covered services or cannot access the type of providers experienced in dealing with the member's health care needs;

(vi) The PCP selected by a member leaves the MCO's network and was the only available and accessible PCP speaking the primary language of the member, and another PCP speaking the language is available and accessible in another MCO in the member's service area; and

(vii) ODM determines that continued enrollment in the MCO would be harmful to the interests of the member.

(f) The following provisions apply when a member seeks a change or termination in MCO enrollment for just cause:

(i) The member may make the request for just cause directly to ODM or an ODM-approved entity, either orally or in writing.

(ii) ODM shall review all requests for just cause within seven working days of receipt. ODM may request documentation as necessary from both the member and the MCO. ODM shall make a decision within forty-five days from the date ODM receives the just cause request. If ODM fails to make the determination within this timeframe, the just cause request is considered approved.

(iii) ODM may establish retroactive termination dates and recover capitation payments as determined necessary and appropriate.

(iv) Regardless of the procedures followed, the effective date of an approved just cause request must be no later than the first day of the second month following the month in which the member requests change or termination.

(v) If the just cause request is not approved, ODM shall notify the member or the authorized representative of the member's right to a state hearing.

(vi) Requests for just cause may be processed at the individual level or case level as ODM determines necessary and appropriate.

(vii) If a member submits a request to change or terminate enrollment for just cause, and the member loses medicaid eligibility prior to action by ODM on the request, ODM shall ensure that the member's MCO enrollment is not automatically renewed if eligibility for medicaid is reauthorized.

(F) MCO initiated terminations.

(1) The MCO may submit a request to ODM for the termination of a member for the following reasons:

(a) Fraudulent behavior by the member; or

(b) Uncooperative or disruptive behavior by the member or someone acting on the member's behalf to the extent that such behavior seriously impairs the MCO's ability to provide services to either the member or other MCO members.

(2) The MCO may not request termination due to the member's age, gender, gender identity, sexual orientation, disability, national origin, race, color, religion, military status, genetic information, ancestry, health status or need for health services.

(3) The MCO must provide medicaid-covered services to a terminated member through the last day of the month in which the MCO enrollment is terminated, notwithstanding the date of ODM written approval of the termination request. Inpatient facility services must be provided in accordance with rule 5160-26-02 of the Administrative Code.

(4) If ODM approves the MCO's request for termination, ODM shall notify in writing the member, the authorized representative, the Ohio medicaid consumer hotline, and the MCO.

(G) MCO open enrollment.

(1) Open enrollment months will occur at least annually.

(2) At least sixty days prior to the designated open enrollment month, ODM will notify eligible individuals by mail of the opportunity to change or terminate MCO enrollment and will explain where to obtain further information.

Last updated January 3, 2023 at 9:23 AM

History

Effective: January 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-26-03 Managed care: covered services.

(B) Except as otherwise provided in this rule, a managed care organization (MCO) and the single pharmacy benefit manager (SPBM) must ensure members have access to all medically necessary services, as applicable, covered by Ohio medicaid under the state plan. The MCO and SPBM must ensure:

(1) Services are sufficient in amount, duration, and scope to reasonably be expected to achieve the purpose for which the services are provided;

(2) The amount, duration, and scope of a required service is not arbitrarily denied or reduced solely because of the diagnosis, type of illness, or condition;

(3) Prior authorization is available for services on which the MCO or the SPBM has placed a pre-identified limitation to ensure the limitation may be exceeded when medically necessary, unless the MCO or SPBM's limitation is also a limitation for fee-for-service medicaid coverage;

(4) Coverage decisions are based on the coverage and medical necessity criteria published in agency 5160 of the Administrative Code and practice guidelines specified in rule 5160-26-05.1 of the Administrative Code; and

(5) If a member is unable to obtain medically necessary services offered by medicaid from an MCO or SPBM network provider, the MCO or SPBM must adequately and timely cover the services out of network, until the MCO or SPBM is able to provide the services from a network provider.

(1) On the basis of medical necessity for the member's condition or diagnosis; or

(2) For the purposes of utilization control, provided the services can be reasonably expected to achieve their purpose as specified in paragraph (B)(1) of this rule.

(D) Upon implementation of the SPBM will provide pharmacy services in compliance with rule 5160-9-03 of the Administrative Code, including all prescribing and prior authorization requirements, and any grandfathered drug classes as established by the Ohio department of medicaid (ODM) preferred drug list located at https://pharmacy.medicaid.ohio.gov/. The SPBM will not charge co-pays unless directed by ODM. Until implementation of the SPBM, the provisions outlined in this paragraph are applicable to the MCO.

(E) Services covered by an MCO.

(1) The MCO must cover annual physical examinations for adults.

(2) At the request of the member, the MCO must provide for a second opinion from a qualified health care professional within the MCO's network. If such a qualified health care professional is not available within the MCO's network, the MCO must arrange for the member to obtain a second opinion outside the MCO's network, at no cost to the member.

(3) The MCO must ensure emergency services as defined in rule 5160-26-01 of the Administrative Code are provided and covered twenty-four hours a day, seven days a week. At a minimum, such services must be provided and reimbursed in accordance with the following:

(a) The MCO cannot deny payment for treatment obtained when a member had an emergency medical condition as defined in rule 5160-26-01 of the Administrative Code.

(b) The MCO cannot limit what constitutes an emergency medical condition on the basis of lists of diagnoses or symptoms.

(d) The MCO must cover medicaid-covered services related to the member's emergency medical condition when the member is instructed to go to an emergency facility by a representative of the MCO, including but not limited to, the member's primary care provider (PCP) or the MCO's twenty-four-hour toll-free phone number.

(e) The MCO cannot deny payment of emergency services based on the treating provider, hospital, or fiscal representative not notifying the member's PCP of the visit.

(f) The MCO must cover emergency services as defined in rule 5160-26-01 of the Administrative Code when the services are delivered by a non-contracting provider of emergency services and claims for these services cannot be denied regardless of whether the services meet an emergency medical condition as defined in rule 5160-26-01 of the Administrative Code. Such services must be reimbursed by the MCO at the lesser of billed charges or one hundred per cent of the Ohio medicaid program reimbursement rate (less any payments for indirect costs of medical education and direct costs of graduate medical education that is included in the Ohio medicaid program reimbursement rate) in effect for the date of service. If an inpatient admission results, the MCO is required to reimburse at this rate only until the member can be transferred to a provider designated by the MCO. Pursuant to section 5167.10 of the Revised Code, the MCO shall not compensate a hospital for inpatient capital costs in an amount that exceeds the maximum rate established by ODM.

(g) The MCO must cover emergency services until the member is stabilized and can be safely discharged or transferred.

(h) The MCO must adhere to the judgment of the attending provider when requesting a member's transfer to another facility or discharge. The MCO may establish arrangements with hospitals whereby the MCO may designate one of its contracting providers to assume the attending provider's responsibilities to stabilize, treat, and transfer the member.

(i) A member who has had an emergency medical condition may not be held liable for payment of any subsequent screening and treatment needed to diagnose the specific condition or stabilize the member.

(4) The MCO must establish, in writing, the process and procedures for the submission of claims for services delivered by non-contracting providers, including non-contracting providers of emergency services. Such information must be made available upon request to non-contracting providers, including non-contracting providers of emergency services. The MCO shall not establish claims filing and processing procedures for non-contracting providers, including non-contracting providers of emergency services, that are more stringent than those established for their contracting providers.

(5) The MCO must ensure post-stabilization care services as defined in rule 5160-26-01 of the Administrative Code are provided and covered twenty-four hours a day, seven days a week.

(a) The MCO must designate a telephone line to receive provider requests for coverage of post-stabilization care services. The line must be available twenty-four hours a day. The MCO must document that the telephone number and process for obtaining authorization has been provided to each emergency facility in the service area. The MCO must maintain a record of any request for coverage of post-stabilization care services that is denied including, at a minimum, the time of the provider's request and the time the MCO communicated the decision in writing to the provider.

(b) At a minimum, post-stabilization care services must be provided and reimbursed in accordance with the following:

(i) The MCO must cover services obtained within or outside the MCO's network that are pre-approved in writing to the requesting provider by an MCO provider or other MCO representative.

(ii) The MCO must cover services obtained within or outside the MCO's network that are not pre-approved by an MCO provider or other MCO representative but are administered to maintain the member's stabilized condition within one hour of a request to the MCO for pre-approval of further post-stabilization care services.

(iii) The MCO must cover services obtained within or outside the MCO's network that are not pre-approved by an MCO provider or other MCO representative but are administered to maintain, improve, or resolve the member's stabilized condition if:

(a) The MCO fails to respond within one hour to a provider request for authorization to provide such services.

(b) The provider has documented an attempt to contact the MCO to request authorization, but the MCO connot be contacted.

(c) The MCO's representative and treating provider cannot reach an agreement concerning the member's care and an MCO provider is not available for consultation. In this situation, the MCO must give the treating provider the opportunity to consult with an MCO provider and the treating provider may continue with care until an MCO provider is reached or one of the criteria specified in paragraph (E)(5)(c) of this rule is met.

(i) An MCO provider with privileges at the treating hospital assumes responsibility for the member's care;

(ii) An MCO provider assumes responsibility for the member's care through transfer;

(iii) An MCO representative and the treating provider reach an agreement concerning the member's care; or

(iv) The member is discharged.

(6) When an MCO member has a nursing facility (NF) stay, the MCO is responsible for payment of medically necessary NF services until the member is discharged or until the member is disenrolled in accordance with the processes set forth in rule 5160-26-02.1 of the Administrative Code.

(7) The MCO is not responsible for payment of home and community-based services (HCBS) provided to a member who is enrolled in an HCBS waiver program administered by ODM, the Ohio department of aging (ODA), or the Ohio department of developmental disabilities (DODD).

(8) MCO members are permitted to self-refer to Title X services provided by any qualified family planning provider (QFPP). The MCO is responsible for payment of claims for Title X services delivered by QFPPs not contracting with the MCO at the lesser of one hundred per cent of the Ohio medicaid program fee-for-service reimbursement rate or billed charges in effect for the date of service.

(9) The MCO must permit members to self-refer to any women's health specialist within the MCO's network for covered care necessary to provide women's routine and preventive health care services. This is in addition to the member's designated PCP if that PCP is not a women's health specialist.

(10) The MCO must ensure access to covered services provided by all federally qualified health centers (FQHCs) and rural health clinics (RHCs).

(11) Where available, the MCO must ensure access to covered services provided by a certified nurse practitioner.

(12) ODM may approve an MCO's members to be referred to certain MCO non-contracting hospitals, as specified in rule 5160-26-11 of the Administrative Code, for medicaid-covered non-emergency hospital services. When ODM permits such authorization, ODM will notify the MCO and the MCO non-contracting hospital of the terms and conditions, including the duration, of the approval and the MCO must reimburse the MCO non-contracting hospital at one hundred per cent of the current Ohio medicaid program fee-for-service reimbursement rate in effect for the date of service for all medicaid-covered non-emergency hospital services delivered by the MCO non-contracting hospital. ODM will base its determination of when an MCO's members can be referred to MCO non-contracting hospitals pursuant to the following:

(a) The MCO's submission of a written request to ODM for the approval to refer members to a hospital that has declined to contract with the MCO. The request must document the MCO's contracting efforts and why the MCO believes it will be necessary for members to be referred to this hospital; and

(b) ODM consultation with the MCO non-contracting hospital to determine the basis for the hospital's decision to decline to contract with the MCO, including but not limited to whether the MCO's contracting efforts were unreasonable and/or that contracting with the MCO would have adversely impacted the hospital's business.

(13) Paragraph (E)(12) of this rule is not applicable when the MCO and an MCO non-contracting hospital have mutually agreed that the non-contracting hospital will provide non-emergency hospital services to an MCO's members. The MCO must ensure that such arrangements comply with rule 5160-26-05 of the Administrative Code.

(14) The MCO is not responsible for payment of services provided through medicaid school program (MSP) pursuant to Chapter 5160-35 of the Administrative Code. The MCO must ensure access to medicaid-covered services for members who are unable to timely access services or unwilling to access services through MSP providers.

(15) When a member is determined to be no longer eligible for enrollment in an MCO during a stay in an institution for mental disease (IMD), the MCO is not responsible for payment of that IMD stay after the date of disenrollment from the MCO.

(16) The MCO must provide two dental cleanings per year to pregnant members of the eligibility group described in section 5163.06 of the Revised Code.

(17) The MCO must cover respite services as described in rule 5160-26-03.2 of the Administrative Code.

(18) The MCO is not responsible for covering services described in rule 5160-59-03 of the Administrative Code for a member enrolled in the OhioRISE plan.

(F) The MCO and SPBM are not required to cover services provided to members outside the United States.

(G) The MCO and SPBM must ensure that eligible members receive all early and periodic screening, diagnosis and treatment (EPSDT) services, also known as healthchek services, in accordance with rule 5160-1-14 of the Administrative Code. The MCO will ensure healthchek exams:

(1) Include the components specified in rule 5160-1-14 of the Administrative Code. All components of exams must be documented and included in the medical record of each healthchek eligible member and made available for the ODM annual external quality review.

(2) Are completed within ninety days of the initial effective date of enrollment for those children found to have a possible ongoing condition likely to require care management services.

Last updated July 18, 2022 at 8:18 AM

History

Effective: July 18, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-26-03.1 Managed care: primary care and utilization management.

(B) A managed care organization (MCO) must ensure each member has a primary care provider (PCP) who will serve as an ongoing source of primary care and assist with care coordination appropriate to the member's needs.

(1) The MCO must ensure PCPs are in compliance with the following triage requirements:

(a) Members with emergency care needs must be triaged and treated immediately on presentation at the PCP site;

(b) Members with persistent symptoms must be treated no later than the end of the following working day after their initial contact with the PCP site; and

(2) PCP care coordination responsibilities include at a minimum the following:

(a) Assisting with coordination of the member's overall care, as appropriate for the member;

(b) Providing services which are medically necessary as described in rule 5160-1-01 of the Administrative Code;

(d) Recommending referrals to specialists, as required; and

(e) Triaging members as described in paragraph (B)(1) of this rule.

(C) The MCO and the single pharmacy benefit manager (SPBM) must have a utilization management (UM) program with clearly defined structures and processes designed to maximize the effectiveness of the care provided to the member. The MCO and the SPBM must ensure decisions rendered through the UM program are based on medical necessity.

(1) The UM program must be based on written policies and procedures that include, at a minimum:

(a) The information sources used to make determinations of medical necessity;

(b) The criteria, based on sound clinical evidence, to make UM decisions and the specific procedures for appropriately applying the criteria;

(c) A specification that written UM criteria will be made available to both contracting and non-contracting providers; and

(d) A description of how the MCO or SPBM will monitor the impact of the UM program to detect and correct potential under- and over-utilization.

(2) The MCO and SPBM's UM programs must also ensure and document the following:

(a) An annual review and update of the UM program.

(b) The involvement of a designated senior physician in the UM program.

(c) The use of appropriate qualified licensed health professionals to assess the clinical information used to support UM decisions.

(d) The use of board-certified consultants to assist in making medical necessity determinations, as necessary.

(e) That UM decisions are consistent with clinical practice guidelines as specified in rule 5160-26-05.1 of the Administrative Code. The MCO may not impose conditions around the coverage of a medically necessary medicaid-covered service unless they are supported by such clinical practice guidelines.

(f) The reason for each denial of a service, based on sound clinical evidence.

(g) That compensation by the MCO or SPBM to individuals or entities that conduct UM activities does not offer incentives to deny, limit, or discontinue medically necessary services to any member.

(h) Compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA) requirements outlined in 42 CFR Part 438 Subpart K (October 1, 2025).

(3) The MCO and the SPBM must process requests for initial and continuing authorizations of services from their providers and members. The MCO and the SPBM must have written policies and procedures to process initial requests and continuing authorizations. Upon request, the MCO and SPBM's policies and procedures for initial and continuing authorizations must be made available for review by the Ohio department of medicaid (ODM). The MCO and SPBM's written policies and procedures for initial and continuing authorizations of services must also be made available to contracting and non-contracting providers upon request. The MCO and SPBM must ensure and document the following occurs when processing requests for initial and continuing authorizations of services:

(a) Consistent application of review criteria for authorization decisions.

(b) Consultation with the requesting provider, when necessary.

(c) Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested, must be made by a health care professional who has appropriate clinical expertise in treating the member's condition or disease.

(d) That a written notice will be sent to the member and the requesting provider of any decision to reduce, suspend, terminate, or deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice to the member must meet the requirements of division 5101:6 and rule 5160-26-08.4 of the Administrative Code.

(e) For standard authorization decisions, the MCO must provide notice to the provider and member as expeditiously as the member's health condition requires but no later than seven calendar days following receipt of the request for service. If requested by the member, provider, or MCO, standard authorization decisions may be extended up to fourteen additional calendar days. If requested by the MCO, the MCO must submit to ODM for prior-approval, documentation as to how the extension is in the member's interest. If ODM approves the MCO's extension request, the MCO must give the member written notice of the reason for the decision to extend the time frame and inform the member of the right to file a grievance if he or she disagrees with that decision. The MCO must carry out its determination as expeditiously as the member's health condition requires and no later than the date the extension expires.

(f) If a provider indicates or the MCO determines that following the standard authorization timeframe could seriously jeopardize the member's life or health or ability to attain, maintain, or regain maximum function, the MCO must make an expedited authorization decision and provide notice of the authorization decision as expeditiously as the member's health condition requires but no later than forty-eight hours after receipt of the request for service. If requested by the member or MCO, expedited authorization decisions may be extended up to fourteen additional calendar days. If requested by the MCO, the MCO must submit to ODM for prior-approval, documentation as to how the extension is in the member's interest. If ODM approves the MCO's extension request, the MCO must give the member written notice of the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if he or she disagrees with that decision. The MCO must carry out its determination as expeditiously as the member's health condition requires and no later than the date the extension expires.

(g) For prior authorization of covered outpatient drugs as defined in 42 U.S.C. 1396r-8(k)(2) (as in effect January 1, 2026), the SPBM will provide a response to the provider by telephone or other telecommunication device within twenty-four hours of the initial request.

(i) If the prior authorization request contains sufficient information to render a final decision, the SPBM must provide notice to the provider of the decision within twenty-four hours of receipt of the initial request.

(ii) If the prior authorization request contains insufficient information to render a final decision, the SPBM must notify the provider of the need for additional information within twenty-four hours of the initial request.

(iii) If the prior authorization request is for an emergency situation, a seventy-two hour supply of the covered outpatient drug that was prescribed must be authorized while the SPBM reviews the prior authorization request.

(h) The MCO and the SPBM must maintain and submit as directed by ODM, a record of all authorization requests, including standard and expedited authorization requests and any extensions granted. MCO and SPBM records must include member identifying information, service requested, date initial request received, any extension requests, decision made, date of decision, date of member notice, and basis for denial, if applicable.

(4) The SPBM may, subject to ODM prior approval, implement strategies for the management of drug utilization, and the MCO may, subject to ODM approval, develop other UM programs.

(5) At a minimum, the MCO has to implement a coordinated services program (CSP) as described in Chapter 5160-20 of the Administrative Code. The MCO has to offer care management services to any member enrolled in CSP

Last updated January 5, 2026 at 8:50 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-26-03.2 Managed care: long-term services and supports respite services for children.

(B) The managed care organization (MCO) is responsible for payment of long-term services and supports (LTSS) respite services as defined in rule 5160-26-01 of the Administrative Code.

(1) Reside with his or her informal, unpaid primary caregiver in a home that is not owned, leased, or controlled by a provider of any health-related treatment or support services;

(2) Not be a foster child, as defined in Chapter 5101:2-1 of the Administrative Code;

(3) Be under twenty-one years of age;

(4) Have long-term services and supports (LTSS) needs resulting in the need for respite services as indicated by:

(a) Skilled nursing or skilled rehabilitation services at least once per week; or

(b) Having a need for at least fourteen hours per week of home health aide services for at least two consecutive months immediately preceding the date respite services are requested; or

(c) Being determined eligible for social security income for children with disabilities or supplemental security income; or

(d) Having an LTSS needs as determined by the MCO through an institutional level of care determination as set forth in rule 5123-8-01 or 5160-3-08, of the Administrative Code.

(5) Be participating in a care management or coordination arrangement.

(D) Authorization for LTSS respite.

(1) Prior authorization of LTSS respite services will be in accordance with rule 5160-26-03.1 of the Administrative Code.

(2) Respite services can be provided on a planned or unplanned basis.

(3) The MCO has to determine 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 LTSS needs, or in order to prevent an inpatient, institutional, or out-of-home stay.

(E) LTSS respite services have to be provided by individuals employed by medicaid enrolled agency providers that are either medicare-certified home health agencies pursuant to Chapter 3701-60 of the Administrative Code, or accredited by the "Joint Commission," the "Community Health Accreditation Program," or the "Accreditation Commission for Health Care."

(1) LTSS respite providers have to comply with the criminal records check set forth in rules 5160-45-07 and 5160-45-11 of the Administrative Code.

(2) The provider has to be awake when the member is awake during the provision of respite services.

(3) Respite providers has to not be the member's "legally responsible family member," as defined in rule 5160-45-01 of the Administrative Code.

(4) Before commencing service delivery, the LTSS provider agency employee has to:

(a) Obtain a certificate of completion of either a competency evaluation program or a training and competency evaluation program approved or conducted by the director of health under section 3721.31 of the Revised Code, and be registered as active or in good standing on the Ohio nurse aide registry maintained by the director of health under section 3721.32 of the Revised Code.

(b) Obtain and maintain first aid certification from a class that is not solely internet-based and that includes hands-on training by a certified first aid instructor and a successful return demonstration of what was learned in the course. At its discretion, ODM may accept training conducted by a solely internet-based class as sufficient for the purposes of first aid certification.

(i) Maintain evidence of completion of twelve hours of in-service continuing education within a twelve-month period, excluding agency and program-specific orientation, and

(ii) Receive supervision from an Ohio-licensed registered nurse (RN) and meet any additional supervisory requirements pursuant to the agency's certification or accreditation.

Last updated March 25, 2024 at 9:11 AM

History

Effective: July 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-26-05 Managed care: provider network and contracting requirements.

(A) Provider contracts.

(1) A managed care entity (MCE) must provide or arrange for the delivery of covered health care services described in rule 5160-26-03 of the Administrative Code either through the use of employees or through contracts with network providers of health care services ("providers"). All provider contracts must be in writing and in accordance with paragraph (D) of this rule, 42 C.F.R. 434.6 and 42 C.F.R 438.6 (October 1, 2024). The MCE's execution of a provider contract does not terminate the MCE's legal responsibility to the Ohio department of medicaid (ODM) to ensure all of the MCE's activities and obligations are performed in accordance with agency 5160 of the Administrative Code, as applicable, the MCE's provider agreement or contract with ODM, and all applicable federal, state, and local regulations.

(2) The MCE will make all provider contracts available to ODM upon request.

(3) Provider contracts may not include language that conflicts with the specifications identified in paragraph (C) of this rule.

(4) MCE network providers have to maintain an active, valid medicaid provider agreement as set forth in rule 5160-1-17.2 of the Administrative Code.

(5) When utilizing an out of network provider, the MCE must establish a mutually agreed upon compensation amount for the authorized service and notify the provider of the applicable provisions of the medicaid addendum (ODM 10235). For medicaid-covered non-emergency hospital services outlined in rule 5160-26-03 of the Administrative Code, the compensation amount is identified in rule 5160-26-11 of the Administrative Code.

(B) Notification.

(1) Notwithstanding applicable provisions outlined in the medicaid addendum (ODM 10235), the MCE must notify ODM of any addition to or deletion from its provider network on an ongoing basis and must follow the time restrictions contained in this paragraph unless an explanation of extenuating circumstances is accepted by ODM.

(2) At the direction of ODM, the MCE must submit evidence of the following:

(a) A copy of the provider's current licensure;

(b) Copies of written agreements with the provider, including but not limited to provider contracts, amendments, and the medicaid addendum as specified in paragraph (D) of this rule;

(d) The provider's medicaid provider identification number.

(3) The MCE will notify ODM in writing of the expiration, nonrenewal, or termination of any provider contract at least fifty-five calendar days prior to the expiration, nonrenewal, or termination of the provider contract in a manner and format directed by ODM. If the MCE receives less than fifty-five calendar days' notice from the provider, the MCE must inform ODM in writing within one working day of becoming aware of this information.

(4) If the provider contract is for a hospital:

(a) Forty-five calendar days prior to the effective date of the expiration, nonrenewal or termination of the hospital's provider contract, the MCE shall notify in writing all providers who have admitting privileges at the hospital of the impending expiration, nonrenewal, or termination of the provider contract and the last date the hospital will provide services to members under the MCE provider contract. If the MCE receives less than forty-five calendar days' notice from the hospital, the MCE shall send the notice within one working day of becoming aware of the expiration, nonrenewal, or termination of the provider contract.

(b) Forty-five calendar days prior to the effective date of the expiration, nonrenewal, or termination of the hospital's provider contract, the MCE shall notify in writing all members in the service area, or in an area authorized by ODM, of the impending expiration, nonrenewal, or termination of the hospital's provider contract. If the MCE receives less than forty-five calendar days' notice from the hospital provider, the MCE shall send the notice within one working day of becoming aware of the expiration, nonrenewal, or termination of the provider contract.

(c) The MCE shall submit a template for member and provider notifications to ODM along with the MCE's notification to ODM of the impending expiration, nonrenewal, or termination of the hospital's provider contract. The notifications shall comply with the following:

(i) The form and content of the member notice have to be prior-approved by ODM and contain an ODM designated toll-free telephone number members can call for information and assistance.

(ii) The form and content of the provider notice have to be prior-approved by ODM.

(d) ODM may require the MCE to notify additional members or providers if the impending expiration, nonrenewal, or termination of the hospital's provider contract adversely impacts additional members or providers.

(5) If the provider contract is for a primary care provider (PCP):

(a) The MCE will include the number of members that will be affected by the change in the notice to ODM; and

(b) The MCE will notify in writing all members who use or are assigned to the provider as a PCP at least forty-five calendar days prior to the effective date of the change. If the MCE receives less than forty-five calendar days prior notice from the PCP, the MCE will issue the notification within one working day of the MCE becoming aware of the expiration, nonrenewal, or termination of PCP's provider contract. The form of the notice and its content have to be prior-approved by ODM and must contain, at a minimum, all of the following information:

(i) The PCP's name and last date the PCP is available to provide care to the MCE's members;

(ii) Information regarding how members can select a different PCP; and

(iii) An MCE telephone number members can call for further information or assistance.

(6) ODM may require the MCE to notify members or providers of the expiration, nonrenewal, or termination of other provider contracts that may adversely impact the MCE's members.

(7) In order to ensure availability of services and qualifications of providers, ODM may require submission of documentation in accordance with paragraph (B) of this rule regardless of whether the MCE contracts directly for services or does so through another entity.

(8) In the event that the MCE's medicaid managed care program participation in a service area is terminated, the MCE must provide written notification to its affected contracted providers at least forty-five calendar days prior to the termination date, unless otherwise specified by ODM.

(1) The MCE must ensure that none of its employees or contracted providers are sanctioned or excluded from providing medicaid or medicare services. The MCE shall use available resources for identifying sanctioned or excluded providers, at least monthly, including, but not limited to, the following:

(a) The federal office of inspector general provider exclusion list;

(b) The ODM excluded provider web page; and

(c) The discipline pages of the applicable state boards that license providers or an alternative data resource, such as the national practitioner databank, that is as complete and accurate as the discipline pages of the applicable state boards.

(2) The MCE may not discriminate with regard to the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable state law, solely on the basis of that license or certification. If the MCE declines to include individual or groups of providers in its network, it must give the affected providers written notice of the reasons for its decision. This paragraph may not be construed to:

(a) Require the MCE to contract with providers beyond the number necessary to meet the needs of its members as described in the MCE's provider agreement or contract with ODM;

(b) Preclude the MCE from using different reimbursement amounts for different specialties or for different practitioners in the same specialty; or

(c) Preclude the MCE from establishing measures that are designed to maintain quality of services and control costs and are consistent with its responsibilities to members.

(3) The MCE must have written policies and procedures for the selection and retention of providers that prohibit discrimination against particular providers that serve high-risk populations or specialize in conditions that require costly treatment.

(4) The MCE will accept ODM credentialing of ODM-enrolled providers and will not conduct any further credentialing activities for those providers.

(D) Provider contract specifications.

All provider contracts, including single case agreements, must include a medicaid addendum that has been approved by ODM. A template for the medicaid addendum (ODM 10235) is available on the department's website at medicaid.ohio.gov.

Last updated May 5, 2025 at 7:38 AM

History

Effective: May 5, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-26-05.1 Managed care: provider services.

(A) A managed care entity (MCE) must provide the following written information to their contracting providers:

(1) The MCE's grievance, appeal and state fair hearing procedures and time frames, including:

(a) The member's right to file grievances and appeals and the requirements and time frames for filing;

(b) The MCE's toll-free telephone number to file oral grievances and appeals;

(c) The member's right to a state fair hearing, the requirements and time frames for requesting a hearing, and representation rules at a hearing;

(d) The availability of assistance from the MCE in filing any of these actions;

(e) The member's right to request continuation of benefits during an appeal or a state hearing and specification that at the discretion of ODM the member may be liable for the cost of any such continued benefits; and

(f) The provider's rights to participate in these processes on behalf of the provider's patients and to challenge the failure of the MCE to cover a specific service.

(2) The MCE's requirements regarding the submission and processing of prior authorization requests including:

(a) A list of the benefits, if any, that require prior authorization approval from the MCE;

(b) The process and format to be used in submitting such requests;

(d) Pursuant to the provisions of paragraph (A)(1) of this rule, how the provider will be notified of the MCE's decision regarding such requests; and

(e) Pursuant to the provisions of paragraph (A)(1) of this rule, the procedures to be followed in appealing the MCE's denial of a prior authorization request.

(3) The MCE's documentation, legibility, confidentiality, maintenance, and access standards for member medical records; including a member's right to amend or correct his or her medical record as specified in 45 C.F.R. 164.526 (October 1, 2021).

(4) The MCE's process and requirements for the submission of claims and the appeal of denied claims.

(5) The MCE's policies and procedures regarding what action the MCE may take in response to occurrences of undelivered, inappropriate, or substandard health care services, including the reporting of serious deficiencies to the appropriate authorities.

(6) The mutually agreed upon policies and procedures between the MCE and the provider that explains the provider's obligation to provide oral translation, oral interpretation, and sign language services to the MCE's members including:

(a) The provider's responsibility to identify those members who may require such assistance;

(b) The process the provider is to follow in arranging for such services to be provided;

(d) Specification of whether the MCE or the provider will be financially responsible for the costs of providing these services.

(7) The procedures that providers are to follow in notifying the MCE of changes in their practice, including at a minimum:

(a) Address and phone numbers;

(b) Providers included in the practice;

(d) Standard office hours.

(8) Specification of what service utilization and provider performance data the MCE will make available to providers.

(9) Specification of the healthchek components to be provided to eligible members as specified in Chapter 5160-14 of the Administrative Code.

(B) In addition to the information in paragraph (A) of this rule, a managed care organization (MCO) has to provide the following written information to providers:

(1) The MCO's expectations for primary care providers (PCPs), including triage obligations.

(2) A description of the MCO's care coordination and care management programs, and the role of the provider in those programs, including:

(a) The MCO's criteria for determining which members might benefit from care management;

(b) The provider's responsibility in identifying members who may meet the MCO's care management criteria; and

(3) The MCO's expectations regarding the submission and processing of requests for specialist referrals including:

(a) A list of the provider types, if any, that need prior authorization approval from the MCO;

(b) The process and format to be used in submitting prior authorization requests;

(d) The procedures to be followed in appealing the MCO's denial of prior authorization requests.

(C) An MCO must adopt practice guidelines and disseminate the guidelines to all affected providers, and upon request to members and pending members. These guidelines must:

(1) Be based on valid and reliable clinical evidence or a consensus of health care professionals in the particular field;

(2) Consider the needs of the MCO's members;

(3) Be adopted in consultation with contracting health care professionals; and

(4) Be reviewed and updated periodically, as appropriate.

(D) The MCE must have staff specifically responsible for resolving individual provider issues, including, but not limited to, problems with claims payment, prior authorizations and referrals. The MCE must provide written information to their contracting providers detailing how to contact these designated staff.

Last updated July 10, 2026 at 11:54 AM

History

Effective: July 18, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-26-06 Managed care: program integrity - fraud, waste and abuse, audits, reporting, and record retention.

(A) A managed care entity (MCE) must have administrative and management arrangements or procedures, including a mandatory compliance plan, to guard against fraud, waste and abuse as required in the MCE provider agreement or contract with the Ohio department of medicaid (ODM) located at http://medicaid.ohio.gov/.

(1) These arrangements or procedures must be made available to ODM upon request.

(2) The MCE must annually submit to ODM a report that summarizes the MCE's fraud, waste, and abuse activities for the previous year and identifies any proposed changes to the MCE's fraud, waste, and abuse program for the coming year.

(B) ODM or its designee, the state auditor's office, the state attorney general's office, and the U.S. department of health and human services may evaluate or audit the MCE's performance for the purpose of determining compliance with the requirements of Chapter 5160-26 of the Administrative Code, fraud, waste, and abuse statutes, applicable state and federal regulations, or requirements under federal waiver authority.

(C) ODM or its designee may conduct on-site audits and reviews as deemed necessary based on periodic analysis of financial, utilization, provider network, and other information.

(D) The MCE must submit required reports and additional information, as requested by ODM, as related to its duties and obligations and where needed to ensure operation in accordance with all state and federal regulations or requirements.

(E) If the MCE fails to submit any ODM-requested materials, as specified in paragraph (D) of this rule, without cause as determined by ODM, on or before the due date, ODM may impose any or all of the sanctions listed in rule 5160-26-10 of the Administrative Code or the MCE's provider agreement or contract with ODM.

(F) Record retention.

The MCE and its contracted providers and subcontractors shall retain and safeguard all hard copy or electronic records originated or prepared in connection with the MCE's performance of its obligations under the MCO provider agreement or the SPBM contract, including but not limited to working papers or information related to the preparation of reports, medical records, progress notes, charges, journals, ledgers, and fiscal reports, in accordance with applicable sections of the federal regulations, the Revised Code, and the Administrative Code. Records stored electronically must be produced at the MCE's expense, upon request, in the format specified by state or federal authorities. As specified in 42 C.F.R. 438.3 (October 1, 2021), such records must be maintained for a minimum of ten years from the renewal, amendment or termination date of the provider agreement. In the event the MCE has been notified that state or federal authorities have commenced an audit or investigation of the MCO provider agreement or the SPBM contract, records must be maintained until such time as the matter under audit or investigation has been resolved. For the initial three years of the retention period, the MCE and its contracted providers and subcontractors must store the records in a manner and place that provides readily available access.

Last updated July 18, 2022 at 8:19 AM

History

Effective: July 18, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-26-08.3 Managed care: member rights.

(A) A managed care entity (MCE) must develop and implement written policies in accordance with 42 C.F.R. 438.100 (October 1, 2021), as applicable, to ensure each member has and is informed of his or her right to:

(1) Receive all services the MCE is required to provide pursuant to the terms of the MCE provider agreement or contract, as applicable, with the Ohio department of medicaid (ODM).

(2) Be treated with respect and with due consideration for their dignity and privacy.

(3) Be ensured of confidential handling of information concerning their diagnoses, treatments, prognoses, and medical and social history.

(4) Be provided information about their health. Such information should also be made available to the individual legally authorized by the member to have such information or the person to be notified in the event of an emergency when concern for a member's health makes it inadvisable to give him/her such information.

(5) Be given the opportunity to participate in decisions involving their health care.

(6) Receive information on available treatment options and alternatives, presented in a manner appropriate to the member's condition and ability to understand.

(7) Maintain auditory and visual privacy during all health care examinations or treatment visits.

(8) Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.

(9) Request and receive a copy of their medical records, and to be able to request that their medical records be amended or corrected.

(10) Be afforded the opportunity to approve or refuse the release of information except when release is required by law.

(11) Be afforded the opportunity to refuse treatment or therapy. Members who refuse treatment or therapy will be counseled relative to the consequences of their decision and documentation will be entered into the medical record accordingly.

(12) Be afforded the opportunity to file grievances, appeals, or state hearings pursuant to the provisions of rule 5160-26-08.4 of the Administrative Code.

(13) Be provided written member information from the MCE:

(a) At no cost to the member,

(b) In the prevalent non-English languages of members specified by ODM, and

(14) Receive necessary oral interpretation and oral translation services at no cost.

(15) Receive necessary services of sign language assistance at no cost.

(16) Be informed of specific student practitioner roles and the right to refuse student care.

(17) Refuse to participate in experimental research.

(18) Formulate advance directives and to file any complaints concerning noncompliance with advance directives with the Ohio department of health.

(19) Change primary care providers (PCPs) no less often than monthly. The MCO must mail written confirmation to the member of his or her new PCP selection prior to or on the effective date of the change.

(20) Appeal to or file directly with the United States department of health and human services office of civil rights any complaints of discrimination on the basis of race, color, national origin, age or disability in the receipt of health services.

(21) Appeal to or file directly with the ODM office of civil rights any complaints of discrimination on the basis of race, color, religion, gender, gender identity, sexual orientation, age, disability, national origin, military status, genetic information, ancestry, health status or need for health services in the receipt of health services.

(22) Be free to exercise their rights and to be assured that exercising their rights does not adversely affect the way the MCE, the MCE's providers, or ODM treats the member.

(23) Be assured the MCE must comply with all applicable federal and state laws and other laws regarding privacy and confidentiality.

(24) Choose his or her health professional to the extent possible and appropriate.

(25) For female members, to obtain direct access to a woman's health specialist within the network for covered care necessary to provide women's routine and preventive health care services. This is in addition to a member's designated PCP if the PCP is not a woman's health specialist.

(26) Be provided a second opinion from a qualified health care professional within the MCO's network. If such a qualified health care professional is not available within the MCO's network, the MCO must arrange for a second opinion outside the network, at no cost to the member.

(27) Receive information on their MCE.

(B) The MCE must advise members via the member handbook of the member rights specified in paragraph (A) of this rule.

Last updated September 1, 2023 at 1:09 PM

History

Effective: July 18, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-26-08.4 Managed care: appeal and grievance system.

(A) This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code.

(B) Notice of action (NOA) by a managed care organization (MCO) or the single pharmacy benefit manager (SPBM).

(1) When an adverse benefit determination has occurred or will occur, the MCO or SPBM shall provide the affected member with a NOA.

(2) The language and format of the NOA shall comply with the requirements listed in 42 CFR 438.10 (October 1, 2021), and the NOA shall explain:

(a) The adverse benefit determination the MCO or SPBM has taken or intends to take;

(b) The reasons for the adverse benefit determination, including the right of the member to be provided, upon request and free of charge, reasonable access to copies of all documents, records, and other relevant determination information;

(d) Information related to exhausting the MCO or SPBM appeal process;

(e) The member's right to request a state hearing through the state's hearing system upon exhausting the MCO or SPBM appeal process;

(f) Procedures for exercising the member's rights to appeal the adverse benefit determination;

(g) Circumstances under which expedited resolution is available and how to request it;

(h) If applicable, the member's right to have benefits continue pending the resolution of the appeal, how to request that benefits be continued, and the circumstances under which the member may be required to pay for the cost of these services; and

(i) The date the notice is issued.

(3) NOAs shall be issued within the following time frames:

(a) For a decision to deny or limit authorization of a requested service the MCO or SPBM shall issue a NOA simultaneously with the MCO or SPBM's decision.

(b) For reduction, suspension, or termination of services prior to the member receiving the services previously authorized by the MCO or SPBM, the MCO or SPBM shall give notice at least fifteen calendar days before the effective date of the adverse benefit determination except:

(i) If probable recipient fraud has been verified, the MCO or SPBM shall give notice five calendar days before the effective date of the adverse benefit determination.

(ii) Under the circumstances set forth in 42 CFR 431.213 (October 1, 2021), the MCO or SPBM shall give notice on or before the effective date of the adverse benefit determination.

(c) For denial of payment for a non-covered service, the MCO or SPBM shall give notice simultaneously with the MCO or SPBM's determination to deny the claim, in whole or part, for a service not covered by medicaid, including a service determined through the MCO or SPBM's prior authorization process as not medically necessary.

(d) For untimely prior authorization, appeal, or grievance resolution, the MCO or SPBM shall give notice simultaneously with the MCO or SPBM becoming aware of the untimely resolution. Service authorization decisions not reached within the time frames specified in rule 5160-26-03.1 of the Administrative Code constitutes a denial and is thus considered to be an adverse benefit determination. Notice shall be given on the date the authorization decision time frame expires.

(1) A member may file a grievance with the MCO or SPBM orally or in writing at any time. An authorized representative must have the member's written consent to file a grievance on the member's behalf.

(2) The MCO or SPBM shall acknowledge the receipt of each grievance to the member filing the grievance. Oral acknowledgment by the MCO or SPBM is acceptable. If the grievance is filed in writing, written acknowledgment shall be made within three business days of receipt of the grievance.

(3) The MCO or SPBM shall review and resolve all grievances as expeditiously as the member's health condition requires. Grievance resolutions, including member notification, shall meet the following time frames:

(a) Within two business days of receipt if the grievance is regarding access to services.

(b) Within thirty calendar days of receipt for non claims-related grievances except as specified in paragraph (C)(3)(a) of this rule.

(4) At a minimum, the MCO or SPBM shall provide oral notification to the member of a grievance resolution. If the MCO or SPBM is unable to speak directly with the member, or the resolution includes information that must be confirmed in writing, the resolution shall be provided in writing simultaneously with the MCO or SPBM's resolution.

(5) If the MCO or SPBM's resolution to a grievance is to uphold the denial, reduction, suspension, or termination of a service or billing of a member due to the MCO or SPBM's denial of payment for that service, the MCO or SPBM shall notify the member of his or her right to request a state hearing as specified in paragraph (G) of this rule, if the member has not previously been notified.

(D) Standard appeals.

(1) A member, a member's authorized representative, or a provider may file an appeal orally or in writing within sixty calendar days from the date that the NOA was issued. An oral appeal filing must be followed with a written appeal. The MCO or SPBM shall:

(a) Immediately convert an oral appeal filing to a written appeal on behalf of the member; and

(b) Consider the date of the oral appeal filing as the filing date.

(2) Any provider acting on the member's behalf shall have the member's written consent to file an appeal. The MCO or SPBM shall begin processing the appeal upon receipt of the written consent.

(3) The MCO or SPBM shall acknowledge receipt of each appeal to the member filing the appeal. At a minimum, acknowledgment shall be made in the same manner the appeal was filed. If an appeal is filed in writing, written acknowledgment shall be made by the MCO or SPBM within three business days of receipt of the appeal.

(4) The MCO or SPBM shall provide the member reasonable opportunity to present evidence and allegations of fact or law, in person as well as in writing, and inform the member of this opportunity sufficiently in advance of the resolution time frame. Upon request, the member and/or member's authorized representative shall be provided, free of charge and sufficiently in advance of the resolution time frame, the case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon or generated by the MCO or SPBM, or at the direction of the MCO or SPBM, in connection with the appeal of the adverse benefit determination.

(5) The MCO or SPBM shall consider the member, the member's authorized representative, or an estate representative of a deceased member as parties to the appeal.

(6) The MCO or SPBM shall review and resolve each appeal as expeditiously as the member's health condition requires, but the resolution time frame shall not exceed fifteen calendar days from the receipt of the appeal unless the resolution time frame is extended as outlined in paragraph (F) of this rule.

(7) The MCO or SPBM shall provide written notice of the appeal's resolution to the member, and to the member's authorized representative if applicable. At a minimum, the written notice shall include the resolution decision and date of the resolution.

(8) For appeal resolutions not resolved wholly in the member's favor, the written notice to the member shall also include the following information:

(a) The right to request a state hearing through the state's hearing system;

(b) How to request a state hearing; and if applicable:

(i) The right to continue to receive benefits pending a state hearing;

(ii) How to request the continuation of benefits; and

(iii) If the adverse benefit determination is upheld at the state hearing, the member may be liable for the cost of any continued benefit.

(d) Written translation is available in prevalent non-English languages as applicable;

(e) Written alternative formats may be available as needed; and

(f) How to access interpretation and translation services as well as alternative formats that can be provided by the MCO or SPBM.

(9) For appeal resolutions decided in favor of the member, the MCO or SPBM shall:

(a) Authorize or provide the disputed services promptly and as expeditiously as the member's health condition requires, but no later than seventy-two hours from the appeal resolution date, if the services were not furnished while the appeal was pending.

(b) Pay for the disputed services if the member received the services while the appeal was pending.

(E) Expedited appeals.

(1) The MCO and SPBM shall establish and maintain an expedited review process to resolve appeals when the member requests and the MCO or SPBM determines, or the provider indicates in making the request on the member's behalf or supporting the member's request, that the standard resolution time frame could seriously jeopardize the member's life, physical or mental health or ability to attain, maintain, or regain maximum function.

(2) In utilizing an expedited appeal process, the MCO and SPBM shall comply with the standard appeal process specified in paragraph (D) of this rule, except the MCO and SPBM shall:

(a) Determine within one business day of the appeal request whether to expedite the appeal resolution;

(b) Make reasonable efforts to provide prompt oral notification to the member of the decision to expedite or not expedite the appeal resolution;

(c) Inform the member of the limited time available for the member to present evidence and allegations of fact or law in person or in writing;

(d) Resolve the appeal as expeditiously as the member's health condition requires, but the resolution time frame shall not exceed seventy-two hours from the date the MCO or SPBM received the appeal unless the resolution time frame is extended as outlined in paragraph (F) of this rule;

(e) Make reasonable efforts to provide oral notice of the appeal resolution in addition to the required written notification; and

(f) Ensure punitive action is not taken against a provider who requests an expedited resolution or supports a member's appeal.

(3) If the MCO or SPBM denies a member's request for expedited resolution of an appeal, the MCO or SPBM shall:

(a) Transfer the appeal to the standard resolution time frame of fifteen calendar days from the date the appeal was received unless the resolution time frame is extended as outlined in paragraph (F) of this rule;

(b) Make reasonable efforts to provide the member prompt oral notification of the decision not to expedite, and within two calendar days of the receipt of the appeal, provide the member written notice of the reason for the denial, including information that the member can grieve the decision.

(F) Grievance and appeal resolution extensions.

(1) A member may request the time frame for the MCO or SPBM to resolve a grievance or a standard or expedited appeal be extended up to fourteen calendar days.

(2) The MCO or SPBM may request the time frame to resolve a grievance or a standard or expedited appeal be extended up to fourteen calendar days. The following requirements apply:

(a) The MCO or SPBM shall seek such an extension from ODM prior to the expiration of the standard or expedited appeal or grievance resolution time frame;

(b) The MCO or SPBM request shall be supported by documentation of the need for additional information and that the extension is in the member's best interest; and

(c) If ODM approves the extension, the MCO or SPBM shall make reasonable efforts to provide the member prompt oral notification of the extension and, within two calendar days, provide the member written notice of the reason for the extension and the date by which a decision shall be made.

(3) The MCO and SPBM shall maintain documentation of any extension request.

(G) Access to state's hearing system.

(1) Except as set forth in paragraph (G)(2) of this rule, and in accordance with 42 CFR 438.402 (October 1, 2021), members may request a state hearing only after exhausting the MCO or SPBM's appeal process. If the MCO or SPBM fails to adhere to the notice and timing requirements for appeals set forth in this rule, the member is deemed to have exhausted the appeal process and may request a state hearing.

(2) In accordance with rule 5160-20-01 of the Administrative Code, members proposed for enrollment or currently enrolled in the coordinated services program (CSP) are afforded state hearing rights in accordance with division 5101:6 of the Administrative Code and are not subject to the requirement of first appealing to the MCO.

(3) When required by paragraph (D)(8) of this rule, and in accordance with division 5101:6 of the Administrative Code, the MCO or SPBM shall notify members, and any authorized representatives on file with the MCO or SPBM, of the right to a state hearing subject to the following requirements:

(a) If an appeal resolution upholds the denial of a request for the authorization of a service, in whole or in part, the MCO or SPBM shall simultaneously issue the "Notice of Denial of Medical Services By Your Managed Care Entity" (ODM 04043).

(b) If an appeal resolution upholds the decision to reduce, suspend, or terminate services prior to the member receiving the services as previously authorized by the MCO or SPBM, the MCO or SPBM shall issue the "Notice of Reduction, Suspension or Termination of Medical Services By Your Managed Care Entity" (ODM 04066).

(c) If the MCO or SPBM learns a member has been billed for services received by the member due to the MCO or SPBM's denial of payment, and the MCO or SPBM upholds the denial of payment, the MCO or SPBM shall immediately issue the "Notice of Denial of Payment for Medical Services By Your Managed Care Entity" (ODM 04046).

(4) The member or member's authorized representative may request a state hearing within ninety calendar days from the date of an adverse appeal resolution by contacting the ODJFS bureau of state hearings or local county department of job and family services (CDJFS).

(5) There are no state hearing rights for a member terminated from the MCO pursuant to an MCO-initiated membership termination in accordance with rule 5160-26-02.1 of the Administrative Code.

(6) Following the bureau of state hearing's notification to the MCO or SPBM that a member has requested a state hearing, the MCO or SPBM shall:

(a) Complete the "Appeal Summary for Managed Care Entity" (ODM 01959) with appropriate supporting attachments, and file it with the bureau of state hearings at least three business days prior to the scheduled hearing date. The appeal summary shall include all facts and documents relevant to the issue, in accordance with rule 5160-26-03.1 of the Administrative Code, and be sufficient to demonstrate the basis for the MCO or SPBM's adverse benefit determination;

(b) Send a copy of the completed ODM 01959 to the member and the member's authorized representative, if applicable, the CDJFS, and the designated ODM contact; and

(c) If benefits were continued through the appeal process in accordance with paragraph (H)(1) of this rule, continue or reinstate the benefit(s) if the MCO or SPBM is notified that the member's state hearing request was received within fifteen days from the date of the appeal resolution.

(7) The MCO or SPBM shall participate in the state hearing, in person or by telephone, on the date indicated on the "Notice to Appear for a Scheduled Hearing" (JFS 04002) sent by the bureau of state hearings.

(8) The MCO or SPBM shall comply with the state hearing decision provided via the "State Hearing Decision" (JFS 04005). If the state hearing decision sustains the member's appeal, the MCO or SPBM shall submit the information required by the "Order of Compliance" (JFS 04068) to the bureau of state hearings. The information, including applicable supporting documentation, is due to the bureau of state hearings and the designated ODM contact by no later than the compliance date specified in the hearing decision. If applicable, the MCO or SPBM shall:

(a) Authorize or provide the disputed services promptly and as expeditiously as the member's health condition requires, but no later than seventy-two hours from the date it receives notice reversing the adverse benefit determination if services were not furnished while the appeal was pending.

(b) Pay for the disputed services if the member received the services while the appeal was pending.

(H) Continuation of benefits while an appeal or state hearing are pending.

(1) Unless a member requests that previously authorized benefits not be continued, the MCO or SPBM shall continue a member's benefits when all the following conditions are met:

(a) The member requests an appeal within fifteen days of the MCO or SPBM issuing the NOA;

(b) The appeal involves the termination, suspension, or reduction of services prior to the member receiving the previously authorized services;

(d) The authorization period has not expired.

(2) If the MCO or SPBM continues or reinstates the member's benefits while the appeal or state hearing are pending, the benefits shall be continued until one of the following occurs:

(a) The member withdraws the appeal or the state hearing request;

(b) The member fails to request a state hearing within fifteen days after the MCO or SPBM issues an adverse appeal resolution; or

(c) The bureau of state hearings issues a state hearing decision upholding the reduction, suspension or termination of services.

(3) If the final resolution of the appeal or state hearing upholds the MCO or SPBM's original adverse benefit determination, at the discretion of ODM, the MCO or SPBM may recover the cost of the services furnished to the member while the appeal and/or state hearing was pending.

(I) Additional provisions regarding appeals and grievances.

(1) The MCO and SPBM shall give members all reasonable assistance filing a grievance, an appeal, or a state hearing request including but not limited to:

(a) Explaining the MCO or SPBM's process to be followed in resolving the member's appeal or grievance;

(b) Completing forms and taking other procedural steps as outlined in this rule; and

(c) Providing oral interpretation and oral translation services, sign language assistance, and access to the appeals and grievance system through a toll-free number with text telephone yoke (TTY) and interpreter capability.

(2) The MCO and SPBM shall ensure the individuals who make decisions on appeals and grievances are individuals who:

(a) Were neither involved in any previous level of review or decision-making nor a subordinate of any such individual; and

(b) Are health care professionals who have the appropriate clinical expertise in treating the member's condition or disease if deciding any of the following:

(i) An appeal of a denial based on lack of medical necessity;

(ii) A grievance regarding the denial of an expedited resolution of an appeal; or

(iii) An appeal or grievance involving clinical issues.

(3) In reaching an appeal resolution, the MCO and SPBM shall take into account all comments, documents, records, and other information submitted by the member or their authorized representative without regard to whether such information was submitted or considered in the initial adverse benefit determination.

Last updated January 3, 2023 at 9:23 AM

History

Effective: January 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-26-09.1 Managed care: third party liability and recovery.

(A) Tort.

(1) Pursuant to sections 5160.37 and 5160.38 of the Revised Code, the Ohio department of medicaid (ODM) maintains all rights of recovery (tort) against the liability of any third party payer (TPP) for the cost of medical services.

(2) A managed care entity (MCE) is prohibited from accepting any settlement, compromise, judgment, award, or recovery of any action or claim by a member.

(3) The MCE must notify ODM and/or its designated entity within fourteen calendar days of all requests for the release of financial and medical records to a member or the member's representative pursuant to the filing of a tort action. Notification must be made via the "Notification of Third Party (tort) Request For Release" form (ODM 03245) or a method determined by the ODM designated entity, provided ODM approved the designated entity's method and notified the MCE.

(4) The MCE must submit a summary of financial information to ODM and/or its designated entity within thirty calendar days of receiving an original authorization to release a financial claim statement letter from ODM pursuant to a tort action. The MCE must use the "Tort Summary Statement" form (ODM 03246) or a method determined by the ODM designated entity, provided ODM has approved the designated entity's method and notified the MCE. Upon request, the MCE must provide ODM and/or its designated entity with true copies of medical claims.

(B) Fraud, waste, and abuse recovery. ODM assigns to the MCE its rights of recovery against any TPP for costs due to provider fraud, waste, or abuse as defined in rule 5160-26-01 of the Administrative Code related to each member during periods of enrollment in the MCE. In instances when the MCE fails to properly report suspected fraud, waste, or abuse, before the suspected fraud, waste, or abuse is identified by the state of Ohio, any portion of the fraud, waste, or abuse recovered by the state shall be retained by the state.

(1) ODM assigns its right to third party resources (coordination of benefits) to the MCE for services rendered to each member during periods of enrollment. ODM reserves the right to identify, pursue, and retain any recovery of third party resources assigned to the MCE but not collected by the MCE after one year from date of claim payment.

(2) Except as specified in paragraph (C)(3) of this rule, the MCE must act to provide coordination of benefits if a member has third party resources available for the payment of medical expenses for medically necessary medicaid-covered services. Such expenses will be paid in accordance with this rule and sections 5160.37 and 5160.38 of the Revised Code.

(3) Children that have been legally placed in the custody of an Ohio county public children's services agency (PCSA) or related entity are excluded from third party liability cooperation and are exempt from post-payment recovery unless it is confirmed that the child will not be put at risk for doing so (e.g. medical support order).

(4) The MCE is the payer of last resort when a member has third party resources available for payment of medical expenses for medicaid-covered services, except:

(a) The MCE pays after any TPP including medicare but before:

(i) Resources provided through the program for children and youth with special health care needs under sections 3701.021 to 3701.0210 of the Revised Code.

(ii) Resources that are exempt from primary payer status under federal medicaid law, 42 U.S.C. 1396 (as in effect July 1, 2022).

(iii) Resources provided through the state sponsored program awarding reparations to victims of crime, as set forth in sections 2743.51 to 2743.72 of the Revised Code.

(b) The MCE, except SPBM, pays first for preventive pediatric services before seeking reimbursement from any liable third party.

(5) The MCE will take reasonable measures to ascertain and verify any third party resources available to a member. When the MCE denies a claim due to third party liability (TPL), the MCE must timely share, on the explanation of payment sent to providers, available information regarding the third party resources for the purposes of coordination of benefits, including:

(a) Insurance company name;

(b) Insurance company billing address for claims;

(d) Member's policy number; and

(e) Policy holder name.

(6) The MCE must require providers who are submitting TPL claims to the MCE to request information regarding third party benefits from the member or his/her authorized representative. If the member or the member's authorized representative specifies that the member has no third party benefits, or the provider is unable to determine that the member has third party benefits, the MCE must permit the provider to submit a claim to the MCE. If, as a result of requesting the information, the provider determines that third party liability exists, the MCE must allow the provider to submit a claim for reimbursement if he/she first takes reasonable measures to obtain third party payment as set forth in paragraph (C)(7) of this rule.

(7) The MCE must require providers to take reasonable measures to obtain all third party payments and file claims with all TPPs prior to billing the MCE. The MCE must permit providers who have taken reasonable measures to obtain all third party payments, but who have not received payment from a TPP or received partial payment, to submit a claim to the MCE requesting reimbursement for rendered services.

(a) The MCE must process claims when the provider has complied with one or more of the following reasonable measures:

(i) The provider first submits a claim to the TPP for the rendered services and does not receive a remittance advice or other communication from the TPP within ninety days after the submission date. The MCE may require providers to document the claim and date of the claim submission to the TPP.

(ii) The provider has retained and/or submitted one of the following types of documentation indicating a valid reason for non-payment for the services not related to provider error:

(a) Documentation from the TPP;

(b) Documentation from the TPP's automated eligibility and claim verification system;

(d) Any other documentation from the TPP showing there is no third party benefit coverage for the rendered services.

(iii) The provider submitted a claim to the TPP and received a partial payment along with a remittance advice documenting the allocation of the charges.

(b) Valid reasons for non-payment from a TPP to the provider for a third party benefit claim include, but are not limited to:

(i) The service is not covered under the member's third party benefits.

(ii) The member does not have third party benefits through the TPP for the date of service.

(iii) All of the provider's billed charges or the TPP's approved rate was applied, in whole or in part, to the member's third party benefit deductible amount, coinsurance and/or co-payment for the TPP. The provider may then submit a secondary claim to the MCE showing the appropriate amount received from the TPP.

(iv) The member has not met any required waiting periods, or residency requirements for his/her third party benefits, or was non-compliant with the TPP's requirements in order to maintain coverage.

(v) The member is a dependent of the individual with third party benefits, but the benefits do not cover the individual's dependents.

(vi) The member has reached the lifetime benefit maximum for the medical service or third party benefits being billed to the TPP.

(vii) The TPP is disputing or contesting its liability to pay the claim or cover the service.

(8) If the provider receives payment from the TPP after the MCE has made payment, the MCE must require the provider to repay the MCE any amount overpaid by the MCE. The MCE must not allow the provider to reimburse any overpaid amounts to the member.

(9) The MCE must make available to providers information on how to submit a claim that will have a zero paid amount in the third party field on the claim.

(10) The MCE payment for third party claims will not exceed the MCE allowed amount for the service, less all third party payments for the service.

(11) The MCE's timely filing limits for provider claims shall be at least ninety days from the date of the remittance advice that indicates adjudication or adjustment of the third party claim by the TPP.

(12) The MCE must ensure that providers do not hold liable or bill members in the event that the MCE cannot or will not pay for covered services unless all of the specifications set forth in rule 5160-26-05 and rule 5160-26-11 of the Administrative Code are met. The provider may not collect and/or bill the member for any difference between the MCE's payment and the provider's charge or request the member to share in the cost through a deductible, coinsurance, co-payment, or other similar charge, other than MCE co-payments.

(D) The MCE is required to submit information regarding members with third party coverage as directed by ODM.

Last updated April 1, 2025 at 7:46 AM

History

Effective: April 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-26-10 Managed care: sanctions and provider agreement actions.

(A) This rule does not apply to the single pharmacy benefit manager as defined in rule 5160-26-01 of the Administrative Code.

(B) If the MCO fails to fulfill its duties and obligations under 42 C.F.R. Part 438 (October 1, 2021), 42 U.S.C. 1396b(m) (as in effect July 1, 2022), 42 U.S.C. 1396u-2 (as in effect July 1, 2022), agency 5160 of the Administrative Code, or the MCO provider agreement, ODM will provide timely written notification to the MCO identifying the violations or deficiencies, and may impose corrective actions or any of the following sanctions in addition to or instead of any actions or sanctions specified in the provider agreement:

(1) ODM may require corrective action plans (CAPs) in accordance with the following:

(a) If requested by ODM, the MCO must submit, within the specified time frame, a proposed CAP for each cited violation or deficiency.

(b) The CAP must contain the proposed correction date, describe the manner in which each violation or deficiency will be resolved, and address all items specified in the ODM notification.

(d) Following the approval of the CAP, ODM will monitor the correction process until all violations or deficiencies are corrected to the satisfaction of ODM.

(e) If the MCO fails to submit an approvable CAP within the ODM-specified time frames, ODM may impose an ODM-developed CAP, sanctions, or both.

(f) If ODM has already determined the specific action that must be implemented by the MCO, ODM may require the MCO to comply with an ODM-developed or directed CAP.

(g) Failure by the MCO to successfully complete the correction process and correct the violations or deficiencies to the satisfaction of ODM may lead to the imposition of any or all of the sanctions listed in paragraph (B)(2) of this rule.

(2) Sanctions that may be imposed on the MCO by ODM include but are not limited to the following:

(a) Suspension of the enrollment of the MCO's members.

(b) Disenrollment of the MCO's members.

(d) Prohibition or reduction of the MCO's involuntary assignments.

(e) Granting the MCO's members the right to terminate without cause and notifying the affected members of their right to disenroll.

(f) Retention by ODM of the MCO's premium payments or a portion thereof until the violations or deficiencies are corrected.

(g) Imposition of financial sanctions.

(C) ODM will select sanction(s) specified in paragraph (B)(2) of this rule based on a pattern of repeated violations or deficiencies, the severity of the cited violations or deficiencies, the failure of the MCO to meet the requirements of an approved CAP, or all these factors.

(D) The sanctions in paragraph (B)(2) of this rule are subject to reconsideration by ODM as specified in Chapter 5160-70 of the Administrative Code, with the exception that the involuntary assignments referenced in paragraph (B)(2)(d) of this rule are not subject to reconsideration.

(E) Regardless of any other sanction that may be imposed, ODM may impose temporary management on any MCO that has repeatedly failed to meet substantive requirements in 42 U.S.C. 1396b(m) (as in effect July 1, 2022), 42 U.S.C. 1396 u-2 (as in effect July 1, 2022) or 42 C.F.R. Part 438 subpart I (October 1, 2021). Such temporary management shall be imposed in accordance with the following:

(1) The MCO must pay the costs of a temporary manager for performing the duties of a temporary manager as determined by ODM.

(2) The MCO is solely responsible for any costs or liabilities incurred on behalf of the MCO when temporary management is imposed by ODM.

(3) The imposition of temporary management is not subject to the appeals process provided under Chapter 119. of the Revised Code; however, the MCO may request that the director for the medicaid program reconsider this action. ODM will not delay imposition of temporary management to provide reconsideration prior to imposing this sanction.

(4) Unless the director for the medicaid program determines through the reconsideration process that temporary management should not have been imposed, the temporary management will remain in place until such time as ODM determines that the MCO can ensure that the sanctioned behavior will not recur.

(5) Regardless of the imposition of temporary management, the MCO retains the right to appeal any proposed termination or nonrenewal of its provider agreement under Chapter 119. of the Revised Code. The MCO also retains the right to initiate the sale of the MCO or its assets.

(6) If temporary management is imposed, ODM will notify the MCO's members that such action has occurred and inform them that they therefore have the right to terminate their membership in the MCO without cause. Termination of the MCO's membership without cause is not subject to the appeals process provided under Chapter 119. of the Revised Code; however, the MCO may request that the director for the medicaid program reconsider this action. ODM will not delay the notification to the MCO's membership to provide reconsideration prior to imposing this sanction.

(F) ODM will provide the MCO with written notice before imposing any sanction. The notice will describe any reconsideration or appeal rights that are available to the MCO.

(G) Regardless of whether ODM imposes a sanction, the MCO shall initiate corrective action for any MCO program violations or deficiencies as soon as they are identified by either the MCO or ODM.

(H) The following provisions apply in the event ODM decides to terminate, nonrenew, deny, or amend the MCO provider agreement.

(1) ODM may terminate, nonrenew, deny, or amend the MCO provider agreement if at any time ODM determines that continuation or assumption of a provider agreement is not in the best interest of recipients or the state of Ohio. For the purposes of this rule, an amendment to the MCO provider agreement is defined as, and limited to, the elimination of one or more service areas included in the MCO's current provider agreement. The phrase "not in the best interest" includes, but is not limited to, the following:

(a) The MCO's delivery system does not assure adequate access to services for its members.

(b) The MCO's delivery system does not assure the availability of all services covered under the provider agreement.

(d) The MCO fails to provide proper assurances of financial solvency.

(e) The number of members enrolled in the MCO's service area is not sufficient to ensure the effective or efficient delivery of services to members.

(f) The MCO fails to comply with any of the following:

(i) Chapter 5160-26, 5160-58, or 5160-59 of the Administrative Code;

(ii) The MCO provider agreement;

(iii) The applicable requirements in 42 U.S.C. 1396b(m) (as in effect July 1, 2022) or 42 U.S.C. 1396u-2 (as in effect July 1, 2022);

(iv) 42 C.F.R. Part 438 (October 1, 2021).

(2) If ODM has proposed termination, nonrenewal, denial, or amendment of the MCO's provider agreement, ODM may notify the MCO's members of this proposed action and inform the members of their right to immediately disenroll from the MCO without cause.

(3) If ODM determines that the termination, nonrenewal, or denial of a provider agreement is warranted:

(a) ODM will provide notice, at a minimum, forty-five days prior to the effective date of the proposed action;

(b) The action will be in accordance with and subject to Chapter 5160-70 of the Administrative Code; and

(4) If ODM determines that the amendment of a provider agreement is warranted, the proposed action is subject to reconsideration pursuant to Chapter 5160-70 of the Administrative Code.

(5) Notwithstanding the preceding paragraphs of this rule, ODM may terminate the MCO's provider agreement effective on the last day of the calendar month in which any of the following occur:

(a) The determination by ODM that the loss or reduction of federal or state funding has reduced funding to a level which is insufficient to maintain the activities or services agreed to in the provider agreement;

(b) The exclusion from participation of the MCO in a program administered under Title XVIII, XIX, or XX of the Social Security Act due to criminal conviction or the imposition of civil monetary penalties in accordance with 42 C.F.R. Part 455 subpart B (October 1, 2021), 42 C.F.R. Part 1002 subpart A (October 1, 2021), and rule 5160-1-17.3 of the Administrative Code;

(c) The suspension, revocation, or nonrenewal of ODM's authority to operate the program under the state plan or waivers of certain federal regulations granted by CMS or congress;

(d) The suspension, revocation, or nonrenewal of the MCO's certificate of authority or license.

(e) The exclusion of the MCO from participation in accordance with 42 C.F.R. 438.808 (October 1, 2021).

(6) If the MCO's provider agreement is amended, terminated, denied, or nonrenewed for any reason including procurement, the MCO is required to fulfill all duties and obligations under agency 5160 of the Administrative Code, as applicable, and the MCO provider agreement.

Last updated July 18, 2022 at 8:19 AM

History

Effective: July 18, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-26-11 Managed care: managed care plan non-contracting providers.

(A) Non-contracting providers of emergency services must accept as payment in full from a managed care organization (MCO) the lesser of billed charges or one hundred per cent of the Ohio medicaid program reimbursement rate (less any payments for indirect costs of medical education and direct costs of graduate medical education that is included in the Ohio medicaid program reimbursement rate) in effect for the date of service. Pursuant to section 5167.101 of the Revised Code, the MCO shall not compensate a hospital for inpatient capital costs in an amount that exceeds the maximum rate established by ODM.

(B) When ODM has approved the MCO's members to be referred to a non-contracting hospital pursuant to rule 5160-26-03 of the Administrative Code, the non-contracting hospital must provide the service for which the referral was authorized and must accept as payment in full from the MCO one hundred per cent of the current Ohio medicaid program reimbursement rate in effect for the date of service. Pursuant to section 5167.101 of the Revised Code, the MCO shall not compensate a hospital for inpatient capital costs in an amount that exceeds the maximum rate established by ODM. Non-contracting hospitals are exempted from this provision when:

(1) The hospital is located in a county in which eligible individuals were required to enroll in an MCO prior to January 1, 2006;

(2) The hospital is contracted with at least one MCO serving the eligible individuals specified in paragraph (B)(1) of this rule prior to January 1, 2006; and

(3) The hospital remains contracted with at least one MCO serving eligible individuals who are required to enroll in an MCO in the service area where the hospital is located.

(C) Non-contracting qualified family planning providers (QFPPs) must accept as payment in full from the MCO the lesser of one hundred per cent of the Ohio medicaid program reimbursement rate or billed charges, in effect for the date of service.

(D) A managed care entity (MCE) non-contracting provider may not bill the MCE member unless:

(1) The conditions described in rule 5160-1-13.1 of the Administrative Code are met; and

(2) The reason the service is not covered by the MCE is specified and is one of the following:

(a) The service is a benefit exclusion;

(b) The provider is not contracted with the MCE and the MCE has denied approval for the provider to provide the service because the service is available from a contracted provider, at no cost to the member; or

(E) An MCE non-contracting provider may not bill a member for a missed appointment.

(F) Non-contracting providers, including non-contracting providers of emergency services, must contact the twenty-four hour post-stabilization services phone line designated by the MCO to request authorization to provide post-stabilization services in accordance with rule 5160-26-03 of the Administrative Code.

(G) Non-contracting providers, including non-contracting providers of emergency services, must allow the MCE, ODM, and ODM's designee access to all member medical records for a period not less than ten years from the date of service or until any audit initiated within the ten year period is completed. Access must include copies of the medical records at no cost for the purpose of activities related to the annual external quality review specified by 42 C.F.R. 438.358 (October 1, 2021).

(H) If the MCE elects to impose member co-payments in accordance with rule 5160-26-12 of the Administrative Code, applicable co-payments shall also apply to services rendered by non-contracting providers. If the MCE has not elected to impose co-payments, non-contracting providers are not permitted to impose co-payments on MCE members.

Last updated September 1, 2023 at 1:10 PM

History

Effective: July 18, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-26-12 Managed care: member co-payments.

(B) The managed care organization (MCO) may elect to implement a member co-payment program pursuant to section 5162.20 of the Revised Code for dental services, vision services, or non-emergency emergency department services or until implementation of the single pharmacy benefit manager (SPBM), prescription drugs as provided for in this rule. The MCO must receive prior approval from the Ohio department of medicaid (ODM) before notifying members that a co-payment program will be implemented.

(C) Upon implementation of the SPBM, the SPBM may only elect to implement a member co-payment program pursuant to section 5162.20 of the Revised Code for prescription drugs as provided for in this rule if directed to by ODM.

(D) If the MCO or SPBM implements a member co-payment program, the MCO and SPBM must:

(1) Exclude the populations and services set forth in paragraph (E) of this rule;

(2) Not deny services to members as specified in paragraph (F) of this rule;

(3) Not impose co-payment amounts in excess of the maximum amounts specified in 42 C.F.R. 447.54 (October 1, 2021);

(4) Specify in provider contracts governed by rule 5160-26-05 of the Administrative Code the circumstances under which member co-payment amounts can be requested. If the MCO or SPBM implements a co-payment program, no provider can waive a member's obligation to pay the provider a co-payment except as described in paragraph (I) of this rule;

(5) Ensure that the member is not billed for any difference between the MCO or SPBM's payment and the provider's charge or request that the member share in the cost through co-payment or other similar charge, other than medicaid co-payments as defined in this rule;

(6) Ensure that member co-payment amounts are requested by providers in accordance with this rule; and

(7) Ensure that no provider or drug manufacturer, including the manufacturer's representative, employee, independent contractor, or agent shall pay any co-payment on behalf of the member.

(E) Exclusions to the member co-payment program for dental, vision, non-emergency emergency department services, and prescription medications include the following:

(1) Children. Members who are under the age of twenty-one are excluded from medicaid co-payment obligations.

(2) Pregnant women. With the exception of routine eye examinations and the dispensation of eyeglasses during a member's pregnancy or post-partum period, all services provided to pregnant women during their pregnancy and the post-partum period are excluded from a medicaid co-payment obligation. The post-partum period is the period that begins on the last day of pregnancy and extends through the end of the month in which the twelve month period following termination of pregnancy ends.

(3) Institutionalized members. Services or medications provided to members who reside in a nursing facility (NF) or intermediate care facility for individuals with intellectual disabilities (ICF/IID) are excluded from medicaid co-payment obligations.

(4) Emergency. An MCO shall not impose a co-payment obligation for emergency services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily part or organ.

(5) Family planning (pregnancy prevention or contraceptive management). The MCO or SPBM shall not impose a medicaid co-payment obligation on any service identified by ODM as a pregnancy prevention/contraceptive management service in accordance with rules 5160-21-02 and 5160-1-09 of the Administrative Code and provided to an individual of child-bearing age.

(6) Hospice. Members receiving services for hospice care are excluded from medicaid co-payment obligation.

(7) Medicare cross-over claims. Medicare cross-over claims defined in accordance with rule 5160-1-05 of the Administrative Code will not be subject to medicaid co-payment obligations.

(8) Medications administered to a member during a medical encounter provided in a hospital, clinic, office or other facility, when the medication is part of the evaluation and treatment of the condition, are not subject to a member co-payment.

(F) No provider may deny services to a member who is eligible for services due to the member's inability to pay the member co-payment. Members who are unable to pay their member co-payment may declare their inability to pay for services or medication and receive their services or medications without paying their member co-payment amount. This provision does not relieve the member from the obligation to pay a member co-payment or prohibit the provider from attempting to collect an unpaid member co-payment. If it is the routine business practice of the provider to refuse service to any individual who owes an outstanding debt to the provider, the provider may consider an unpaid medicaid co-payment as an outstanding debt and may refuse service to a member who owes the provider an outstanding debt. If the provider intends to refuse service to a member who owes the provider an outstanding debt, the provider shall notify the individual of the provider's intent to refuse services. In such situations, the MCO or SPBM must still ensure that the member has access to needed services.

(G) The MCO or SPBM may impose member co-payments as follows:

(1) For dental services, the member co-payment amount may not exceed the amount set forth in Chapter 5160-5 of the Administrative Code. Services provided to a member on the same date of service by the same provider are subject to only one co-payment.

(2) For non-emergency emergency department services, the member co-payment amount must not exceed the amount set forth in Chapter 5160-2 of the Administrative Code. For purposes of this rule, the hospital provider shall determine if services rendered are non-emergency emergency department services and will report, through claim submission, the applicable co-payment to the MCO in accordance with medicaid hospital billing instructions.

(3) For vision services, the member co-payment amounts must not exceed the amounts set forth in Chapter 5160-6 of the Administrative Code.

(4) For pharmacy services, the member co-payment amounts must not exceed the amounts set forth in Chapter 5160-9 of the Administrative Code.

(H) Prescriptions for medications are subject to the applicable member co-payment for medications if they are given to a member during a medical encounter provided in the emergency department or other hospital setting, clinic, office, or other facility as a result of the evaluation and treatment of the condition, regardless of whether they are filled at a pharmacy located at the facility or at an outside location.

(I) If the MCO has implemented a member co-payment program for non-emergency emergency department services, as described in paragraph (G)(2) of this rule, a hospital may take action to collect a co-payment by providing, at the time services are rendered to a managed care member, notice that a co-payment may be owed. If the hospital provides the notice and chooses not to take further action to pursue collection of the co-payment, the prohibition against waiving co-payments, as described in paragraph (D)(4) of this rule, does not apply.

(J) If the MCO or SPBM does not to impose a co-payment amount for dental services, vision services, non-emergency emergency department services or prescription drugs, and the MCO or SPBM reimburses contracting or non-contracting providers for these services using the medicaid provider reimbursement rate, the MCO or SPBM must not reduce its provider payments by the applicable co-payment amount set forth in this rule.

Last updated January 3, 2023 at 9:25 AM

History

Effective: January 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-26-13 Managed health care programs: claim billing for pharmaceuticals.

Upon implementation of the Ohio department of medicaid's (ODM) single pharmacy benefit manager (SPBM), ODM or its designees will accept provider claim submissions for pharmaceuticals through ODM's managed care entities (MCEs) in the following manner:

(A) Claims for pharmaceuticals that are dispensed by pharmacy providers are billed through ODM's SPBM.

(B) For all other provider types, claims for pharmaceuticals are billed through an MCO, or in accordance with rule 5160-59-03 of the Administrative Code for individuals enrolled in the OhioRISE plan, as applicable.

Last updated October 3, 2022 at 8:44 AM

History

Effective: October 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-26-14 Medicaid managed care organizations: incident management.

This rule does not apply to the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code. This rule sets the standards and procedures for managing incidents that may have a negative impact on medicaid managed care and MyCare Ohio members. The purpose of this rule is to establish the procedures for reporting and addressing critical incidents and to prevent and reduce the risk of harm to members. The Ohio department of medicaid (ODM) may designate other entities to perform one or more of the incident management functions set forth in this rule.

(A) For the purposes of this rule, the following definitions apply:

(1) "Incident" means as defined in rule 5160-44-05 of the Administrative Code.

(2) "Incident management system" means as defined in rule 5160-44-05 of the Administrative Code.

(3) "Restraint" means as defined in rule 5160-45-01 of the Administrative Code.

(4) "Restrictive intervention" means as defined in rule 5160-45-01 of the Administrative Code.

(5) "Seclusion" means as defined in rule 5160-45-01 of the Administrative Code.

(6) "Substantiated" means as defined in rule 5160-44-05 of the Administrative Code.

(7) "Unauthorized restraint" means as defined in rule 5160-44-05 of the Administrative Code.

(8) "Unauthorized restrictive intervention" means as defined in rule 5160-44-05 of the Administrative Code.

(9) "Unauthorized seclusion" means as defined in rule 5160-44-05 of the Administrative Code.

(B) The following incidents defined in paragraph (B) of rule 5160-44-05 of the Administrative Code will be reported and investigated as described in paragraph (D) of this rule:

(1) Abuse.

(2) Behavioral support misuse.

(3) Neglect.

(4) Exploitation.

(5) Misappropriation.

(6) Unnatural or accidental death.

(7) Self-harm or suicide attempt.

(8) Medication error.

(1) Members enrolled in a medicaid managed care organization (MCO) as defined in rule 5160-26-01 of the Administrative Code, but not also enrolled in a nursing facility-based level of care home and community-based services (HCBS) waiver program.

Incidents discovered by an MCO for a member enrolled in a nursing facility-based level of care HCBS waiver program are reported to the administering agency per rule 5160-44-05 of the Administrative Code.

(2) Members enrolled in a MyCare Ohio plan (MCOP) as defined in rule 5160-58-01 of the Administrative Code, but not also enrolled in a nursing facility-based level of care HCBS waiver program or the specialized recovery services program (SRSP).

Incidents discovered by an MCO for a member enrolled in a nursing facility-based level of care HCBS waiver program or the SRSP are reported to the administering agency per rule 5160-44-05 of the Administrative Code.

(D) The following process will be followed upon the occurrence of an incident.

(1) Initial incident report.

(a) Upon discovering an incident, ODM, its delegates, and providers of services under contract with an MCO or MCOP will:

(i) Take immediate action to ensure the health and welfare of the member.

(ii) Report the incident to the relevant MCO or MCOP immediately upon discovery of the incident, but no later than one business day after discovering the incident, unless bound by federal, state, or local law, or the requirements of professional licensure or certification to report sooner.

(b) All incident reports will include the following information when available:

(i) The facts relevant to the incident;

(ii) A description of the incident;

(iii) The incident type;

(iv) The date of the incident;

(v) The location of the incident;

(vi) The names and contact information of all persons involved; and

(vii) All actions taken to ensure the health and welfare of the member.

(2) Receipt of report and documentation of the incident.

(a) The MCO, MCOP, or their designee will do the following upon discovering or receiving a report of an incident.

(i) Ensure immediate action was taken to protect the health and welfare of the member. If such action was not taken, take action immediately, but no later than twenty-four hours after the report was received.

(ii) Notify all of the appropriate entities with investigative or protective authority, and the appropriate additional regulatory, oversight, or advocacy agencies, including but not limited to:

(a) Local law enforcement if the incident involves suspected criminal conduct;

(b) The local coroner's office when the death of a member is reportable in accordance with section 313.12 of the Revised Code;

(d) The local child protective services agency (CPS);

(e) The local adult protective services agency (APS);

(f) The Ohio department of health, or other licensure or certification board or accreditation body if the incident involves a provider regulated by that entity;

(g) The local probate court if the incident may involve the legal guardian of the recipient.

(b) Enter all critical incidents into the incident management system within one business day of becoming aware of the incident.

(3) Incident investigation.

(a) The MCO, MCOP, or their designee will investigate all critical incidents by doing the following:

(i) Within two business days of entering the incident into the incident management system, initiate an investigation.

(ii) Conduct a review of all relevant documents including individualized service plans, care plans, assessments, clinical notes, communication notes, results from an investigation conducted by a third-party entity when available, provider documentation, provider billing records, medical reports, police and fire department reports, and emergency response system reports.

(iii) Conduct and document interviews with everyone who may have information relevant to the incident including.

(iv) Identify, to the extent possible, all causes and contributing factors.

(v) Determine whether the incident is substantiated.

(vi) Document all investigative activities in the incident management system.

(vii) Conclude the investigation no later than forty-five business days after the documented start date of the investigation, unless a longer time frame has been previously approved by ODM.

(4) Follow-up and closeout responsibilities.

(a) For incidents that resulted in a CPS or APS referral, communicate a summary of the investigative findings to the relevant agency within seven business days after being notified that the investigation is complete.

(b) For substantiated incidents, except in the case of death, enter a prevention plan into the incident management system no later than seven business days after the conclusion of the investigation, indicating closure of the incident.

(E) ODM may request further review of any incident, conduct a separate independent review or investigation of any incident, determine additional action, or assume responsibility for conducting an investigation or review.

Last updated August 27, 2026 at 8:02 AM

History

Effective: August 27, 2026
Promulgated Under: 119.03

Chapter 5160-27 Community Behavioral Health Agency Services

Ohio Adm.Code 5160-27-01 Eligible provider of community behavioral health services.

(A) For the purposes of this chapter, an "eligible billing provider" is an entity that meets the conditions in paragraph (A)(1) or (A)(2) of this rule. An "eligible rendering provider" is an individual who meets one or more of the conditions stated in paragraphs (A)(3) to (A)(8) of this rule and is employed by or under contract with an eligible billing provider.

(1) An entity certified by the Ohio department of mental health and addiction services operating in accordance with sections 5119.35 and 5119.36 of the Revised Code and Chapters 5122-24 to 5122-29 and Chapter 5160-1 of the Administrative Code and providing mental health or substance use disorder treatment services.

(2) An out-of-state entity furnishing mental health and/or substance use disorder services and operating in accordance with rule 5160-1-11 of the Administrative Code.

(3) Physician or physician assistant in accordance with agency 4731 and agency 4730 of the Administrative Code, respectively, and Chapter 5160-4 of the Administrative Code, or a clinical nurse specialist or certified nurse practitioner, as described in Chapter 4723. of the Revised Code.

(4) Registered nurse or licensed practical nurse as defined in section 4723.01 of the Revised Code and working under an order authorized by one of the practitioners listed in paragraph (A)(3) of this rule, except as allowable in accordance with section 4723.01 of the Revised Code or rule 5160-27-11 of the Administrative Code.

(5) A practitioner type described in rule 5160-8-05 of the Administrative Code.

(6) An unlicensed practitioner who operates under general supervision, as described in rule 5160-8-05 of the Administrative Code, of one of the practitioners listed in paragraphs (D)(1) to (D)(17) of this rule and meets the requirements for one of the following practitioner types:

(a) A qualified mental health specialist providing mental health services who:

(i) Meets the requirements for a qualified behavioral health specialist in accordance with agency 5122 of the Administrative Code,

(ii) Holds a valid high school diploma or equivalent, and

(iii) Has both work experience and training related to the service(s) being provided.

(b) A care management specialist providing substance use disorder services who:

(i) Meets the requirements for a qualified behavioral health specialist in accordance with agency 5122 of the Administrative Code,

(ii) Is eighteen years of age or older and has a high school diploma or equivalent, and

(iii) Has an understanding of substance use disorder treatment and recovery including how to engage a person in treatment and recovery.

(7) A pharmacist operating in accordance with rule 5160-8-52 of the Administrative Code.

(8) A certified peer supporter operating in accordance with rule 5122-29-15.1 of the Administrative Code.

(B) All practitioners will practice within their professional scope of practice.

(C) Supervisors will ensure that individuals whom they supervise meet the appropriate education and training qualifications for the service(s) they render.

(D) The following practitioners operating within their scope of practice, licensure, or certification, and in accordance with any service-specific supervison requirements may supervise:

(1) Physician.

(2) Physician assistant.

(3) Certified nurse practitioner.

(4) Clinical nurse specialist.

(5) Psychologist.

(6) Board licensed school psychologist.

(7) Licensed independent social worker.

(8) Licensed professional clinical counselor.

(9) Licensed independent marriage and family therapist.

(10) Licensed independent chemical dependency counselor.

(11) Registered nurse.

(12) Licensed marriage and family therapist.

(13) Licensed chemical dependency counselor II.

(14) Licensed chemical dependency counselor III.

(15) Licensed professional counselor.

(16) Licensed social worker.

(17) Certified peer supporter as defined in rule 5122-29-15.1 of the Administrative Code.

Last updated October 1, 2024 at 9:23 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-27-02 Coverage and limitations of behavioral health services.

(A) This rule sets forth coverage and limitations for behavioral health services rendered to medicaid recipients by behavioral health provider agencies who meet all requirements found in agency 5160 of the Administrative Code unless otherwise specified.

(1) All claims for behavioral health services submitted to the Ohio department of medicaid (ODM) must include an ICD-10 diagnosis of mental illness or substance use disorder. The list of recognized diagnoses can be accessed at www.medicaid.ohio.gov.

(2) Medicaid reimbursable behavioral health services are limited to medically necessary services defined in rule 5160-8-05 of the Administrative Code and Chapter 5160-27 of the Administrative Code. Providers shall follow the requirements in rule 5160-8-05 of the Administrative Code and Chapter 5160-27 of the Administrative Code regarding services that cannot be billed in combination with other services.

(B) The following services have limitations on the amount, scope or duration of service that can be rendered to a recipient within a certain timeframe. These limits can be exceeded with prior authorization from ODM or its designee.

(1) Screening, brief intervention and referral to treatment (SBIRT) as defined by the American medical association's current procedural terminology book. Limitation for this service is one per code, per recipient, per billing provider, per calendar year.

(2) Assertive community treatment (ACT) as defined in rule 5160-27-04 of the Administrative Code is available on or after the date as determined by prior authorization approval.

(3) Community psychiatric supportive treatment (CPST) services as defined in rule 5122-29-17 of the Administrative Code and meet the following requirements:

(a) All CPST services provided in social, recreational, vocational, or educational settings are allowable only if they are documented mental health service interventions addressing the specific individualized mental health treatment needs as identified in the recipient's individualized service plan.

(b) A billable unit of service for CPST may include contact between the mental health professional and the recipient or an individual essential to the mental health treatment of the recipient.

(c) CPST services are not covered under this rule when provided in a hospital setting, except for the purpose of coordinating admission to the inpatient hospital or facilitating discharge from an inpatient hospital.

(d) Medicaid reimbursement of CPST services is described in rule 5160-27-03 of the Administrative Code.

(4) Psychiatric diagnostic evaluation and psychiatric diagnostic evaluation with medical services are each limited to one encounter per recipient, per billing provider, per calendar year.

(C) The following services delivered to recipients with substance use disorders have limitations on the amount, scope or duration of service that can be rendered to a recipient within a certain timeframe. These limits can be exceeded with prior authorization from the ODM designated entity.

(1) Substance use disorder assessment as referenced in rule 5160-27-09 of the Administrative Code is limited to two assessments per recipient, per billing agency, per calendar year.

(2) Substance use disorder urine drug screening as referenced in rule 5160-27-09 of the Administrative Code, is limited to one per day, per recipient.

(3) Peer recovery support as referenced in rules 5160-27-09 and 5160-43-04 of the Administrative Code is limited to four hours per day per recipient.

(4) Substance use disorder partial hospitalization as described in rule 5160-27-09 of the Administrative Code.

(5) Substance use disorder residential level of care as described in rule 5160-27-09 of the Administrative Code.

(D) The medications listed in the appendix to rule 5160-27-03 or appendix DD to rule 5160-1-60 of the Administrative Code are covered by ODM when rendered and billed by an eligible provider as described in rule 5160-27-01 of the Administrative Code. The medication must be administered by a qualified practitioner acting within their professional scope of practice.

(E) Laboratory services, vaccines, and medications administered in a prescriber office may be administered in accordance with rule 5160-1-60 of the Administrative Code.

(F) Medical and evaluation and management services stated in the appendix to rule 5160-27-03 of the Administrative Code or appendix DD to rule 5160-1-60 of the Administrative Code are covered by ODM when rendered by:

(1) A practitioner as described in paragraphs (A)(3) and (A)(4) of rule 5160-27-01 of the Administrative Code and operating within their scope of practice; or

(2) A pharmacist, rendering services in accordance with rule 5160-8-52 of the Administrative Code.

(G) CMS place of service code set descriptions may be found at www.cms.gov. The department further defines place of service 99 as "community," and this place of service may only be used when a more specific place of service is not available. Place of service 99 shall not be used to provide services to a recipient of any age if the recipient is being held in a public institution as defined in 42 C.F.R. 435.1010 (October 1, 2016).

(H) The activities that comprise or are included in the aforementioned medicaid reimbursable behavioral health services must be intended to achieve identified treatment plan goals or objectives. Providers shall maintain treatment records and progress notes as specified in rules 5160-01-27 and 5160-8-05 of the Administrative Code. A treatment plan for mental health services may only be developed by a practitioner who, at a minimum, meets the practitioner requirements found in paragraph (A)(6)(a) of rule 5160-27-01 of the Administrative Code. A treatment plan for substance use disorder services may only be developed by a practitioner who, at a minimum meets the practitioner requirements found in paragraph (A)(6)(b)(i) or (A)(6)(b)(iii) of rule 5160-27-01 of the Administrative Code.

(I) The medications and services listed in the appendix to rule 5160-27-03 of the Administrative Code or the opiate treatment service section of appendix DD to rule 5160-1-60 of the Administrative Code are reimbursed by the department when rendered and billed by an opiate treatment program as described in Chapter 5122-40 of the Administrative Code and licensed as such by the Ohio department of mental health and addiction services and/or federally certified as such as stated in 42 CFR 8.11 (October 1, 2016). Reimbursement rates are determined by the methodology described in paragraph (E) of rule 5160-4-12 of the Administrative Code or as listed in the appendix to rule 5160-27-03 of the Administrative Code or as listed in appendix DD to rule 5160-1-60 of the Administrative Code.

(J) When permitted, provision of any service addressed in Chapter 5160-27 of the Administrative Code by telehealth as defined in rule 5122-29-31 of the Administrative Code, must comply with the appropriate telehealth requirement(s) found in rule 5160-1-18 of the Administrative Code.

(K) The services described in this chapter shall not substitute or supplant natural supports and do not include any of the following:

(1) Educational, vocational, or job training services.

(2) Room and board.

(3) Habilitation services including but not limited to financial management, supportive housing, supportive employment services, and basic skill acquisition services that are habilitative in nature.

(4) Services to recipients who are being held in a public institution as defined in 42 C.F.R. 435.1010 (October 1, 2016);

(5) Services to individuals residing in institutions for mental diseases as described in 42 C.F.R. 435.1010 (October 1, 2016);

(6) Recreational and social activities, including but not limited to art, music, and equine therapies;

(7) Services that are covered elsewhere in agency 5160 of the Administrative Code; and

(8) Transportation for the recipient or family.

(L) Peer recovery services defined as peer support services in rule 5122-29-15 of the Administrative Code are covered when delivered:

(1) Through the specialized recovery services program in accordance with rule 5160-43-04 of the Administrative Code; or

(2) As a component of assertive community treatment as defined in rule 5160-27-04 of the Administrative Code: or

(3) As a component of substance use disorder residential treatment as defined in rule 5160-27-09 of the Administrative Code; or

(4) As a substance use disorder outpatient treatment service in accordance with rule 5160-27-09 of the Administrative Code; or

(5) As a component of intensive home-based treatment service as defined in rule 5122-29-28 of the Administrative Code; or

(6) As a component of mobile response and stabilization service in accordance with rule 5122-29-14 of the Administrative Code.

(M) The "Ohio children's initiative brief CANS assessment" and the "Ohio children's initiative comprehensive CANS assessment" are covered as defined in rule 5160-59-01 of the Administrative Code and may be billed separately for reimbursement. Payment for CPST, therapeutic behavioral services, or psychiatric diagnostic evaluation is not allowable for provision of the Ohio brief or Ohio comprehensive CANS assessment.

Last updated March 25, 2024 at 9:13 AM

History

Effective: July 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-27-03 Reimbursement for community behavioral health services.

(A) This rule sets forth the reimbursement requirements and rates for behavioral health services as described in Chapter 5160-27 of the Administrative Code and applies to providers as described in rule 5160-27-01 of the Administrative Code.

(B) With the exception of pharmacists as described in paragraph (A)(7) of rule 5160-27-01 of the Administrative Code, medicaid reimbursement rates for services and practitioners described in Chapter 5160-27 of the Administrative Code are listed in the appendix to this rule. Ohio medicaid will reimburse the provider the lower of either their usual and customary charges or the reimbursement amount described in the appendix to this rule. Practitioner-specific reimbursement rates that are not otherwise stated in the appendix to this rule are determined by paragraphs (B)(1) to (B)(5) of this rule.

(1) The reimbursement rate for physicians, as described in paragraph (A)(3) of rule 5160-27-01 of the Administrative Code, is one hundred per cent of the medicaid maximum rate stated in the appendix to this rule.

(2) The reimbursement rate for clinical nurse specialists, certified nurse practitioners, and physician assistants, as described in paragraph (A)(3) of rule 5160-27-01 of the Administrative Code, is eighty-five per cent of the medicaid maximum rate stated in the appendix to this rule; except for evaluation and management office/outpatient visits, psychiatric diagnostic evaluations, and smoking and tobacco cessation counseling the reimbursement rate is one hundred per cent of the medicaid maximum rate stated in the appendix to this rule.

(3) The reimbursement rate for practitioners described in paragraph (A)(5) of rule 5160-27-01 of the Administrative Code is the reimbursement rate percentage described in rule 5160-8-05 of the Administrative Code (medicaid maximum rate stated in the appendix to this rule). The reimbursement rates for services not defined in rule 5160-8-05 of the Administrative Code are stated in the appendix to this rule.

(4) The reimbursement rates for practitioners described in rule 5160-27-01 of the Administrative Code and not otherwise addressed in paragraph (B) of this rule, are stated in the appendix to this rule.

(5) The reimbursement rate for pharmacists as described in paragraph (A)(7) of rule 5160-27-01 of the Administrative Code is set forth in rule 5160-8-52 of the Administrative Code.

(C) The medicaid reimbursement rate for any of the following services provided for more than ninety minutes by the same billing provider, to the same recipient, on the same calendar day will be fifty per cent of the rate listed in appendix to this rule.

(1) Community psychiatric supportive treatment as described in rule 5122-29-17 of the Administrative Code.

(2) Therapeutic behavioral service as described in rule 5160-27-08 of the Administrative Code when delivered in an office setting.

(3) Psychosocial rehabilitation as described in rule 5160-27-08 of the Administrative Code when delivered in an office setting.

(4) Substance use disorder targeted case management as described in rule 5160-27-10 of the Administrative Code.

(D) Place of service (POS) codes for behavioral health services as described in paragraph (G) of rule 5160-27-02 of the Administrative Code are stated in the appendix to this rule. If POS codes are not specified for a service, any valid POS code may be used.

(E) Laboratory services, vaccines, and medications, not stated in the appendix to this rule, and administered in a prescriber office, may be reimbursed in accordance with rule 5160-1-60 of the Administrative Code.

View Appendix

Last updated January 2, 2024 at 9:02 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-27-04 Mental health assertive community treatment service.

(A) For the purposes of medicaid reimbursement, assertive community treatment (ACT) refers to the evidence based model of delivering comprehensive community based behavioral health services to adults with certain serious and persistent mental illnesses who have not benefited from traditional outpatient treatment. The ACT model utilizes a multidisciplinary team of practitioners to deliver services to eligible individuals.

(B) For the purposes of this rule, collateral contact occurs when the practitioner contacts individuals who play a significant role in a medicaid recipient's life. The information gained from the collateral contact can provide insight into treatment or the basic psychoeducation provided to that collateral contact can assist with the treatment of the medicaid recipient.

(C) The ACT team is the sole provider to ACT recipients of outpatient behavioral health services, including level one outpatient services as defined by the American society of addiction medicine.

(D) ACT services include but are not limited to the following:

(1) Psychiatry and primary care as related to the mental health or substance use disorder diagnoses;

(2) Service coordination;

(3) Crisis assessment and intervention;

(4) Symptom assessment and management;

(5) Community based rehabilitative services;

(6) Education, support, and consultation to families, legal custodians, and significant others who are part of the recipient's support network.

(E) The desired outcomes of ACT intervention for medicaid recipients include but are not limited to:

(1) Achieving and maintaining a stable life in a community based setting;

(2) Reducing the need for inpatient hospital admission and emergency department visits;

(3) Improving mental and physical health status, and improving life satisfaction.

(F) A medicaid recipient may receive ACT services when determined by the ODM designated entity to have met all of the following:

(1) The recipient has a diagnosis of schizophrenia, bipolar, or major depressive disorder with psychosis, in accordance with the ICD-10 diagnosis code group list found at https://bh.medicaid.ohio.gov/manuals;

(2) The recipient has a supplemental security income or social security disability insurance determination or has a score of two or greater on at least one of the items in the "mental health needs" or "risk behaviors" sections or a score of three on at least one of the items in the "life domain function" section of the adult needs and strengths assessment (ANSA) administered by an individual with a bachelor's degree or higher and with training in the administration of the assessment; and

(3) The recipient has one or more of the following:

(a) Two or more admissions to a psychiatric inpatient hospital setting during the past twelve months; or

(b) Two or more occasions of utilizing psychiatric emergency services during the past twelve months; or

(d) History within the past two years of criminal justice involvement including but not limited to arrest, incarceration, or probation; and

(4) The recipient experiences one or more of the following:

(a) Persistent or recurrent severe psychiatric symptoms; or

(b) Coexisting substance use disorder of more than six month in duration; or

(c) Residing in an inpatient or supervised residence, but clinically assessed to be able to live in a more independent living situation if intensive services are provided; or

(d) At risk of psychiatric hospitalization, institutional or supervised residential placement if more intensive services are not available; or

(e) Has been unsuccessful in using traditional office-based outpatient services; and

(5) The recipient is eighteen years of age or older at the time of ACT enrollment.

(G) Prior authorization of ACT services.

(1) The provider must submit a request for prior authorization and receive approval from the ODM designated entity before ACT services can be rendered. The request for prior authorization must be accompanied by the appropriate documentation which includes, but is not limited to, the ANSA results or the documentation that supports the social security determination. The maximum amount of ACT service which may be prior authorized at any one time is twelve months.

(2) At the conclusion of the previous ACT service period, the provider agency may request additional ACT service to be prior authorized by the ODM designated entity.

(3) The provider may begin submitting claims for medicaid reimbursement of ACT services for dates of service within the subsequent calendar month following the date on which prior authorization is approved by the ODM designated entity.

(H) Disenrollment of a recipient from ACT. Upon planned or unplanned disenrollment of an ACT recipient, the ACT team shall document the circumstances regarding disenrollment in the recipient's medical record.

(1) A planned disenrollment from ACT occurs when a recipient, or recipient's guardian and ACT team members mutually agree to the termination of ACT services and transition of the recipient to a different care setting, provider, or benefit package. A planned disenrollment is appropriate when:

(a) The recipient has successfully reached established goals for disenrollment and the recipient and/or their guardian and ACT team members agree to the discharge from ACT; or

(b) The recipient moves outside the geographic area of the ACT team's responsibility. In such cases, the ACT team shall arrange to transfer mental health and substance use disorder service responsibility to another ACT program or other provider wherever the recipient is moving. The ACT team shall maintain contact with the recipient until the transfer is complete; or

(d) The recipient is determined by the ODM designated entity to no longer meet the eligibility or medical necessity criteria for ACT.

(2) As part of a planned disenrollment, the ACT team shall document that the recipient has actively participated in disenrollment activities by documenting in the recipient's medical record the following information:

(a) The reason(s) for the recipient's disenrollment as stated by both the recipient and the ACT team;

(b) The recipient's progress toward the goals set forth in the treatment plan;

(c) Documentation that the recipient's behavioral health care is being linked and transfered to a provider other than the ACT team;

(d) The signature of the recipient or their guardian, the ACT team leader, and the psychiatric prescriber.

(3) A recipient's disenrollment from ACT may be unplanned and due to circumstances facilitated by:

(a) The inability of the ACT team to locate the recipient for more than forty-five days; or

(b) The recipient's incarceration, hospitalization or admission to a residential substance use disorder treatment facility. In these circumstances, the primary responsibility for the recipient's health care is transferred to the aforementioned setting.

(i) The ACT team is expected to maintain contact with the recipient to assist with transition between settings if the recipient is likely to be discharged and resume service from the ACT team within two months.

(ii) If the recipient's stay is predicted to be longer than two months, the recipient shall be disenrolled from the ACT team.

(iii) The recipient may be re-enrolled with the ACT team when discharged from the incarcerated, inpatient or residential setting. Any re-enrollment shall follow the eligibility determination criteria described in paragraph (F) of this rule.

(4) Except for services found in paragraph (O) of this rule, a recipient may not obtain behavioral health services from a provider other than the ACT team unless the recipient is disenrolled from ACT services.

(5) The provider must inform the ODM designated entity of disenrollment within three business days of the discharge date. The ODM designated entity shall deactivate the authorization for the ACT service. Failure to timely dis-enroll the recipient from ACT may result in claim denial for other mental health or substance use disorder services.

(I) A provider furnishing ACT services must meet both of the following criteria:

(1) Meets the eligibility requirements found in paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code; and

(2) Employs one or more teams of mental health and substance use disorder practitioners who comprise the ACT treatment team.

(J) Each team must meet the following criteria:

(1) Completed a fidelity review within the previous twelve months by an independent validation entity recognized by ODM. In year one of an ACT team's participation with Ohio medicaid the team must participate in a fidelity review based on the dartmouth assertive community treatment scale (DACTS) and performed by an independent validation entity recognized by ODM. The DACTS fidelity scale and protocol can be found at www.medicaid.ohio.gov.

(a) Fidelity reviews of ACT teams must be repeated every twelve months from the report date of the previous fidelity review.

(b) An ACT team must have documented evidence of compliance to the requirements stated in paragraph (J) of this rule prior to submitting any prior authorization requests for recipients of ACT services.

(2) Each team shall have a designated full-time team leader who may serve in that capacity with only one team.

(a) An ACT team leader shall have a national provider identification number and be actively enrolled as an Ohio medicaid provider.

(b) A team leader shall have psychiatric training and shall hold one of the following valid licenses from the appropriate Ohio professional licensure board or licensure equivalents for ACT teams located in other states:

(i) Licensed independent social worker.

(ii) Licensed independent marriage and family therapist.

(iii) Licensed professional clinical counselor.

(iv) Licensed psychologist.

(v) Physician medical doctor, psychiatrist, doctor of osteopathy.

(vi) Clinical nurse specialist

(vii) Certified nurse practitioner.

(viii) Physician assistant.

(ix) Registered nurse.

(c) Team leaders who are licensed in accordance with paragraph (A)(5) of rule 5160-27-01 of the Administrative Code but do not have independent licensure status from one of the boards referenced in paragraph (A)(5) of rule 5160-27-01 of the Administrative Code must receive approval from ODM before the ACT team to which they are assigned can begin billing Ohio medicaid.

(3) ACT teams that employ peer recovery supporters must ensure that they meet the criteria and requirements for the peer recovery support services set forth in rule 5160-43-09 of the Administrative Code.

(4) ACT teams must have a caseload no greater than one hundred and twenty and must maintain an average caseload ratio of one practitioner for every ten ACT recipients. Upon request from the ODM, the ACT team must provide to the ODM or its designated entity the ACT team caseload size and composition of medicaid and non-medicaid enrollees.

(K) ODM reserves the right to suspend or terminate the payment of ACT services and to require subsequent review of an ACT team's fidelity performance if ODM has reason to believe that the ACT team's fidelity to the DACTS model described in paragraph (J)(1) of this rule may be in question. ODM may, at its discretion, suspend payment of ACT medicaid claims from the provider agency employing the ACT team until such time as ODM receives documentation from its independent validation entity that the team does meet the fidelity criteria described in paragraph (J)(1) of this rule.

(L) A provider employing an ACT team may bill up to four ACT units per month per recipient when all clinical and billing requirements for each unit are met. The billing of ACT units are subject to the following limits per provider category, per recipient, per month:

(1) Not more than one unit may be billed per medicaid recipient per month for services rendered by the ACT team medical prescriber including physician, clinical nurse specialist, certified nurse practitioner, or physician assistant operating within their respective scopes of practice.

(2) Not more than one unit per medicaid recipient per month may be billed for services rendered by any one of the following ACT team members: psychologist, licensed independent social worker, licensed social worker, licensed clinical social worker, licensed professional counselor, licensed professional clinical counselor, licensed independent clinical counselor, licensed independent marriage and family therapist, licensed marriage and family therapist, licensed practical nurse, registered nurse, licensed independent chemical dependency counselor, licensed chemical dependency counselor II or licensed chemical dependency counselor III.

(3) Not more than two units per medicaid recipient per month may be billed by an ACT team member not listed in paragraph (L)(1) or (L)(2) of this rule. This unit category includes: psychology assistant, psychology intern, psychology trainee, social worker assistant, social worker trainee, marriage and family therapist trainee, counselor trainee, chemical dependency counselor assistant, qualified mental health specialist (QMHS), including QMHS with three or more years of experience, and peer recovery supporter.

(M) The medicaid payment rates for ACT are stated in the appendix to rule 5160-27-03 of the Administrative Code. Payment for services provided by authorized ACT teams is only available for dates of services on or after January 1, 2018.

(N) ACT teams shall maintain regular contact and deliver all medically necessary outpatient mental health and substance use disorder services and supports to ACT recipients enrolled with their team.

(O) Services rendered by the ACT team medical prescriber, including physician, clinical nurse specialist, certified nurse practitioner, or physician assistant, are billable when rendered to an ACT recipient or via a case specific consultation with another member of the ACT team regarding the medical aspects of the ACT recipient's treatment plan. The ACT team medical prescriber must have at least one contact with each ACT recipient every three months.

(P) When a recipient is enrolled on an ACT team, no other medicaid community behavioral health services, as defined in Chapter 5160-27 of the Administrative Code, are eligible for reimbursement except:

(1) Supported employment as identified on a recipient's specialized recovery services program treatment plan if applicable, as described in rule 5160-43-01 of the Administrative Code.

(2) Substance use disorder services that are not considered part of the benefit package encompassed under level one of the american society of addiction medicine (ASAM) as defined in rule 5160-27-09 of the Administrative Code. Prior authorization from the ODM designated entity is required.

(3) Crisis services furnished by a provider other than the billing provider agency employing the ACT team.

(Q) Documentation requirements for ACT.

(1) Documentation in the recipient's medical record of the services provided by the ACT team must meet the requirements stated in this paragraph as well as those stated in rules 5160-1-27 and 5160-8-05 of the Administrative Code.

(2) The ACT team must develop a specific treatment plan for each enrolled recipient. The treatment plan must, at a minimum, meet the requirements of rule 5160-8-05 of the Administrative Code plus the following additional requirements:

(a) The treatment plan shall be individualized based on the recipient's needs, strengths, and preferences and shall set measurable long-term and short-term goals and specify approaches and interventions necessary for the recipient to achieve the recipient goals. The treatment plan shall also identify who will carry out the approaches and interventions.

(b) The treatment plan shall address, at a minimum, the following key areas:

(i) Psychiatric illness or symptom reduction.

(ii) Stable, safe, and affordable housing.

(iii) Activities of daily living.

(iv) Daily structure and activities, including employment if appropriate.

(v) Family and social relationships.

(c) The treatment plan shall be reviewed and revised by a member of the ACT team with the recipient whenever a change is needed in the recipient's course of treatment or at least every six months. In conjunction with a treatment plan review, the ACT team member shall prepare a summary of the recipient's progress, goal attainment, effectiveness of the intervention and recipient's satisfaction with the ACT team interventions since enactment of the previous treatment plan.

(d) The treatment plan, and all subsequent revisions of it, shall be reviewed and signed by the recipient and the ACT team practitioner.

(R) The following activities performed by members of the ACT team are not eligible for reimbursement:

(1) Time spent attending or participating in recreational activities.

(2) Services provided to teach academic subjects or as a substitute for educational personnel, including but not limited to a teacher, teacher's aide, or an academic tutor.

(3) Habilitative services for the recipient to acquire, retain, and improve the self-help, socialization, and adaptive skills necessary to reside successfully in community settings.

(4) Child care services or services provided as a substitute for the parent or other individuals responsible for providing care and supervision.

(5) Respite care.

(6) Transportation for the recipient or family.

(7) Services provided to children, spouse, parents, or siblings of the eligible recipient under treatment or others in the eligible recipient's life to address problems not directly related to the eligible recipient's issues and not listed in the eligible recipient's ACT treatment plan.

(8) Art, movement, dance, or drama therapies.

(9) Services provided to collaterals of the recipient.

(10) Contacts that are not medically necessary.

(11) Any service outside the responsibility of the ACT team.

(12) Vocational training and supported employment services, unless the recipient is enrolled in the specialized recovery services program as described in rule 5160-43-01 of the Administrative Code.

(13) Crisis intervention provided by the provider agency employing the ACT team.

History

Effective: January 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-27-06 Therapeutic behavioral group service-hourly and per diem.

(A) For the purpose of medicaid reimbursement, therapeutic behavioral (day treatment), group service-hourly and per diem, is defined as an intensive, structured, goal-oriented, distinct and identifiable group treatment service that addresses the individualized mental health needs of the client. The therapeutic behavioral group service-hourly and per diem is clinically indicated by assessment. The environment at this level of treatment is highly structured, and has an appropriate staff-to-client ratio to guarantee sufficient therapeutic services and professional monitoring, control, and protection. The purpose and intent of therapeutic behavioral group service-hourly and per diem is to stabilize, increase or sustain the highest level of functioning.

(1) Therapeutic behavioral group service-hourly and per diem must be a group treatment service that includes but is not limited to the following:

(a) Skills development of interpersonal and social competency, problem solving, conflict resolution, and emotions/behavior management,

(b) Developing of positive coping mechanisms,

(d) Psychoeducational services including instruction and training of persons served in order to increase their knowledge and understanding of their psychiatric diagnosis(es), prognosis(es), treatment, and rehabilitation in order to enhance their acceptance, increase their cooperation and collaboration with treatment and rehabilitation, and favorably affect their outcomes.

(B) Service requirements.

(1) When the service is provided for less than 2.5 hours per day, the therapeutic behavioral group service hourly billing code must be used.

(2) When the service is provided for 2.5 or more hours per day, the therapeutic behavioral group service per diem must be used and the service must:

(a) Be delivered at a nationally-accredited program and must be provided by a licensed practitioner, or an unlicensed mental health practitioner as described in paragraph (A)(2) of rule 5160-27-08 of the Administrative Code.

(b) The staff to client ratio cannot exceed 1:12.

(1) Reimbursement for therapeutic behavioral group service-hourly and per diem will not be made while the patient is enrolled in assertive community treatment (ACT), or a substance use disorder (SUD) residential treatment facility.

(2) For adults, reimbursement for the following medically necessary behavioral health group services will be limited to no more than four fifteen-minute units, or one hour per day on the same day as the therapeutic behavioral group service (hourly, or per diem) except when prior authorized.

(a) Group psychotherapy for mental health or substance use disorder diagnoses.

(b) Group therapeutic behavioral services as defined in rule 5160-27-08 of the Administrative Code.

(d) Group community psychiatric supportive treatment.

(3) A therapeutic behavioral group service per diem and therapeutic behavioral group service hourly reimbursement will not be reimbursed when delivered on the same day by the same billing provider for the same individual.

(4) A medicaid recipient can receive one therapeutic behavioral group service per diem service per day per provider. Reimbursement of therapeutic behavioral group service per diem and therapeutic behavioral service hourly by more than one billing provider to the same individual on the same day is allowable with prior authorization.

(5) Other behavioral health individual services may be reimbursed on the same day as therapeutic behavioral group service-hourly or therapeutic behavioral group service per diem.

(D) Providers must adhere to documentation requirements set forth in rules 5160-1-27 and 5160-8-05 of the Administrative Code.

Last updated March 1, 2022 at 8:33 AM

History

Effective: March 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-27-08 Mental health therapeutic behavioral services and psychosocial rehabilitation.

(A) For the purposes of medicaid reimbursement, therapeutic behavioral services (TBS) are goal-directed supports and solution-focused interventions.

(1) Activities included must be intended to achieve the identified goals or objectives as set forth in the individual's treatment plan. Activities include but are not limited to the following:

(a) Treatment planning. Participating in and utilizing strengths based treatments/planning which may include assisting the individual and family members or other collaterals with identifying strengths and needs.

(b) Identification of strategies or treatment options. Assisting the individual and family members or other collaterals to identify strategies or treatment options associated with the individual's mental illness.

(c) Developing and providing solution focused interventions and emotional and behavioral management drawn from evidence-based psychotherapeutic treatments.

(d) Restoration of social skills. Rehabilitation and support with the restoration of social and interpersonal skills to increase community tenure, enhance personal relationships, establish support networks, increase community awareness, develop coping strategies, and promote effective functioning in the individual's social environment including home, work and school.

(e) Restoration of daily functioning. Assisting the individual to restore daily functioning specific to managing their own home including managing their money, medications, and using community resources and other self-care requirements; and

(f) Crisis prevention and amelioration. Assisting the individual with effectively responding to or avoiding identified precursors or triggers that would risk their remaining in a community setting or that result in functional impairments. Activities may include, but not be limited to, assisting the individual and family members or other collaterals with identifying a potential psychiatric or personal crisis, developing a crisis management plan, and/or, as appropriate, seeking other supports to restore stability and functioning.

(2) Eligible providers must be a licensed or an unlicensed mental health practitioner in accordance with rule 5160-27-01 of the Administrative Code who have at a minimum:

(a) A bachelor's or a master's degree in social work, psychology, nursing, or in related human services, or

(b) A high school diploma with a minimum of three years of relevant experience as determined by the employing agency and documented in the employee's record.

(B) For the purposes of this rule, collateral/collateral supports contact occurs when the practitioner contacts individuals who play a significant role in a medicaid recipient's life. The information gained from the collateral contact can provide insight into the individual's treatment. Basic psychoeducation provided to a medicaid recipient's collateral contacts can assist with their treatment.

(C) For the purposes of medicaid reimbursement, psychosocial rehabilitation (PSR) assists individuals with implementing interventions outlined on a treatment plan to compensate for or eliminate functional deficits and interpersonal and/or mental health barriers associated with an individual's mental health diagnosis.

(1) Activities include:

(a) Restoration, rehabilitation and support of daily functioning to improve self-management of the negative effects of psychiatric or emotional symptoms that interfere with a person's daily functioning.

(b) Supporting the individual with restoration and implementation of daily functioning and daily routines critical to remaining successful in home, school, work, and community.

(2) Eligible providers are unlicensed mental health practitioners in accordance with rule 5160-27-01 of the Administrative Code, are at least eighteen years of age and who have, at a minimum, a high school diploma with appropriate mental health training as determined by the employing agency and documented in the employee's record.

(D) Limitations.

(1) TBS and PSR will not be reimbursed when a patient is enrolled in assertive community treatment (ACT) or receiving residential substance use disorder treatment services. A separate payment will not be made for TBS and PSR while a youth is enrolled in intensive home based treatment (IHBT) unless the service is prior authorized.

(2) TBS must be delivered as an individual or group intervention with the individual, family/caregiver and/or other collateral supports.

(3) PSR must be delivered as an intervention with the individual, not in a group setting.

(E) Providers shall adhere to documentation requirements set forth in rules 5160-01-27 and 5160-8-05 of the Administrative Code.

Last updated March 1, 2022 at 8:33 AM

History

Effective: March 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-27-09 Substance use disorder treatment services.

(A) For the purpose of medicaid reimbursement, substance use disorder treatment services shall be defined by and shall be provided according to the American society of addiction medicine also known as the ASAM treatment criteria for addictive, substance related and co-occurring conditions for admission, continued stay, discharge, or referral to each level of care (LOC).

(B) Medicaid will reimburse for the services provided under the following ASAM levels of care:

(1) LOC 1: outpatient services. LOC 1 services are designed to treat the recipient's level of clinical severity and function. These services may be delivered in a variety of settings. Addiction, mental health, or general health care treatment personnel provide professionally directed screening, evaluation, treatment, and ongoing recovery and disease management services. Such services are provided in regularly scheduled sessions and follow a defined set of policies and procedures or medical protocols. Service provision is limited to less than nine hours per week for adults and less than six hours per week for adolescents.

(2) LOC 2: intensive outpatient/partial hospitalization including LOC 2 withdrawal management (WM). LOC 2 services are capable of meeting the complex needs of people with addiction and co-occurring conditions. They can be rendered during the day, before or after work or school, in the evening, and/or on weekends.

(3) LOC 3: residential services/inpatient services including LOC 3 WM. These services are co-occurring capable, co-occurring enhanced, and complexity capable in nature and provided by addiction treatment, mental health and general medical personnel in a twenty four hour treatment setting. Services are provided in Ohio department of mental health and addiction services certified permanent facilities which are staffed twenty four hours a day. The following services are included in the residential treatment service and will not be reimbursed separately:

(a) Ongoing assessments and diagnostic evaluations.

(b) Crisis intervention.

(d) Case management.

(e) Substance use disorder peer recovery services.

(f) Urine drug screens.

(g) Medical services.

(4) The following services are considered non-covered for individuals in residential treatment:

(a) Therapeutic behavioral services.

(b) Psychosocial rehabilitation.

(d) Mental health day treatment.

(e) Assertive community treatment.

(f) Intensive home based treatment.

(C) Individuals in residential treatment may receive medically necessary services from practitioners who are not affiliated with the residential treatment program. Examples include, but are not limited to, psychiatry, medication assisted treatment, or other medical treatment that is outside the scope of the residential level of care as defined by the American society of addiction medicine. Medicaid will reimburse providers of these services outside the per diem rate paid to residential treatment programs. All treatment services, regardless of whether they are rendered by the residential treatment program or unaffiliated billing practitioners or agencies must be documented in the client's treatment plan maintained by the residential treatment provider.

(D) The entity providing a residential service must ensure that the medicaid recipient has access to the appropriate practitioner for receipt of clinical services as stated in the ASAM treatment criteria.

(E) Eligible practitioners of substance use disorder treatment services must meet all applicable requirements stated in rule 5160-27-01 of the Administrative Code. Qualified mental health specialists are not eligible to be a residential treatment team practitioner.

(F) Limitations.

(1) Residential levels of care are mutually exclusive, therefore a patient can only receive services through one level of care at a time.

(2) Prior authorization is required for LOC 2.5 (partial hospitalization) which requires a minimum of twenty hours of services per week. If, after the first four consecutive weeks of treatment, the amount of services provided is less than twenty hours, the prior authorization will be rescinded but services may still be reimbursed at a lower level of care not to exceed 19.9 hours per week.

(3) Prior authorization is required for LOC 3 residential treatment according to the following:

(a) Up to thirty consecutive days without prior authorization per medicaid enrollee for the first and second admission in a calendar year. If the stay continues beyond the thirty days of the first or second stay, prior authorization is required to support the medical necessity of the continued stay. If medical necessity is not substantiated and approved by the ODM designated entity, only the initial thirty consecutive days will be reimbursed.

(b) Third and subsequent admissions during the same calendar year must be prior authorized from the first day of admission.

(G) The patient's medical record must substantiate the medical necessity of services performed. Providers shall adhere to documentation requirements set forth in rules 5160-1-27 and 5160-8-05 of the Administrative Code.

Last updated August 5, 2021 at 9:02 AM

History

Effective: January 1, 2018
Promulgated Under: 119.03

Ohio Adm.Code 5160-27-10 Substance use disorder targeted case management.

(A) Targeted case management assists an individual receiving alcohol or substance use disorder treatment services from an Ohio department of mental health and addiction services (OhioMHAS) certified substance use disorder treatment program to gain access to needed medical, social, educational and other services.

(1) Targeted case management services shall include, at a minimum, the following activities:

(a) Comprehensive assessment and periodic reassessment of individual needs to determine the need for any medical, educational, social or other services. Assessment activities include taking client history; identifying the individual's needs and completing related documentation and gathering information from other sources such as family members, medical providers, social workers and educators to form a complete assessment of the eligible individual.

(b) Development and periodic revision of a specific care plan that is based on the information gathered through the assessment. The care plan must include the following requirements:

(i) Goals and actions to address the medical, social, educational and other services needed by the individual; and

(ii) A plan to ensure the active participation of the eligible individual and or their authorized health care decision maker; and

(iii) A course of action to respond to the assessed needs of the eligible individual.

(d) Monitoring and follow-up activities or contacts that are necessary to ensure that the care plan is implemented and adequately addresses the eligible individual's needs. Changes in needs or status must be reflected in the care plan. Monitoring shall be performed no less frequently than annually. Monitoring may be performed in person or by electronic communication.

(B) In order to provide targeted case management, practitioners must meet the requirements in rule 5160-27-01 of the Administrative Code. For the purposes of this rule, the following unlicensed practitioners are excluded: qualified mental health specialists and certified peer supporters.

(C) The following activities or contacts do not constitute targeted case management and are ineligible for reimbursement as targeted case management:

(1) Transportation.

(2) Waiting with an individual for appointments at social service agencies, court hearings and similar activities does not, in and of itself, constitute case management.

(3) Direct services to which the client has been referred such as medical, educational or social services.

(4) Internal quality assurance activities, such as clinical supervisory activities and/or case review/staffing sessions.

(D) Targeted case management services will not be separately reimbursed when a recipient is enrolled in a substance use disorder (SUD) residential treatment facility.

(E) Targeted case management services require prior authorization from the Ohio department of medicaid (ODM) designated entity when a recipient is enrolled in an assertive community treatment (ACT) or intensive home based treatment (IHBT) team.

Last updated October 1, 2024 at 9:23 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-27-11 Behavioral health nursing services.

(A) Behavioral health nursing services are mental health and substance use disorder (SUD) nursing services performed by registered nurses or licensed practical nurses. They include those activities that are performed within professional scope of practice and in authorized settings by a registered nurse or licensed practical nurse as defined in section 4723.01 of the Revised Code and are intended to address the behavioral and other physical health needs of individuals receiving treatment for psychiatric symptoms or substance use disorders.

(B) Behavioral health nursing services may include but are not limited to performance of the following:

(1) Health care screenings

(2) Nursing assessments

(3) Nursing exams

(4) Checking vital signs

(5) Monitoring the effects of medication

(6) Monitoring symptoms

(7) Behavioral health education

(8) Collaboration with the individual and/or family as clinically indicated

(9) Group nursing services

(1) Registered nurse (RN) as described in rule 5160-27-01 of the Administrative Code.

(2) Licensed practical nurse (LPN) as described in rule 5160-27-01 of the Administrative Code.

(D) Limitations.

(1) Group nursing services and nursing assessments must be provided by an RN.

(2) When behavioral health nursing services are provided, medication administration will not be reimbursed when provided by the same practitioner, to the same recipient, on the same day.

(3) Behavioral health nursing services will not be reimbursed when a recipient is enrolled in assertive community treatment (ACT) or in a SUD residential treatment facility.

Last updated October 1, 2024 at 9:24 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-27-12 Behavioral health crisis intervention provided by unlicensed practitioners.

(A) For the purpose of medicaid reimbursement, behavioral health crisis intervention is a timely intervention with medicaid recipients who are experiencing a life threatening or complex emergent situation related to mental illness or a substance use disorder.

(1) The goals of crisis intervention are to ease the crisis, re-establish safety and institute interventions to minimize psychological trauma.

(2) Activities may include but are not limited to: emergent care, assessment, immediate stabilization, de-escalation, counseling, care planning and resolution.

(B) In order to provide behavioral health crisis intervention, practitioners must meet the requirements in paragraph (A)(6) of rule 5160-27-01 of the Administrative Code.

(1) For the purposes of this rule, the following unlicensed practitioners are excluded: care management specialist and peer recovery supporter.

(2) Practitioners of crisis intervention shall have current certification in first aid and cardio-pulmonary resuscitation (CPR).

(C) Limitations: crisis intervention will not be reimbursed when a recipient is enrolled in assertive community treatment (ACT), intensive home based treatment (IHBT) or receiving services in a substance use disorder (SUD) residential treatment facility.

(D) Providers shall adhere to documentation requirements set forth in rules 5160-1-27 and 5160-8-05 of the Administrative Code.

(E) Crisis psychotherapy rendered by licensed practitioners is authorized in rule 5160-8-05 of the Administrative Code and as defined by the American medical association's current procedural terminology book.

History

Effective: January 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-27-13 Mobile response and stabilization service.

(A) For the purposes of this rule, mobile response and stabilization service (MRSS), is the service as set forth by the Ohio department of mental health and addiction services (OhioMHAS) in rule 5122-29-14 of the Administrative Code.

(B) Eligible providers.

(1) Providers eligible to provide MRSS in accordance with rule 5122-29-14 of the Administrative Code and designated by OhioMHAS as regional MRSS providers are eligible for MRSS reimbursement.

(2) Eligible rendering providers are MRSS team staff described in rule 5122-29-14 of the Administrative Code that are eligible providers of behavioral health services in accordance with rule 5160-27-01 of the Administrative Code and employed by or under contract with an eligible provider described in paragraph (B)(1) of this rule or with an organization providing MRSS under a contract or agreement with an eligible provider described in paragraph (B)(1) of this rule.

(3) Grandfathering: As determined by the Ohio department of medicaid (ODM), providers who are eligible to provide MRSS in accordance with rule 5122-29-14 of the Administrative Code but are not designated by OhioMHAS as regional MRSS providers may continue to provide and be reimbursed for MRSS until the OhioMHAS designated regional MRSS provider takes full responsibility for the region. ODM will provide a written notifiction to each provider eligible to receive reimbursement under this section and will provide ten business days written notice when the provider is determined no longer eligible for reimbursement.

(C) Coverage. The following services and activities provided in accordance with rule 5122-29-14 of the Administrative Code to individuals twenty years of age or younger are covered services:

(1) Mobile response activities as described in rule 5122-29-14 of the Administrative Code.

(2) Stabilization services as described in rule 5122-29-14 of the Administrative Code.

(D) Limitations. The following are not covered as MRSS:

(1) Childcare services or services provided as a substitute for the parent or other individuals responsible for providing care and supervision.

(2) Respite care.

(3) Transportation activities that do not include the provision of a mobile response activity or stabilization service.

(4) A service that is covered as part of another medicaid reimbursable service, including but not limited to:

(a) Intensive home-based treatment as described in rule 5122-29-28 of the Administrative Code except when a mobile response team is dispatched to de-escalate a presenting crisis as described in rule 5122-29-14 of the Administrative Code.

(b) Substance use disorder residential treatment services as described in rule 51602-27-09 of the Administrative Code, except for MRSS necessary to support admission to or discharge from the facility.

(d) Inpatient or outpatient hospital services as described in Chapter 5160-2 of the Administrative Code, except for MRSS necessary to support admission to or discharge from the hospital.

(e) Psychiatric residential treatment facility services as described in rule 5160-59-03.6 of the Administrative Code, except for MRSS necessary to support admission to or discharge from the facility.

(E) Reimbursement.

(1) Providers described in paragraph (B)(1) of this rule will be reimbursed in accordance with the contracted rates described in their OhioMHAS provider agreements.

(2) Providers described in paragraph (B)(3) of this rule will be reimbursed in accordance with the fee schedule stated in the appendix to rule 5160-27-03 of the Administrative Code.

Last updated July 1, 2025 at 8:07 AM

History

Effective: July 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-27-14 Behavioral health peer support service.

(A) For the purposes of this rule, behavioral health peer support service is the service as set forth by the Ohio department of mental health and addiction services (OhioMHAS) in rule 5122-29-15 of the Administrative Code.

(B) Eligible providers.

(1) An eligible rendering provider of peer support services is:

(a) A person who is eligible to provide peer support services in accordance with rule 5122-29-15.1 of the Administrative Code; and

(b) An eligible provider of behavioral health services in accordance with rule 5160-27-01 of the Administrative Code.

(2) An eligible billing provider is:

(a) An eligible behavioral health provider that meets the conditions in paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code; and

(b) Employs or contracts with an eligible rendering provider of peer support services as described in this rule.

(1) The peer support service is covered when:

(a) Provided in accordance with the activities as described in rule 5122-29-15 of the Administrative Code.

(b) Rendered as a component of behavioral health treatment for the purpose of addressing the individual's behavioral health care needs relating to a mental health or substance use disorder.

(c) Intended to achieve goals or objectives based on and documented in a current individualized treatment plan meeting the requirements in rule 5122-27-03 of the Administrative Code.

(D) Limitations.

(1) The peer recovery service has to be prior authorized when rendered for more than four hours to the same individual on the same date of service.

(2) Transportation activities that do not include the provision of a peer support service are not covered.

(3) Provision of a peer support service is reimbursed in accordance with this rule and may not be reimbursed as another covered medicaid service, including, but not limited to, the following:

(a) Community psychiatric supportive treatment.

(b) Therapeutic behavioral services.

(d) Substance use disorder target case management.

(4) Payment is not allowable when a peer support service is provided in a group setting and the certified peer supporter to client ratio exceeds one to twelve.

(5) When peer support service is delivered to caregivers or family members of the individual, it is reimburseable when the purpose of the service is to address the behavioral health needs, goals, and objectives as documented in the individual's treatment plan.

(E) Reimbursement.

(1) The medicaid reimbursement rate for the peer support service is stated in the appendix to rule 5160-27-03 of the Administrative Code. The peer support service is not reimbursable when covered as part of another medicaid reimbursable service. Reimbursement will not be made for peer support services when an individual is:

(a) Receiving intensive home-based treatment as described in rule 5122-29-28 of the Administrative Code.

(b) Receiving assertive community treatment as described in rule 5160-27-04 of the Administrative Code.

(d) Receiving substance use disorder residential treatment services as described in rule 5160-27-09 of the Administrative Code, except when the peer support service is necessary to support admission to and discharge from the substance use disorder residential treatment. Payment for the services provided during a substance use disorder residential treatment stay is made in accordance with rule 5160-27-09 of the Administrative Code.

(e) Receiving inpatient hospital psychiatric services as described in Chapter 5160-2 of the Administrative Code, except when the peer support service is necessary to support admission to and discharge from the hospital. Payment for the services provided during an inpatient hospital stay is made in accordance with Chapter 5160-2 of the Administrative Code.

(f) Receiving psychiatric residential treatment facility (PRTF) services as described in Chapter 5122-41 of the Administrative Code and rule 5160-59-03.6 of the Administrative Code, except when the peer support service is necessary to support admission to and discharge from the PRTF. Payment for the services provided during a PRTF stay is made in accordance with rule 5160-59-03.6 of the Administrative Code.

Last updated September 3, 2024 at 9:09 AM

History

Effective: September 1, 2024
Promulgated Under: 119.03

Chapter 5160-28 Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) Services

Ohio Adm.Code 5160-28-01 Federally qualified health center (FQHC) and rural health clinic (RHC) services: definitions and explanations.

(A) "Change in scope of service" is an alteration in aspects of a prospective payment system (PPS) service such as the procedures or items that are furnished, the frequency with which they are furnished, and the type of personnel who furnish them.

(1) A change in scope of service is characterized by such factors as are specified in the following non-exhaustive list:

(a) The addition or discontinuation of a PPS service;

(b) The addition or discontinuation of a procedure or class of procedures within a PPS service that involves the skills and training of a higher-level practitioner, such as the expansion of PPS medical service to include obstetrical-gynecological care provided by a physician or advanced practice registered nurse or the provision of a full range of dental procedures performed by a licensed dentist where previously only the services of a dental hygienist had been available; or

(c) A change in the distribution of procedures within a PPS service that materially affects the allocation of resources to that PPS service, such as a change in a medical service "case mix" from eighty per cent family practice and twenty per cent obstetrical-gynecological care to forty per cent family practice and sixty per cent obstetrical-gynecological care.

(2) The following factors do not constitute a change in scope of service:

(a) Wage increases;

(b) Changes in negotiated union contracts;

(d) An increase in the number of lower-level staff members, such as a nurse practitioner at a site that employs a family physician, a dental hygienist at a site that employs a dentist, or a physical therapy assistant at a site that employs a physical therapist;

(e) An increase in the number of social service staff members;

(f) An increase in office space, such as the addition of square footage at an FQHC or RHC, a satellite office, a school location, or a mobile unit;

(g) An increase in equipment or supplies;

(h) An increase in patient volume;

(i) An increase in office hours;

(j) The addition of an adjunctive service such as a disease management program; or

(k) Provision of a PPS service by an FQHC or RHC practitioner at a related off-site location.

(B) "Cost report" is a report of FQHC or RHC costs together with all schedules, attachments, and supporting documentation, in accordance with the instructions specified for the form.

(1) For purposes of establishing FQHC per-visit payment amounts, the Ohio department of medicaid (ODM) uses form ODM 03421, "Federally Qualified Health Center Cost Report" (rev. 7/2022).

(2) For purposes of establishing RHC per-visit payment amounts, ODM uses the appropriate medicare form, either CMS-222-17, "Independent Rural Health Clinic Cost Report" (rev. 5/2018) or CMS 2552-10, "Hospital and Hospital Health Care Complex Cost Report Certification and Settlement Summary" (rev. 4/2020).

(C) "Federally qualified health center (FQHC)" is an entity that meets the definition of FQHC set forth in 42 U.S.C. 1395x(aa)(4) (October 1, 2021).

(1) "FQHC look-alike" is an FQHC that does not receive Public Health Service Act (PHSA) grant funding.

(2) "Government-operated FQHC" is an FQHC operated by a state, county, or local government agency.

(D) "Managed care entity (MCE)" has the same meaning as in Chapter 5160-26 of the Administrative Code.

(E) "Medicaid wraparound payment" is an amount that is paid by ODM to augment the payment made by an MCE to an FQHC or RHC. It equals any positive difference obtained when the MCE payment is subtracted from the per-visit payment amount (PVPA) for the visit.

(1) For purposes of determining timely filing in accordance with rule 5160-1-19 of the Administrative Code, an MCE is treated as a third-party payer.

(2) An FQHC or RHC may submit a claim to ODM for medicaid wraparound payment before the later of the following dates:

(a) One hundred eighty days after the date on which the MCE pays the original claim; or

(b) Three hundred sixty-five days after the date of service.

(3) ODM will pay a valid claim for medicaid wraparound payment within four months after submission.

(F) "Non-PPS service" is a service rendered at an FQHC or RHC for which payment is generally made in accordance with rules in agency 5160 outside of Chapter 5160-28 of the Administrative Code.

(G) "PPS" means prospective payment system.

(H) "Per-visit payment amount (PVPA)" is the amount of medicaid payment established for a visit for which payment is made under the PPS method described in rule 5160-28-05 of the Administrative Code.

(I) "PPS payment" is payment that is made under the PPS method described in rule 5160-28-05 of the Administrative Code.

(J) "PPS service" is a service that is rendered during a visit for which PPS payment is made.

(K) "Related off-site location" is a place other than an FQHC or RHC site at which a service is performed, such as a school, a satellite office, a mobile unit, a long-term care facility, an outpatient hospital setting used by an FQHC or RHC for providing services to patients, or a practice location operated by an FQHC- or RHC-contracted practitioner. For reporting purposes, a service rendered at a related off-site location is attributed to the particular FQHC or RHC site whose personnel provided the service.

(L) "Related organization" is an organization that is related to an FQHC or RHC by common ownership or control.

(M) "Rural health clinic (RHC)" is an entity that meets the definition of RHC set forth in 42 U.S.C. 1395x(aa)(2) (October 1, 2021).

(N) "Services and supplies furnished incident to" other services has the same meaning as in chapter 13 of "Centers for Medicare and Medicaid Services (CMS) Publication 100-02, Medicare Benefit Policy Manual" (December 20, 2019), which is available at http://www.cms.gov.

(O) "Site," as used in this chapter of the Administrative Code, is a separate and distinct location operated by an FQHC or RHC at which healthcare services are rendered. An FQHC or RHC may have several sites.

(P) "Visit."

(1) For PPS services other than transportation, a visit is one face-to-face (person-to-person) encounter between a patient and a provider; for medicaid payment purposes, a covered service rendered through telehealth by an FQHC or RHC practitioner is a face-to-face encounter. For transportation services, a visit is a one-way trip provided to or from a site where a covered service is rendered on the same date.

(a) Multiple encounters with one health professional or encounters with multiple health professionals constitute a single visit if all of the following conditions are satisfied:

(i) All encounters take place on the same day;

(ii) All contact involves a single PPS service; and

(iii) The service rendered is for a single purpose, illness, injury, condition, or complaint.

(b) Multiple encounters constitute separate visits if one of the following conditions is satisfied:

(i) The encounters involve different PPS services; or

(ii) The services rendered are for different purposes, illnesses, injuries, conditions, or complaints or for additional diagnosis and treatment.

(2) A visit may take place at an FQHC or RHC site, in a patient's home, at a related off-site location, or (for transportation) between an FQHC or RHC site and a patient's home or a related off-site location.

(3) A visit may be conducted through telehealth if the service is rendered in accordance with rule 5160-1-18 of the Administrative Code.

(4) No service provided to anyone other than a patient may be claimed as a visit with that patient.

(5) The following activities are not visits:

(a) Participation in a meeting or group session at which no health service is provided, such as an orientation session for new patients, a health presentation to a community group, or an informational presentation about a program managed by an FQHC or RHC;

(b) Provision of a health service as part of a community service program such as a mass immunization, a large group screening, or a health fair;

(d) A non-PPS service.

Last updated March 25, 2024 at 9:15 AM

History

Effective: July 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-28-02 FQHC and RHC services: conditions affecting medicaid provider participation.

(A) Unless otherwise noted, any stipulations or limitations specified in the Revised Code or in agency 5160 of the Administrative Code apply to services rendered by a federally qualified health center (FQHC) or rural health clinic (RHC). Provisions of other rules in agency 5160 of the Administrative Code that concern coordination of benefits apply to payment for FQHC and RHC services.

(B) Responsibilities of an FQHC.

(1) When it enrolls or changes its enrollment (e.g., adds a service), an FQHC submits to the Ohio department of medicaid (ODM) a copy of a notice of authorization or notice of look-alike designation it has received from the federal health resources and services administration (HRSA). In particular, two pieces of documentation are needed:

(a) Confirmation that the FQHC satisfies HRSA criteria for providing the PPS services it plans to render (either new services or services added through a change in scope); and

(b) A list of the services approved by HRSA for the FQHC to perform at any of its sites.

(2) Each FQHC site obtains and uses its own medicaid provider number. No FQHC site is allowed to use the provider number of another FQHC site, even if the two share the same parent organization.

(3) The responsibility of an FQHC to pay a health professional for performing a service is described in a written agreement between the FQHC and the health professional.

(4) An FQHC notifies ODM in writing not later than ninety days after any permanent decrease in its scope of service.

(D) No provider can be simultaneously enrolled in medicaid as both an FQHC and an RHC.

Last updated March 25, 2024 at 9:15 AM

History

Effective: July 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-28-03 FQHC and RHC services: covered services, limitations, and copayments.

(A) A federally qualified health center (FQHC) may receive prospective payment system (PPS) payment for providing any of the following FQHC PPS services:

(1) In accordance with section 330 of the Public Health Services Act, 42 U.S.C. chapter 6A (October 1, 2021), medical services, which comprise any of four types of services:

(a) Services referenced at 42 U.S.C. 1395x(aa)(3) (October 1, 2021), including but not limited to an evaluation and management (E&M) service, another medical or surgical procedure, or the administration of a vaccine or other provider-administered pharmaceutical;

(b) Professional services (including the administration of a vaccine) furnished by a qualified healthcare practitioner (physician, physician assistant, advanced practice registered nurse, dietitian, pharmacist, registered nurse working under supervision), along with any services or supplies furnished incident to the professional services on the same date;

(c) Professional services and related supplies provided at a later date as necessary follow-up to a medical services visit, even if the same services and supplies were also provided as part of (or incident to) the original medical services visit; or

(d) Visiting nurse services if the following three conditions are satisfied:

(i) The services are furnished by either a registered nurse or a licensed practical nurse employed by or under contract with the FQHC;

(ii) The FQHC is located in an area determined by the centers for medicare and medicaid services (CMS) to have a shortage of home health agencies; and

(iii) The services are furnished under a written plan of treatment that is established by a physician, physician assistant, or advanced practice registered nurse or by a supervising physician of the FQHC; is signed by a physician, physician assistant, or advanced practice registered nurse or by a supervising physician of the FQHC; and is reviewed at least every sixty days by a supervising physician of the FQHC.

(2) Dental services, which are identified in Chapter 5160-5 of the Administrative Code and to which the following conditions apply:

(a) An FQHC reports every dental procedure or service, in the appropriate claim format, as a PPS service; and

(b) For each set of dentures, an FQHC may submit one claim for providing the service and not more than two additional claims for follow-up visits;

(3) Physical therapy services or occupational therapy services, which are identified in Chapter 5160-8 of the Administrative Code;

(4) Behavioral health services identified in rule 5160-8-05 of the Administrative Code;

(5) Speech pathology and audiology services, which are identified in Chapter 5160-8 of the Administrative Code;

(6) Podiatry services, which are identified in Chapter 5160-7 of the Administrative Code;

(7) Vision services, which are identified in Chapter 5160-6 of the Administrative Code, that are rendered by a non-physician;

(8) Chiropractic services, which are identified in Chapter 5160-8 of the Administrative Code; or

(9) Transportation services that enable an individual to make up to four trips to or from an FQHC site (or related location) where a covered service is rendered on the same date.

(B) A rural health clinic (RHC) may receive PPS payment for providing any of the following RHC PPS services:

(1) Medical services, which comprise any of three types of services:

(a) All services referenced at 42 U.S.C. 1395x(aa)(1) (October 1, 2021), including but not limited to an evaluation and management (E&M) service, another medical or surgical procedure, or the administration of a vaccine or other provider-administered pharmaceutical;

(b) Professional services (including the administration of a vaccine) furnished by a qualified healthcare practitioner (e.g., physician, physician assistant, advanced practice registered nurse, dietitian, pharmacist, registered nurse working under supervision), along with any services or supplies furnished incident to the professional services on the same date;

(2) Behavioral health services identified in rule 5160-8-05 of the Administrative Code; or

(3) Transportation services that enable an individual to make up to four trips to or from an RHC (or related location) where a covered service is rendered on the same date.

(C) An FQHC or RHC may structure its enrollment in medicaid such that it can submit a claim and receive separate payment for a covered service or supply that cannot be claimed as a PPS service under paragraphs (A) and (B) of this rule.

(1) No PPS service may be claimed as a non-PPS service. Payment for a covered non-PPS service is made in accordance with the rule or chapter of the Administrative Code that applies to the service.

(2) The following non-exhaustive list specifies covered medically necessary services and supplies that may be claimed as non-PPS services:

(a) Group therapy;

(b) Remote patient monitoring;

(d) Inpatient hospital services;

(e) Take-home medications;

(f) Hemophilia clotting factor drugs;

(g) Long-acting reversible contraception (LARC);

(h) Durable medical equipment for take-home use;

(i) The technical component of a procedure comprising both a professional and a technical component, such as radiography or other imaging;

(j) Clinical diagnostic laboratory services other than the following procedures:

(i) Venipuncture;

(ii) Chemical examination of urine by stick or tablet method or both;

(iii) Hematocrit or hemoglobin analysis;

(iv) Blood sugar analysis;

(v) Examination of stool specimens for occult blood;

(vi) Pregnancy tests; and

(vii) Primary culturing for transmittal to a certified laboratory;

(k) Eyeglass lenses and frames;

(l) Topical fluoride varnish furnished by a non-dental practitioner in accordance with rule 5160-4-33 of the Administrative Code;

(m) A vaccine administered as part of a mass immunization;

(n) A report of a pregnancy that is diagnosed in conjunction with a PPS service, described in rule 5160-21-04 of the Administrative Code;

(o) A pregnancy risk assessment, described in rule 5160-21-04 of the Administrative Code; and

(p) Behavioral health services and substance use disorder services identified in Chapter 5160-27 of the Administrative Code that meet the following criteria:

(i) They cannot be claimed as PPS services; and

(ii) They are rendered by certified behavioral health practitioners in accordance with Chapter 5160-27 of the Administrative Code and federal and state law.

(3) The provision of a covered non-PPS service on the same date as a covered PPS service does not preclude payment for either service.

(D) Copayments established in accordance with rule 5160-1-09 of the Administrative Code may apply to services rendered by an FQHC or RHC. Copayments for services rendered to MCE members are applied in accordance with applicable medicaid rules in the Administrative Code concerning MCEs.

Last updated March 25, 2024 at 9:16 AM

History

Effective: July 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-28-04 FQHC and RHC services: submission of a cost report.

(A) Data entered into a cost report should represent "reasonable and allowable costs," which are defined in "Principles of reasonable cost reimbursement," 42 C.F.R. part 413 (October 1, 2021).

(B) For purposes of payment determination, an FQHC or RHC submits a cost report in any of the following circumstances:

(1) An FQHC or RHC that is newly enrolled as a medicaid provider submits a cost report covering the twelve-month period beginning either on the first day of the first calendar month or on the first day of the first full fiscal year after enrollment.

(2) An FQHC or RHC that requests an adjustment of a per-visit payment amount (PVPA) based on a change in scope of an existing FQHC or RHC PPS service submits a cost report for that service covering the twelve-month period beginning either on the first day of the first calendar month or on the first day of the first full fiscal year after the change in scope. If the adjustment is granted, the PVPA derived from the cost report becomes the new PVPA.

(3) An FQHC or RHC that has chosen to provide an additional PPS service (other than transportation) submits a cost report for that service covering the twelve-month period beginning either on the first day of the first calendar month or on the first day of the first full fiscal year after addition of the service.

(4) A government-operated FQHC that requests the alternate payment method (APM) described in rule 5160-28-07.1 of the Administrative Code submits cost reports in accordance with that rule.

(C) The Ohio department of medicaid (ODM) or its designee may perform a desk review or conduct a field audit of any cost report submitted and may request any supporting documentation it deems necessary.

(D) No extension will be granted for submission of cost reports. If an FQHC or RHC fails to submit a complete and accurate cost report within one hundred twenty days after the end of a reporting period, ODM may choose to take either or both of two courses of action:

(1) It may decline to make any adjustments to the established PVPA or PVPAs.

(2) It may impose a penalty of not more than five hundred dollars for each business day on which the cost report is late.

(E) An FQHC or RHC may request adjustment of a PVPA.

(1) In its request, it addresses in writing the following topics:

(a) It specifies the basis for the request, such as a change in scope of an existing service or the addition of a new service.

(b) It specifies which cost centers have been affected and why.

(c) It describes the steps it took to arrive at the conclusion that an adjustment would be the most efficient means of responding to cost changes.

(d) It provides documentation to support its request, such as a community needs assessment or other analysis.

(e) If the change in scope is directly attributable to a change in the intensity of services provided, then the FQHC or RHC provides evidence such as a change in the acuity of care caused by a shift in the distribution of diagnoses or a change in the relative-value components of the services provided.

(f) An FQHC that is adding a PPS service submits to ODM a copy of the notice of grant award authorization from the federal health resources and services administration (HRSA) confirming that its sites satisfy HRSA criteria for providing the new PPS service it plans to render.

(2) ODM has sole discretion over whether to grant a request for adjustment of a PVPA.

(F) ODM will respond in writing within sixty days after it receives a request for an adjustment of a PVPA based on a change in scope or after it receives additional information needed to determine whether an adjustment is warranted.

(G) The following conditions apply to any adjustment of a PVPA based on a change in scope:

(1) Such an adjustment can be granted only once for a particular circumstance for a particular FQHC or RHC service site.

(2) No adjustment will be made if the percentage of change represented by the calculated PVPA for the service is not at least twice the medicare economic index (MEI) for the relevant year.

(3) No adjusted PVPA may exceed any limit, ceiling, or other maximum set forth in agency 5160 of the Administrative Code.

Last updated March 25, 2024 at 9:16 AM

History

Effective: July 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-28-05 FQHC and RHC services: prospective payment system (PPS) method for determining payment.

(A) A discrete, all-inclusive per-visit payment amount (PVPA) is established for each FQHC PPS service provided at an FQHC or related off-site location and for an RHC PPS service provided at an RHC or related off-site location.

(1) For all FQHC or RHC sites that are already enrolled as medicaid providers, the Ohio department of medicaid (ODM) establishes new PVPAs equal to the current PVPAs revised to reflect the latest available medicare economic index (MEI) percentage. The new PVPAs are established by October first of each year and are in effect from October first through the following September thirtieth.

(2) On the effective date of this rule, the following amounts ("FQHC PVPA add-on amounts") are added to the PVPA for the respective FQHC PPS service:

(a) Medical, fifteen dollars and eighty cents;

(b) Dental, sixteen dollars and fifty cents;

(d) Physical therapy or occupational therapy, nine dollars and seventy cents;

(e) Speech pathology and audiology, fifteen dollars and twenty cents;

(f) Podiatry, six dollars and sixty cents;

(g) Vision, ten dollars and fifty cents;

(h) Chiropractic, nine dollars and twenty cents; and

(i) Transportation, two dollars and fifty cents.

(3) Beginning July 1, 2025, the FQHC PVPA add-on amounts described in paragraph (A)(2) of this rule are reduced to the following amounts:

(a) Medical, ten dollars and fifty cents;

(b) Dental, eleven dollars;

(d) Physical therapy or occupational therapy, six dollars and forty cents;

(e) Speech pathology and audiology, ten dollars and twenty cents;

(f) Podiatry, four dollars and forty cents;

(g) Vision, seven dollars;

(h) Chiropractic, six dollars and twenty cents; and

(i) Transportation, one dollar and seventy cents.

(4) When an enrolled FQHC or RHC site requests adjustment of a PVPA, ODM may establish a new PVPA based on a cost report in accordance with rule 5160-28-04 of the Administrative Code.

(5) For an FQHC or RHC site that is enrolling as a new medicaid provider or an FQHC site that is adding a new FQHC PPS service, ODM establishes an initial PVPA in accordance with the following procedure:

(a) First, the initial PVPA is set equal to the corresponding PVPA of other FQHC or RHC sites in the immediate area that are similar in size, caseload, and scope of services. If no such FQHC or RHC site exists, then the initial PVPA is set equal to the current PVPA at the applicable statewide sixtieth percentile for the appropriate FQHC or RHC classification.

(b) This initial PVPA remains in effect until a new PVPA is established.

(c) After the initial PVPA is set, the FQHC or RHC site submits a cost report in accordance with rule 5160-28-04 of the Administrative Code. A new PVPA is established based on the cost report and is revised to reflect any changes in the MEI that have occurred since the cost report was submitted.

(d) Thereafter, the PVPA is revised in accordance with paragraph (A)(1) of this rule.

(6) For an FQHC PPS service only, if no current PVPA at the applicable statewide sixtieth percentile is available, then the initial PVPA, P, is obtained by the formula P = M (S / E), rounded up to the next whole dollar.

(a) "M" is the greater of two figures:

(i) The current PVPA for medical services at the applicable statewide sixtieth percentile for FQHC sites; or

(ii) The current PVPA for medical services at the particular FQHC site.

(b) "S" is the medicaid maximum payment amount (or the median of the medicaid maximum payment amounts) for a procedure (or a group of procedures) typical of the service for which a PVPA is being established.

(c) "E" is the medicaid maximum non-facility payment amount for a mid-level evaluation and management service (office visit) for an established patient.

(B) A PVPA based on a cost report is effective from the first day of the first full calendar month after ODM has established or adjusted the PVPA through the following September thirtieth. A PVPA that is established or adjusted before September thirtieth and becomes effective on or after October first is then further revised to reflect the applicable MEI. No retroactive establishment or adjustment will be made for a PVPA.

(C) A PVPA is specific to an FQHC or RHC site. No FQHC or RHC site may submit claims based on the PVPAs of another FQHC or RHC site.

(D) Decisions of ODM with respect to the establishment or adjustment of a PVPA are not subject to Chapter 119. of the Revised Code.

Last updated July 2, 2024 at 10:46 AM

History

Effective: July 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-28-06.1 FQHC and RHC services: limits on a per-visit payment amount (PVPA) determined on the basis of a cost report for an FQHC PPS service.

(A) Allowable costs are calculated in accordance with the instructions for the FQHC cost report. Certain restrictions apply:

(1) Costs related to direct inpatient care are not allowable.

(2) Procedures or items that are not PPS services are not allowable.

(3) The straight-line method of computing depreciation is used for all depreciable assets.

(4) The cost claimed for services, facilities, and supplies furnished by a related organization cannot exceed the lesser of two figures:

(a) The cost to the related organization; or

(b) The price of comparable services, facilities, or supplies that are generally available in the competitive marketplace.

(5) Total allowable administrative and general overhead costs cannot exceed thirty-five per cent of the costs of the services to which they are applied. Of these costs, not more than thirty thousand dollars are allowable annually as recruitment cost incurred by a provider of FQHC medical service.

(B) Limits are established by applying tests of reasonableness to the allowable costs.

(1) For each PPS service except transportation, a limit is established by dividing the allowable cost by the greater of two figures:

(a) The total number of visits; or

(b) The product of the actual number of direct hours worked by the professional and the applicable number of visits per hour from the following list:

(i) Physician services, per physician 2.4;

(ii) Physician assistant or advanced practice registered nurse services, per practitioner 1.2;

(iii) Dental services 1.8;

(iv) Physical therapy services 2.0;

(v) Behavioral health services or substance use disorder services 0.7;

(vi) Speech pathology and audiology services 1.8;

(vii) Podiatry services 2.4;

(viii) Vision services 1.9;

(ix) Chiropractor services 2.4. and

(x) Occupational therapy services 2.0;

(2) For transportation, a limit is established of thirty-five dollars per unit of service.

(C) Except for transportation services, ceilings are established at one hundred twenty per cent of the statewide sixtieth percentile PVPA for the respective PPS service.

(D) The final PVPA for an FQHC PPS service, except transportation services, is the least of the allowable cost, the limit, or the ceiling. For transportation services, the final PVPA is the initial PVPA established in accordance with rule 5160-28-05 of the Administrative Code.

Last updated July 2, 2024 at 10:47 AM

History

Effective: July 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-28-07.1 FQHC and RHC services: alternate payment method (APM) for determining payment for government-operated FQHCs.

(A) This rule describes an APM that may be selected, with approval from the Ohio department of medicaid (ODM), by a government-operated FQHC such as a public health department. Under this APM, a government-operated FQHC may receive payment in addition to amounts established under the prospective payment system (PPS) method described in rule 5160-28-05 of the Administrative Code. To qualify for additional payment under this APM, a government-operated FQHC site submits a fully audited cost report for each cost-reporting period. The government-operated FQHC may also submit an optional preliminary cost report for a cost-reporting period. For purposes of this rule, a cost-reporting period is the fiscal year used by the government-operated FQHC. For a government-operated FQHC that has newly selected the APM, ODM may agree to an initial cost-reporting period covering not less than six months nor more than seventeen months.

(B) The APM involves the following steps:

(1) Submission of at least one cost report each cost-reporting period.

(a) Within one hundred twenty days after the close of a cost-reporting period, the government-operated FQHC site may submit an optional preliminary cost report of all PPS services rendered during that cost-reporting period.

(b) Within five-hundred days after the close of a cost-reporting period, the government-operated FQHC site submits a fully audited cost report. Government-operated FQHC sites of the same parent organization compile and submit separate cost reports. When it submits a cost report, a government-operated FQHC site certifies that its costs were an expenditure of public funds not derived from a federal funding source and not otherwise used as a state or local match for federal funds.

(2) Calculation of an APM payment. After it receives a cost report and certification, ODM performs a desk review of the cost report and determines the amount for which the government-operated FQHC site is eligible to receive payment, in the form of federal matching funds, in addition to amounts established under the PPS. The cost report is not used in any way to alter amounts established under the PPS.

(a) No additional limitation, test of reasonableness, or ceiling described in rule 5160 28-06.1 of the Administrative Code is applied to the cost report. The resulting figures represent the total actual allowable costs during the cost-reporting period.

(b) From these figures, the "average cost per visit" for each PPS service offered at the site is obtained by dividing the total actual allowable costs for the service by the total number of visits.

(c) For each PPS service, the "total allowable medicaid cost" for the cost-reporting period is the product of the average cost per visit and the number of visits made by medicaid-eligible individuals.

(d) The "total medicaid payment" for a PPS service during the cost-reporting period is the sum of the per-visit payment amounts (PVPAs) paid to an FQHC site under the PPS, payments made by MCEs, and medicaid wraparound payments.

(e) The "total medicaid variance" for a PPS service is the difference obtained by subtracting the total medicaid payment from the total allowable medicaid cost. The "aggregate add-on" is the sum of the products of the FQHC PVPA add-on amount for each PPS service and the number of visits for each PPS service. The "matchable expenditure" is the sum of the total medicaid variance and the aggregate add-on. ODM calculates the federal share of the matchable expenditure by applying the appropriate federal match percentage and then remits this amount to the government-operated FQHC site.

(f) Payment is expected to be made within ninety days after submission of a cost report. If the total expenditure derived from the fully audited cost report differs from the total expenditure derived from the optional preliminary cost report, then the difference in the federal share is remitted to the FQHC or to ODM, as appropriate. Amounts owed to ODM are paid within ninety days.

(C) For payment purposes, the federal share amounts for the various PPS services offered at an FQHC site may be aggregated.

Last updated July 2, 2024 at 10:47 AM

History

Effective: July 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-28-12 Establishment of a per-visit payment amount (PVPA) derived from a cost report submitted by a federally qualified health center (FQHC) or rural health clinic (RHC) site affected by a public health emergency (PHE) declaration.

(A) The purpose of this rule is to allow a change to the time period of a cost report from which per-visit payment amounts (PVPAs) are derived. This rule applies to cost report time periods affected by a nationwide federal or Ohio public health emergency (PHE) declaration.

(B) This rule applies to a cost report prepared by an individual federally qualified health center (FQHC) or rural health clinic (RHC) site in accordance with this chapter of the Administrative Code for one of the following reasons:

(1) The FQHC or RHC is newly enrolled as a medicaid provider; or

(2) The FQHC or RHC plans to request the establishment or adjustment of a PVPA based on a change in scope of a prospective payment system (PPS) service.

(1) The length of the period is set at not less than eight consecutive months nor more than twelve consecutive months; or

(2) An alternate beginning date of the period is set by the Ohio department of medicaid in collaboration with the FQHC or RHC site.

Last updated May 11, 2026 at 10:22 AM

History

Effective: December 27, 2021
Promulgated Under: 119.03

Chapter 5160-31 Medicaid Home and Community Based Services Waiver Portion of the PASSPORT Program

Ohio Adm.Code 5160-31-02 Pre-admission screening system providing options and resources today (PASSPORT) HCBS waiver program definitions.

(A) The purpose of this rule is to define the terms used in Chapter 5160-31 of the Administrative Code governing the preadmission screening system providing options and resources today (PASSPORT) home and community-based services (HCBS) waiver program.

(B) "Assessment" means an evaluation used to obtain information about an individual including their condition, personal goals and preferences, functional limitations, health status, and other factors that are relevant to the authorization and provision of services. Information obtained from the assessment supports the determination of program eligibility and the development of the person-centered services plan.

(D) "Case manager" means as defined in rule 173-39-01 of the Administrative Code.

(E) "Centers for medicare and medicaid services (CMS)" means the federal agency that is part of the United States department of health and human services, and that administers the medicaid program and approves HCBS waivers.

(F) "Financial management service (FMS)" means a support provided to waiver participants who direct some or all of their waiver services. In the PASSPORT waiver, this support is conducted as an administrative activity through an entity under contract with the state of Ohio. When used in conjunction with the participant-directed authorities available to individuals enrolled in PASSPORT, this support includes operating a payroll service for participant-employed workers and making required payroll withholdings.

(G) "Home and community-based services (HCBS)" means services furnished under the provisions set forth in 42 C.F.R. 441 Subpart G (October 1, 2024) that permit individuals to live in a home setting rather than in a facility. HCBS waiver services are approved by CMS for specific populations and are not otherwise available under the medicaid state plan.

(H) "Home first" means the component of the PASSPORT HCBS waiver program that offers priority enrollment in the waiver for certain individuals in accordance with section 173.521 of the Revised Code.

(I) "Individual" means a person applying for or receiving medical assistance or home and community-based services.

(J) "Level of care (LOC)" means the designation describing an individual's person's functional levels and nursing needs pursuant to the criteria defined in rule 5160-3-05 of the Administrative Code.

(K) "Nursing Facility (NF)" means as defined in section 5165.01 of the Revised Code.

(L) "ODA's designee" means as defined in rule 173-39-01 of the Administrative Code.

(M) "ODM's administrative agency" has the same meaning as "administrative agency" as defined in rule 5160:1-1-01 of the Administrative Code.

(N) "PASSPORT" or "PASSPORT HCBS waiver program" means the medicaid-funded component of the PASSPORT program created under section 173.52 of the Revised Code and approved by the centers for medicare and medicaid services.

(O) "Person-centered services plan" means as defined in rule 5160-44-02 of the Administrative Code.

(P) "Provider" means an agency or a person with a signed medicaid provider agreement with ODM and certified by ODA.

Last updated September 22, 2025 at 7:44 AM

History

Effective: September 22, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-31-03 PASSPORT HCBS waiver program: eligibility and enrollment.

(A) The "Ohio department of aging (ODA)" is the agency responsible for daily operations for the pre-admission screening system providing options and resources today (PASSPORT) home and community-based services (HCBS) waiver. ODA will operate this waiver pursuant to an interagency agreement with the Ohio department of medicaid (ODM) in accordance with sections 5162.35 and 173.52 of the Revised Code. ODA will establish processes and procedures to enroll individuals on the waiver that is in accordance with rule 173-42-03 of the Administrative Code.

(B) An individual is eligible for the medicaid-funded component of the PASSPORT program only if the individual meets all of the following criteria:

(1) The individual is determined eligible for medicaid in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code.

(2) The needed services are not readily available through another source at the level required to allow the individual to live in the community.

(3) The individual agrees to participate in PASSPORT and not be simultaneously enrolled in the state-funded component of the PASSPORT program, the state-funded component of the assisted living program, another medicaid home and community-based program, the residential state supplement (RSS) program, or the program of all inclusive care for the elderly (PACE) while enrolled in PASSPORT.

(4) The individual's health related needs can be safely met in a home and community-based setting as determined by ODA or its designee.

(5) The individual agrees to participate in the development of a person-centered services plan in accordance with the process and requirements set forth in rule 5160-44-02 of the Administrative Code.

(6) The individual:

(a) Has a need for and agrees to receive at least one waiver service monthly that is otherwise unavailable through another source (including, but not limited to, private pay, community resources and the medicaid state plan) in an amount sufficient to meet the individual's assessed needs; or

(b) Has a need for:

(i) Continuous nursing services for more than four hours in length,

(ii) At least one waiver service annually, and

(iii) Monthly monitoring of the individual's health and welfare through a combination of telephonic and in-person contacts with the case manager and agrees to cooperate with the monthly monitoring.

(7) The individual resides in a setting that possesses the home and community-based setting characteristics set forth in rule 5160-44-01 of the Administrative Code and that is not a hospital, nursing facility (NF), intermediate care facility for individuals with an intellectual disability (ICF-IID), or another licensed or certified facility, any facility covered by section 1616(e) of the Social Security Act (42 U.S.C. 1382(e) (January 1, 2025) residential care facility or another group living arrangement subject to state licensure or certification.

(8) The individual is age sixty years or older at the time of enrollment.

(9) The individual is determined to meet the criteria for an intermediate or skilled level of care in accordance with rule 5160-3-08 of the Administrative Code and, in the absence of PASSPORT, requires NF services as defined in 42 C.F.R. 440.40 (as in effect on October 1, 2024).

(1) The individual is determined eligible for PASSPORT in accordance with paragraph (B) of this rule.

(2) The services in the person-centered services plan are approved by one of the medical practitioners in paragraphs (C)(2)(a) to (C)(2)(c) of this rule, acting within their scope of practice. Approval may be verbal or written and is to be obtained prior to initial enrollment. Written approval may be satisfied via electronic signature.

(a) A licensed physician;

(b) A licensed certified nurse practitioner;

(3) The individual cost limit does not exceed fourteen thousand and seven hundred dollars per month for waiver services.

(a) At the time of enrollment, the initial cost of waiver services in the person-centered services plan does not exceed the cost limit.

(b) The ongoing cost of waiver services in the person-centered services plan may not exceed the cost limit unless otherwise approved by ODA.

(4) There is an available PASSPORT slot that does not exceed the CMS-authorized limit for individuals enrolled for the waiver program year.

(D) If, at any time, the individual does not meet the criteria in paragraph (B) or paragraph (C) of this rule, the individual will be denied enrollment or disenrolled from PASSPORT. In such instances, the individual is notified of their hearing rights in accordance with division 5101:6 of the Administrative Code.

Last updated September 22, 2025 at 7:44 AM

History

Effective: September 22, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-31-05 PASSPORT HCBS waiver program covered services.

(A) The purpose of this rule is to establish the services covered by the pre-admission screening system providing options and resources today (PASSPORT) home and community based services (HCBS) program.

(B) The PASSPORT program benefit package is limited to the following services:

(1) Adult day as set forth in rule 173-39-02.1 of the Administrative Code;

(2) Alternative meals as set forth in rule 173-39-02.2 of the Administrative Code;

(3) Choices home care attendant as set forth in rule 173-39-02.4 of the Administrative Code;

(4) Community integration as set forth in rule 173-39-02.15 of the Administrative Code;

(5) Community transition as set forth in rule 173-39-02.17 of the Administrative Code;

(6) Enhanced community living as set forth in rule 173-39-02.20 of the Administrative Code;

(7) Homemaker as set forth in rule 173-39-02.8 of the Administrative Code;

(8) Home care attendant as set forth in rule 173-39-02.24 of the Administrative Code;

(9) Home delivered meals as set forth in rule 173-39-02.14 of the Administrative Code;

(10) Home maintenance and chore as set forth in rule 173-39-02.5 of the Administrative Code;

(11) Home medical equipment and supplies as set forth in rule 173-39-02.7 of the Administrative Code;

(12) Home modification as set forth in rule 173-39-02.9 of the Administrative Code;

(13) Non-medical transportation as set forth in rule 173-39-02.18 of the Administrative Code;

(14) Nutrition consultation as set forth in rule 173-39-02.10 of the Administrative Code;

(15) Out-of-home respite as set forth in rule 173-39-02.23 of the Administrative Code;

(16) Personal care as set forth in rule 173-39-02.11 of the Administrative Code;

(17) Personal emergency response system as set forth in rule 173-39-02.6 of the Administrative Code;

(18) Social work or counseling as set forth in rule 173-39-02.12 of the Administrative Code;

(19) Structured family caregiving as set forth in rule 173-39-02.25 of the Administrative Code;

(20) Vehicle modifications as set forth in rule 173-39-02.26 of the Administrative Code; and

(21) Waiver nursing as set forth in rule 173-39-02.22 of the Administrative Code.

(C) Services will be delivered by providers who meet the requirements in Chapter 173-39 of the Administrative Code in a manner that is consistent with the individual's person-centered services plan as documented in the PASSPORT information management system (PIMS).

(D) In accordance with the federally approved PASSPORT waiver, the services identified in this paragraph are subject to employer and/or budget authority if elected by the individual. Services will be provided in accordance with the requirements in paragraph (B) of this rule:

(1) The following services are subject to employer authority, including the ability to hire, fire, and train employees:

(a) Choices home care attendant; and

(b) Personal care.

(2) The following services are subject to budget authority, including the ability to negotiate reimbursement rates paid to providers furnishing services:

(a) Alternative meals;

(b) Choices home care attendant;

(d) Home maintenance and chore; and

(e) Home modification.

(E) An individual who elects to direct any of the services provided in paragraph (D) of this rule will be assessed by their case manager to determine the individual's ability to direct their services as set forth in rule 173-42-06 of the Administrative Code.

(1) If an individual demonstrates the ability to direct their services, the case manager may initiate the orientation process to familiarize the individual with the participant direction of services including the role of the financial management service (FMS).

(2) If an individual is unable to demonstrate the ability to direct his or her care and to assume the responsibilities associated with the participant direction authorities in paragraph (D) of this rule, the individual may choose an authorized representative to act on his or her behalf.

(3) If no authorized representative is available, the case manager will assist the individual with obtaining services through Ohio department of aging-certified long-term care agency providers.

(F) If an individual who is seeking to direct his or her services chooses an authorized representative to act on his or her behalf in accordance with paragraph (E)(2) of this rule, the authorized representative will not serve as the individual's provider.

Last updated April 17, 2026 at 8:04 AM

History

Effective: April 17, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-31-07 PASSPORT HCBS waiver program rate setting.

The purpose of this rule is to describe the methods used to determine provider rates for the pre-admission screening system providing options and resources today (PASSPORT) program.

(A) Rates determined under this rule will not exceed the maximum allowable rates for PASSPORT services in appendix A to rule 5160-1-06.1 of the Administrative Code. Payment for PASSPORT waiver services constitutes payment in full and will not be construed as a partial payment when the payment amount is less than the provider's usual and customary rate. In accordance with rule 5160-1-13.1 of the Administrative Code, the provider will not bill the individual for any difference between the medicaid payment and the provider's rate or request the individual to share in the cost through a co-payment or other similar charge.

(B) PASSPORT rates are established for the services in rule 5160-31-05 of the Administrative Code under the following categories:

(1) Per-job bid rate;

(2) Per-item rate; and

(3) Unit rate.

(1) Participant-directed, in which the individual or a designated authorized representative, who is acting on the individual's behalf, may negotiate the rate for services furnished by providers as specified in paragraphs (D)(3), (E)(3), and (G)(1) of this rule.

(2) Statewide, in which the state establishes a rate used on a statewide basis to pay for services specified in paragraph (F)(1) of this rule.

(3) Group rates which are seventy-five per cent of the rate the provider would be paid for providing PASSPORT services as specified in paragraphs (D)(2), (F)(2), and (F)(3) of this rule.

(D) For the services listed in this paragraph, the provider and the Ohio department of aging or its designee negotiate a per-job rate.

(1) A per-job bid rate applies to the following services:

(a) Community transition;

(b) Home maintenance and chores;

(d) Non-medical transportation.

(2) Non-medical transportation rendered simultaneously by the same provider to more than one individual enrolled in the PASSPORT program, who reside in the same home and who travel in the same vehicle to the same destination is paid at a group rate of seventy-five per cent of the provider's per-job bid rate.

(3) Home modification and home maintenance and chores may be participant-directed services in which the individual enrolled in the PASSPORT program, or their authorized representative, acting on the individual's behalf, may negotiate rates.

(a) The negotiated rate is reviewed by Ohio department of aging's (ODA) designee and reflected on the individual's person-centered service plan prior to service delivery.

(b) Should the individual choose not to negotiate a rate the service may be paid at a rate proposed by the provider and accepted by the individual and ODA's designee. The accepted rate is reflected on the individual's person-centered service plan.

(E) A per-item rate applies to home medical equipment and supplies.

(1) No per-item rate may exceed the medicaid state plan rate.

(2) A home medical equipment and supplies item that does not have an established medicaid rate may be paid at a per-item bid rate from the provider which has been agreed to in writing by ODA's designee prior to delivery of the item.

(3) Home medical equipment and supplies may be participant-directed in which the individual enrolled on PASSPORT or the authorized representative acting on the individual's behalf, may negotiate rates.

(a) The negotiated rate is reviewed by ODA's designee and reflected on the individual's person-centered services plan prior to service delivery.

(b) Should the individual choose not to negotiate a rate, the service may be paid at a rate agreed upon between the provider, the individual, and ODA's designee. The agreed upon rate is reflected on the individual's person-centered services plan.

(F) ODA will establish unit rates for the services listed in this paragraph.

(1) Statewide unit rates are established and used for the following services:

(a) Adult day;

(b) Adult day transportation;

(d) Enhanced community living;

(e) Home care attendant;

(f) Home delivered meals;

(g) Homemaker;

(h) Nutritional consultation;

(i) Out-of-home respite;

(j) Personal care;

(k) Personal emergency response system;

(l) Social work or counseling;

(m) Structured family caregiving; and

(n) Waiver nursing.

(2) The services in paragraphs (F)(1)(e), (F)(1)(j), and (F)(1)(m) of this rule, when rendered consecutively during the same visit to more than one but fewer than four PASSPORT individuals in the same household, and identified in the individuals' person-centered service plans, are paid to one hundred per cent of the provider's per unit rate set in accordance with paragraph (C) of this rule for one PASSPORT individual and paid a group rate for each subsequent PASSPORT individual in the household receiving services during the visit.

(3) Adult day transportation rendered simultaneously by the same provider to more than one individual residing in the same household and traveling in the same vehicle to the same destination is paid using a group rate equal to seventy-five per cent of the provider's rate.

(G) The services in this paragraph are participant directed and the individual may negotiate unit rates with providers.

(1) The participant directed services include:

(a) Alternative meals; and

(b) Choices home care attendant.

(2) The individual will have in effect, before choices home care attendant services are delivered, a signed provider agreement with each ODA-certified participant-directed individual provider delivering services to the individual. The provider agreement will:

(a) Include the rate negotiated with the provider;

(b) Specify the time period the rates are in effect;

(d) Be signed by the individual receiving the choices home care attendant service and the home and community based services (HCBS) provider.

(3) The rates negotiated by the individual with providers of services in paragraph (G)(1) of this rule will not exceed the maximum allowed per unit of service as specified in appendix A to rule 5160-1-06.1 of the Administrative Code. The negotiated rate is reviewed by ODA's designee, and reflected on the individual's person-centered service plan prior to service delivery.

(4) Should the individual choose not to negotiate a rate for any of the services in paragraph (G)(1) of this rule, the service may be paid at a rate agreed upon by the provider, the individual and the individual's case manager. The agreed upon rate is reflected on the individual's person-centered services plan.

(H) The Ohio department of medicaid, or its designee,will evaluate unit rates within two years of the effective date of this rule and every two years thereafter.

Last updated October 1, 2024 at 9:07 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Chapter 5160-32 Electronic Visit Verification

Ohio Adm.Code 5160-32-01 Electronic visit verification (EVV) program.

(A) This rule establishes Ohio medicaid programs and program services subject to participation in the EVV program, required under Section 1903 of the Social Security Act (42 U.S.C. 1396b) as in effect on the effective date of this rule.

(B) For purposes of this chapter, EVV is the use of technology to verify certain data elements related to the delivery of medicaid-covered services.

(C) Ohio medicaid services subject to the EVV program include any medicaid state plan or 1915 (c) home and community-based services (HCBS) waiver program meeting the following criteria:

(1) Service definition includes one of the following:

(a) Assistance with activities of daily living, as described in rule 5160-3-05 of the Administrative Code; or

(b) Includes activities provided by a licensed healthcare professional; and

(2) The service is provided in the home or community of the individual; and

(3) The service is measured and paid in units of hours, partial hours, or per assessment.

(D) The following are subject to the EVV program:

(1) Nursing facility-based level of care HCBS waiver programs:

(a) Programs:

(i) Ohio home care waiver, described in Chapter 5160-46 of the Administrative Code;

(ii) MyCare Ohio waiver, described in Chapter 5160-58 of the Administrative Code; and

(iii) Preadmission screening system providing options and resources today (PASSPORT) waiver, described in Chapter 5160-31 of the Administrative Code.

(b) Services:

(i) Choices home care attendant;

(ii) Enhanced community living;

(iii) Home care attendant;

(iv) Personal care aide; and

(v) Waiver nursing service.

(2) Developmental disabilities level of care-based waiver programs:

(a) Programs

(i) Individual options (IO) waiver, described in Chapter 5160-40 of the Administrative Code;

(ii) Level 1 waiver, described in Chapter 5160-41 of the Administrative Code; and

(iii) Self-empowered life funding (SELF) waiver, described in Chapter 5160-41 of the Administrative Code.

(b) Services

(i) Homemaker/personal care;

(ii) Participant-directed homemaker/personal care;

(iii) Residential respite, when billed in fifteen-minute units;

(iv) Waiver nursing delegation; and

(v) Waiver nursing service.

(3) State plan program services, described in Chapter 5160-12 of the Administrative Code.

(a) Home health services:

(i) Home health aide;

(ii) Home health nursing; and

(iii) Home health therapies.

(b) Private duty nursing;

(d) Registered nurse consultation.

(E) Exemptions

(1) Services provided using telehealth as the direct delivery method in accordance with rule 5160-1-18 of the Administrative Code are exempt from this rule.

(2) Live-in caregiver exemption: visits in which the direct care service worker is a resident of the same household as the individual receiving services are exempt from this rule when the EVV system reflects approval from ODM has been granted. To obtain approval, the service provider will submit the request using the exemption process found on ODM's website https://medicaid.ohio.gov/INITIATIVES/Electronic-Visit-Verification/.

(F) The Ohio department of aging, Ohio department of developmental disabilities, Ohio department of medicaid (ODM), and managed care entities are responsible to:

(1) Establish and maintain processes to ensure proper payment of claims paid by each entity, in accordance with EVV guidelines; and

(2) Provide assistance and education to service providers and program participants.

(G) Service providers billing for programs and services subject to the EVV program will comply with provisions of Chapter 5160-32 of the Administrative Code.

Last updated July 3, 2024 at 1:06 PM

History

Effective: July 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-32-02 Electronic visit verification (EVV) data collection.

(A) The Ohio department of medicaid (ODM) EVV system collects and maintains data for medicaid programs and services subject to participation in the EVV program.

(B) Data collection method option:

(1) Application installed on one of the following devices:

(a) An electronic device provided by ODM that is available at no cost to the service provider. ODM's contracted entity is responsible for electronic device distribution, collection, and ongoing maintenance activities.

(b) A mobile electronic device owned by the service provider or direct care worker.

(i) ODM is not responsible for any costs incurred.

(ii) Data services connected to the service provider or direct care worker owned device will be used to transmit visit data from the application to the data aggregator in near real time.

(iii) The device used with the application will comply with device qualifications found at https://medicaid.ohio.gov/resources-for-providers/special-programs-and-initiatives/electronic-visit-verification.

(2) Telephony: The use of a phone call to start or end a visit.

(3) Manual entry: Manual visit entry is only permissible in the event verification through a device with an application or telephony is not available or appropriate based on the immediate needs of the individual. It is not to be used for routine visit verification.

(4) Alternate vendor:

(a) Providers may utilize an alternate EVV system, as described in rule 5160-32-03 of the Administrative Code.

(b) Financial management service vendors contracted with ODM, the Ohio department of aging, the Ohio department of developmental disabilities, or their designees will obtain and maintain certification as an alternate vendor.

(1) The type of service performed;

(2) The individual receiving the service;

(3) The date of the service;

(4) The location of service delivery;

(5) The direct care worker providing the service; and

(6) The time the service begins and ends.

(D) Data aggregator:

(1) Collects and stores visit data, regardless of method of visit capture.

(2) Confirms visit data present in the EVV system contains all necessary elements.

(3) Confirms claims submitted to the payor are supported by the service provider's visit data.

(E) Global positioning system (GPS) functionality of any application or device may be used only upon obtaining the signed consent of the individual receiving the service. Signed consent will be obtained annually, and GPS functionality cannot be activated if consent is not obtained for a respective annual period. The provider will maintain a copy of that signed consent. An individual who has provided consent for GPS functionality may revoke that consent at any time.

(F) The location of service delivery for each visit will be recorded by some other means, such as drop-down menus indicating the location of service in the home or community of the individual.

(G) It is the responsibility of the service provider to ensure accuracy of information entered into the EVV system. Missing visit data or details needing additional action by the service provider will result in a notification to the service provider, otherwise known as an exception.

(H) Claims cannot be substantiated for payment until all exceptions are resolved by the service provider and EVV visit data supports the claim. Unsubstantiated claims may result in denial of payment or post payment review penalty. ODM will communicate with affected service providers at least three months prior to initiating the process of claims denial or post payment review penalty due to EVV as set forth in this paragraph.

Last updated November 5, 2025 at 8:44 AM

History

Effective: October 30, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-32-03 Alternate electronic visit verification (EVV) vendor.

(A) An alternate EVV vendor may be used for EVV data collection.

(B) The state is not responsible for any costs related to the development, approval, testing, and utilization of a qualifying alternate EVV vendor.

(1) Notify the Ohio department of medicaid (ODM) or its contracted entity of the intent to seek ODM approval to utilize the selected alternate EVV vendor; and

(2) Complete alternate system aggregator training.

(D) The provider is responsible to ensure:

(1) The visit data in the aggregator is correct and reflects the visit as it occurred; and

(2) Billing is supported by visit data.

(E) System, technical, and business specifications to become an alternate EVV vendor are published on the ODM website https://medicaid.ohio.gov/resources-for-providers/special-programs-and-initiatives/electronic-visit-verification . Failure to meet the specifications at any time could result in Ohio certification revocation.

(F) A financial management service vendor contracted with ODM, the Ohio department of aging, and the Ohio department of developmental disabilities will obtain and maintain the alternate EVV vendor certifications.

(G) ODM may request re-approval of any alternate EVV system at any time.

Last updated November 5, 2025 at 8:44 AM

History

Effective: October 30, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-32-04 Electronic visit verification (EVV) program providers.

(A) This rule establishes Ohio medicaid service provider requirements for services subject to EVV as described in rule 5160-32-01 of the Administrative Code.

(B) All providers and financial management service vendors will:

(1) Complete initial and ongoing training per Ohio department of medicaid (ODM) instructions published on the ODM website https://medicaid.ohio.gov/resources-for-providers/special-programs-and-initiatives.

(2) Create and maintain updated and accurate records of individuals receiving EVV subject services. Needed data elements in the EVV system include:

(a) First and last name.

(b) A minimum of one known address at which the individual may routinely receive services. For individuals participating in the address confidentiality program, in accordance with section 111.42 of the Revised Code, the address documented will be according to program policy and may include a post office box.

(d) Program billing identifier of the individual receiving the service:

(i) Medicaid identification number, otherwise known as medicaid ID: the unique billing number assigned by ODM. The individual's medicaid ID is necessary for claims validation;

(ii) PASSPORT information management system ID assigned by the Ohio department of aging for individuals temporarily enrolled in the state funded preadmission screening system providing options and resources today (PASSPORT) waiver program. When the individual receiving the service has been assigned a medicaid ID, the provider should update the EVV system with the individual's medicaid ID. Billed claims will not be validated unless the individual receiving the service has an active and valid medicaid ID entered into the system; or

(iii) An indicator that the individual receiving the service is a newborn, not yet assigned a medicaid ID. When the newborn receiving the service has been assigned a medicaid ID, the provider should update the EVV system with the individual's medicaid ID. Billed claims will not be validated unless the newborn receiving the service has an active and valid medicaid ID entered into the system.

(e) Payer, program, and service provided. Valid values accepted are found on ODM's website https://medicaid.ohio.gov/INITIATIVES/Electronic-Visit-Verification/.

(3) Utilize EVV for all services described in rule 5160-32-01 of the Administrative Code.

(4) Report known or suspected tampering of devices to ODM upon discovery.

(5) Report any known or suspected falsification of EVV data to ODM upon discovery.

(C) Providers and financial management service vendors will create and maintain updated and accurate records of direct care workers providing services. Needed data elements in the EVV system include:

(1) First and last name.

(2) Social security number.

(3) Email address.

(D) State provided electronic device.

(1) A provider electing to request an electronic device provided by ODM will complete EVV training and submit the device request using https://etraconline.net/login.

(2) When a provider is no longer providing services requiring EVV or determines use of the state provided electronic device is no longer desired, the provider will initiate the return process. The return process can be found on ODM's website, https://medicaid.ohio.gov/INITIATIVES/Electronic-Visit-Verification/.

Last updated July 19, 2024 at 9:27 AM

History

Effective: July 1, 2024
Promulgated Under: 119.03

Chapter 5160-33 Assisted living HCBS waiver program

Ohio Adm.Code 5160-33-02 Definitions for the assisted living home and community based services waiver (HCBS) program.

(A) The purpose of this rule is to define the terms used in Chapter 5160-33 of the Administrative Code governing the medicaid assisted living HCBS waiver program.

As used in this chapter:

(B) "Assessment" means a face-to-face evaluation used to obtain information about an individual including his or her condition, personal goals and preferences, functional limitations, health status and other factors that are relevant to the authorization and provision of services. Assessment information supports the determination an individual needs waiver services as well as the development of a person-centered services plan.

(C) "Assisted living HCBS waiver program" means the medicaid-funded component of the assisted living program created under section 173.54 of the Revised Code and approved by the centers for medicare and medicaid services.

(D) "CDJFS" means a county department of job and family services.

(E) "CMS" means the centers for medicare and medicaid services, a federal agency that is part of the United States department of health and human services, and administers the medicaid program and approves HCBS waivers.

(F) "Certified" or "certification" means a provider's state of being certified by the Ohio department of aging (ODA) as an assisted living provider pursuant to Chapter 173-39 of the Administrative Code or the certification ODA gives to a certified assisted living provider.

(G) "HCBS" or "home and community-based services" means services furnished under the provisions set forth in 42 C.F.R. Part 441 Subpart G (October 1, 2021) that permit individuals to live in a home setting rather than a nursing facility (NF) or hospital. HCBS waiver services are approved by CMS for specific populations and are not otherwise available under the medicaid state plan.

(H) "Home first" means the component of the assisted living HCBS waiver program that offers priority enrollment in the waiver to certain individuals in accordance with section 173.542 of the Revised Code.

(I) "Individual" is a person enrolled on the assisted living HCBS waiver.

(J) "Level of care" (LOC) means the designation describing an individual's functional levels and nursing needs pursuant to the criteria set forth in rules 5160-3-05, 5160-3-06, and 5160-3-08 of the Administrative Code.

(K) The Ohio department of aging (ODA) is responsible for the daily operation of the assisted living home and community based services (HCBS) waiver. ODA will operate this waiver pursuant to an interagency agreement with the Ohio department of medicaid (ODM) in accordance with sections 5162.35 and 5166.21 of the Revised Code. ODA will establish processes and procedures to enroll individuals on this waiver.

(L) "ODA's designee" has the same meaning as in rule 173-39-01 of the Administrative Code.

(M) "Residential care facility" means a residential care facility as defined in section 3721.01 of the Revised Code that is issued a license pursuant to section 3721.02 of the Revised Code.

(N) "Room and board" means a payment made by an individual enrolled in the assisted living waiver directly to the ODA certified assisted living waiver provider. When paying "room" the individual will not be charged for the same furnishings and other shelter expenses the residential care facility provides at no cost to private pay non-waiver residents pursuant to the facility's resident agreement. The term "board" means three meals a day or any other full nutritional regimen.

Room and board does not include charges for ancillary items, services, and/or social activities purchased or paid for by the individual including hygiene and supplies not provided through medicaid and reflected on the individual's person-centered services plan, recreation and activities, and/or other items or services purchased by the individual; however ODA certified assisted living providers may, at their own discretion, provide ancillary items, services and/or social activities as part of the room and board payment.

(O) "Person-centered services plan" has the same meaning as in rule 5160-44-02 of the Administrative Code.

Last updated October 13, 2022 at 8:12 AM

History

Effective: October 13, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-33-03 Eligibility for the medicaid funded component of the assisted living program.

(A) The purpose of this rule is to outline the requirements that must be met for an individual to be eligible to enroll in the medicaid funded component of the assisted living program.

(B) To be eligible for the medicaid funded component of the assisted living program, an individual must meet all of the following:

(1) Be eligible for medicaid in accordance with Chapters 5160:1-3 to 5160:1-6 of the Administrative Code.

(2) Have an intermediate or skilled level of care in accordance with rule 5160-3-08 of the Administrative Code. If the individual requires skilled nursing care beyond supervision of special diets, application of dressings, or administration of medication, it must be provided in accordance with rule 3701-16-09.1 of the Administrative Code.

(3) Be age twenty-one years old or older at the time of enrollment.

(4) Participate in the development of a person-centered services plan in accordance with the process and requirements set forth in rule 5160-44-02 of the Administrative Code.

(5) Have the ability to make room and board payments calculated at the current supplemental security income (SSI) federal benefit level minus fifty dollars. Providers shall not charge or collect room and board payments from individuals in excess of the room and board payment calculated in accordance with this paragraph. In the event an individual does not have sufficient personal income:

(a) An individual may arrange for informal supports to provide a supplemental payment to the provider in order to meet room and board requirements;

(i) The supplemental payment shall represent no more than the difference between the individual's personal income and the maximum room and board payment established in paragraph (B)(5) of this rule.

(ii) The amount of the supplemental payment shall not be considered when calculating the individual's patient liability as described in rule 5160:1-6-07.1 of the Administrative Code.

(b) A provider may elect to accept a reduced room and board rate.

(6) Have health and safety related needs met, as determined by the Ohio department of aging's (ODA) designee.

(C) The individual must reside in a residential care facility (RCF) licensed by the Ohio department of health. At the time of initial and continued enrollment, the individual must reside in a resident unit that meets the qualifications in rule 173-39-02.16 of the Administrative Code and possesses the home and community-based setting characteristics set forth in rule 5160-44-01 of the Administrative Code.

(D) If, at any time, the individual does not meet any of the eligibility requirements identified in this rule, the individual shall be denied or disenrolled from the assisted living HCBS waiver. In such instances, the individual shall be notified of his or her hearing rights in accordance with division 5101:6 of the Administrative Code.

Last updated September 7, 2023 at 8:18 AM

History

Effective: September 7, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-33-04 Enrollment process for medicaid-funded component of the assisted living waiver program.

(A) The purpose of this rule is to outline the requirement that must be met for an individual to enroll in the medicaid-funded component of the assisted living waiver program.

(B) To be eligible for enrollment, an individual must:

(1) Have been determined to meet the eligibility requirements set forth in rule 5160-33-03 of the Administrative Code; and

(2) Upon initial and continued enrollment, reside in an approved living unit in accordance with paragraph (C) of rule 173-38-03 of the Administrative Code, located in a licensed residential care facility (RCF) certified by the Ohio department of aging (ODA) that possesses the home and community-based setting characteristics set forth in rule 5160-44-01 of the Administrative Code.

(C) If the individual has been determined eligible and the medicaid component of the assisted living waiver program has not reached the centers for medicare and medicaid services (CMS) authorized limit of participants for the current year, the individual shall be enrolled in accordance with the assisted living waiver program's home first component, if applicable, and rule 173-38-03 of the Administrative Code.

(D) Pursuant to Chapters 5160:1-3 to 5160:1-6 of the Administrative Code, if an individual is determined eligible for medicaid by the county department of job and family services, the individual shall not enroll in the assisted living waiver program until ODA's designee establishes a waiver program enrollment date and authorizes the provision of waiver services by an ODA certified assisted living provider. The waiver program enrollment date shall in no way restrict retroactive eligibility for non-assisted living waiver services available to individuals through the medicaid state plan.

(E) Any applicant for the assisted living waiver program is entitled to notice and hearing rights as set forth in section 5101.35 of the Revised Code and division 5101:6 of the Administrative Code.

History

Effective: October 17, 2020
Promulgated Under: 119.03

Ohio Adm.Code 5160-33-05 Provider conditions of participation for the assisted living home and community based services (HCBS) waiver program.

(A) The purpose of this rule is to establish the conditions under which providers are able to participate in the assisted living HCBS waiver program.

(B) In order to obtain a medicaid provider agreement to be an assisted living services provider, the provider will be certified by the Ohio department of aging (ODA) as an assisted living provider in accordance with Chapter 173-39 of the Administrative Code.

(C) Individuals enrolled in the assisted living HCBS waiver are given a free choice of qualified providers in accordance with rule 173-42-06 of the Administrative Code and 42 C.F.R. 431.51 (as in effect on October 1, 2021).

Last updated October 13, 2022 at 8:13 AM

History

Effective: October 13, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-33-06 Covered services for the assisted living services home and community based services (HCBS) waiver program.

(A) The purpose of this rule is to establish the services covered by the assisted living HCBS waiver program.

(B) The assisted living HCBS waiver program is limited to the following services:

(1) Assisted living service as defined in rule 173-39-02.16 of the Administrative Code, and

(2) Community transition service as defined in rule 173-39-02.17 of the Administrative Code.

Last updated October 13, 2022 at 8:13 AM

History

Effective: October 13, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-33-07 Assisted living home and community based services (HCBS) waiver rate setting.

(A) The purpose of this rule is to describe the methods used to determine provider rates for the assisted living HCBS waiver as set forth in appendix A to rule 5160-1-06.5 of the Administrative Code.

(B) Provider rates are determined for the following categories:

(1) Per-job bid rate or deposit made.

(2) Unit rate.

(C) A per-job bid rate or deposit made shall be determined on a per-job basis for the community transition service as set forth in rule 173-39-02.17 of the Administrative Code. The cost per job shall be paid at a per-job bid rate that is negotiated and approved by Ohio department of aging's (ODA) designee and accepted by the individual. The per-job bid rate includes the items and supports set forth in rule 173-39-02.17 of the Administrative Code and authorized on the person-centered services plan.

(D) A unit rate shall be based on a three-tiered model, and shall not exceed the amounts in appendix A to rule 5160-1-06.5 of the Administrative Code. These rates are used for assisted living services as set forth in rule 173-39-02.16 of the Administrative Code.

(1) The rate for assisted living services for each individual shall be determined by the ODA's designee through an assessment of the individual's service needs in four areas:

(a) Cognitive impairments,

(b) Medication administration,

(d) Functional impairments.

(2) The ODA-certified assisted living provider must agree to provide the services in the individual's person-centered service plan at the rate determined by the assessment.

(E) ODA certified assisted living providers shall only be paid for assisted living services authorized by ODA's designee and reflected on the individual's person-centered service plan.

(F) Assisted living service payment constitutes payment in full and may not be construed as a partial payment when the payment amount is less than the provider's charge. The provider may not bill an individual enrolled in the assisted living program for any difference between the medicaid payment and the provider's charge or request that the individual share in the cost through a co-payment or other similar charge.

(G) The assisted living service payment is for assisted living services as defined in rule 173-39-02.16 of the Administrative Code and does not include payment for room and board as calculated pursuant to rule 5160-33-03 of the Administrative Code, which is the responsibility of the individual.

History

Effective: July 1, 2019
Promulgated Under: 119.03

Chapter 5160-35 Medicaid School Program

Ohio Adm.Code 5160-35-01 Definitions.

(A) For the purposes of Chapter 5160-35 of the Administrative Code, the following terms are defined.

(1) At the direction of: the communication of a practitioner plan of care to a licensed practical nurse as defined in Chapter 4723. of the Revised Code by a physician as defined in Chapter 4731. of the Revised Code or a registered nurse as defined in Chapter 4723. of the Revised Code who is acting within the scope of his or her practice under Ohio law for the provision of nursing services by the licensed practical nurse as defined in Chapter 4723. of the Revised Code.

(2) Clinical setting: for the purpose of counseling and social work roles, a location in the school, or a location for which the medicaid school program provider has contracted for the delivery of services, where the eligible child's privacy can be maintained when a service is being rendered.

(3) Community school: a public school, independent of any school district, established in accordance with Chapter 3314. of the Revised Code that is part of the state's program of education.

(4) Common procedural terminology (CPT): also known as current procedural terminology, is a list of descriptive terms and identifying codes, as published by the American medical association (AMA) for reporting medical services and procedures performed.

(5) Direct service costs: costs associated with salaries, benefits, and contract compensation for individuals and entities delivering services to an eligible child, services as defined in rule 5160-35-05 of the Administrative Code, and as defined in rule 5160-35-07 of the Administrative Code.

(6) Eligible child: a student for whom medicaid reimbursement may be sought through the medicaid school program who is enrolled in an entity defined in paragraph (B)(1) of rule 5160-35-02 of the Administrative Code, who is between the age of three to twenty-one, and has an individualized education program (IEP), a 504 plan, or a school services plan of care documenting medical necessity in that it indicates services that are allowable under medicaid. An eligible child can also be a student who is enrolled in an entity defined in paragraph (B)(1) of rule 5160-35-02 of the Administrative Code, who is between the ages of three and twenty-one years, who receives an allowable service outlined in rule 5160-35-07 of the Administrative Code.

(7) Healthcare common procedure coding system (HCPCS): is a uniform method for health care providers and medical suppliers to report professional services, procedures and supplies.

(8) The individualized education program (IEP): is as defined in section 3323.011 of the Revised Code.

(9) Practitioner of the healing arts: for purposes of Chapter 5160-35 of the Administrative Code, includes the qualified practitioners delineated in rule 5160-35-05 of the Administrative Code.

(10) Local education agency: school districts of the state as defined in sections 3311.01 to 3311.04 of the Revised Code.

(11) Medicaid authorized prescriber: means as defined in rule 5160-1-17 of the Administrative Code.

(12) Medicaid school program authorized referrer: is a practitioner of the healing arts who refers for services under the medicaid school component of the medicaid program defined in section 5162.366 of the Revised Code.

(13) Medically necessary: means as defined in rule 5160-1-01 of the Administrative Code. For the purpose of the medicaid school program, medically necessary services are education related services identified in the individualized education program (IEP), 504 plan, or school services plan of care that meet medicaid reimbursement requirements.

(14) Medicaid school program (MSP): means the program set forth in Chapter 5160-35 of the Administrative Code.

(15) MSP provider: educational entity as defined in section 5162.364 of the Revised Code and rule 5160-35-02 of the Administrative Code.

(16) Other costs: costs for service-related activities for which there is no current procedural terminology (CPT) or healthcare common procedure coding system (HCPCS) code and for which claiming is not possible by the MSP provider due to medicaid rule restrictions; administrative claiming, equipment, supplies, indirect costs, audit fees, and billing fees.

(17) Skilled services: services of such complexity and sophistication that the service can be safely and effectively performed only by or under the supervision of a practitioner as defined in rule 5160-35-05 of the Administrative Code of the healing arts practicing within the scope of their licensure. Skilled services do not include services provided by persons not licensed in accordance with the Ohio Revised Code.

(18) State school: school under the control and supervision of the department of education and workforce (DEW) established for students who are deaf or blind as defined by section 3325.01 of the Revised Code.

(19) Supervision: is as defined in rules 4755:2-2-02, 4755:2-2-03, 4755:2-2-05 and 4753-7-02 of the Administrative Code as applicable to each provider type.

(20) Telehealth: will be in accordance with rule 5160-1-18 of the Administrative Code.

(21) School services plan of care: a standardized and timebound template developed and maintained by the Ohio department of medicaid to be used by the MSP provider. The school services plan of care serves as documentation of the services an eligible child will receive as part of the medicaid school program to address an eligible child's physical, mental, or behavioral health needs that inhibit the eligible child's academic performance or regular school attendance. The school services plan of care details services provided to an eligible child as described in rules 5160-35-05, 5160-35-06, and 5160-35-07 of the Administrative Code and includes components described in paragraph (J) of rule 5160-35-05 of the Administrative Code. The school services plan of care is not a treatment record and does not qualify as a medical record. MSP providers will ensure compliance with the Family Educational Rights and Privacy Act (FERPA) and Health Insurance Portability and Accountability Act (HIPAA). The school services plan of care does not supplant any state or federal processes or timelines related to identifying and serving students with disabilities.

(22) The 504 plan: means as defined in rule 3301-13-01 of the Administrative Code.

(23) Eligible provider: means as defined in rule 5160-1-17 of the Administrative Code.

(24) Random moment time study (RMTS): is defined as a tool used to analyze work done by employees and contractors over a specified time period. The RMTS is designed to document the level of effort MSP providers provide on a state-wide basis in compliance with the applicable RMTS guide provided by the Ohio department of medicaid.

Last updated January 5, 2026 at 8:13 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-35-02 Qualifications to be a medicaid school program (MSP) provider.

(A) The purpose of this rule is to set forth the qualifications to become a medicaid school program provider (MSP) and processes to be followed by an MSP provider.

(B) An MSP provider:

(1) Is one of the following:

(a) A local education agency (LEA) city school district, local school district, exempted village school district, or any other school district as defined in sections 3311.01 to 3311.04 of the Revised Code;

(b) A state school for the deaf as defined by section 3325.01 of the Revised Code;

(d) A community school as defined by section 3314.01 of the Revised Code.

(2) Is an eligible medicaid provider as defined in rule 5160-1-17 of the Administrative Code.

(3) Will employ or contract for at least one of the following:

(a) Occupational therapist as defined in Chapter 4755. of the Revised Code.

(b) Physical therapist as defined in Chapter 4755. of the Revised Code.

(d) Audiologist as defined in ,Chapter 4753. of the Revised Code.

(e) Professional clinical counselor or professional counselor as defined in Chapter 4757. of the Revised Code.

(f) Psychologist or school psychologist as defined in Chapter 4732. of the Revised Code or in rule 3301-24-05 of the Administrative Code.

(g) Independent social worker or social worker as defined in Chapter 4757. of the Revised Code.

(h) Independent marriage and family therapist or marriage and family therapist as defined in Chapter 4757. of the Revised Code;

(i) Independent chemical dependency counselor or chemical dependency counselor II or III as defined in Chapter 4758. of the Revised Code;

(j) Registered nurse as defined in Chapter 4723. of the Revised Code.

(k) Clinical nurse specialist as defined in Chapter 4723. of the Revised Code;

(l) Nurse practitioner as defined in Chapter 4723. of the Revised Code;

(m) Physician assistant as defined in Chapter 4730. of the Revised Code.

(C) An MSP provider will ensure all employees and contractors who have in-person or virtual contact with consumers for the provision of face-to-face or telehealth services undergo and successfully complete criminal records checks pursuant to rules adopted under section 5164.34 of the Revised Code.

(D) An MSP provider is obligated to provide services in accordance with rules 5160-35-05, 5160-35-06, and 5160-35-07 of the Administrative Code.

(E) An MSP provider is obligated to submit claims in accordance with rule 5160-35-04 of the Administrative Code to receive reimbursement for the provision of services.

(F) An MSP provider will maintain documentation of services delivered.

(G) An MSP provider is obligated to comply with the following for cost reporting and cost reconciliation purposes:

(1) Participate in all random moment time studies (RMTS) as defined in rule 5160-35-01 of the Administrative Code .

(2) Submit the federal child count of special education students as defined in section 3301.011 of the Revised Code.

(3) Prepare a cost report in accordance with rule 5160-35-04 of the Administrative Code.

(4) Contract with an independent certified public accountant or firm to perform an agreed upon procedures review of the cost report and to document adjustments to the cost report, in accordance with paragraph (K)(2) of rule 5160-35-04 of the Administrative Code.

(5) An MSP provider delivers and documents services in accordance with all state and federal laws .

Last updated January 5, 2026 at 8:12 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-35-04 Reimbursement for services provided by medicaid school program (MSP) providers.

(A) The purpose of this rule is to set forth the provisions for claiming to receive medicaid reimbursement for the provision of services by medicaid school program (MSP) providers as defined in Chapter 5160-35 of the Administrative Code.

(B) The CPT (common procedural terminology) and HCPCS (healthcare common procedure coding system) covered services provided through MSP providers that are allowable for medicaid reimbursement are listed on the department's website, http://medicaid.ohio.gov and are provided in accordance with Chapter 5160-35 and rule 5160-8-35 of the Administrative Code. The following limits apply:

(1) Assessment/evaluation services cannot be billed more than once per continuous twelve month period.

(2) Re-assessment/re-evaluation services may be performed not more frequently than every thirty days nor less frequently than every sixty days; for developmental services, reevaluation may be performed not more frequently than every thirty days nor less frequently than every six months.

(3) Skilled services cannot be billed for dates of service beyond twelve months of the initial assessment/evaluation or re-assessment/re-evaluation.

(C) Medically necessary services for individuals under age twenty-one that go beyond the coverage and limitations established in this rule will be:

(1) Prior authorized by the Ohio department of medicaid (ODM) in accordance with rule 5160-1-31 of the Administrative Code; and

(2) Services defined as medical assistance in accordance with section 1905(a) of the Social Security Act, 42 U.S.C. 1396d (January 1, 2013).

(D) The following conditions will be met in order to receive medicaid reimbursement for services provided through the medicaid school program:

(1) The school district will be a qualified MSP provider in accordance with rule 5160-35-02 of the Administrative Code.

(2) The MSP provider will submit claims for reimbursement for all direct service costs provided in accordance with rule 5160-35-05 of the Administrative Code and paragraph (B)(3) of rule 5160-35-06 of the Administrative Code for which the MSP provider will submit a cost report seeking cost reconciliation. Costs for direct services for which a provider has not submitted an interim claim will not be paid to the provider in any final cost report settlement.

(3) The MSP provider will submit claims for only those services for which it has statutory responsibility to provide to either an eligible child with an IEP or for assessment/evaluation for a medicaid eligible child for whom they are trying to determine the appropriateness of developing an individualized education program (IEP).

(4) The executive officer of the MSP provider or his/her designee will attest to the validity of the non-federal share of expenditures in accordance with paragraph (G) of this rule.

(5) The service provided through the MSP provider will be in accordance with rules 5160-35-05 and 5160-35-06 of the Administrative Code.

(6) The service for which reimbursement is sought will be one clearly identified in the IEP of an eligible child, with the exception of the initial assessment/evaluation as described in paragraph (B)(7) of rule 5160-35-05 of the Administrative Code.

(7) The service must be agreed to by the medicaid-covered individual or the medicaid-covered individual's authorized representative.

(E) MSP providers will enroll and submit claims as an ODM electronic data interchange (EDI) trading partner or contract with an ODM EDI trading partner for the submission of claims to ODM.

(F) Claims will be submitted in accordance with rule 5160-1-02 of the Administrative Code, will only be for services agreed to by the medicaid-covered individual or the medicaid-covered individual's authorized representative, and will include the most appropriate code representing each procedure, service, or supply provided in accordance with rule 5160-1-60 of the Administrative Code.

(G) When a medicaid claim is submitted through an EDI trading partner, the claim shall include a ten character code that is the first item listed in the NTE02 field, and that is an attestation of whether or not the claim is certified by the executive officer of the MSP provider or his/her designee as follows:

(1) Attest yes: used if the claim is certified by the executive officer of the MSP provider or his/her designee to only include expenditures under the medicaid program under Title XIX of the Social Security Act (the Act), and as applicable, under the state children's health insurance program (SCHIP), under Title XXI of the Act, that are allowable in accordance with applicable implementing federal, state, and local statutes, regulations, and policies, and the state plan approved by the secretary of health and human services and in effect at the time of the submission of this claim; and the expenditures included in the claim are based on the MSP provider's accounting of actual recorded expenditures; and the established amount of local public funds were available and used to match the MSP provider's (local public school district's) allowable expenditures included in this claim, and such local public funds were in accordance with all applicable federal mandates for the non-federal share match of expenditures; and federal matching funds are not being claimed in this claim submission to match any expenditure under any medicaid and/or SCHIP state plan amendment that has not been approved by the secretary of health and human services effective for the period of this claim.

(2) Attest nay: used if the claim is not certified by the executive officer of the MSP provider or his/her designee to only include expenditures under the medicaid program under Title XIX of the Social Security Act (the Act), and as applicable, under the state children's health insurance program (SCHIP), under Title XXI of the Act, that are allowable in accordance with applicable implementing federal, state, and local statutes, regulations, and policies, and the state plan approved by the secretary of health and human services and in effect at the time of the submission of this claim; and the expenditures included in the claim are based on the MSP provider's accounting of actual recorded expenditures; and the mandated amount of local public funds were available and used to match the MSP provider's (local public school district's) allowable expenditures included in this claim, and such local public funds were in accordance with all applicable federal mandates for the non-federal share match of expenditures; and federal matching funds are not being claimed in this claim submission to match any expenditure under any medicaid and/or SCHIP state plan amendment that has not been approved by the secretary of health and human services effective for the period of this claim. If attest nay is used, the claim will be denied for payment.

(H) Claim submissions are considered for reimbursement only when they are received by ODM within three-hundred sixty-five days of the actual date the service was provided.

(I) References to cartridge tape, paper claim and pharmacy-point-of-sale in rule 5160-1-20 of the Administrative Code are not applicable to the claim and will not be allowed.

(J) MSP reimbursable services will be billed in units of service, as indicated on ODM's website at http://medicaid.ohio.gov. Service coverage and reimbursement rates are in accordance with "Healthcare Common Procedure Coding System (HCPS)," the "Current Procedural Terminology (CPT)" codes, and as listed in appendix to rule 5160-1-60 of the Administrative.

(K) The following applies to medicaid reimbursement:

(1) Interim payments. ODM will reimburse the MSP provider interim payments. The interim payments will be the federal financial participation (FFP) portion of the lesser of the billed charge (not to exceed the usual and customary charge) or the medicaid maximum according to the department's procedure code reference files for the particular services performed.

(2) Cost reports. Each MSP provider will complete the Ohio department of education (ODE) developed MSP school based cost report. The cost report is to be completed by the MSP provider in compliance with all state and federal provisions the cost report instructions also developed by ODE. The MSP provider will contract with an independent certified public accountant (CPA) firm, the state auditor, or other entity authorized to conduct audits in the state of Ohio to perform an agreed upon procedures review of the cost report and document adjustments to the cost report. Once the agreed upon procedures review is completed, the reviewed cost report will be submitted to ODE no later than eighteen months after the end of the cost reporting period as identified in the cost report instructions. The submitted cost report will be used by ODE and ODM in the cost reconciliation and final settlement process. It is possible for ODM or ODE to conduct a desk or field audit up to three years after the fiscal year end based on risk assessment criteria developed by ODM. All cost reports for each fiscal year prior to the effective date of this rule but not starting earlier than July 1, 2005 will be submitted in accordance with the schedule developed by ODM in cooperation with ODE and approved by CMS.

(3) Cost report extension. For good cause and upon written request from the MSP provider, ODE can grant an extension of the cost report filing deadline. The written request is to be submitted to the grants management unit at ODE thirty calendar days before the cost report submission deadline specified in paragraph (K)(2) of this rule. The request will include information explaining the facts and circumstances giving rise to the need for a cost report extension, projected time line for filing the cost report, and any other information which the MSP provider would like to have considered. Upon reviewing the written request, ODE can, at its sole discretion, request additional information, approve or deny the extension.

(4) Final cost settlement and reconciliation. The ODM and /or its designee will review the cost reports identify adjustments needed, compare the federal financial participation (FFP) identified in the cost report against the interim payments made by ODM to the MSP provider, identify the number of students for which claims for services were received and paid and determine the proportionate costs for those students using the costs from the cost report for the total population of medicaid eligible IEP students, and issue a notice of intended action pursuant to rule 5160-70-03 of the Administrative Code that denotes the amount due to or from the MSP provider as a result of the reconciliation. The MSP provider will have thirty-days from the date of the notice to request a hearing. If no hearing request is received, ODM will process the reconciled amount. An overpayment determined as a result of this annual reconciliation to actual cost will be collected from the MSP provider by ODM. An underpayment determined as a result of this annual reconciliation to actual cost will be paid to the MSP provider by ODM. Failure by a MSP provider to submit an acceptable cost report in accordance with paragraphs (K)(2) and (K)(3) of this rule, will result in full repayment by the MSP provider of the total interim payment received by the MSP provider for the cost reporting period. In addition, failure to submit an acceptable cost report will result in possible revocation of the MSP provider agreement and number.

(5) Reimbursements for all covered services as are to be considered payment in full with limitations as set forth in accordance with rule 5160-1-60 of the Administrative Code.

(6) The MSP providers will comply with all applicable federal and state rules, including but not limited to 45 C.F.R. Part 92 (December 24, 2013), 45 C.F.R. Part 74 (December 24, 2013), Chapters 5160-1 and 5160-35 of the Administrative Code, CMS Publication 15-1 (found at www.cms.gov/manuals), and the terms and conditions set forth within the provider agreement.

(L) Records are to be maintained and disclosed by providers in accordance with rule 5160-1-27 of the Administrative Code. Records necessary to fully disclose the extent of services provided and costs associated with these services will be maintained for a period of six years from the end of the cost reporting period based upon those records or until any initiated audit, review, investigation or other activities are completed and appropriately resolved, whichever is longer. Records will be made available upon request to ODM, ODE or the U.S. department of health and human services. Failure to supply requested records, documentation or information could result in no payment for outstanding services, recoupment of any reimbursements provided for services that cannot be validated, termination from the medicaid program and/or any sanctions available pursuant to section 5162.10 of the Revised Code.

(M) State monitoring: ODM or its designee has the authority to conduct audits, reviews, investigations, or any other activities necessary to assure a medicaid school program provider, its subgrantee(s) or subcontractor(s) are compliant with federal and state mandates. Based on the results of an audit, review, investigation or other activities, ODM will potentially seek recoupment of funding related to overpayments, misuse, fraud waste or abuse or noncompliance with federal or state mandates from the MSP provider.

History

Effective: July 1, 2020
Promulgated Under: 119.03

Ohio Adm.Code 5160-35-05 Services authorized for medicaid coverage that can be provided by medicaid school program (MSP) providers.

(A) The purpose of this rule is to set forth the services authorized for medicaid coverage that an MSP provider can provide, and to set forth the conditions for providing the services.

(B) The MSP provider will only submit claims for services which it has statutory authority to provide, including medically necessary services to eligible children in accordance with this rule and rules 5160-35-06 and 5160-35-07 of the Administrative Code that are appropriately documented in the following:

(1) The individualized education program (IEP) as defined in section 3323.011 of the Revised Code;

(2) 504 plan as defined in rule 3301-13-01 of the Administrative Code;

(3) A school services plan of care as defined in rule 5160-35-01 of the Administrative Code.

(1) Occupational therapy services:

(a) Description: services that evaluate and treat, as well as services to analyze, select, and adapt activities for an eligible child whose functioning is impaired by developmental deficiencies, physical injury or illness. The occupational therapy service will be recommended by an occupational therapist as defined in Chapter 4755. of the Revised Code.

(b) Qualified practitioners who can deliver the services:

(i) Occupational therapist as defined in Chapter 4755. of the Revised Code and in accordance with rule 5160-35-02 of the Administrative Code.

(ii) Occupational therapy assistant as defined in Chapter 4755. of the Revised Code and in accordance with rule 5160-35-02 of the Administrative Code and the occupational therapy assistant will be practicing under the supervision of an occupational therapist who is employed or contracted by the MSP provider.

(iii) A student occupational therapist or a student occupational therapy assistant as defined by rule 4755:1-2-02 of the Administrative Code.

(i) Evaluation and re-evaluation to determine the current sensory and motor functional level of the eligible child and identifying appropriate therapeutic interventions to address the findings of the evaluation/re-evaluation.

(ii) Therapy to improve the sensory and motor functioning of the eligible child, to teach skills and behaviors crucial to the eligible child's independent and productive level of functioning.

(iii) Application and instruction in the use of orthotic and prosthetic devices, and other equipment to accomplish the goal of therapy in accordance with paragraph (C)(1)(c)(ii) of this rule.

(iv) May make referrals for occupational therapy services under the MSP component of the medicaid program as authorized in section 5162.366 of the Revised Code.

(2) Physical therapy services

(a) Description: services that evaluate and treat an eligible child by physical measures and the use of therapeutic exercises and procedures, with or without assistive devices, for the purpose of correcting, or alleviating a disability. The physical therapy service will be recommended by a physical therapist as defined in Chapter 4755. of the Revised Code.

(b) Qualified practitioners who can deliver the services:

(i) Physical therapist as defined in Chapter 4755. of the Revised Code and in accordance with rule 5160-35-02 of the Administrative Code.

(ii) Physical therapist assistant as defined in Chapter 4755. of the Revised Code, in accordance with rule 5160-35-02 of the Administrative Code, and who is practicing under the supervision of a physical therapist as defined in Chapter 4755. of the Revised Code who is employed or contracted by the MSP provider.

(iii) A student physical therapist or a student physical therapist assistant as defined by rule 4755:2-2-02 of the Administrative Code.

(i) Evaluation and re-evaluation to determine the current level of physical functioning of the eligible child and to identify appropriate therapeutic interventions to address the findings of the evaluation/re-evaluation.

(ii) Therapy, with or without assistive devices, for the purpose of preventing, correcting or alleviating the impairment of the eligible child.

(iii) Application and instruction in the use of orthotic and prosthetic devices, and other equipment to accomplish the goal of therapy in accordance with paragraph (C)(2)(c)(ii) of this rule.

(iv) May make referrals for physical therapy services under the MSP component of the medicaid program as authorized in section 5162.366 of the Revised Code.

(3) Speech-language pathology services

(a) Description: services that are planned, directed, supervised and conducted for individuals or groups of individuals who have or are suspected of having disorders of communication. The application of principles, methods, or procedures related to the development and disorders of human communication can include identification, evaluation, and treatment. The speech-language pathology service will be recommended by a speech-language pathologist as defined in Chapter 4753. of the Revised Code.

(b) Qualified practitioners who can deliver the services:

(i) Speech-language pathologist as defined in Chapter 4753. of the Revised Code and in accordance with rule 5160-35-02 of the Administrative Code.

(ii) Speech-language pathology aide as defined in Chapter 4753. of the Revised Code in accordance with rule 5160-35-02 of the Administrative Code, and who is practicing under the supervision of the speech-language pathologist as defined in Chapter 4753. of the Revised Code who meets the criteria in rule 4753-7-01 of the Administrative Code.

(iii) A person who meets conditional criteria to practice speech-language pathology as defined in section 4753.071 of the Revised Code.

(iv) A speech-language pathology student who is completing an internship or externship in accordance with the clinical requirements as established by the credentialing board.

(i) Evaluation and re-evaluation to determine the current level of speech-language of the eligible child and to identify the appropriate speech-language treatment to address the findings of the evaluation/re-evaluation.

(ii) Therapy, with or without assistive devices, for the purpose of preventing, correcting or alleviating the impairment of the eligible child.

(iii) Application and instruction in the use of assistive devices.

(iv) May make referrals for speech-language pathology services under the MSP component of the medicaid program as authorized in section 5162.366 of the Revised Code.

(4) Audiology services

(a) Description: hearing exams, diagnostic tests, and services requiring the application of principles, methods, or procedures related to hearing and the disorders of hearing. The audiology service will be recommended by an audiologist as defined in Chapter 4753. of the Revised Code.

(b) Qualified practitioners who can deliver the services:

(i) Audiologist as defined in Chapter 4753. of the Revised Code and in accordance with rule 5160-35-02 of the Administrative Code.

(ii) Audiology aide as defined in Chapter 4753. of the Revised Code, in accordance with rule 5160-35-02 of the Administrative Code, and who is practicing under the supervision of an audiologist as defined in Chapter 4753. of the Revised Code who meets criteria defined in rule 4753-7-01 of the Administrative Code.

(iii) An audiology student who is completing an internship or externship in accordance with clinical requirements as established by the credentialing board.

(i) Evaluation and re-evaluation to determine the current level of hearing of the eligible child and to identify the appropriate audiology treatment, as well as treatment to address the findings of the evaluation/re-evaluation.

(ii) May make referrals for audiology services under the MSP component of the medicaid program as authorized in section 5162.366 of the Revised Code.

(5) Physical health services.

(a) Description: services from a registered nurse that provides care to individuals and groups as defined in Chapter 4723. of the Revised Code. Additionally, services from a licensed practical nurse that provides care to individuals and groups nursing care as defined in Chapter 4723. of the Revised Code. The nursing service, with the exception of evaluations and assessments, will be prescribed by a medicaid authorized prescriber acting within the scope of his or her practice under Ohio law who holds a current, valid license.

(b) Qualified practitioners who may deliver the services:

(i) Registered nurse as defined in Chapter 4723. of the Revised Code and in accordance with rule 5160-35-02 of the Administrative Code.

(ii) Licensed practical nurse as defined in Chapter 4723. of the Revised Code and in accordance with rule 5160-35-02 of the Administrative Code.

(iii) Clinical nurse specialist as defined in Chapter 4723. of the Revised Code and in accordance with rule 5160-35-02 of the Administrative Code.

(iv) Nurse practitioner as defined in Chapter 4723. of the Revised Code and in accordance with rule 5160-35-02 of the Administrative Code.

(v) Physician assistant as defined in Chapter 4730. of the Revised Code and in accordance with rule 5160-35-02 of the Administrative Code.

(i) Assessment/evaluation and re-assessment/re-evaluation to determine the current health status of the eligible child in order to identify and facilitate provision of appropriate nursing treatment to address the findings of the assessment/evaluation or re-assessment/re-evaluation.

(ii) The implementation of medical/nursing procedures/treatments in accordance with paragraph (A)(11) of rule 5160-35-01 of the Administrative Code for the medicaid eligible child, which may include tube feeds, bowel and bladder care, colostomy care, catheterizations, respiratory treatment, wound care, chronic disease management, and behavioral health services as described in paragraph (C)(6)(c)(iii)(c)(i) of this rule and any other services that are prescribed in accordance with paragraph (A)(11) of rule 5160-35-01 of the Administrative Code.

(6) Behavioral health services as defined by each profession's scope of practice and licensing criteria.

(a) Description: Behavioral health services are services or procedures that are performed for the diagnosis and treatment of mental, behavioral, substance use, or emotional disorders by an allowable professional as defined in paragraph (C)(6)(b) of this rule or by an allowable professional as defined in paragraph (C)(6)(b) of this rule who is under appropriate supervision according to the criteria of their respective boards and who is acting within their appropriate scope of practice under Ohio law.

(b) Qualified practitioners who can deliver the services:

(i) A professional counselor, professional clinical counselor, professional clinical counselor - supervisor, counselor trainee, independent social worker, independent social worker - supervisor, social worker, social worker trainee, independent marriage and family therapist, marriage and family therapist, or marriage and family therapist trainee as defined in Chapter 4757. of the Revised Code and in accordance with rule 5160-35-02 of the Administrative Code.

(ii) Psychologist or a school psychologist as defined in Chapter 4732. of the Revised Code, or to practice school psychology as defined in Chapter 4732. of the Revised Code or under rule 3301-24-05 of the Administrative Code in accordance with rule 5160-35-02 of the Administrative Code.

(iii) Psychology or school psychology trainee or intern who is completing an internship or externship in accordance with clinical criteria as defined in section 4732.22 of the Revised Code and in accordance with rule 5160-35-02 of the Administrative Code.

(iv) Independent chemical dependency counselor or chemical dependency counselor II or III as defined in Chapter 4758. of the Revised Code and in accordance with rule 5160-35-02 of the Administrative Code.

(v) Registered nurse or a licensed practical nurse as defined in Chapter 4723. of the Revised Code providing behavioral health services as described in paragraph (C)(6)(c)(iii)(c)(i) of this rule and in accordance with rule 5160-35-02 of the Administrative Code.

(i) Screening activities.

Behavioral health screenings that identify potential need for services related to a mental health or substance use disorder.

(ii) Assessment activities.

(a) An assessment is a clinical evaluation of a person which is individualized as well as age, gender, and culturally appropriate.

(b) An assessment determines diagnosis and treatment needs, and establishes a treatment plan to address the eligible child's mental illness or substance use disorder.

(iii) Treatment activities.

(a) Counseling and therapy services provided by an allowable MSP provider acting within their scope of practice where there is an interaction with an eligible child or eligible children and the focus is on achieving treatment objectives related to alcohol and other substance use; or the eligible child's mental illness or emotional disturbance.

(i) Counseling and therapy involves an encounter between an eligible child, group of eligible children, an eligible child and family members, or family members and a behavioral health professional.

(ii) Group counseling and therapy encounters will not exceed a one-to-twelve behavioral health professional to patient ratio.

(b) Therapeutic behavioral services (TBS).

Provided by an allowable MSP provider listed in paragraphs (C)(1)(b)(i) to (C)(1)(b)(iii) of this rule acting within their scope of practice who is rendering activities described in rules 5160-27-08 and 5122-29-18 of the Administrative Code.

Behavioral health nursing services are mental health and substance use disorder (SUD) nursing services performed by registered nurses or licensed practical nurses. They include those activities that are performed within professional scope of practice and in authorized settings by a registered nurse or licensed practical nurse as defined in section 4723.01 of the Revised Code and are intended to address the behavioral and other physical health needs of eligible children receiving treatment for psychiatric symptoms or substance use disorders.

(d) Allowable practitioners providing behavioral health services to eligible children are subject to all clinical supervision and documentation criteria outlined by each profession's scope of practice and licensing criteria and as described in rule 5160-8-05 of the Administrative Code and will document appropriate supervision where applicable and in accordance with respective boards.

(7) Assessments/evaluations for IEPs.

(a) Description: the initial assessment/evaluation that is part of the evaluation team report (ETR) process (reimbursement is limited to one per continuous twelve month period per eligible child unless prior authorization is obtained) conducted for an eligible child without an IEP or conducted for a two year old eligible child with a disability to determine whether or not an IEP is appropriate. The assessment/evaluation will include a description of the services and supports which are needed to address the findings from the assessment/evaluation and will be signed by the qualified practitioner who conducted the assessment/ evaluation. Reimbursement is not available for the development of the IEP.

(b) Description: the re-assessment/re-evaluation conducted thereafter and identified in the eligible child's IEP (reimbursement is limited to one per continuous six month period per eligible child unless prior authorization is obtained). The re-assessment/re-evaluation will include a recommendation that describes the services and supports which are needed to address the findings from the re-assessment/re-evaluation and be signed by the qualified practitioner who conducted the re-assessment/re-evaluation. Reimbursement is not available for the development of the IEP.

(c) Qualified practitioners who may deliver the initial assessment/evaluation, or re-assessment/re-evaluation services: one of the qualified practitioners identified in paragraphs (C)(1) to (C)(6) of this rule who is employed or contracted with the MSP provider, and who is acting within the scope of his or her practice under Ohio law.

(D) An MSP provider may provide telehealth services. Telehealth services are to be delivered in accordance with an eligible child's IEP, 504 plan, or school services plan of care and in accordance with the telehealth service delivery methods as identified in rule 5160-1-18 of the Administrative Code or as provided in written guidance, as set forth by ODM or the appointing authority, when not clarified in rule 5160-1-18 of the Administrative Code.

(E) In accordance with an eligible child's IEP, 504 plan, or school services plan of care and section 5162.366 of the Revised Code, a physical therapist, occupational therapist, speech-language pathologist, and audiologist can make a referral for the eligible child when the referral is within the practitioner's specific discipline. In accordance with an eligible child's IEP, 504 plan, or school services plan of care and section 5162.366 of the Revised Code, a clinical nurse specialist, certified nurse practitioner, and physician assistant can be an ordering and referring provider for the eligible child if it is within the practitioner's specific discipline.

The physical therapist, occupational therapist, speech-language pathologist, audiologist, clinical nurse specialist, certified nurse practitioner, and physician assistant will meet criteria in rule 5160-1-17.2 of the Administrative Code.

(F) Although the following list is not all-inclusive, the following are not allowable for reimbursement through the medicaid school program:

(1) Services and activities that go beyond the recommendation of the qualified practitioner conducting the assessment/evaluation, re-assessment/re-evaluation and therefore are provided solely for the purpose of education, special education or special instruction.

(2) Counseling parents and teachers regarding hearing loss.

(3) In-house training.

(4) Fittings for amplification devices, and equipment troubleshooting or repair.

(5) Nursing services provided as a part of immunizations process.

(6) Instruction on self-care that does not need the expertise of the licensed practitioner.

(7) Services not indicated in an eligible child's IEP, 504 plan, or school services plan of care documenting medical necessity as described in paragraph (B) of this rule prior to the provision of the service with the exception of the initial assessment/evaluation as described in paragraph (C)(7) of this rule and with the exception of services described in rule 5160-35-07 of the Administrative Code.

(8) Services provided on days or at times when the eligible child is not in attendance in the designated school setting as defined by the child's IEP, 504 plan or school services plan of care as described in paragraph (B) of this rule with the exception of the initial assessment/evaluation as described in paragraph (C)(7) of this rule.

(9) Services that are not provided under the appropriate supervision or at the appropriate direction of a licensed practitioner of the healing arts.

(10) Services provided by a non-licensed person.

(11) Services for which an eligible child fails to show progress toward identified goals in the IEP, 504 plan or school services plan of care over two consecutive three-month periods and there is no documentation that the methods or techniques applied have been modified to improve progress.

(12) Services provided as a part of the eligible child's waiver services, or as a part of services through an intermediate care facility or of a nursing facility.

(13) Services and activities that are not a direct benefit to the eligible child.

(14) Sensitivity training.

(15) Sexual competency training.

(16) Educational activities (including testing and diagnosis - this does not include initial assessments nor re-assessment as indicated in paragraph (C)(7) of this rule).

(17) Monitoring activities of daily living.

(18) Recreational therapies.

(19) Teaching grooming skills.

(20) Sensory stimulation.

(21) Teaching social interaction/diversion skills.

(22) Family therapy that is not a direct benefit to the eligible child.

(G) In accordance with rule 5160-1-01 of the Administrative Code, the services provided will be medically necessary and the type, frequency, scope and duration of the services will fall within the normal range of services considered under acceptable standards of medical and healing arts professional practice, as appropriate.

(H) The services provided are of such level of complexity and sophistication, or the condition of the patient is such that the service can be safely and effectively performed only by or under the supervision of a licensed practitioner as indicated in this rule.

(I) The eligible child's IEP is to contain the following components. These IEP components do not supplant any practitioner plan of care, and will:

(1) Be based on the initial assessment/evaluation conducted during the ETR as defined in rule 3301-51-01 of the Administrative Code or the subsequent assessments/evaluations and re-assessments/re-evaluations.

(2) Be signed by the qualified practitioner who recommends the service as a result of the assessment/evaluation, re-assessment/re-evaluation.

(3) Include specific services to be used, and the amount, duration and frequency of each service.

(4) Include specific goals to be achieved as a result of service provided, including the level or degree of improvement expected.

(5) For nursing services, reference and identify the location of the prescription of a physician. For medications, reference and identify the location of the prescription of a physician, physician assistant, or an advanced practice nurse in accordance with Ohio law.

(6) Specify timelines for re-assessment, which should be no more than twelve-months from the date of the initial evaluation or re-assessment, of the eligible child and updates to the IEP.

(J) The eligible child's school services plan of care will contain the following components. These components do not supplant any practitioner plan of care. The school services plan of care does not supplant any state or federal processes or timelines related to identifying and serving children with disabilities.

(1) Be based on an assessment of need conducted by an authorized school district provider or community provider.

(2) Be signed by the authorized school district provider in accordance with rule 5160-35-02 of the Administrative Code who recommends the service as a result of the assessment of need.

(3) Include specific services to be used, and the amount, duration, and frequency of each service.

(4) Include specific goals to be achieved as a result of the service provided, including the level or degree of improvement expected.

(5) For nursing services, reference and identify the location of the prescription of a physician. For medications, reference and identify the location of the prescription of a physician, a physician assistant, or an advanced practice nurse in accordance with Ohio law.

(6) Specify timelines for re-assessment, which should be no more than twelve-months from the date of the initial evaluation or most recent re-assessment, of the eligible child and updates to the school services plan of care.

(7) Include specific criteria regarding referrals to community providers, when appropriate.

(K) The documentation for the provision of service will be maintained for purposes of supporting the delivery of the service and to provide an audit trail. Documentation will include:

(1) The date (i.e., day, month, and year) that the activity was provided.

(2) The full legal name of the eligible child for whom the activity was provided.

(3) A description of the service, procedure, and method provided, as well as the location where the service is delivered (may be in case notes or a coded system with a corresponding key).

(4) Group size if the service was provided to more than one individual during the service delivery time.

(5) The duration in minutes or time in/time out of the activity provided. Duration in minutes is acceptable if the schedule of the person delivering the service is maintained on file.

(6) A description of the actual progress demonstrated by the eligible child toward the stated goals outlined in the practitioner plan of care or the school services plan of care for each continuous three-month reporting period.

(7) The signature or initials of the person delivering the service on each entry of service delivery. Each documentation recording sheet will contain a legend that indicates the name (electronic, typed, or printed), title, signature, and initials of the person delivering the service to correspond with each entry's identifying signature or initials.

(8) Evidence in either the eligible child's case file or a separate supervision log that the appropriate supervision was provided in accordance with appropriate licensing standards.

(9) A description of efforts made to coordinate services with the eligible child's medical provider in accordance with the medicaid provider agreement.

(L) The claims for reimbursement for services will be submitted in accordance with rule 5160-35-04 of the Administrative Code.

(M) Guidance in this rule is specific to services performed by qualified practitioners in a school-based setting. Qualified practitioners will exercise reasonable professional judgement consistent with standards as set by his or her professional board. This guidance does not alter any practitioner's scope of practice, nor does it negate the necessity to meet other mandates as obligated when services are furnished outside of the medicaid school program.

Last updated January 5, 2026 at 8:13 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-35-06 Other services, medical supplies and equipment authorized for medicaid coverage that can be provided by medicaid school program (MSP) providers.

(A) The purpose of this rule is to set forth the services authorized for medicaid coverage, beyond those indicated in rule 5160-35-05 of the Administrative Code, that a MSP provider can provide, and to set forth the conditions for providing the services.

(B) In addition to the services indicated in rules 5160-35-05 and 5160-35-07 of the Administrative Code, a MSP provider may render and receive payment for the following services:

(1) Transportation:

(a) For purposes of Chapter 5160-35 of the Administrative Code, "transportation" is specialized conveyance that accommodates the specific needs of an eligible child with an individualized education plan (IEP) (for example, transportation by wheelchair-accessible vehicle or adapted school bus) for the purpose of traveling to or from the MSP provider to receive medically necessary services allowable under rules 5160-35-05 and 5160-35-07 of the Administrative Code.

(b) Claims for transportation mileage are paid in accordance with rates as found in the "Healthcare Common Procedure Coding System (HCPS)," with the "Current Procedural Terminology (CPT)" codes, and in rule 5160-1-60 of the Administrative Code.

(c) Unallowable services include transportation that is otherwise available to all students, transportation that is provided in a vehicle that is not used specifically to accommodate an eligible child, transportation accommodations that are not indicated in an eligible child's individualized education program (IEP), and transportation provided from home to school or from school to home if no medicaid-covered service allowable under rule 5160-35-05 of the Administrative Code was received at school on that day.

(2) Medical supplies and equipment:

(a) Supplies and equipment that are medically necessary as described in rule 5160-1-01 of the Administrative Code for the care and treatment of an eligible child with an IEP while attending school and that are necessary for the qualified practitioner, as described in rule 5160-35-05 of the Administrative Code, to perform his or her function for an eligible child.

(b) Claims for the cost of medical supplies and equipment are reimbursed through the cost reporting process in accordance with paragraph (K)(2) of rule 5160-35-04 of the Administrative Code.

(c) Unallowable: supplies and equipment furnished to an eligible child for use outside the school. In order to be reimbursed for supplies and equipment furnished to an eligible child for use outside the school, the school will be approved under the medicaid program as a medical supplies provider. See Chapter 5160-10 of the Administrative Code for coverage, limitation, billing, and reimbursement provisions relative to medical supplies providers.

(d) Claims cannot be submitted for medical supplies and equipment for which a claim was submitted or should have been submitted through another program.

(C) The service provided is to be necessary to enable the eligible child to access medically necessary services of the type, frequency, scope, and duration that fall within the normal range of services considered under acceptable standards of medical and healing arts professional practice, as appropriate, in accordance with rule 5160-1-01 of the Administrative Code.

(D) The eligible child's IEP is to contain the following components. These IEP components do not supplant any practitioner plan of care, and will:

(1) Be based on the initial assessment/evaluation conducted during the evaluation team report (ETR) as defined in rule 3301-51-01 of the Administrative Code or the subsequent assessments/evaluations and re-assessments/re-evaluations.

(2) Be signed by the qualified practitioner who recommends the service as a result of the assessment/evaluation, re-assessment/re-evaluation.

(3) Include specific services to be provided, and the amount, duration and frequency of each service.

(4) Include specific goals to be achieved for each service, including the level or degree of improvement expected.

(6) Specify timelines forre-assessment, which should be no more than twelve-months from the date of the initial evaluation or re-assessment of the eligible child and updates to the IEP.

(E) The eligible child's school services plan of care will contain the following components. These components do not supplant any practitioner plan of care. The school services plan of care does not supplant any state or federal processes or timelines related to identifying and serving eligible children with disabilities.

(1) Be based on an assessment of need conducted by an authorized school district provider or community provider.

(2) Be signed by the authorized school district provider in accordance with rule 5160-35-02 of the Administrative Code who recommends the service as a result of the assessment of need.

(3) Include specific services to be used, and the amount, duration, and frequency of each service.

(4) Include specific goals to be achieved as a result of services provided, including the level or degree of improvement expected.

(5) For nursing services, reference and identify the location of the prescription of a physician, and for medications, reference and identify the location of the prescription of a physician, physician assistant, or an advanced practice nurse in accordance with Ohio law.

(6) Specify timelines for re-assessment, which should be no more than twelve-months from the date of the initial evaluation or re-assessment, of the eligible child and updates to the school services plan of care.

(7) Include specific criteria regarding referrals to community providers, when appropriate.

(F) The documentation for the provision of each service will be maintained for purposes of an audit trail. Documentation will include:

(1) The date (i.e., day, month, and year) that the services, medical supplies or equipment were provided.

(2) The full legal name of the eligible child for whom the services, medical supplies or equipment was provided.

(3) A description of the services, medical supplies or equipment provided and location where the services, medical supplies and/or equipment are delivered (may be in case notes or a coded system with a corresponding key).

(4) The duration in minutes or time in/time out of the transportation. Duration in minutes is acceptable if the schedule of the person delivering the service is maintained on file.

(5) A description of actual progress the eligible child is making/has made toward the stated goals in the practitioner plan of care or the school services plan of care for each continuous three-month reporting period.

(6) The signature or initials of the person delivering the services, medical supplies or equipment on each entry of services, medical supplies or equipment delivery. Each documentation recording sheet will contain a legend that indicates the name (electronic, typed, or printed), title, signature, and initials of the person delivering the services, medical supplies or equipment to correspond with each entry's identifying signature or initials.

(7) A description of efforts made to coordinate services with the eligible child's physical or behavioral health provider in accordance with the medicaid provider agreement.

(G) The documentation for reimbursement for services will be submitted in accordance with rule 5160-35-04 of the Administrative Code.

Last updated January 5, 2026 at 8:12 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-35-07 Services that can be provided by medicaid school program (MSP) providers to eligible children enrolled in medicaid without a plan of care.

(A) The purpose of this rule is to set forth the services authorized for medicaid coverage, beyond those indicated in rules 5160-35-05 and 5160-35-06 of the Administrative Code, that an MSP provider can provide, and to set forth the conditions for providing the services.

(B) MSP providers listed in rule 5160-35-05 of the Administrative Code are authorized to provide services to eligible children without a school services plan of care or an IEP defined in paragraph (B) of rule 5160-35-05 of the Administrative Code with sufficient documentation of medical necessity:

(1) Physical, mental, and behavioral health screenings recognized as valid and within scope of practice by the direct service providers listed in rule 5160-35-05 of the Administrative Code, and used to identify eligible children who may be at risk of experiencing physical, mental, or behavioral health conditions, and refer for services as appropriate.

(2) Administration of medication prescribed in accordance with paragraph (A)(11) of rule 5160-35-01 of the Administrative Code.

(3) Contacting the prescribing or ordering providers about prescription or treatment orders.

(4) Consultation with parents and providers regarding a physical, mental, or behavioral health condition or diagnosis.

(5) Administration of the children and adolescent strengths and needs (CANS) assessment as defined in rule 5160-59-01 of the Administrative Code for children who have not had a CANS assessment previously completed.

(6) Direct service activities to address tobacco prevention, cessation, and vaping.

(7) Screening, brief intervention, referral, and treatment (SBIRT) as defined in rule 5160-27-02 of the Administrative Code.

(C) Services provided to an eligible child as described in this rule are subject to all provisions described in rules 5160-35-02 and 5160-35-04 of the Administrative Code.

(D) Services provided to an eligible child as described in this rule are subject to provisions listed in paragraphs (F), (G), (H), (K), (L), and (M) of rule 5160-35-05 of the Administrative Code.

(E) Documentation of MSP services provided to an eligible child described in this rule is subject to provisions described in paragraph (F) of rule 5160-35-06 of the Administrative Code.

Last updated January 5, 2026 at 8:12 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Chapter 5160-36 Program of All-Inclusive Care for the Elderly (PACE)

Ohio Adm.Code 5160-36-01 Program of all-inclusive care for the elderly (PACE) definitionsand acronyms.

(A) "Authorized representative" has the same meaning as in rule 5160:1-1-01 of the Administrative Code.

(B) "Capitated payment" means the monthly payment paid to the program of all inclusive care for the elderly PACE organization by the Ohio department of medicaid (ODM) for medical care and services provided to medicaid recipients enrolled in PACE.

(D) "Involuntary disenrollment" means the disenrollment of a participant from PACE at the request of the PACE organization or a county department of job and family services.

(E) "PACE" means the 'program of all-inclusive care for the elderly' as set forth in 42 C.F.R. Part 460 as in effect on October 1, 2019.

(F) "PACE center" means a facility operated by a PACE organization where primary care or other related services offered by PACE are provided to participants.

(G) "PACE organization" means an entity that has a medicaid provider agreement and also has in effect a PACE agreement with the centers for medicare and medicaid services (CMS) and the Ohio department of aging (ODA).

(H) "PACE agreement" means an agreement between a PACE organization, CMS, and ODA.

(I) "Participant" means a person enrolled in and receiving services through PACE.

(J) "Private pay participant" means an individual who does not meet the medicaid eligibility criteria but chooses to participate in PACE and is responsible for payment of the PACE organization's private pay premium.

(K) "Service area" means the geographic area in which a PACE organization is approved by CMS and ODA to provide services to PACE participants.

(L) "State administering agency" means the state agency responsible for administering the PACE agreement. Pursuant to section 173.50 of the Revised Code ODA shall serve as the state administering agency for PACE in Ohio.

(M) "Voluntary disenrollment" means the disenrollment of a participant from PACE at the request of the participant or the participant's authorized representative.

History

Effective: January 1, 2020
Promulgated Under: 119.03

Ohio Adm.Code 5160-36-02 Program of all-inclusive care for the elderly (PACE) program administration.

(A) In accordance with section 173.50 of the Revised Code, the Ohio department of aging (ODA) shall serve as the designated state administering agency for PACE and shall adhere to and monitor the implementation of all applicable requirements for the program's administration as set forth in 42 C.F.R Part 460 as in effect on October 1, 2019.

(B) ODA shall:

(1) Facilitate the process in which prospective PACE organizations apply to the centers for medicare and medicaid services (CMS) for approval to provide PACE services;

(2) Enter into a PACE agreement with (CMS) and each PACE organization approved by CMS to provide PACE services to participants in Ohio who reside in the PACE organization's designated service area. The content and duration of that agreement shall conform to standards set forth in 42 C.F.R. Part 460 as in effect on October 1, 2019.

(3) Verify that PACE organizations providing PACE services have signed medicaid provider agreements as required by rule 5160-1-17 of the Administrative Code.

(4) Work with PACE organizations to assist individuals seeking enrollment in PACE.

(5) Manage PACE enrollment.

(6) Adopt rules including, but not limited to, participant eligibility, participant enrollment, participant voluntary disenrollment and participant involuntary disenrollment.

(7) Confer as necessary and appropriate with the Ohio department of medicaid (ODM) on matters including but not limited to:

(a) Participant eligibility;

(b) Participant enrollment and disenrollment, and program waiting list;

(d) Designating each PACE organization's service area;

(e) The enrollment and disenrollment of PACE organizations; and

(f) The termination of PACE agreements.

(C) ODM shall be responsible for the capitated payments made to PACE organizations for medicaid services rendered to PACE participants.

History

Effective: January 1, 2020
Promulgated Under: 119.03

Ohio Adm.Code 5160-36-03 Medicaid funded program of all-inclusive care for the elderly (PACE) eligibility.

(A) To be eligible and maintain eligibility for PACE, an individual will meet the requirements for PACE participant eligibility set forth in rule 173-50-02 of the Administrative Code and will have been determined to be eligible for medicaid in accordance with Chapters 5160:1-3 to 5160:1-6 of the Administrative Code.

(B) If a PACE participant who is also enrolled in medicaid has a continuous period of institutionalization as defined in rule 5160:1-6-01.1 of the Administrative Code, that individual's patient liability amount is to be calculated by the county department of job and family services as directed in rule 5160:1-6-07.1 of the Administrative Code.

(C) Individuals who fail to meet the eligibility requirements in paragraph (A) of this rule will not be enrolled as a medicaid participant in PACE.

(1) Once enrolled, participants who no longer meet the eligibility requirements in paragraph (A) of this rule will be involuntarily disenrolled from the medicaid-funded component of PACE pursuant to rule 173-50-05 of the Administrative Code.

(2) An individual who no longer meets medicaid eligibility requirements in paragraph (A) of this rule may continue non-medicaid funded enrollment in PACE as defined within rule 173-50-02 of the Administrative Code.

(D) PACE eligibility and enrollment for persons who are either medicaid enrollees or non-medicaid enrollees are described in section 173.50 of the Revised Code.

Last updated November 7, 2023 at 8:15 AM

History

Effective: November 5, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-36-05 Program of all-inclusive care for the elderly (PACE)interdisciplinary team, participant plan of care, and services.

(A) Each PACE organization shall establish and maintain at each PACE center an interdisciplinary team to assess the care and service needs of participants. The composition, qualifications, and activities of the interdisciplinary team shall be consistent with 42 C.F.R. Part 460 as in effect on October 1, 2019.

(B) PACE organizations shall ensure that all participants have access to all medically necessary services including, but not limited to, services covered by Ohio's medicaid program, in addition to those prescribed in 42 C.F.R. Part 460.92 as in effect on October 1, 2019 to 42 C.F.R. Part 460.96 as in effect on October 1, 2019.

(1) Services provided shall be sufficient in their amount, duration and scope to meet the participant's medical, physical, emotional, and social needs as identified in the comprehensive assessment to achieve the measurable outcomes identified in the participant's plan of care.

(2) Services provided shall be reflected in the participant's plan of care unless the services are an emergency service.

History

Effective: January 1, 2020
Promulgated Under: 119.03

Ohio Adm.Code 5160-36-06 Program of all-inclusive care for the elderly (PACE) organization reimbursement.

(A) PACE is a full-risk program in which the PACE organization assumes all financial risk for the cost of the medical care and services provided to participants.

(B) PACE organizations shall receive a monthly capitated payment from the Ohio department of medicaid (ODM) for each PACE participant enrolled in the medicaid program including individuals enrolled in both medicaid and medicare.

(D) The amount paid in accordance with paragraph (B) of this rule represents the total maximum payment obligation of the state administering agency to the PACE organization for the cost of medical care and services provided to participants enrolled in medicaid including those participants enrolled in both medicaid and medicare.

(E) The PACE organization shall accept the capitation payment amount as payment in full for medicaid participants and shall not bill, charge, collect, or receive any other form of payment from ODM or from, or on behalf of, the participant, except as permitted under 42 C.F.R. Part 460.182(c) as in effect on October 1, 2019.

History

Effective: January 1, 2020
Promulgated Under: 119.03

Chapter 5160-40 Individual Options waiver

Ohio Adm.Code 5160-40-01 Medicaid home and community-based services program - individual options waiver.

(A) Purpose

(1) The Ohio department of developmental disabilities (DODD) is responsible for the daily operations of the individual options (IO) waiver which will be administered pursuant to sections 5166.02 and 5166.20 of the Revised Code.

(2) DODD operates the IO waiver program pursuant to an interagency agreement with the Ohio department of medicaid (ODM) in accordance with section 5162.35 of the Revised Code.

(B) Definitions

(1) "County board" means a county board of developmental disabilities established under Chapter 5126. of the Revised Code.

(2) "Funding range" means the dollar range to which an individual has been assigned for the purpose of funding waiver services. The funding range applicable to an individual is determined by the score derived from an assessment using the Ohio developmental disabilities profile "ODDP" that has been completed by a county board employee qualified to administer the tool.

(3) "Home and community-based services" (HCBS) means any federally approved medicaid waiver service provided to a waiver enrollee as an alternative to institutional care under Section 1915(c) of the Social Security Act, 49 Stat. 620 (1935), 42 U.S.C.A. 1396n, as in effect on January 1, 2024, under which federal reimbursement is provided for designated home and community-based services to eligible individuals.

(4) "Individual" means a person with a developmental disability who is eligible to receive HCBS as an alternative to placement in an intermediate care facility for individuals with intellectual disabilities (ICF/IID) under the applicable HCBS waiver. A guardian or authorized representative may give, refuse to give or withdraw consent for services and may receive notice on behalf of an individual to the extent permitted by applicable law.

(5) "Individual funding level" means the total funds, calculated on a twelve month basis, that are necessary for payment for waiver services that have been determined through the individual service plan (ISP) development process to be sufficient in amount, duration and scope to meet the health and welfare needs of an individual.

(6) "Individual Service Plan" (ISP) means a written description of the services, supports, and activities to be provided to an individual. The ISP is developed using a person-centered planning process.

(7) "Participant direction" means an individual has authority to make decisions about the individual's waiver services and accepts responsibility for taking a direct role in managing the services. Participant direction includes the exercise of budget authority and employer authority.

(8) "Person-centered planning" is a process directed by the individual, that identifies his or her strengths, values, capacities, preferences, needs, and desired outcomes. The process includes team members who assist and support the individual to identify and access medically necessary services and supports needed to achieve his or her defined outcomes in the most inclusive community setting.

(9) "Provider" means a person or agency who is eligible per Chapter 5123-2 of the Administrative Code and rule 5160-1-17.2 of the Administrative Code to provide IO waiver services as specified in this rule.

(10) "SSA" means a service and support administrator who is eligible to perform the functions of service and support administration per rules 5123-4-02 and 5123-5-02 of the Administrative Code.

To be eligible for the IO waiver program:

(1) The individual's medicaid eligibility has been established in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code;

(2) The individual has been determined to have a developmental disabilities level of care in accordance with rule 5123-8-01 of the Administrative Code;

(3) The individual's health and welfare can be ensured through the utilization of IO waiver services at or below the federally approved cost limitation, and other formal and informal supports regardless of funding source;

(4) The individual participates in the development of a person-centered services plan in accordance with the process and requirements set forth in rules 5123-9-02 and 5123-4-02 of the Administrative Code; and

(5) The individual requires the provision of at least one waiver service monthly as documented in the individual's approved person-centered services plan.

(D) Enrollment

(1) Requests for the IO waver program are set forth in rules 5160:1-2-03 and 5123-9-01 of the Administrative Code utilizing ODM 02399 form Request for Medicaid Home and Community Based Services (HCBS) Waiver.

(2) Individuals who meet the eligibility criteria in paragraph (C) of this rule, or their legal representative, will be informed of the following:

(a) All services available on the IO waiver, and any choices that the individual may make regarding those services;

(b) Any viable alternative to the waiver; and

(3) DODD allocates waivers to the county board in accordance with section 5166.22 of the Revised Code.

(4) The county board offers an available IO waiver to eligible individuals in accordance with applicable waiting list category requirements set forth in rules 5160-41-05 and 5123-9-04 of the Administrative Code.

(5) An individual's continued enrollment in the IO waiver program is redetermined no less frequently than every twelve months beginning with the individual's initial enrollment date or subsequent redetermination date. Individuals must continue to meet the eligibility criteria specified in paragraph (C) of this rule to continue enrollment in the waiver program.

(6) The maximum number of individuals that can be enrolled in the IO waiver program statewide will not exceed the allowable number specified in the federally approved waiver document.

(E) Benefit Package

(1) The IO waiver program provides necessary home and community-based services to individuals of any age as an alternative to institutional care in an intermediate care facility for individuals with intellectual disabilities (ICF/IID).

(a) The IO waiver program benefit package, as indicated in the federally approved waiver application, is limited to the services specified in Chapter 5123-9 of Administrative Code.

(b) The IO waiver program supports individuals who want to direct some of their services through participant direction. The individual or the individual's guardian or the individual's designee perform the duties associated with participant direction.

(2) All services will be provided to an individual enrolled in the IO waiver program pursuant to a written person-centered ISP.

(a) The ISP will be developed by qualified persons with input from the individual in accordance with rule 5123-4-02 of the Administrative Code;

(b) The ISP will be developed to include only waiver services which are consistent with efficiency, economy and quality of care and identify non-waiver services, regardless of funding source; and

(c) The ISP will include an individual funding level. If the county board, with the involvement of the individual enrolled on the IO waiver program, is unable to recommend an ISP that includes a funding level within or below the funding range, the county board will inform the individual of the right to request prior authorization as specified in rule 5123-9-07 of the Administrative Code and will provide the individual notification of hearing rights.

(3) The ISP is subject to approval by ODM and DODD pursuant to section 5166.05 of the Revised Code. Notwithstanding the procedures set forth in this rule, ODM may in its sole discretion, and in accordance with section 5166.05 of the Revised Code direct the county board or DODD to amend ISPs for individuals.

(4) When DODD, ODM, or the county board takes action to approve, deny, or terminate enrollment in the IO waiver program, or to deny or change the level of waiver services delivered to an enrollee, the individual will be notified of his or her hearing rights in accordance with division 5101:6 of the Administrative Code.

(5) The county board shall offer an available IO waiver to eligible individuals in accordance with applicable waiting list category requirements set forth in rules 5160-41-05 and 5123-9-04 of the Administrative Code.

(F) Service Provision

(1) Authorized IO waiver services will be provided by persons or agencies who:

(a) Are eligible per rule 5160-1-17.2 of the Administrative Code and

(b) Are eligible in accordance with chapter 5123-2 and if applicable chapter 5123-3 of the Administrative Code.

(2) Services will be provided utilizing person-centered practices and in settings in accordance with 42 C.F.R. 441.530 (as in effect January 1, 2024).

(3) Individuals enrolled, or their legal representative, will be informed of freedom of choice in qualified providers in accordance with rule 5160-41-08 of the Administrative Code and 42 C.F.R.431.51 (as in effect on January 1, 2024).

(4) IO waiver program payment standards are operated in accordance with rule 5160-41-18 of the Administrative Code.

The maximum allowable payment rates of the IO waiver program services are provided in Chapter 5123-9 of the Administrative Code.

(5) ODM may conduct periodic monitoring and compliance reviews in accordance with section 5162.10 of the Revised Code.

Reviews may consist of, but are not limited to, physical inspections of records and sites where services are provided, interviews of providers, recipients, and administrators of waiver services.

(6) Records related to the administration and provision of IO waiver services may be reviewed by ODM, the auditor of the state, the attorney general, and the medicaid fraud control unit or their designees per sections 5162.10 and 5160.22 of the Revised Code.

(7) Individuals enrolled in the IO waiver program are responsible for the provision of information to administering agencies as set forth in Chapter 5160:1-2 of the Administrative Code.

Last updated July 2, 2024 at 10:48 AM

History

Effective: July 1, 2024
Promulgated Under: 119.03

Chapter 5160-41 HCBS Waiver Programs for Individuals with Intellectual and Developmental Disabilities

Ohio Adm.Code 5160-41-05 Waiting lists for home and community-based services administered by the Ohio department of developmental disabilities.

(A) Purpose

This rule sets forth the requirements of a county board of developmental disabilities to establish and maintain a waiting list for home and community-based services.

(B) Definitions

(1) "County board" means a county board of developmental disabilities established under Chapter 5126. of the Revised Code with local administrative authority.

(2) "DODD" means the Ohio department of developmental disabilities established under section 121.02 of the Revised Code.

(3) "Home and community-based services" means services provided under a medicaid-funded waiver pursuant to section 5166.04 of the Revised Code.

(4) "ODM" means the Ohio department of medicaid.

(5) "Waiting lists" means a list established and maintained in accordance with rule 5123-9-04 of the Administrative Code.

(1) County boards shall establish and maintain waiting lists for home and community-based services in accordance with rule 5123-9-04 of the Administrative Code.

(2) There shall be no waiting list for the following services:

(a) Medicaid state plan services.

(b) Home and community-based services for individuals already enrolled in a home and community-based services waiver administered by DODD who are assessed and determined to have a need for the services covered by the waiver in which the individual is enrolled.

(c) Home and community-based services to children who are subject to a determination under section 121.38 of the Revised Code and require the services.

(D) DODD shall monitor compliance with this rule by the county boards and their contract agencies.

(E) Due process.

(1) Whenever an applicant for or enrollee of a waiver program administered by DODD is affected by any action proposed or taken by DODD and/or ODM, or when action is recommended by the county board, the entity recommending or taking the action will provide medicaid due process in accordance with section 5101.35 of the Revised Code through the state fair hearing process, and as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code. Such actions may include, but are not limited to, the approval, denial, or termination of enrollment or a denial or change in the level, and/or type of waiver services delivered to a waiver enrollee.

(2) If an applicant or enrollee requests a hearing, as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code, the participation of DODD and the county board is required during the hearing proceedings to justify the decision under appeal.

Last updated June 25, 2025 at 5:51 PM

History

Effective: April 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-41-08 Free choice of provider requirements for medicaid home and community-based services programs administered by the Ohio department of developmental disabilities.

(A) The purpose of this rule is to set forth the requirements the Ohio department of developmental disabilities (DODD) must meet to assure free choice of provider.

(B) The DODD through an interagency agreement with the Ohio department of medicaid (ODM), acts as the administrative agency for components of the medicaid home and community-based services programs in accordance with section 5162.35 of the Revised Code. In accordance with section 5166.21 of the Revised Code, the DODD, as the designated administrator, shall promulgate rule(s) to require that recipients of home and community-based services are provided choice of medicaid home and community-based providers consistent with federal free choice of provider requirements set forth in 42 C.F.R. 431.51 (October 1, 2021). Any rule(s) authorized by this rule and promulgated by the DODD are valid only to the extent they are consistent with 42 C.F.R. 431.51. If the rules promulgated by DODD are capable of more than one interpretation, they shall be applied in a manner most consistent with the letter and intent of 42 C.F.R. 431.51.

(C) Rules promulgated by DODD shall establish policies related to the provision of free choice of medicaid home and community-based service providers for each service specified in a recipient's individual service plan and shall include the following:

(1) The general roles and responsibilities of the county board of developmental disabilities as specified in rule 5123-9-11 of the Administrative Code.

(2) The roles and responsibilities of the county board of developmental disabilities for the assurance of due process and fair hearing rights regarding recipients' free choice of medicaid home and community-based service providers.

(3) The roles and responsibilities of DODD for monitoring and assuring compliance with recipients' free choice of medicaid home and community-based service provider requirements.

(D) ODM shall conduct periodic monitoring and compliance reviews related to free choice of medicaid home and community-based service providers.

Last updated April 1, 2022 at 8:26 AM

History

Effective: April 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-41-16 Assistance to enable a county board of developmental disabilities to pay non-federal share of medicaid expenditures for home and community-based services.

(A) Purpose.

This rule authorizes the provisions set forth in rule 5123-4-05 of the Administrative Code which sets forth the process a county board of developmental disabilities follows to request assistance from the department of developmental disabilities (DODD) for home and community-based services (HCBS) to individuals with developmental disabilities in that county.

(B) The following definitions are applicable to this rule:

(1) "County board" means a county board of developmental disabilities established under Chapter 5126. of the Revised Code.

(2) "Home and community-based services" means medicaid-funded home and community-based services provided pursuant to section 5166.20 of the Revised Code.

(3) "OBM" means the office of budget and management as established by section 121.02 of the Revised Code.

(4) "ODM" means the Ohio department of medicaid.

(5) "DODD" means the Ohio department of developmental disabilities established under section 121.02 of the Revised Code.

(C) A county board of developmental disabilities may request assistance from DODD to pay the non-federal share of medicaid expenditures for home and community-based services in accordance with rule 5123-4-05 of the Administrative Code.

(D) Prior to a county board of developmental disabilities receiving assistance, DODD will notify and consult with both OBM and ODM.

(E) The DODD will render a decision on the provision of assistance to a county board in accordance with the process, criteria, and documentation established in rule 5123-4-05 of the Administrative Code.

(F) Documentation submitted to DODD by a county board to request assistance and any documentation used by DODD to determine a decision of approval or denial may be reviewed by OBM or ODM.

Last updated July 7, 2025 at 6:53 PM

History

Effective: July 3, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-41-17 Medicaid home and community-based services program - self-empowered life funding waiver.

(A) Purpose.

(1) The Ohio department of developmental disabilities (DODD) is responsible for the daily operation of the self-empowered life funding (SELF) waiver which will be administered pursuant to sections 5166.02 and 5166.20 of the Revised Code.

(2) DODD operates the SELF waiver program pursuant to an interagency agreement with the Ohio department of medicaid (ODM) in accordance with section 5162.35 of the Revised Code.

(B) Definitions.

(1) "Budget authority" means an individual has the authority and responsibility to manage the individual's budget for participant-directed services. This authority supports the individual in determining the budgeted dollar amount for each participant-directed waiver service that will be provided to the individual and making decisions about the acquisition of participant-directed waiver services that are authorized in the individual service plan.

(2) "Common law employer" means the individual is the legally responsible and liable employer of staff selected by the individual. The individual hires, supervises, and discharges staff. The individual is liable for the performance of necessary employment-related tasks and uses a financial management services entity under contract with the state to perform necessary payroll and other employment-related functions as the individual's agent in order to ensure that the employer-related legal obligations are fulfilled.

(3) "County board" means a county board of developmental disabilities established under Chapter 5126. of the Revised Code.

(4) "Employer authority" means an individual has the authority to recruit, hire, supervise, and direct the staff who furnish supports. The individual functions as the common law employer or the co-employer of these staff.

(5) "Financial management services" means services provided to an individual who directs some or all of the individual's waiver services.

(6) "Financial management services entity" means a governmental entity and another third-party entity designated to perform necessary financial transactions on behalf of individuals who receive participant-directed services.

(7) "Home and community-based services (HCBS)" means any federally approved medicaid waiver service provided to a waiver enrollee as an alternative to institutional care under Section 1915(c) of the Social Security Act, 49 Stat. 620 (1935), 42 U.S.C.1396n, as in effect on January 1, 2024, under which federal reimbursement is provided for designated home and community-based services to eligible individuals.

(8) "Individual" means a person with a developmental disability who is eligible to receive HCBS as an alternative to placement in an intermediate care facility for individuals with intellectual disabilities (ICF/IID) under the applicable HCBS waiver. A guardian or authorized representative may give, refuse to give, or withdraw consent for services and may receive notice on behalf of an individual to the extent permitted by applicable law.

(9) "Individual Service Plan (ISP)" means a written description of the services, supports, and activities to be provided to an individual. The ISP is developed using a person-centered planning process.

(10) "Participant direction" means an individual has authority to make decisions about the individual's waiver services and accepts responsibility for taking a direct role in managing the services. Participant direction includes the exercise of budget authority and employer authority.

(11) "Person-centered planning" is a process directed by the individual, that identifies his or her strengths, values, capacities, preferences, needs and desired outcomes. The process includes team members who assist and support the individual to identify and access medically necessary services and supports needed to achieve his or her defined outcomes in the most inclusive community setting.

(12) "Provider" means a person or agency who is eligible per Chapter 5123-2 and rule 5160-1-17.2 of the Administrative Code to provide the specific SELF waiver service as specified in this rule.

(13) "SSA" means a service and support administrator who is eligible to perform the functions of service and support administration per rules 5123-4-02 and 5123-5-02 of the Administrative Code.

(14) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date.

To be eligible for the SELF waiver program:

(1) The individual's medicaid eligibilty has been established in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code;

(2) The individual has been determined to have a developmental disabilities level of care in accordance with rule 5123-8-01 of the Administrative Code;

(3) The individual's health and welfare can be ensured through the utilization of SELF waiver services at or below the federally approved cost limitation and other formal and informal supports regardless of funding source;

(5) The individual requires the provision of at least one waiver service on a monthly basis as documented in the individual's approved person-centered services plan.

(D) Enrollment.

(1) Requests for the SELF waiver program are set forth in rules 5160:1-2-03 and 5123-9-01 of the Administrative Code utilizing ODM 02399 form Request for Medicaid Home and Community Based Services (HCBS) Waiver.

(2) Individuals who meet the eligibility criteria in paragraph (C) of this rule will be informed of the following:

(a) All services available on this self-empowered life funding waiver, and any choices that the individual may make regarding those services;

(b) Any viable alternatives to the waiver; and

(3) DODD allocates waivers to the county board in accordance with section 5166.22 of the Revised Code.

(4) The county board offers an available SELF waiver to eligible individuals in accordance with applicable waiting list category requirements set forth in rules 5160-41-05 and 5123-9-04 of the Administrative Code.

(5) An individual's continued enrollment in the SELF waiver program is redetermined no less frequently than every twelve months beginning with the individual's initial enrollment date or subsequent redetermination date. Individuals will continue to meet the eligibility criteria specified in paragraph (C) of this rule to continue enrollment in the waiver program.

(6) The maximum number of individuals that can be enrolled in the SELF waiver program statewide will not exceed the allowable number specified in the federally approved waiver document.

(E) Benefit Package

(1) The SELF waiver program provides necessary home and community-based services to individuals of any age as an alternative to institutional care in an intermediate care facility for individuals with intellectual disabilities (ICF/IID).

(a) The SELF benefit package, as indicated in the federally approved waiver application, is limited to the services specified in Chapter 5123-9 of Administrative Code.

(b) The SELF waiver program is a participant directed program as described in rule 5123-9-40 of the Administrative Code.

(c) Financial management services provided by a financial management services entity are included in the benefit package.

(d) The individual or the individual's guardian or the individual's designee perform the duties associated with participant direction including budget authority and employer authority in accordance with rule 5123-9-40 of the Administrative Code.

(2) All services will be provided to an individual enrolled in the SELF waiver program pursuant to a written person-centered Individual Service Plan (ISP).

(a) The ISP will be developed by qualified persons with input from the individual in accordance with rule 5123-4-02 of the Administrative Code.

(b) The ISP will be developed to include only waiver services which are consistent with efficiency, economy, and quality of care and identify non-waiver services, regardless of funding source.

(4) When DODD, ODM, or the county board acts to, deny, or terminate enrollment in the SELF waiver program, or to deny or reduce the level of waiver services delivered to an enrollee, the individual will be notified of his or her hearing rights in accordance with division 5101:6 of the Administrative Code.

(F) Service Provisions

(1) Authorized SELF waiver services will be provided by persons or agencies who:

(a) Are eligible per rule 5160-1-17.2 of the Administrative Code and

(b) Are eligible in accordance with Chapter 5123-2 and if applicable 5123-3 of the Administrative Code.

(2) Services will be provided utilizing person-centered practices and in settings in accordance with 42 C.F.R. 441.530 (as in effect January 1, 2024).

(3) Individuals enrolled, or their legal representative will be informed of freedom of choice in qualified providers in accordance with rule 5160-41-08 of the Administrative Code and 42 C.F.R. 431.51 (as in effect on January 1, 2024).

(4) SELF waiver program payment standards are operated in accordance with rules 5160-41-20 and 5123-9-40 of the Administrative Code.

The maximum allowable payment rates of the SELF waiver program services are provided in Chapter 5123-9 of the Administrative Code.

(5) ODM may conduct periodic monitoring and compliance reviews in accordance with section 5162.10 of the Revised Code.

Reviews may consist of, but are not limited to, physical inspections of records and sites where services are provided, interviews of providers, recipients, and administrators of waiver services.

(6) Records related to the administration and provision of SELF waiver services may be reviewed by ODM, the auditor of the state, the attorney general, and the medicaid fraud control unit or their designees per sections 5162.10 and 5160.22 of the Revised Code.

(7) Individuals enrolled in the SELF waiver program are responsible for the provision of information to administering agencies as set forth in Chapter 5160:1-2 of the Administrative Code.

Last updated July 2, 2024 at 10:48 AM

History

Effective: July 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-41-18 Individual options waiver-payment standards.

(A) Purpose.

The purpose of this rule is to establish the payment standards for the individual options home and community-based services (HCBS) waiver for services provided to individuals enrolled in a HCBS program, as a component of the medicaid program and as administered by the Ohio department of developmental disabilities (DODD) in accordance with sections 5166.02 and 5166.23 of the Revised Code.

(B) The DODD is responsible for the daily administration of certain components of the medicaid program, to include HCBS, pursuant to an interagency agreement with the Ohio department of medicaid (ODM) in accordance with sections 5162.35 and 5166.21 of the Revised Code.

(C) Individuals enrolled in the individual options HCBS program administered by DODD are subject to payment standards set forth in this rule and the rules associated with the individual options waiver program as established in Chapter 5123-9 of the Administrative Code.

(D) Payment for individual options waiver services will not exceed the maximum rates established in Chapter 5123-9 of the Administrative Code.

(E) Claims for the provision of HCBS will be submitted in accordance with the process specified in rule 5123-9-06 of the Administrative Code.

(F) Claims for the provision of HCBS will be paid as indicated in this rule when the following conditions exist:

(1) The waiver service is provided to an individual who is enrolled in the individual options waiver program at the time of service; and

(2) The waiver service is provided within the limitations specified by the individual options waiver program in which the individual is enrolled; and

(3) The waiver service is provided to an enrollee who is not an inpatient of a hospital, unless otherwise permitted in other HCBS waiver program rules pertaining to acute care, and is not residing in a nursing facility or an intermediate care facility for individuals with intellectual disabilities (ICF/IID).

(a) An individual enrolled in a DODD administered waiver program which offers residential respite as one of the waiver services will not be considered a resident of an ICF/IID if the ICF/IID is providing the residential respite service.

(b) An ICF/IID providing respite services for any DODD administered waiver program that offers such services will not bill medicaid through the ICF/IID program. Payments for respite services will be made through the waiver program in which the individual is enrolled.

(G) In accordance with rule 5160-1-13.1 of the Administrative Code, payments made under authority of this rule constitute payment-in-full and will not be construed as a partial payment.

(H) ODM authority.

ODM retains the final authority to establish payment rates for waiver services approved under the individual options waiver and has final approval of any policies and rules that govern any component of the medicaid program.

Last updated June 25, 2025 at 5:51 PM

History

Effective: September 6, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-41-19 Level one waiver-payment standards.

(A) Purpose.

The purpose of this rule is to establish the payment standards for the level one home and community-based services (HCBS) waiver for services provided to individuals enrolled in a HCBS program, as a component of the medicaid program and as administered by the department of developmental disabilities (DODD) in accordance with sections 5166.02 and 5166.23 of the Revised Code.

(C) Individuals enrolled in the level one HCBS program administered by DODD are subject to payment standards set forth in this rule and the rules associated with the level one waiver program as established in Chapter 5123-9 of the Administrative Code.

(D) Payment for level one waiver services will not exceed the maximum rates established in Chapter 5123-9 of the Administrative Code.

(E) Claims for the provision of HCBS will be submitted in accordance with the process specified in rule 5123-9-06 of the Administrative Code.

(F) Claims for the provision of HCBS will be paid as indicated in this rule when the following conditions exist:

(1) The waiver service is provided to an individual who is enrolled in the level one waiver program at the time of service; and

(2) The waiver service is provided within the limitations specified by the level one waiver program in which the individual is enrolled; and

(3) The waiver service is provided to an enrollee who is not an inpatient of a hospital unless otherwise permitted in other HCBS waiver program rules pertaining to acute care, and is not residing in a nursing facility or an intermediate care facility for individuals with intellectual disabilities (ICF/IID).

(b) An ICF/IID providing residential respite services for any DODD administered waiver program that offers such services will not bill medicaid through the ICF/IID program. Payments for residential respite services will be made through the waiver program in which the individual is enrolled.

(G) In accordance with rule 5160-1-13.1 of the Administrative Code, payments made under authority of this rule constitute payment-in-full and shall not be construed as a partial payment.

(H) ODM authority.

ODM retains the final authority to establish payment rates for waiver services approved under the level one waiver and has final approval of any policies and rules that govern any component of the medicaid program.

Last updated June 25, 2025 at 5:51 PM

History

Effective: September 6, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-41-20 Self-empowered life funding waiver - payment standards.

(A) Purpose.

The purpose of this rule is to establish the payment standards for the self-empowered life funding (SELF) home and community-based services (HCBS) waiver for services provided to individuals enrolled in a HCBS program, as a component of the medicaid program and as administered by the department of developmental disabilities (DODD) in accordance with sections 5166.02 and 5166.23 of the Revised Code.

(C) Payment for SELF waiver services will not exceed the maximum rates established in rule 5123-9-40 of the Administrative Code.

(D) Claims for the provision of HCBS will be submitted in accordance with the process specified in rule 5123-9-40 of the Administrative Code.

(E) Claims for the provision of HCBS will be paid as indicated in this rule when the following conditions exist:

(1) The waiver service is provided to an individual who is enrolled in the SELF waiver program at the time of service; and

(2) The waiver service is provided within the limitations specified by the SELF waiver program in which the individual is enrolled; and

(3) The waiver service is provided to an enrollee who is not an inpatient of a hospital unless otherwise permitted in other HCBS waiver program rules pertaining to acute care and is not residing in a nursing facility or an intermediate care facility for individuals with intellectual disabilities (ICF/IID).

(F) In accordance with rule 5160-1-13.1 of the Administrative Code, payments made under authority of this rule constitute payment-in-full and will not be construed as a partial payment.

(G) ODM authority.

ODM retains the final authority to establish payment rates for waiver services approved under the SELF waiver and has final approval of any policies and rules that govern any component of the medicaid program.

Last updated September 6, 2024 at 8:20 AM

History

Effective: September 6, 2024
Promulgated Under: 119.03

Chapter 5160-42 Medicaid Home and Community-Based Services-Level One Waiver Program

Ohio Adm.Code 5160-42-01 Medicaid home and community-based services program - level one waiver.

(A) Purpose

(1) The Ohio department of developmental disabilities (DODD) is responsible for the daily operation of the level one (L1) waiver which will be administered pursuant to sections 5166.20 and 5166.02 of the Revised Code.

(2) DODD operates the L1 waiver program pursuant to an interagency agreement with the Ohio department of medicaid (ODM) in accordance with section 5162.35 of the Revised Code.

(B) Definitions

(1) "County board" means a county board of developmental disabilities established under Chapter 5126. of the Revised Code.

(2) "Home and community-based services" (HCBS) means any federally approved medicaid waiver service provided to a waiver enrollee as an alternative to institutional care under Section 1915(c) of the Social Security Act, 49 Stat. 620 (1935), 42 U.S.C.A. 1396n, as in effect on January 1, 2024, under which federal reimbursement is provided for designated home and community-based services to eligible individuals.

(3) "Individual" means a person with a developmental disability who is eligible to receive HCBS as an alternative to placement in an intermediate care facility for individuals with intellectual disabilities (ICF/IID) under the applicable HCBS waiver. A guardian or authorized representative may give, refuse to give, or withdraw consent for services and may receive notice on behalf of an individual to the extent permitted by applicable law.

(4) "Individual Service Plan" (ISP) means a written description of the services, supports, and activities to be provided to an individual. The ISP is developed using a person-centered planning process.

(5) "Participant direction" means an individual has authority to make decisions about the individual's waiver services and accepts responsibility for taking a direct role in managing the services. Participant direction includes the exercise of budget authority and employer authority.

(6) "Person-centered planning" is a process directed by the individual, that identifies his or her strengths, values, capacities, preferences, needs and desired outcomes. The process includes team members who assist and support the individual to identify and access medically necessary services and supports needed to achieve his or her defined outcomes in the most inclusive community setting.

(7) "Provider" means a person or agency who is eligible per Chapter 5123-2 of the Administrative Code and rule 5160-1-17.2 of the Administrative Code to provide L1 waiver services as specified in this rule.

(8) "SSA" means a service and support administrator who is eligible to perform the functions of service and support administration per rules 5123-4-02 and 5123-5-02 of the Administrative Code.

To be eligible for the L1 waiver program:

(1) The individual's medicaid eligibility has been established in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code;

(2) The individual has been determined to have a developmental disabilities level of care in accordance with rule 5123-8-01 of the Administrative Code;

(3) The individual's health and welfare can be ensured through the utilization of L1 waiver services at or below the federally approved cost limitation, and other formal and informal supports regardless of funding source;

(5) The individual requires the provision of at least one waiver service monthly as documented in the individual's approved person-centered services plan.

(D) Enrollment

(1) Requests for the L1 waver program are set forth in rules 5160:1-2-03 and 5123-9-01 of the Administrative Code utilizing ODM 02399 form Request for Medicaid Home and Community Based Services (HCBS) Waiver.

(2) Individuals who meet the eligibility criteria established in paragraph (C) of this rule, or their legal representative will be informed of the following:

(a) All services available on the L1 waiver, and any choices that the individual may make regarding those services;

(b) Any viable alternative to the waiver program; and

(3) DODD allocates waivers to the county board in accordance with section 5166.22 of the Revised Code.

(4) The county board offers an available L1 waiver to eligible individuals in accordance with applicable waiting list category requirements as set forth in rules 5160-41-05 and 5123-9-04 of the Administrative Code.

(5) An individual's continued enrollment in the L1 waiver program is redetermined no less frequently than every twelve months after the individual's initial enrollment or subsequent redetermination date. Individuals must continue to meet the eligibility criteria specified in paragraph (C) of this rule to continue enrollment in the waiver program.

(6) The maximum number of individuals that can be enrolled in the L1 waiver program statewide will not exceed the allowable number specified in the federally approved waiver document.

(E) Benefit Package

(1) The L1 waiver program provides necessary home and community-based services to individuals of any age as an alternative to institutional care in an intermediate care facility for individuals with intellectual disabilities (ICF/IID).

(a) The L1 waiver program benefit package, as indicated in the federally approved waiver application, is limited to the services specified in Chapter 5123-9 of the Administrative Code.

(b) The L1 waiver program supports individuals who want to direct some of their services through participant direction. The individual or the individual's guardian or the individual's designee perform the duties associated with participant direction.

(2) All services will be provided to an individual enrolled on the L1 waiver program pursuant to a written person-centered Individual Service Plan (ISP).

(a) The ISP will be developed by qualified persons with input from the individual in accordance with rule 5123-4-02 of the Administrative Code.

(b) The ISP will be developed to include only waiver services which are consistent with efficiency, economy and quality of care and identify non-waiver services, regardless of funding source.

(3) The ISP is subject to approval by ODM and DODD pursuant to section 5166.05 of the Revised Code. Notwithstanding the procedures set forth in this rule, ODM may in its sole discretion, and in accordance with section 5166.05 of the Revised Code, authorize services and direct the county board or DODD to amend ISPs for individuals.

(4) When DODD, ODM, or the county board acts to, deny, or terminate enrollment in the L1 waiver program, or to deny or reduce the level of waiver services delivered to an enrollee, the individual will be notified of his or her hearing rights in accordance with division 5101:6 of the Administrative Code.

(F) Service Provision

(1) Authorized L1 waiver services will be provided by persons or agencies who:

(a) Are eligible per rule 5160-1-17.2 of the Administrative Code; and

(b) Are eligible per Chapter 5123-2 and if applicable Chapter 5123-3 of the Administrative Code.

(2) Services will be provided utilizing person-centered practices and in settings in accordance with 42 C.F.R. 441.530 (as in effect January 1, 2024).

(4) L1 waiver program payment standards are operated in accordance with rule 5160-41-19 of the Administrative Code.

The maximum allowable payment rates of the L1 waiver program services are provided in Chapter 5123-9 of the Administrative Code.

(5) ODM may conduct periodic monitoring and compliance reviews related to the level one waiver program in accordance with section 5162.10 of the Revised Code.

Reviews may consist of, but are not limited to, physical inspections of records and sites where services are provided, interviews of providers, enrollees, and administrators of waiver services.

(6) Records related to the administration and provision of L1 services may be reviewed b ODM, the auditor of the state, the attorney general, and the medicaid fraud unit or their desgnees per sections 5162.10 and 6160.22 of the Revised Code.

(7) Individuals enrolled in the waiver program will be responsible for provision of information to administering agencies as set forth in Chapter 5160:1-2 of the Administrative Code.

Last updated July 2, 2024 at 10:49 AM

History

Effective: July 1, 2024
Promulgated Under: 119.03

Chapter 5160-43 Specialized Recovery Services Program

Ohio Adm.Code 5160-43-01 Specialized recovery services program definitions.

(A) The following definitions apply to Chapter 5160-43 of the Administrative Code:

(1) "Adult Needs and Strengths Assessment (ANSA)" (8/2021) is an integration information assessment tool for use in the development of individualized person-centered care plans, to monitor outcomes, and to help design and plan systems of care for adults with behavioral health challenges.

(2) "Authorized representative" means a person the individual appoints to act on his or her behalf in accordance with rule 5160-1-33 of the Administrative Code.

(3) "Clinical record" is a record containing written documentation that must be maintained by a service provider.

(4) "Health and safety action plan" means the document created between the Ohio department of medicaid (ODM) or its designee and an individual enrolled in the program that identifies the interventions recommended by the recovery manager to remedy risks to the health and welfare of the individual.

(5) "Home and community-based services (HCBS) setting" has the same meaning as set forth in rule 5160-44-01 of the Administrative Code.

(6) "Incident" means an alleged, suspected or actual event that is not consistent with the routine care of and/or service delivery to an individual as set forth in rule 5160-44-05 of the Administrative Code. Incidents include, but are not limited to abuse, neglect, exploitation, misappropriation, and inappropriate service delivery.

(7) "Individual" means a person who is pending enrollment or who is enrolled in the specialized recovery services program and therefore is directed to adhere to the rules in Chapter 5160-43 of the Administrative Code.

(8) "Individualized placement and support - supported employment (IPS-SE)" means the implementation of evidence-based practices allowing individuals to obtain and maintain meaningful employment by providing training, ongoing individualized support, and skill development to promote recovery. IPS-SE is an evidence based practice which is integrated and coordinated with mental health treatment and rehabilitation designed to provide individualized placement and support to assist individuals with a severe and persistent mental illness to obtain, maintain, and advance within competitive community integrated employment positions.

(9) "Legally responsible family member" means an individual's spouse, or in the case of a minor, the individual's birth or adoptive parent.

(10) "Person-centered service plan" means a document that identifies goals, objectives, and interventions selected by the individual. The plan identifies and addresses the assessed needs, services, and supports of the individual and is developed in accordance with 42 CFR 441.725(a) (October 1,2023).

(11) "Provider" means a person or entity who has a provider agreement with ODM and who delivers a specialized recovery services program service, any other service provider that is directed to adhere to this rule, and all of their respective staff who have direct contact with individuals.

(12) "Provider occurrence" means any alleged, suspected or actual performance or operational issue by a provider furnishing program services that does not meet the definition of an incident as set forth in this rule. Provider occurrences include, but are not limited to, alleged violations of provider eligibility and/or service specification requirements, and billing issues including overpayments and medicaid fraud.

(13) "Recovery management" means the coordination of all specialized recovery services program services received by an individual and assisting him or her in gaining access to needed medicaid services, as well as medical, social, educational, and other resources, regardless of funding source.

(14) "Recovery manager" means the person responsible for performing the needs-based assessment and monitoring the provision of services included in the person-centered service plan to ensure the individual's needs, preferences, health and welfare are supported as described in rule 5160-43-04 of the Administrative Code.

(15) "Significant change" means a variation in the health, care or needs of an individual that warrants further evaluation to determine if changes to the type, amount or scope of services are needed.

(16) "Specialized recovery services" means recovery management and IPS-SE.

(17) "Specialized recovery services program" means the home and community-based services (HCBS) program jointly administered by ODM and the Ohio department of mental health and addiction services (OhioMHAS) or only administered by ODM to provide services to individuals with qualifying diagnoses of severe and persistent mental illness or diagnosed chronic conditions.

(18) "Trans-disciplinary care team" or "care team" means the group of persons freely chosen by the individual to assist and support him or her in the collaboration of creating and implementing a person-centered service plan. The team is led by the individual where possible and must include a recovery manager. It may also include, but is not limited to, the individual's friends, family and natural supports, the physician(s) and other professionals and providers.

Last updated September 3, 2024 at 9:10 AM

History

Effective: September 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-43-02 Specialized recovery services program individual eligibility and program enrollment.

(A) An individual may be eligible for enrollment in the specialized recovery services program if they meet all of the following:

(1) Be at least twenty-one years of age;

(2) Be determined eligible for Ohio medicaid in accordance with Chapters 5160:1-1 to 5160:1-5 of the Administrative Code;

(3) Have a behavioral health diagnosis, be active on the solid organ or soft tissue waiting list, or have a diagnosed chronic condition as listed in qualifying diagnosis appendix which is available on the ODM website at https://medicaid.ohio.gov/resources-for-providers/special-programs-and-initiatives/srs;

(4) Participate in an initial assessment using the "Adult Needs and Strengths Assessment (ANSA)" (8/2021) and obtain a qualifying score of either:

(a) Two or greater on at least one item in the "behavioral/emotional needs" or "risk behaviors" sections; or

(b) Three on at least one item in the "life functioning" section.

(5) Demonstrate needs related to the management of his or her behavioral health or diagnosed chronic condition as documented in the "ANSA" (8/2021);

(6) Have at least one of the following risk factors prior to enrollment in the program:

(a) One or more psychiatric inpatient admissions at an inpatient psychiatric hospital; or

(b) A discharge from a correctional facility with a history of inpatient or outpatient behavioral health treatment while residing in that correctional facility; or

(d) A history of treatment in an intensive outpatient rehabilitation program for greater than ninety days; or

(e) One or more hospital inpatient admissions due to a diagnosed chronic condition as listed in the qualifying diagnosis appendix available at https://medicaid.ohio.gov/resources-for-providers/special-programs-and-initiatives/srs.

(7) Meet at least one of the following:

(a) Currently have a need for one or more of the specialized recovery services to maintain stability, improve functioning, prevent relapse, maintain residency in the community, and be assessed and found that, if not for the provision of home and community-based services (HCBS) for stabilization and maintenance purposes, he or she would decline to prior levels of need (i.e., subsequent medically necessary services and coordination of care for stabilization and maintenance is needed to prevent decline to previous needs-based functioning); or

(b) Previously have met the needs-based criteria described in paragraph (A)(6) of this rule within two years of the date of initial assessment, and be assessed and found that, but for the provision of HCBS for stabilization and maintenance purposes, he or she would decline to prior levels of need (i.e., subsequent medically necessary services and coordination of care for stabilization and maintenance is needed to prevent decline to previous needs-based functioning).

(8) Reside in an HCBS setting;

(9) Demonstrate a need for specialized recovery services, and not otherwise receive those services;

(10) Have needs that can be safely met through the program in an HCBS setting as determined by the Ohio department of medicaid (ODM) or its designee; and

(11) Participate in the development of a person-centered service plan.

(B) To be enrolled in and to maintain enrollment in the specialized recovery services program, an individual shall be determined by ODM or its designee to meet all of the following requirements:

(1) Be determined eligible for the program in accordance with paragraph (A) of this rule;

(2) Maintain residency in an HCBS setting;

(3) Agree to and receive recovery management services in accordance with his or her person-centered service plan from ODM or its designee including, but not limited to:

(a) Participation in reassessments at least annually and ongoing reassessments as needed;

(b) Participation in the development and implementation of the person-centered service plan and consent to the plan by signing and dating it; and

(c) Participation in quality assurance and participant satisfaction activities during his or her enrollment in the program including, but not limited to, in-person visits.

(C) If an individual fails to meet any of the requirements set forth in paragraph (A) of this rule, the individual shall be denied enrollment in the program.

(D) Once enrolled in the program, an individual's level of need shall be reassessed at least annually, and more frequently if there is a significant change in the individual's condition that may impact his or her health and welfare. If the reassessment determines the individual no longer meets the requirements set forth in paragraph (B) of this rule, he or she shall be disenrolled from the program.

(E) If, at any time, it is determined that an individual enrolled in the program no longer meets the requirements set forth in paragraph (A) and/or paragraph (B) of this rule, he or she shall be disenrolled from the program. Reassessment pursuant to paragraph (D) of this rule is not required to make this determination.

(F) If an individual is denied enrollment in the program pursuant to paragraph (C) of this rule, or is disenrolled from the program pursuant to paragraph (D) or (E) of this rule, the individual shall be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

Last updated October 15, 2021 at 8:27 AM

History

Effective: October 15, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-43-03 Specialized recovery services program individual rights and responsibilities.

(A) Enrollment in the specialized recovery services program is voluntary. Individuals enrolled in the program in accordance with rule 5160-43-02 of the Administrative Code shall be informed of their rights and responsibilities. Individuals also have choice and control over the arrangement and provision of home and community-based services (HCBS), and the selection and control over the direction of approved services.

(B) An individual enrolled in a specialized recovery services program has the right to:

(1) Be treated with dignity and respect.

(2) Be protected from abuse, neglect, exploitation and other threats to personal health, safety and well-being.

(3) Appoint an authorized representative to act on his or her behalf in accordance with rule 5160-1-33 of the Administrative Code.

(4) Receive program services in a person-centered manner that is in accordance with an approved person-centered service plan, that is attentive to the individual's needs and maximizes personal independence.

(5) Choose his or her recovery management agency and recovery managers from among qualified and available providers; and

(a) Have the recovery manager explain the program, how it will assist the individual, and his or her rights and responsibilities;

(b) Participate with the recovery manager and the care team in the person-centered service plan development process, and when possible, lead the process;

(d) Effectively communicate with the recovery manager and care team and receive information in a manner that is easy to understand;

(e) Be able to meet privately with the recovery manager;

(f) Receive ongoing assistance from the recovery manager; and

(g) Be able to request a change of recovery management agency or recovery manager.

(6) Make informed choices regarding the HCBS and supports he or she receives and from whom those services are received.

(7) Obtain the results of criminal records checks for current agency providers or provider applicants pursuant to section 5164.34 of the Revised Code. All personal identifying information such as home address, social security number, and home phone number may be redacted to ensure the safety and security of the provider.

(8) Access files, records or other information related to his or her health care.

(9) Be assured of confidentiality of protected health information pursuant to relevant confidentiality and information disclosure laws.

(10) Request assistance with problems, concerns, and issues, and suggest changes without fear of repercussion.

(11) Be fully informed about how to contact the recovery manager and the Ohio department of medicaid (ODM) or its designee, with problems, concerns, issues, or inquiries.

(12) Be informed of the right to appeal decisions made by ODM or its designee about program eligibility or services pursuant to division 5101:6 of the Administrative Code.

(1) Participate in, and cooperate during assessments to determine ongoing program eligibility and service needs.

(2) Decide who, in addition to the recovery manager, will participate in the service planning process.

(3) Participate in, and cooperate with, the recovery manager and care team in the development and implementation of the person-centered service plan.

(4) Participate in the recruitment, selection and dismissal of his or her provider(s).

(5) Not direct any HCBS provider to act in a manner that is contrary to relevant ODM-administered HCBS program requirements, medicaid rules, regulations and all other applicable laws, rules and regulations.

(6) Work with the recovery manager when he or she wants to make a change in provider. Notification to the recovery manager shall include the end date of the former provider and the start date of the new provider.

(7) Authorize the exchange of information for development of the person-centered service plan between the care team and his or her service providers, and in compliance with the "Health Insurance Portability and Accountability Act of 1996" (HIPAA) regulations set forth in 45 C.F.R. parts 160 and 164 (October 1, 2023), confidentiality of alcohol and drug abuse patient records as set forth in 42 C.F.R part 2 (October 1, 2023) and the medicaid safeguarding information requirements set forth in 42 C.F.R. parts 431.300 to 431.307 (October 1, 2023) along with sections 5160.45 to 5160.481 of the Revised Code.

(8) Provide accurate and complete information including up-to-date contact information and medical history.

(9) Utilize services in accordance with the approved person-centered service plan.

(10) Report to the recovery manager any service delivery issue(s) including, but not limited to, service disruption, complaints, and concerns about the provider and/or health and safety issues.

(11) Keep and attend scheduled appointments and notify the provider and recovery manager if he or she is going to miss a scheduled visit or service.

(12) Treat the recovery manager, care team and providers with respect.

(13) Report to the recovery manager any significant change as defined in rule 5160-43-01 of the Administrative Code that may affect the provision of services;

(14) Report to the recovery manager and when applicable, the managed care plan care manager, in accordance with rule 5160-44-05 of the Administrative Code, incidents that may impact his or her health and welfare.

(15) Refuse to participate in dishonest or illegal activities involving providers, caregivers and care team members.

Last updated September 3, 2024 at 9:10 AM

History

Effective: September 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-43-04 Specialized recovery services program covered services and provider requirements.

(A) This rule sets forth the covered services available to an individual enrolled in the specialized recovery services program (SRSP) and the requirements for providers of those services.

(B) Individualized placement and support

supported employment (IPS-SE) is the implementation of evidence-based practices allowing individuals to obtain and maintain meaningful employment by providing training, ongoing individualized support, and skill development to promote recovery. IPS-SE is an evidence based practice which is integrated and coordinated with mental health treatment and rehabilitation designed to provide individualized placement and support to assist individuals with a severe and persistent mental illness obtain, maintain, and advance within competitive community integrated employment positions.

(1) IPS-SE activities include:

(a) Benefits planning;

(b) Development of a vocational plan;

(d) Individualized job supports, including regular contact with the individual's employer(s), family members, guardians, advocates, treatment providers, and other community supports;

(e) Job coaching;

(f) Job development and placement;

(g) Job seeking skills training;

(h) On-the-job training and skill development;

(i) Vocational rehabilitation guidance and counseling;

(j) Time unlimited vocational support; and

(k) Vocational assessment.

(2) IPS-SE activities may include the following when provided in conjunction with an IPS-SE activity listed in paragraph (B)(1) of this rule:

(a) Facilitation of natural supports; or

(b) Transportation.

(3) The following activities are not payable under IPS-SE:

(a) Adaptations, assistance and training used to meet the employer's responsibility to fulfill requirements for reasonable accommodations under the Americans with Disabilities Act, 42 U.S.C. 12101 et. seq. (January 1, 2024);

(b) Job placements paying below minimum wage;

(c) Supervision, training, support and adaptations typically available to the general workforce filling similar positions in the business;

(d) Supervisory activities rendered as the normal part of business setting;

(e) Unpaid internships, unless they are considered crucial for job placement and such experience is vital to the individual achieving his or her vocational goal(s);

(f) Services which are not provided in integrated settings including sheltered work or other types of vocational services in specialized facilities, or incentive payments, subsidies, or unrelated vocational training expenses such as the following:

(i) Incentive payments made to an employer to encourage hiring the individual;

(ii) Payments that are passed through to the individual; or

(iii) Payments for supervision, training, support and adaptations typically available to other workers without disabilities filling similar positions in the business; or payments used to defray the expenses associated with starting up or operating a business.

(4) To be a provider and submit a claim for payment of IPS-SE services, the provider delivering the service must meet all of the following requirements:

(a) Comply with all rules set forth in this chapter and Chapter 5160-27 of the Administrative Code;

(b) Request payment for the provision of services in accordance with rule 5160-27-03 of the Administrative Code;

(c) Be certified by the Ohio department of mental health and addiction services (OhioMHAS) under section 5119.36 of the Revised Code;

(d) Not be the individual's legally responsible family member, as defined in rule 5160-43-01 of the Administrative Code;

(e) Be identified as the provider and have specified on the individual's person-centered service plan, that is prior approved by the Ohio department of medicaid (ODM) or its designee, the number of hours the provider is authorized to furnish program services to the individual;

(f) Provide services that are supported by an identified need or recovery goal in a manner that supports and respects the individual's communication needs including translation services, and/or assistance with communication devices; and

(g) Not provide IPS-SE services simultaneously with other rehabilitation services available under the medicaid state plan.

(5) IPS-SE providers must maintain a record for each individual served in a manner that protects the confidentiality of those records. At a minimum, the record must contain:

(a) A copy of the current person-centered service plan;

(b) Documentation of each service interaction including the duration IPS-SE was provided; and

(c) Documentation that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973, 29 U.S.C. 701 et. seq. (July 1, 2023), relating to vocational rehabilitation services, or the Individuals with Disabilities Education Act (1990), set forth in 20 U.S.C. section 1400 et. seq. (January 1, 2024), relating to special education.

(C) Recovery management is the coordination of all SRSP services received by an individual and assisting him or her in gaining access to needed medicaid services, as well as medical, social, educational, and other resources, regardless of funding source.

(1) Recovery managers shall:

(a) Be a registered nurse, or hold at least a bachelor's degree in social work, counseling, psychology, or related field;

(b) Have a minimum of three years post degree experience working with individuals with severe and persistent mental illness or have a minimum of one year post degree experience working with individuals with diagnosed chronic conditions;

(c) Possess an active medicaid provider agreement or be employed by an entity that has an active medicaid provider agreement;

(d) Demonstrate knowledge of issues affecting people with severe and persistent mental illness (SPMI) or diagnosed chronic conditions (DCC) and community-based interventions/resources for those individuals;

(e) Attend training activities including, but not limited to:

(i) Person-centered service planning;

(ii) Administering the "Adult Needs and Strengths Assessment (ANSA)" (8/2021);

(iii) Home and community-based services (HCBS) settings;

(iv) "Health Insurance Portability and Accountability Act of 1996" (HIPAA) regulations set forth in 45 C.F.R. parts 160 and 164 (October 1, 2023);

(v) 42 C.F.R. part 2 (October 1, 2023), confidentiality of alcohol and drug abuse patient records; and

(vi) Incident management as described in rule 5160-44-05 of the Administrative Code.

(f) Be supervised by clinical staff who possess a current, valid and unrestricted license with the appropriate licensure board from the fields of nursing, social work, psychology, or psychiatry.

(2) Recovery management activities include:

(a) Face-to-face eligibility evaluation, including:

(i) Administration of the "ANSA" (8/2021);

(ii) Verification of the individual's residence in an HCBS setting;

(iii) Verification of the individual's qualifying behavioral health diagnoses or diagnosed chronic conditions as described in the qualifying diagnosis appendix which is available on the ODM website at https://medicaid.ohio.gov/resources-for-providers/special-programs-and-initiatives/srs; and

(iv) Evaluation of all other eligibility criteria as described in paragraph (A) of rule 5160-43-02 of the Administrative Code.

(v) At the discretion of ODM or its designee, evaluations may be conducted by video conference or telephonically at the request of the individual, unless the individual's needs require a face-to-face visit.

(b) Person-centered care planning and updating the individual's service plan;

(c) Facilitation of transitioning to the community for individuals who receive medicaid-funded institutional services. Recovery management activities for individuals leaving institutions shall be coordinated with, and shall not duplicate, institutional, mycare and managed care plan discharge planning, and other community resources.

(d) Informing the individual about SRSP services, person centered planning, resources for recovery, and individual rights and responsibilities;

(e) Supporting the review and approval of the individual's person-centered service plan in accordance with rule 5160-44-02 of the Administrative Code;

(f) Monitoring the individual's service plan;

(g) Identifying and resolving issues that impede access to needed SRSP services;

(h) Identifying resources in the person-centered service plan to support the individual's recovery goals, including non-HCBS medicaid, medicare, private insurance, and community resources;

(i) Coordinating with other service providers and systems;

(j) Assisting with accessing resources necessary to complete medicaid redetermination and retain HCBS and medicaid eligibility;

(k) Responding to and assessing emergency situations and incidents and assuring that appropriate actions are taken to protect the health, welfare, wellness, and safety of the individual in accordance with rule 5160-44-05 of the Administrative Code and assist in meeting the needs of the individual in those situations;

(l) Evaluating the individual's progress in meeting his or her goals;

(m) Participating in quality oversight activities and reporting activities as described in rule 5160-43-07 of the Administrative Code;

(n) Participating in case consultations regarding an individual's progress with a trans-disciplinary care team, as defined in rule 5160-43-01 of the Administrative Code. When an individual is assigned to or enrolled in a comprehensive care management program operated by an accountable entity (e.g. patient centered medical home or managed care plan), the recovery manager will support access to the individual's full set of medicaid and medicare benefits and community resources across the continuum of care, including behavioral, medical, LTSS and social services;

(o) Updating the assessment at least annually, making revisions to the individual's service plan, and making recommendations to the accountable care management entity, as appropriate;

(p) Educating the individual about hearing and appeal rights; and

(q) Assisting the individual with preparing and submitting a hearing request, as needed.

(3) Recovery management activities do not include:

(a) Travel time incurred by the recovery manager billed as a discrete unit of service;

(b) Services that constitute the administration of another program such as child welfare, child protective services, foster care, parole and probation functions, legal services, public guardianship, and special education;

(d) Other activities identified by ODM.

(4) To be a provider and submit a claim for payment of recovery management services, the provider delivering the service shall meet all of the following requirements:

(a) Comply with all rules set forth in this chapter of the Administrative Code;

(b) Request payment for the provision of services in accordance with rule 5160-43-08 of the Administrative Code;

(d) Be identified as the provider and have specified on the individual's person-centered service plan, that is prior approved by ODM or its designee, the number of hours the provider is authorized to furnish services to the individual;

(e) Provide services that are supported by an identified need or recovery goal in a manner that supports and respects the individual's communication needs including translation services, and/or assistance with communication devices.

(5) All recovery management activities shall be documented in a record using the process prescribed by ODM for each individual served in a manner that protects the confidentiality of these records. At a minimum, the record shall contain:

(a) A copy of the current person-centered service plan;

(b) Documentation of each service interaction including the duration recovery management was provided; and

(c) Documentation that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973, 29 U.S.C. 701 et. seq. (January 1, 2024) relating to vocational rehabilitation services, or the Individuals with Disabilities Education Act, of 1990 set forth in 20 U.S.C. 1400 et. seq. (January 1, 2024), relating to special education.

Last updated September 3, 2024 at 9:10 AM

History

Effective: September 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-43-05 Specialized recovery services program provider conditions of participation.

(A) Specialized recovery service program providers shall maintain professional relationships with the individuals they serve. Providers shall furnish services in a person-centered manner that is in accordance with the individual's approved person-centered service plan, is attentive to the individual's needs and maximizes the individual's independence. Providers shall refrain from any behavior that may detract from the goals, objectives and services outlined in the individual's approved person-centered service plan and/or that may jeopardize the individual's health and welfare.

(B) Specialized recovery services program providers shall:

(1) Maintain an active, valid medicaid provider agreement as set forth in rule 5160-1-17.2 of the Administrative Code.

(2) Comply with all applicable provider requirements set forth in this chapter of the Administrative Code, including but not limited to:

(a) Provider requirements as set forth in rule 5160-43-04 of the Administrative Code;

(b) Incident reporting as set forth in rule 5160-44-05 of the Administrative Code;

(c) Provider monitoring, oversight, reviews and investigations as set forth in rule 5160-43-07 of the Administrative Code; and

(d) Criminal records checks for providers of home and community-based services (HCBS) as set forth in rule 5160-43-09 of the Administrative Code.

(3) Deliver services in a person-centered manner, professionally, respectfully and legally.

(4) Ensure that individuals to whom the provider is furnishing services are protected from abuse, neglect, exploitation and other threats to their health, safety and well-being. Upon entering into a medicaid provider agreement, and annually thereafter, all providers including all employees who have direct contact with individuals enrolled in the program must acknowledge in writing they have reviewed rule 5160-44-05 of the Administrative Code regarding incident management procedures.

(5) Work with the individual and his or her trans-disciplinary care team to coordinate service delivery, including, but not limited to:

(a) Agreeing to provide and providing services in the amount, scope, location and duration they have capacity to provide, and as specified on the individual's approved person-centered service plan.

(b) Contacting the individual, the recovery manager and/or his or her supervisor, as applicable, when the provider is unable to render services on the appointed date and time, and verify their receipt of information about the absence.

(6) To the extent not otherwise required by rule 5160-44-05 of the Administrative Code, notify the Ohio department of medicaid (ODM) or its designee within twenty-four hours when the provider is aware of issues that may affect the individual and/or provider's ability to render services as directed in the individual's person-centered service plan. Issues may include, but are not limited to:

(a) The individual consistently declines services,

(b) The individual plans to or has moved to another residential address,

(d) There are changes in the individual's environmental conditions,

(e) The individual's caregiver status has changed causing service delivery to be impacted or interrupted,

(f) The individual no longer requires medically necessary services as defined in rule 5160-1-01 of the Administrative Code,

(g) The individual's actions toward the provider are threatening or the provider feels unsafe in the individual's environment,

(h) The individual's requests conflict with his or her person-centered service plan and may jeopardize his or her health and welfare, and

(i) Any other situation that affects the individual's health and welfare.

(7) Upon request and within the time frame prescribed in the request, provide information and documentation to ODM, its designee and the centers for medicare and medicaid services (CMS).

(8) Cooperate with ODM and its designee during all provider monitoring and oversight activities by being available to answer questions during reviews, and by ensuring the availability and confidentiality of documentation that may be requested regarding service delivery to individuals.

(9) Participate in all provider trainings mandated or sponsored by ODM or its designees, including but not limited to those set forth in rule 5160-43-04 of the Administrative Code.

(10) Be knowledgeable about and comply with all applicable federal and state laws, including the "Health Insurance Portability and Accountability Act of 1996" (HIPAA) regulations set forth in 45 C.F.R. parts 160 and 164 (October 1, 2023), confidentiality of alcohol and drug abuse patient records set forth in 42 C.F.R part 2 (October 1, 2023), and the medicaid safeguarding information requirements set forth in 42 C.F.R. parts 431.300 to 431.307 (October 1, 2023), along with sections 5160.45 to 5160.481 of the Revised Code.

(11) Ensure that the provider's contact information, including but not limited to address, telephone number, fax number and email address, is current. When contact information changes, the provider shall notify ODM via the medicaid information technology system (MITS) and its designee, no later than seven calendar days after such changes have occurred.

(12) Make arrangements to accept all correspondence sent by ODM or its designee, including certified mail.

(13) Maintain and retain all required documentation related to the services delivered during a visit including but not limited to: an individual-specific description and details of the services provided or not provided in accordance with the person-centered service plan.

(a) Validation of service delivery shall include, but not be limited to, the date and location of service delivery, arrival and departure times and the dated signature of the provider.

(b) Retain all records of service delivery and billing for a period of six years after the date of receipt of the payment based upon those records, or until any initiated audit is completed, whichever is longer.

(14) Submit written notification to the individual and ODM or its designee at least thirty calendar days before the anticipated last date of service if the provider is terminating the provision of program services to the individual. Exceptions to the thirty-day advance notification requirement include:

(a) A verbal and written notification to the individual and ODM or its designee at least ten days before the anticipated last date of services when the individual:

(i) Has been admitted to a hospital;

(ii) Has entered into an institutional setting; or

(iii) Has been incarcerated.

(b) ODM may waive advance notification for a provider upon request and on a case-by-case basis.

(1) Engage in any behavior that causes or may cause physical, verbal, mental or emotional abuse or distress to the individual.

(2) Engage in any behavior that may compromise the health and welfare of the individual.

(3) Engage in any behavior that may take advantage of the individual, his or her family, household members or authorized representative, or that may result in a conflict of interest, exploitation or any other advantage for personal gain. This includes but is not limited to:

(a) Misrepresentation;

(b) Accepting, obtaining, attempting to obtain, borrowing, or receiving money or anything of value including but not limited to gifts, tips, credit cards or other items;

(d) Using real or personal property of another;

(e) Using information of another;

(f) Lending or giving money or anything of value;

(g) Engaging in the sale or purchase of products, services or personal items;

(h) Engaging in any activity that takes advantage of or manipulates specialized recovery services program rules.

(4) Falsify the individual's signature, including copies of the signature.

(5) Make fraudulent, deceptive or misleading statements in the advertising, solicitation, administration or billing of services.

(6) Submit a claim for program services rendered while the individual is hospitalized, institutionalized, incarcerated, or otherwise residing in a setting that does not meet the HCBS setting requirements set forth in rule 5160-44-01 of the Administrative Code.

(D) While rendering services, specialized recovery services providers shall not:

(1) Take the individual to the provider's place of residence;

(2) Bring animals which are not service animals, children, friends, relatives, or any others to the individual's place of residence;

(3) Provide care to persons other than the individual;

(4) Smoke without consent of the individual;

(5) Sleep;

(6) Engage in any distracting activity that is not related to the provision of services which may interfere with service delivery. Such activities include, but are not limited to:

(a) Using electronic devices for personal or entertainment purposes including, but not limited to watching television, using a computer or playing games;

(b) Making or receiving personal communications; and

(7) Deliver services when the provider is medically, physically or emotionally unfit;

(8) Use or be under the influence of the following while providing services:

(a) Alcohol,

(b) Illegal drugs,

(d) Controlled substances that may adversely affect the provider's ability to furnish services.

(9) Engage in any activity that may reasonably be interpreted as sexual in nature, regardless of whether it is consensual;

(10) Engage in any behavior that may reasonably be interpreted as inappropriate involvement in the individual's personal beliefs or relationships including, but not limited to discussing religion, politics or personal issues; or

(11) Consume the individual's food and/or drink without his or her offer and consent.

(E) Program service providers shall not be designated to serve or make decisions for the individual in any capacity involving a declaration for mental health treatment, general power of attorney, health care power of attorney, financial power of attorney, guardianship pursuant to court order, as an authorized representative, or as a representative payee.

(F) Providers shall pay applicable federal, state and local income and employment taxes in compliance with federal, state and local requirements. Federal employment taxes include medicare and social security.

(G) Failure to meet the requirements set forth in this rule may result in any of the actions set forth in rules 5160-44-05 and 5160-43-07 of the Administrative Code including, but not limited to, termination of the medicaid provider agreement in accordance with rule 5160-1-17.6 of the Administrative Code. When ODM proposes termination of the medicaid provider agreement, the provider shall be entitled to a hearing under Chapter 119. of the Revised Code in accordance with Chapter 5160-70 of the Administrative Code.

Last updated September 3, 2024 at 9:10 AM

History

Effective: September 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-43-07 Specialized recovery services program compliance: provider monitoring, oversight, structural reviews and investigations.

(A) The Ohio department of medicaid (ODM) is responsible for the ongoing monitoring and oversight of all providers of specialized recovery services (hereafter referred to as providers) and contractors to ensure compliance with program requirements.

(B) Monitoring and oversight of specialized recovery services program providers and recovery management contractors:

(1) ODM and/or its designee (hereafter referred to as ODM) shall conduct ongoing monitoring and oversight of providers and contractors, to verify each provider is:

(a) Complying with the terms and conditions of its medicaid provider agreement or contract, the program and all applicable federal, state and local regulations;

(b) Ensuring the health and welfare of individuals to whom they provide services; and

(2) Monitoring and oversight may include, but is not limited to:

(a) Interviews with individuals enrolled in the program and/or their authorized representative or legal guardian, providers and contractor staff;

(b) Visits to the provider's place of business or another agreed upon location for the purpose of examining or collecting records, reviewing documentation, and conducting structural reviews; and

(3) Providers and contractors shall fully cooperate with all requests made by ODM, as part of the monitoring and oversight process. This includes, but is not limited to:

(a) Upon request, arranging for or furnishing an adequate workspace for ODM to conduct visits. This workspace must be in a secure location which protects sensitive information from being disclosed contrary to relevant confidentiality and information disclosure laws;

(b) Making all requested information available at the time of review, and in accordance with the terms of compliance with contracts, as applicable;

(d) Ensuring the availability of supervisors and/or other staff who may possess relevant information to answer questions.

(4) At the conclusion of a provider monitoring and oversight review:

(a) ODM shall notify the provider or contractor in writing of its findings.

(b) ODM may:

(i) Request the provider or contractor submit to ODM a plan of correction within the prescribed time frame. The plan of correction shall set forth the action(s) that must be taken by the provider or contractor to correct each finding, and establish a target date by which the corrective action must be completed. If ODM does not approve the submitted plan of correction, ODM may request a new plan of correction or take other appropriate action;

(ii) Provide technical assistance to the provider or contractor;

(iii) Refer the provider or contractor to other regulatory and oversight entities for further investigation;

(iv) Issue the provider or contractor a notice of operational deficiency based upon the review and findings;

(v) Propose suspension or termination of the provider's medicaid provider agreement pursuant to section 5164.38 of the Revised Code and rules 5160-1-17.5 and 5160-1-17.6 of the Administrative Code, as applicable; or

(vi) Terminate the contractor's contract pursuant to its terms.

(1) Upon discovery, ODM or its designee shall investigate provider occurrences including requesting any documentation required for the investigation.

(2) If ODM substantiates the provider occurrence, it shall notify the provider in a manner that confirms provider receipt. The notification shall specify:

(a) The provider's action or inaction that constituted the provider occurrence;

(b) The Administrative Code rule(s) that support the finding(s) of non-compliance; and

(c) Actions the provider must take to correct the finding(s) of non-compliance, including any remediation or required payment adjustments.

(3) Plans of correction for provider occurrences must be submitted to ODM for all identified findings of non-compliance, including any remediation, within forty-five calendar days after the date on the written report.

(4) If ODM finds the provider's plan of correction acceptable, it shall acknowledge, in writing, to the provider that the plan addresses the findings outlined in the written report. If ODM determines that it cannot approve the provider's plan of correction, it shall inform the provider of this determination in writing, require the provider to submit a new plan of correction and specify the required actions that must be included in the plan of correction. The provider must submit the new plan of correction within ten calendar days.

(5) If ODM determines through the investigation of a provider occurrence that an overpayment of a provider claim has occurred, the provider shall make all payment adjustments in accordance with rule 5160-1-19 of the Administrative Code and the provider's approved plan of correction.

(6) ODM may take action against the provider as specified in paragraph (B)(4)(b) of this rule for failure to comply with the investigation of provider occurrences requirements set forth in this rule.

Last updated October 15, 2021 at 8:28 AM

History

Effective: October 15, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-43-08 Specialized recovery services program billing procedures and payment rates for recovery management.

(A) Definitions of terms used for billing and calculating rates.

(1) "Billing unit" as used in column 4 of paragraph (C) of this rule, means a single fixed item, amount of time or measurement.

(2) "Unit rate" as used in column 3 of paragraph (C) of this rule, means the amount reimbursed by the Ohio department of medicaid (ODM) for each fifteen minutes of service delivered, not to exceed a maximum of 8.5 units of service per month.

(B) Payment rates for individualized placement and support - supported employment may be found in rule 5160-27-03 and rule 5160-1-60 of the Administrative Code.

| Column 1 | Column2 | Column 3 | Column 4 | | --- | --- | --- | --- | | Billing code | Service | Unitrate | Billingunit | | T1016 | Recovery management | $27.54 | 15minutes |

(D) Claims will be submitted to ODM and reimbursed in accordance with Chapter 5160-1 of the Administrative Code.

Last updated August 22, 2025 at 8:12 AM

History

Effective: August 22, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-43-09 Specialized recovery services program criminal records checks for providers.

(A) This rule sets forth the process and requirements for the criminal records checks of providers of home and community-based services (HCBS) to individuals enrolled in the specialized recovery services program. HCBS include recovery management and individualized placement and support-supported employment (IPS-SE). This rule only applies to all persons under final consideration for employment with an agency and existing employees in a full-time, part-time or temporary position who are providing HCBS and billing medicaid for these services.

(B) For the purposes of this rule:

(1) "Agency" means an entity certified by the Ohio department of mental health and addiction services under section 5119.36 of the Revised Code.

(2) "Chief administrator" means the head of an agency, or his or her designee.

(3) "Criminal records check" has the same meaning as in section 109.572 of the Revised Code.

(4) "Disqualifying offense" means any of the following:

(a) A violation of one or more Revised Code section(s) set forth in the appendix to this rule;

(b) A violation of section 2923.01, 2923.02, or 2923.03 of the Revised Code when the underlying offense that is the object of the conspiracy, attempt, or complicity is a violation of one of the sections set forth in the appendix to this rule; or

(c) A violation of an existing or former municipal ordinance or law of the state of Ohio, any other state or the United States that is substantially equivalent to any of the disqualifying offenses as set forth in paragraphs (B)(4)(a) and (B)(4)(b) of this rule.

(5) "Employ" means to hire a provider applicant to be an employee as defined in paragraph (B)(6) of this rule.

(6) "Employee" means a person employed by an agency in a full-time, part-time or temporary position, including conditional employment as described in paragraph (D)(4) of this rule, that involves providing HCBS IPS-SE when medicaid is billed for this service.

(7) "Provider applicant" means a person who is under final consideration for employment with an agency in a full-time, part-time or temporary position, when the position provides HCBS when medicaid is billed for these services.

(C) No agency shall employ a provider applicant or continue to employ an employee in a position that involves providing HCBS if the provider applicant or employee:

(1) Is included in one or more of the following databases:

(a) The system for award management (SAM) maintained by the United States general services administration;

(b) The list of excluded individuals and entities maintained by the office of inspector general in the United States department of health and human services pursuant to 42 U.S.C. part 1320a-7 (as in effect on January 1, 2021) and 42 U.S.C. part 1320c-5 (as in effect on January 1, 2021).

(c) The Ohio department of developmental disabilities (DODD) online abuser registry established under section 5123.52 of the Revised Code;

(d) The internet-based sex offender and child-victim offender database established under division (A)(11) of section 2950.13 of the Revised Code;

(e) The internet-based database of inmates established under section 5120.66 of the Revised Code; or

(f) The state nurse aide registry established under section 3721.32 of the Revised Code, and there is a statement detailing findings by the director of health that the provider applicant or employee neglected or abused a long-term care facility or residential care facility resident or misappropriated property of such a resident.

(2) Fails to:

(a) Submit to a criminal records check conducted by the bureau of criminal identification and investigation (BCII), including failing to access, complete and forward to the superintendent the form or the standard fingerprint impression sheet; or

(b) Instruct the superintendent of BCII to submit the completed report of the criminal records check directly to the chief administrator of the agency.

(3) Except as provided for in paragraphs (F) and (G) of this rule, the provider applicant or employee has been convicted of, or pleaded guilty to, a disqualifying offense, regardless of the date of the conviction or data of entry of the guilty plea.

(D) Process for conducting criminal records checks.

(1) At the time of each provider applicant's initial application for employment in a position that involves providing HCBS for an individual enrolled in the specialized recovery services program, the chief administrator of the agency shall conduct a review of the databases listed in paragraph (C)(1) of this rule to determine whether the agency is prohibited from employing the provider applicant in that position. The chief administrator of the agency shall provide the provider applicant with a copy of any disqualifying information disclosed in the review of the databases.

(2) Except as otherwise noted in paragraph (C)(1) of this rule, the chief administrator of an agency shall require each provider applicant to request that the BCII superintendent conduct a criminal records check with respect to the provider applicant, and pursuant to section 109.572 of the Revised Code. The provider applicant must provide a set of fingerprint impressions as part of the criminal records check.

(a) If a provider applicant does not present proof of having been a resident of the state of Ohio for the five-year period immediately prior to the date the criminal records check is requested, or provide evidence that within that five-year period the superintendent has requested information about the provider applicant from the federal bureau of investigation (FBI) in a criminal records check, the chief administrator shall require the provider applicant to request that the superintendent obtain information from the FBI as part of the criminal records check.

(b) Even if a provider applicant presents proof of having been a resident of the state of Ohio for the five-year period, the chief administrator may require the provider applicant to request that the superintendent obtain information from the FBI in the criminal records check.

(3) The chief administrator of an agency shall provide the following to each provider applicant for whom a criminal records check is required by this rule:

(a) Information about accessing, completing and forwarding to the superintendent the form prescribed pursuant to division (C)(1) of section 109.572 of the Revised Code and the standard fingerprint impression sheet presented pursuant to division (C)(2) of that section; and

(b) Written notification that the provider applicant is to instruct the superintendent to submit the completed report of the criminal records check directly to the chief administrator of the agency.

(4) Conditional employment.

(a) An agency may conditionally employ a provider applicant for whom a criminal records check is required by this rule prior to obtaining the results of that check, provided that the agency has conducted a review of the databases listed in paragraph (C)(1) of this rule and has determined the agency is not prohibited from employing the provider applicant in that position. The chief administrator must require the provider applicant to request a criminal records check no later than five business days after he or she begins conditional employment.

(b) The agency shall terminate conditional employment if the results of the criminal records check, other than the results of any request for information from the FBI, are not obtained within sixty days of the criminal records check request.

(5) If the results of the criminal records check indicate that the provider applicant has been convicted of, or has pleaded guilty to any of the disqualifying offenses set forth in paragraph (B)(4) of this rule, and regardless of the date of conviction or the date of entry of the guilty plea, then the agency shall either:

(a) Terminate his or her employment; or

(b) Choose to employ the provider applicant because he or she meets the conditions set forth in paragraph (F) of this rule.

(6) If the agency determines that two or more convictions or guilty pleas result from or are connected with the same act or result from offenses committed at the same time, they shall be counted as one conviction or guilty plea.

(7) Termination of employment shall be considered just cause for discharge for the purposes of division (D)(2) of section 4141.29 of the Revised Code if the employee makes any attempt to deceive the agency about his or her criminal record.

(8) An agency shall pay to BCII the fee prescribed pursuant to division (C)(3) of section 109.572 of the Revised Code for any criminal records check required by this rule. However, an agency may require a provider applicant to pay to BCII the fee for a criminal records check for the applicant. If the agency pays the fee for a provider applicant, it may charge the provider applicant a fee not exceeding the amount the agency pays to BCII if the agency notifies the provider applicant at the time of application for employment of the amount of the fee and that, unless the fee is paid, he or she will not be considered for employment.

(9) Reports of any criminal records checks conducted by BCII in accordance with this rule are not public records for the purposes of section 149.43 of the Revised Code and shall not be made available to any person other than the following:

(a) The person who is the subject of the criminal records check or their representative;

(b) The chief administrator of the agency that requires the provider applicant or employee to request the criminal records check or the administrator's representative;

(c) The director and staff of the Ohio department of medicaid (ODM) who are involved in the administration of the Ohio medicaid program;

(d) An individual enrolled in the specialized recovery services program who receives, or may receive, HCBS from the person who is the subject of the criminal records check provided that the social security number, address and telephone number have been redacted from the record; and

(e) Any court, hearing officer or other necessary individual involved in a case dealing with a denial of employment of the provider applicant or termination of the employee; employment or unemployment benefits of the provider applicant or employee; or a civil or criminal action regarding the Ohio medicaid program.

(E) As a condition of continuing to employ an employee in a position that involves providing HCBS, the chief administrator of the agency shall follow the same process set forth in paragraphs (D)(1) to (D)(9) of this rule. The chief administrator:

(1) Shall conduct a criminal records check of an employee who does not currently have a criminal records check on file with the agency no later than ninety days after August 1, 2021;

(2) Shall conduct a criminal records check no later than thirty days after each employee anniversary date every five years;

(3) May conduct a criminal records check on any employee more frequently than every five years without any need to conduct a criminal records check according to the schedules set forth in paragraphs (E)(1) and (E)(2) of this rule.

(F) An agency may choose to employ a provider applicant or continue to employ an employee who has been convicted of, or has pleaded guilty to, a disqualifying offense set forth in paragraph (B)(4) of this rule when the provider applicant or employee has:

(1) Satisfied the conditions associated with the exclusionary periods set forth in paragraph (G) of this rule; or

(2) Obtained a certificate of qualification for employment issued by a court of common pleas with competent jurisdiction pursuant to section 2953.25 of the Revised Code, except when the provider applicant or employee has been convicted of or pleaded guilty to a tier I offense as described in paragraph (G)(1) of this rule; or

(3) Obtained a certificate of achievement and employability in an HCBS-related field, issued by the Ohio department of rehabilitation and corrections pursuant to section 2961.22 of the Revised Code, except when the provider applicant or employee has been convicted of or pleaded guilty to a tier I offense as described in paragraph (G)(1) of this rule; and

(4) Agreed, in writing, to have the agency inform each individual enrolled in the specialized recovery services program who may receive services from the provider applicant or employee of the disqualifying offense, and has acknowledged, in writing, that the individual has the right to select or reject to receive services from the provider applicant or employee, prior to commencing service delivery.

(G) An agency may employ a provider applicant or continue to employ an employee who has been convicted of or pleaded guilty to an offense listed in paragraph (B)(4) of this rule in a position providing HCBS to an individual enrolled in the specialized recovery services program pursuant to the following timeframes:

(1) Tier I, permanent exclusion.

(a) No agency shall employ a provider applicant or continue to employ an employee in a position that involves providing HCBS to an individual enrolled in the specialized recovery services program, when any of the following applies:

(i) The provider applicant or employee has been convicted of or pleaded guilty to any tier I offense as listed in the appendix to this rule; or

(ii) The provider applicant or employee has been convicted of or pleaded guilty to an offense in section 2923.01 (conspiracy), 2923.02 (attempt), or 2923.03 (complicity) of the Revised Code in relation to any other tier I offense; or

(iii) The provider applicant or employee has a violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the tier I offenses or violations as described in the appendix to this rule.

(b) Tier I permanent exclusion applies when the provider applicant or employee has a conviction related to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct involving a federal or state-funded program, excluding the disqualifying offenses set forth in section 2913.46 of the Revised Code (illegal use of supplemental nutrition assistance program (SNAP) or women, infants, and children (WIC) program benefits) and paragraph (G)(2) of this rule.

(2) Tier II, ten-year exclusionary period.

(a) No agency shall employ a provider applicant or continue to employ an employee in a position that provides HCBS to an individual enrolled in the specialized recovery services program for a period of ten years from the date the provider applicant or employee was fully discharged from all imprisonment, probation or parole, when the following applies:

(i) The provider applicant or employee has been convicted of or pleaded guilty to any tier II offense as listed in the appendix to this rule; or

(iii) The provider applicant or employee has a violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the tier II offenses or violations as described in the appendix to this rule.

(b) If a provider applicant or employee has been convicted of multiple disqualifying offenses, including a tier II offense, and another tier II, tier III or tier IV offense or offenses, the provider applicant or employee is subject to a fifteen-year exclusionary period beginning on the date the provider applicant or employee was fully discharged from all imprisonment, probation or parole for the most recent offense.

(3) Tier III, seven-year exclusionary period.

(a) No agency shall employ a provider applicant or continue to employ an employee in a position that provides HCBS to an individual enrolled in the specialized recovery services program for a period of seven years from the date the provider applicant or employee was fully discharged from all imprisonment, probation or parole, when the following applies:

(i) The provider applicant or employee has been convicted of or pleaded guilty to any tier III offense as listed in the appendix to this rule; or

(iii) The provider applicant or employee has a violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the tier III offenses or violations as described in the appendix to this rule.

(b) If a provider applicant or employee has been convicted of multiple disqualifying offenses, including a tier III offense, and another tier III or tier IV offense or offenses, the provider applicant or employee is subject to a ten-year exclusionary period beginning on the date the provider applicant or employee was fully discharged from all imprisonment, probation or parole for the most recent offense.

(4) Tier IV, five-year exclusionary period.

(a) No agency shall employ a provider applicant or continue to employ an employee in a position that provides HCBS to an individual enrolled in the specialized recovery services program for a period of five years from the date the provider applicant or employee was fully discharged from all imprisonment, probation or parole, when the following applies:

(i) The provider applicant or employee has been convicted of or pleaded guilty to any tier IV offense as listed in the appendix to this rule; or

(iii) The provider applicant or employee has a violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the tier IV offenses or violations as described in the appendix to this rule.

(b) If a provider applicant or employee has been convicted of multiple disqualifying tier IV offenses, the provider applicant or employee is subject to a seven-year exclusionary period beginning on the date the provider applicant or employee was fully discharged from all imprisonment, probation or parole for the most recent offense.

(5) Tier V, no exclusionary period.

(a) An agency may employ a provider applicant or continue to employ an employee in in a position that provides HCBS to an individual enrolled in the specialized recovery services program if the provider applicant or employee has been convicted of or pleaded guilty to any tier V offense as listed in the appendix to this rule.

(b) No exclusionary period applies when the provider applicant or employee has a violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the tier V offenses or violations as described in the appendix to this rule.

(H) Pardons.

(1) A conviction of, or a plea of guilty to an offense as set forth in paragraph (B)(4) of this rule shall not prevent any agency from considering a provider applicant for employment or an employee for continued employment if the provider applicant or employee has been granted any of the following:

(a) An unconditional pardon for the offense pursuant to Chapter 2967. of the Revised Code;

(b) An unconditional pardon for the offense pursuant to an existing or former law of the state of Ohio, any other state, or the United States, if the law is substantially equivalent to Chapter 2967. of the Revised Code; or

(c) A conditional pardon for the offense pursuant to Chapter 2967. of the Revised Code, and the condition(s) under which the pardon was granted have been satisfied.

(2) A conviction of, or plea of guilty to an offense as set forth in paragraph (B)(4) of this rule shall not prevent any agency from considering a provider applicant for employment or an employee for continued employment if the provider applicant's or employee's conviction or guilty plea has been set aside pursuant to law.

(I) Documentation of compliance. Each agency shall maintain a roster of provider applicants and employees, accessible by the ODM director or designee, which includes but is not limited to:

(1) The name of each provider applicant and employee;

(2) The date the employee started work;

(3) The date the criminal records check request is submitted to BCII;

(4) The date the criminal records check is received by the agency; and

(5) A determination of whether the results of the check revealed that the provider applicant or employee committed a disqualifying offense(s).

View Appendix

Last updated September 3, 2024 at 9:11 AM

History

Effective: September 1, 2024
Promulgated Under: 119.03

Chapter 5160-44 Home and Community-Based Care

Ohio Adm.Code 5160-44-01 Nursing facility-based level of care home and community-based services programs: home and community-based settings.

(A) Individuals receiving home and community-based services (HCBS) through either an Ohio department of medicaid (ODM) or Ohio department of aging (ODA) -administered waiver program authorized under section 1915(c) of the Social Security Act (as in effect on January 1, 2023) or the Ohio medicaid state plan authorized under section 1915(i) of the Social Security Act (as in effect on January 1, 2023) have to reside in and/or receive HCBS in a private residence or another setting that meets the home and community-based setting requirements set forth in this rule.

(1) A private residence is presumed to be a home and community-based setting provided it meets the requirements set forth in paragraph (B) of this rule. For the purposes of this rule, provider owned or controlled settings are not private residences.

(2) Home and community-based settings do not include any of the following:

(a) A nursing facility;

(b) An institution for mental diseases;

(d) A hospital;

(e) A psychiatric residential treatment facility; or

(f) Any other locations as determined by the ODM or its designee.

(B) Home and community-based settings will have all of the following characteristics, and such other characteristics as the secretary of the U.S. department of health and human services determines to be appropriate, based on the needs of the individual as indicated in their person-centered services plan:

(1) The setting is integrated in and supports full access of individuals receiving medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources and receive services in the community, to the same degree of access as individuals not receiving services through the ODM or ODA-administered waiver programs authorized under section 1915(c) of the Social Security Act (as in effect on January 1, 2023) or Ohio medicaid state plan authorized under section 1915(i) of the Social Security Act (as in effect on January 1, 2023).

(2) The setting is selected by the individual from among setting options, including non-disability specific settings and an option for a private unit in a residential setting.

(a) The setting options are identified and documented in the person-centered services plan and are based on the individual's needs, preferences, and for residential settings, resources available for room and board.

(b) For the purposes of this rule, non-disability specific setting means a home and community-based setting that is not limited to same or similar types of disabilities, or any disabilities at all.

(3) The setting ensures an individual's rights of privacy, dignity and respect, and freedom from coercion and restraint.

(4) The setting optimizes, but does not regiment, individual initiative, autonomy and independence in making life choices, including but not limited to, daily activities, physical environment and with whom to interact.

(5) The setting facilitates individual choice regarding services and supports, and who provides them.

(C) In addition to the characteristics set forth in paragraph (B) of this rule, in a provider-owned or controlled residential setting, the following additional conditions will be met, consistent with the individual's person-centered services plan.

(1) The individual's unit or dwelling is a specific physical place that can be rented or occupied under either:

(a) A legally enforceable agreement between the individual receiving services, and the owner of the dwelling pursuant to Chapter 5321. of the Revised Code.

(b) For settings in which Chapter 5321. of the Revised Code does not apply, a lease, residency agreement or other legally enforceable agreement in effect for the individual which provides protections that address eviction processes and appeals comparable to those provided under Chapter 5321. and Chapter 1923. of the Revised Code. The agreement will:

(i) Specify the responsibilities of the individual and the home and community-based setting;

(ii) Specify the circumstances under which the individual would be required to relocate, resulting in the termination of the agreement;

(iii) Address the steps an individual will follow in order to request a review and/or appeal of the transfer or discharge from the setting that results in termination of the agreement; and

(iv) Permit the additional conditions set forth in paragraphs (C)(2) to (C)(5) of this rule unless modified in the individual's person-centered services plan.

(2) The individual has privacy in their sleeping or living unit including all of the following:

(a) The unit has entrance doors lockable by the individual, with only appropriate staff having keys; and

(b) An individual sharing a unit has a choice of roommates in that setting.

(3) The individual has the freedom to furnish and decorate their sleeping or living unit within the lease or legally enforceable agreement.

(4) The individual has the freedom and support to control their own schedule and activities, and has access to food at any time.

(5) The individual is able to have visitors of their choosing at any time.

(6) The setting is physically accessible to the individual.

(D) Any modification of the additional conditions set forth in paragraphs (C)(1) to (C)(6) of this rule will be supported by a specific assessed need and justified in the individual's person-centered services plan in accordance with rule 5160-44-02 of the Administrative Code.

Last updated January 2, 2024 at 8:31 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-44-02 Nursing facility-based level of care home and community-based services programs: person-centered planning.

(A) Person-centered planning process.

Individuals receiving home and community-based services (HCBS) through either an Ohio department of medicaid (ODM) or Ohio department of aging (ODA) -administered waiver program authorized under section 1915(c) of the Social Security Act (as in effect on January 1, 2024) or the Ohio medicaid state plan authorized under section 1915(i) of the Social Security Act (as in effect on January 1, 2024) will lead the person-centered planning process where possible. The individual's authorized representative should have a participatory role, as needed, and as defined by the individual, unless Ohio law confers decision-making authority to the legal representative. All references to individuals include the role of the individual's authorized representative. In addition to being led by the individual receiving services and supports, the person-centered planning process will:

(1) Include a team of people chosen by the individual.

(2) Provide necessary information and support to ensure that the individual directs the process to the maximum extent possible and is enabled to make informed choices and decisions.

(3) Be timely and occur at times and locations of convenience to the individual.

(4) Reflect cultural considerations of the individual. The process will be conducted by providing information in plain language and in a manner that is accessible to persons with disabilities and persons who are limited English proficient, consistent with 42 CFR 435.905(b) (as in effect October 1, 2023).

(5) Include strategies for solving conflict or disagreement within the process, including clear conflict of interest guidelines for all planning participants.

(6) Ensure that providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual will not provide case management, provider oversight, or develop the person-centered services plan.

(7) Offer informed choices to the individual regarding the services and supports he or she receives and from whom.

(8) Include a method for the individual to request updates to the person-centered services plan as needed. The individual may request a person-centered services plan review at any time.

(B) Person-centered services plan.

(1) The person-centered services plan describes the person-centered goals, objectives and interventions selected by the individual and team to support him or her in his or her community of choice. The person-centered services plan addresses the assessed needs of the individual by identifying medically-necessary services, natural supports, medical and professional staff, and community resources. The person-centered services plan will:

(a) Identify the setting in which the individual resides is chosen by the individual and document the alternative home and community-based settings that were considered by the individual.

(b) Reflect the individual's strengths.

(d) Reflect clinical and support needs as identified through the assessment process.

(e) Include the individual's identified goals and desired outcomes.

(f) Identify the services and supports (paid and unpaid) that will assist the individual to achieve identified goals, and the providers of those services and supports, including natural supports and those services the individual elects to self-direct. This includes all services and supports provided through private insurance, medicare, medicaid state plan, and waiver services.

(g) Address any risk factors and measures in place to minimize them, when needed.

(h) Include back-up plans that meet the needs of the individual.

(i) Reflect that the setting chosen by the individual is integrated in, and supports the full access of individuals receiving medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources and receive services in the community to the same degree of access as people not receiving medicaid HCBS.

(2) The person-centered services plan will document that any modification of the additional conditions for provider-owned or controlled residential settings set forth in rule 5160-44-01 of the Administrative Code is supported by a specific assessed need and justified in the person-centered services plan. In these cases, the person-centered services plan will:

(a) Identify a specific and individualized assessed need;

(b) Document the positive interventions and supports used prior to any modifications to the person-centered services plan;

(d) Include a clear description of the condition that is directly proportionate to the specific assessed need;

(e) Include a regular collection and review of data to measure the ongoing effectiveness of the modification;

(f) Include established time limits for periodic reviews to determine if the modification is still necessary or can be terminated;

(g) Include informed consent of the individual; and

(h) Include an assurance that interventions and supports will not cause any harm to the individual.

(3) The person-centered services plan will:

(a) Be understandable to the individual receiving services and supports, and the people important in supporting him or her. At a minimum, it will be written in plain language and in a manner that is accessible to persons with disabilities and persons who are limited english proficient, consistent with 42 CFR 435.905(b) (as in effect on October 1, 2023).

(b) Identify the person and/or entity responsible for monitoring the plan.

(c) Be finalized and agreed to, with the informed consent of the individual in writing, and signed by all people and providers responsible for its implementation. Acceptable signatures include, but are not limited to a handwritten signature, initials, a stamp or mark, or an electronic signature. Any accommodations to the individual's or authorized representative's signature will be documented on the plan.

(d) Be distributed to the individual and other people involved in the plan.

(e) Prevent the provision of unnecessary or inappropriate services and supports.

(f) Be reviewed and revised upon reassessment of functional need as required by 42 CFR 441.365(e) (as in effect on October 1, 2023), at least every twelve months, when the individual experiences a significant change, or at the request of the individual.

(1) Documentation standards apply to entities delegated to perform assessments and care coordination activities for nursing facility-based waiver programs. Assessments and care coordination activities include in-person visits, telephone conversations, or email exchanges.

(2) Documentation for each assessment and care coordination activity will include the following:

(a) Individual's name.

(b) Name and relationship to the individual for all that participate.

(d) Location of the assessment or care coordination activity.

(e) Type of assessment or care coordination activity.

(f) Detailed description of the assessment or care coordination activity, including the reason for the activity, actions completed, outcome and next steps.

(3) Documentation of all assessments and care coordination activities will be:

(a) Written in a manner that is objective, accurate, and understandable to the individual as described in paragraph (B)(3)(a) of this rule.

(b) Completed within three business days of the assessment or care coordination activity.

Last updated July 2, 2024 at 10:51 AM

History

Effective: July 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-44-05 Nursing facility-based level of care home and community-based services programs and specialized recovery services program: incident management.

This rule sets the standards and procedures for managing incidents that may have a negative impact on individuals. The purpose of this rule is to establish the procedures for reporting and addressing critical incidents and reportable incidents and to prevent and reduce the risk of harm to individuals. This rule applies to multiple programs administered by the Ohio department of aging (AGE) and the Ohio department of medicaid (ODM). AGE and ODM may designate other entities to perform one or more of the incident management functions set forth in this rule.

(A) For the purposes of this rule, the following definitions apply:

(1) "Case Management Agency" or "CMA" means an entity delegated or contracted by AGE or ODM to perform case management activities and related functions for individuals enrolled on a home and community-based services (HCBS) waiver program.

(2) "Health and safety action plan" or "HSAP" means a document developed by the waiver case management agency or recovery management agency that identifies situations, circumstances, and behaviors that without intervention may jeopardize the individual's health and welfare and potentially risk the individual's program enrollment. The HSAP sets forth the interventions necessary to mitigate risks to the health and welfare of an individual and to ensure the individual's needs are met.

(3) "Incident" means an alleged, suspected, or actual event that is not consistent with the routine care of or service delivery to an individual that may have a negative impact on the health and welfare of the individual.

(4) "Incident management system" means the system in which reported incidents are entered, including investigative and review notes, findings and results, and prevention plans.

(5) "Individual" means a person enrolled on an HCBS waiver or in the specialized recovery services (SRS) program.

(6) "Investigative entity" means ODM, AGE, or their designee.

(7) "Recovery management agency" or "RMA" means the agency delegated or contracted by ODM to perform case management activities via the recovery manager and related functions for individuals enrolled in the SRS program.

(8) "Restraint" means as defined in rule 5160-45-01 of the Administrative Code.

(9) "Restrictive intervention" means as defined in rule 5160-45-01 of the Administrative Code.

(10) "Seclusion" means as defined in rule 5160-45-01 of the Administrative Code.

(11) "Substantiated" means there is a preponderance of evidence to indicate the reported incident is more likely to have occurred than not to have occurred.

(12) "Unauthorized restraint" means any restraint which is prohibited by an individual's HCBS waiver or program, inappropriately applied due to lack of necessity, conducted without individual choice, conducted without the appropriate level of authorization as specified by the waiver or program, or not documented within the individual's record.

(13) "Unauthorized restrictive intervention" means any restrictive intervention which is prohibited by an individual's HCBS waiver or program, inappropriately applied due to lack of necessity, conducted without individual choice, conducted without the appropriate level of authorization as specified by the waiver or program, or not documented within the individual's record.

(14) "Unauthorized seclusion" means any seclusion which is prohibited by an individual's HCBS waiver program, inappropriately applied due to lack of necessity, conducted without individual choice, conducted without the appropriate level of authorization as specified by the waiver or program, or not documented within the individual's record.

(B) The following incidents will be reported and investigated or reviewed as described in paragraph (E) of this rule:

(1) Critical incidents:

(a) Abuse: the injury, confinement, control, intimidation, or punishment of an individual that has resulted in physical harm, pain, fear, or mental anguish. Abuse includes, but is not limited to physical, emotional, psychological, verbal, and sexual abuse.

(b) Behavioral support misuse: the use of unauthorized restraint, unauthorized restrictive intervention, or unauthorized seclusion.

(c) Neglect: when there is a duty to do so, failing to provide an individual with any treatment, care, goods, or services necessary to maintain the health or welfare of the individual.

(d) Exploitation: the unlawful or improper act of using an individual or an individual's resources through the use of manipulation, intimidation, threats, deceptions, or coercion for monetary or personal benefit, profit, or gain.

(e) Misappropriation: the act of depriving, defrauding, or otherwise obtaining the money or real or personal property (including prescribed medication) of an individual that could potentially impact the health and welfare of the individual.

(f) Unnatural or accidental death: death of an individual resulting from an accident or death that otherwise could not have reasonably been expected, including but not limited to death caused by abuse, neglect, suicide, medication error, and homicide.

(g) Self-harm or suicide attempt: self-harm or suicide attempt that includes a physical attempt by an individual to harm themselves that results in emergency department treatment, in-patient observation, or hospital admission.

(h) Medication error: any medication error that results in a consultation with a poison control center (including telephone calls), an emergency department or urgent care visit, hospitalization, or death, involving:

(i) A medication prescribed to the individual; or

(ii) Any supplement, over-the-counter medication, or medication not prescribed to the individual.

(i) The health and welfare of the individual is at risk due to the individual being lost or missing.

(2) Reportable incidents

(a) Natural deaths that are not due to events such as accidents, injuries, homicide, suicide, or overdoses.

(b) Individual or family member behavior, action, or inaction resulting in the creation of, or adjustment to, a health and safety action plan.

(i) Loss of the individual's paid or unpaid caregiver;

(ii) Prescribed medication issue not resulting in a consultation with a poison control center, an emergency department of urgent care visit, hospitalization, or death; or

(iii) Eviction or housing crisis.

(d) Suicide attempt that does not result in emergency room treatment, in-patient observation, or hospital admission.

(1) The nursing facility-based level of care HCBS waiver programs administered by AGE and ODM including the assisted living waiver as set forth in Chapter 173-38 of the Administrative Code, the preadmission screening system providing options and resources today waiver as set forth in Chapter 173-42 of the Administrative Code, the Ohio home care waiver as set forth in Chapter 5160-46 of the Administrative Code, and the MyCare Ohio waiver as set forth in Chapter 5160-58 of the Administrative Code.

(2) The SRS state plan program as set forth in Chapter 5160-43 of the Administrative Code.

(D) Upon an individual's enrollment on an HCBS waiver or the SRS program and at the time of each annual reassessment the CMA or RMA will do the following:

(1) Obtain written confirmation that the individual received information about how to report abuse, neglect, exploitation, and all other incidents as defined in this rule.

(2) Document and maintain the written confirmation within the individual's case record.

(E) The following process will be followed upon the occurrence of an incident.

(1) Initial incident report.

(a) Upon discovering an incident, ODM, AGE, their delegates, and all service providers of nursing facility-based level of care HCBS waiver services or services under the SRS program will:

(i) Take immediate action to ensure the health and welfare of the individual.

(ii) Report the incident to the relevant CMA or RMA immediately upon discovery of the incident, but no later than one business day after discovering the incident, unless bound by federal, state, or local law, or the requirements of professional licensure or certification to report sooner.

(b) All incident reports will include the following information when available:

(i) The facts relevant to the incident;

(ii) A description of what happened;

(iii) The incident type;

(iv) The date of the incident;

(v) The location of the incident;

(vi) The names and contact information of all persons involved; and

(vii) All actions taken to ensure the health and welfare of the individual.

(2) Receipt of report and documentation of the incident.

(a) The CMA or RMA will do the following upon discovering or receiving report of an incident.

(i) Ensure immediate action was taken to protect the health and welfare of the individual. If such action was not taken, take action immediately, but no later than twenty-four hours after becoming aware of the incident.

(ii) Notify all of the appropriate entities with investigative or protective authority, and the appropriate additional regulatory, oversight, or advocacy agencies including but not limited to:

(a) Local law enforcement if the incident involves suspected criminal conduct;

(b) The local coroner's office when the death of an individual is reportable in accordance with section 313.12 of the Revised Code;

(d) The local child protective services agency (CPS);

(e) The local adult protective services agency (APS);

(f) The Ohio department of health, or other licensure or certification board or accreditation body if the incident involves a provider regulated by that entity;

(g) The local probate court if the incident may involve the legal guardian of the recipient.

(iii) Enter all critical incidents into the incident management system within one business day of becoming aware of the incident.

(iv) Enter all reportable incidents into the incident management system within three business days of becoming aware of the incident.

(3) Critical incident investigation.

(a) The investigative entity will investigate all critical incidents and do the following upon receipt of a reported incident.

(i) Within one business day of receiving a report of an incident, review the reported incident and verify the following:

(a) Immediate action was taken to protect the health and welfare of the individual and any other recipients of service who may be at risk. If such action was not taken, take action immediately, but no later than twenty-four hours after discovering the need for such action.

(b) The appropriate entities with investigative or protective authority, and the appropriate additional regulatory, oversight, or advocacy agencies were notified. If such action was not taken, do so as soon as possible.

(ii) Within two business days of receiving a report of an incident, initiate an investigation.

(iii) Conduct a review of all relevant documents, including person-centered care plans, service plans, assessments, clinical notes, communication notes, results from an investigation conducted by a third-party entity when available, provider documentation, provider billing records, medical reports, police and fire department reports, and emergency response system reports.

(iv) Conduct and document interviews with everyone who may have information relevant to the incident.

(v) Identify, to the extent possible, all causes and contributing factors.

(vi) Determine whether the incident is substantiated.

(vii) Document all investigative activities in the incident management system.

(viii) Conclude the investigation no later than forty-five business days after the investigative entity's initial receipt of the incident report, unless a longer time frame has been previously approved by ODM or AGE.

(ix) For investigations conducted by ODM's designee, at the conclusion of the investigation, provide a summary of the investigative findings and whether or not the incident was substantiated to the appropriate CMA or RMA.

(4) Reportable incident review and remediation: For each reportable incident, the CMA or RMA will address and remediate the incident as determined appropriate by the CMA or RMA.

(5) Follow up and closeout responsibilities of the CMA or RMA.

(a) Upon receipt of the findings for a substantiated incident, review the investigation results and include the information from the results when developing a person-centered prevention plan or updating the care plan to ensure the health and safety of the individual.

(b) Communicate a summary of the investigative findings with the individual and their authorized representative or legal guardian using trauma informed care, unless such action could jeopardize the health and welfare of the individual.

(i) The summary will be provided through verbal communication, unless the individual or their authorized representative or legal guardian requests the summary in writing.

(ii) The CMA or RMA will retain documentation that the summary was provided.

(c) For incidents that resulted in a CPS or APS referral, communicate a summary of the investigative findings to the relevant agency within seven business days after being notified that the investigation is complete.

(d) For all substantiated critical incidents, except in the case of death, enter a prevention plan into the incident management system no later than seven business days after the conclusion of the investigation, indicating closure of the incident.

(e) For all reportable incidents, address and remediate the incident as determined appropriate, and close the incident in the incident management system no later than forty-five business days after submission of the incident in the incident management system.

(F) AGE and ODM may request further review of any incident, conduct a separate independent review or investigation of any incident, determine necessary additional action, or assume responsibility for conducting an investigation or review.

Last updated August 27, 2026 at 8:02 AM

History

Effective: August 27, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-44-11 Nursing facility-based level of care home and community-based services programs: home delivered meals.

(A) The following definitions are applicable to this rule:

(1) "Dietitian" and "licensed dietitian" mean a person with a current, valid license to practice dietetics under section 4759.06 of the Revised Code.

(2) "Home delivered meals" is a meal delivery service based on an individual's need for assistance with activities of daily living (ADLs) and/or instrumental activities of daily living (IADLs) in order to safely prepare meals, or ensure meals are prepared to meet the individual's dietary needs or specialized nutritional needs, including kosher meals. The type of home delivered meals are the following

(a) Standard meal means a meal that adheres to the version of the "Dietary Guidelines for Americans" in effect on the delivery day and at least thirty-three per cent of the individual's dietary reference intakes. A standard meal may include, but is not limited to, a reduced calorie meal, reduced sodium meal, reduced sugar meal, a gluten-free meal, or vegetarian meal, if the individual chooses the meal by personal preference.

(b) Kosher meal is a meal that complies with the kosher practices for meal preparation and dietary restrictions and certified as kosher by a recognized kosher certification or a kosher establishment under orthodox rabbinic supervision.

(c) Therapeutic meal means a meal provided in accordance to an order by a licensed healthcare professional whose scope of practice includes ordering therapeutic diets:

(i) For management of a disease or clinical condition;

(ii) To modify, eliminate, decrease or increase certain substances in the diet; or

(iii) To provide mechanically altered food when indicated.

(3) "Meals" are single portions that are ready to eat, frozen, vacuum-packed, modified-atmosphere-packed, or shelf-stable. Meals have all the following characteristics:

(a) It includes instructions on how to safely maintain, heat, reheat and/or assemble the meal, in a manner understandable to the individual and/or their caregiver.

(b) It adheres to the individual's medical restrictions as set forth in their person-centered services plan.

(B) Meal specifications.

(1) Meal menus will be approved in writing by a dietitian who is currently registered with the commission on dietetic registration, and who is also a licensed dietitian in the state in which the dietitian is located if that state licenses dietitians.

(a) Providers will furnish each individual with home delivered meals that accommodate the individual's religious, cultural, ethnic, and dietary preferences.

(b) Providers shall publish their current menu and ingredient information on their websites and offer written menus and ingredient information to individuals.

(2) An individual's person-centered services plan establishes meal delivery parameters which include all the following:

(a) Up to two meals per day. The maximum number of meals delivered will not exceed fourteen meals at one time.

(b) The type of meal.

(d) The delivery-verification method which will include:

(i) Signature upon delivery by the individual or the individual's designee; or

(ii) The delivery driver's confirmation that delivery occurred. The provider may use an electronic system to verify.

(a) If a provider uses a common carrier to deliver meals, the provider will verify the success of the delivery by using the method in paragraph (B)(2)(d) of this rule; or

(b) By retaining the common carrier's tracking statement or other evidence showing successful delivery.

(e) A provider may deliver specifically identified items that are packaged in larger than single servings.

(3) Additional back up meals may be authorized at the discretion of the Ohio department of medicaid (ODM), the Ohio department of aging (ODA), or their designee.

(1) Processed, pre-packed and commercially available to the general public for purchase; or

(2) Provided in order to supplant or replace the purchase of food or groceries for others.

(D) Provider qualifications.

(1) A provider of home delivered meals will maintain evidence of:

(a) A current, valid food operations or other applicable license or certificate as required by licensing or regulatory agencies where the meal is produced.

(b) Good standing with all applicable federal, state and local regulatory agencies; and

(c) Meeting applicable licensing requirements for safety, storage, sanitation and other applicable provisions for food service.

(2) The provider will develop, implement and maintain evidence of a training plan that includes orientation and annual continuing education.

(a) The provider will ensure anyone who participates in meal preparation, handling or delivery receives orientation on topics relevant to the person's job duties before they perform those duties.

(b) The provider will ensure anyone who participates in meal preparation, handling or delivery completes continuing education annually on topics relevant to the person's job duties.

(E) Delivery requirements.

(1) Delivery will be based on a routine delivery date and range of time.

(2) The provider will notify the individual if meal delivery will be delayed or will not occur as planned.

(3) The provider will ensure that delivery provided by commercial or common carrier meets applicable federal, state and local food safety, storage and sanitation requirements.

(F) The provider will maintain the following documentation:

(1) Initial and subsequent person-centered services plans for each individual;

(2) All diet orders;

(3) Documentation of meal delivery, including:

(a) The individual's name;

(b) The date, time and number of meals in the delivery;

(d) Verification that the individual was notified if service delivery was not provided within the established delivery date or time; and

(e) Verification that the individual has been furnished clear instructions about how to safely heat, reheat and assemble each meal.

(4) A written record, including date and topics covered, during the completion of orientation and continuing education sessions;

(5) All licensure or certification documents required by this rule;

(6) All local licensing or regulatory agency inspection reports and documented findings, any resulting plans of correction and any follow up reports; and

(7) All United States department of agriculture inspection reports and documented findings, any resulting plans of correction and any follow-up reports.

(G) The provider will replace any item lost or stolen between the time of delivery and non-receipt by the individual at no cost to the individual, ODM, ODA, or their designee.

Last updated January 2, 2024 at 8:31 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-44-12 Nursing facility-based level of care home and community-based services programs: home maintenance and choreservices.

(A) "Home maintenance and chore" means a service that maintains a clean and safe living environment through the performance of tasks in the individual's home that are beyond the individual's capability. Home maintenance and chore services shall not exceed a total of ten thousand dollars in a calendar year per individual. Covered home maintenance and chore activities include:

(1) Minor home maintenance and repair including inspecting, maintaining, and repairing furnaces, including pilot lights and filters; inspecting, maintaining, and repairing water faucets, drains, heaters, and pumps; replacing or installing electrical fuses; plumbing and electrical repairs; repair or replacement of screens or window panes; fixing floor surfaces posing a threat to the individual's health, safety, and welfare; and moving heavy items to provide safe ingress and egress.

(2) Heavy household cleaning, including washing walls and ceilings; washing the outside of windows; non-routine washing of windows; removing, cleaning and rehanging curtains or drapery; and shampooing carpets or furniture.

(3) Removal of environmental hazards posing a threat to the individual's health, safety, and welfare such as:

(a) Non-routine disposal of garbage or other accumulated items in an individual's residence;

(b) Non-routine yard maintenance including snow removal;

(d) Mold eradication.

(4) Upkeep and maintenance of a home modification or adaptive/assistive devices, such as:

(a) Routine maintenance plan;

(b) Extended warranty; and

(B) Home maintenance and chore do not include:

(1) Tasks of general utility (including routine yardwork), and not of direct medical or remedial benefit to the individual.

(2) Jobs that add to the total square footage of the home.

(3) Jobs that can be accomplished through existing informal or formal supports.

(4) Jobs that are the legal or contractual responsibility of someone other than the individual (e.g., the landlord, etc.).

(5) Jobs involving the removal of home modifications and returning of property to its prior condition when the individual vacates the premises.

(6) Replacement or repair of a previously approved home modification or home maintenance and chore job that has been damaged as a result of apparent misuse, abuse, or negligence.

(C) Home maintenance and chore that are necessary to ensure the health, safety, and welfare of the individual and will exceed the ten-thousand-dollar calendar year threshold may be considered for approval by the Ohio department of medicaid (ODM), Ohio department of aging (ODA) or their designee.

(D) Authorization process.

(1) ODM, ODA, or their designee may require the completion of an in-home evaluation by an appropriately qualified professional to determine the suitability of the immediate environment where the service will be performed and the viability of the completion of the service to improve independence and/or facilitate a healthy and safe environment.

(2) In consultation with the individual and/or caregiver(s), ODM, ODA, or their designee, and if necessary, the qualified professional, will develop a referral that addresses the individual's home maintenance and chore needs.

(3) Home maintenance and chore providers will submit a fixed cost proposal for the services described under the referral which will be good for the term of the proposal.

(a) At a minimum, the proposal will include all of the following:

(i) A breakdown of all the needed materials;

(ii) A breakdown of the costs of all the needed materials;

(iii) A breakdown of the labor costs;

(iv) A list of any permits that must be obtained;

(v) An estimate of the time needed to complete the service;

(vi) A written statement of all warranties provided, including a warranty lasting at least one year from the date of final acceptance of work against defective workmanship, as applicable; and

(vii) A written guarantee that all materials, products, and installed or furnished appliances perform their advertised function.

(b) A fixed cost proposal may be adjusted for good cause only if the proposal is adjusted in writing, and the adjustment is approved by ODM, ODA, or their designee.

(4) ODM, ODA, or their designee will review all submitted proposals with the individual and will approve the proposal with the lowest cost alternative that meets the individual's assessed needs and ensures the health, safety and welfare of the individual.

(5) The provider will be reimbursed for the actual cost of material and/or labor as identified in the proposal.

(E) Provider requirements.

The provider will:

(1) Know and understand the individual's person-centered services plan related to home maintenance and chore, and personal preferences regarding the specific services to be performed.

(2) Before performing a service, inform the individual and ODM, ODA, or their designee of any potential health or welfare risk, and coordinate times and dates of service to ensure minimal risk to the individual.

(3) Comply with applicable federal, state, and local laws, and the individual's homeowners' association (HOA) requirements, as applicable.

(4) Obtain the property owner's written consent prior to performing the service. This written consent will reflect that the property owner has agreed to the maintenance, repair or other service.

(5) Furnish to the individual, ODM, ODA, or their designee a warranty that covers the workmanship and materials involved in performing the service, as applicable.

(6) Provide documentation to ODM, ODA, or their designee that the service was completed in accordance with the agreed upon specifications using the materials and equipment cited in the proposal.

(7) Provide documentation to ODM, ODA, or their designee that the service was tested, is in proper working order, and is usable by the individual, if applicable.

(8) Repair any damage incidental to the service at no additional cost.

(F) Home maintenance and chore may only be provided by an agency or non-agency provider approved by ODM or certified by ODA as a medicaid waiver provider of home maintenance and chore.

(G) Service verification: The provider will obtain the individual's or authorized representative's signature and date of completion of the service to verify service delivery, verify the provider left the individual's home in satisfactory condition, and verify repair of any damages incidental to the service.

(H) Provider record retention. For each service furnished, the provider will retain a record of compliance with all requirements set forth in rule 5160-44-31 of the Administrative Code, or with the requirements set forth in Chapter 173-39 of the Administrative Code for the pre-admission screening system providing options and resources today (PASSPORT) program. The record will include:

(1) Individual's name.

(2) Date of service delivery.

(3) A copy of the fixed cost proposal described in paragraph (D)(3) of this rule, including any approved adjustments.

(4) Service description, including a comparison between the fixed cost proposal and the actual services provided.

(5) Name of each provider staff person in contact with the individual.

(6) List of chemicals and substances used.

(7) Proof of appropriate qualifications to perform services requiring specialized skills such as electrical, heating/ventilation, and plumbing work.

(8) Proof of licensure, insurance, and bonding for services from applicable jurisdictions.

(9) Proof of all necessary post-inspections and post-inspection reports required by law, a HOA, or both to verify whether each episode of service meets federal, state, and local laws or HOA requirements. Proof will be obtained prior to billing,

(10) All of the documents required in paragraphs (E), (F), and (G) of this rule.

(I) The authorization of home maintenance and chore may be combined with other waiver services to meet the assessed needs of the individuals. In such instances, individual waiver service limits as described in paragraph (C) of this rule still apply.

Last updated January 2, 2024 at 8:31 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-44-13 Nursing facility-based level of care home and community-based services programs: home modification.

(A) "Home modifications" are environmental adaptations to the private home(s) of the individual authorized by the individual's person-centered services plan, that are necessary to ensure the health, welfare and safety of the individual or that enable the individual to function with greater independence in the home. Such adaptations include, but are not limited to, the installation of ramps and grab-bars, widening of doorways, modification of bathroom or kitchen facilities, or the installation of specialized electric and plumbing systems that are necessary to accommodate the medical equipment and supplies that are necessary for the welfare of the individual. Home modifications also include replacement of previous home modifications when it is determined the modification cannot be repaired through another resource. Home modifications shall not exceed a total of fifteen thousand dollars in a calendar year per individual. The Ohio department of medicaid (ODM), Ohio department of aging or their designee will approve the lowest cost alternative that meets the individual's assessed needs.

(B) Home modifications do not include:

(1) Adaptations or improvements to the home that are of general utility, and are not of direct medical or remedial benefit to the individual including, but not limited to, carpeting, roof repair and central air conditioning.

(2) Adaptations that add to the total square footage of the home, except when necessary to complete an adaptation (e.g., in order to improve entrance/egress to a home or to configure a bathroom to accommodate a wheelchair).

(3) New, replacement home modifications or repair of previously approved home modifications that have been damaged as a result of apparent misuse, abuse, or negligence.

(4) Removing modifications and returning the property to its prior condition when an individual vacates the premises.

(C) Home modifications may be authorized up to one hundred and eighty consecutive days prior to an individual's transition from an institutional setting into the community.

(1) The modification is not considered complete until the individual leaves the institutional setting.

(2) The date of service for purposes of reimbursement will be the date on which the individual leaves the institutional setting. If an individual fails to transition into the community, the modification is still reimbursable.

(D) Authorization process.

(1) ODM, Ohio department of aging, or their designee may require the completion of an in-home evaluation by an occupational therapist (OT) or physical therapist (PT) licensed pursuant to Chapter 4755. of the Revised Code or other appropriately qualified professional. The qualified professional conducting the evaluation will:

(a) Determine the individual's capacity to utilize the requested home modification.

(b) Determine the suitability of the immediate environment where the modification will be installed.

(d) In consultation with the individual and/or caregiver(s), develop a recommendation for a home modification to address the individual's environmental accessibility needs.

(e) Provide ODM,Ohio department of aging, or their designee with a written home modification referral that addresses the individual's environmental accessibility needs.

(2) Home modification providers will submit a fixed cost proposal for the services submitted under the home modification referral which will be good for the term of the work agreement.

(a) At a minimum, the proposal will include all of the following:

(i) A drawing or diagram of the home modification, as appropriate;

(ii) A breakdown of all of the needed materials;

(iii) A breakdown of the costs of the needed materials;

(iv) A breakdown of the labor costs;

(v) A list of all building permits that must be obtained;

(vi) An estimate of the time needed to complete the home modification;

(vii) A written statement of all warranties provided, including a warranty lasting at least one year from the date of final acceptance of work against defective workmanship; and

(viii) A written guarantee that all materials, products, and installed or furnished appliances perform their advertised function.

(b) A fixed cost proposal may be adjusted for good cause only if the job specifications are modified in writing, and the adjustment is approved by ODM, Ohio department of aging or their designee.

(3) ODM, Ohio department of aging or their designee will review all submitted proposals with the individual and will award the home modification service to the provider that proposes the lowest cost alternative that meets the individual's assessed need.

(E) Limitations.

(1) ODM, Ohio department of aging, or their designee will ensure safeguards are in place to minimize any potential conflicts of interest between the person(s) conducting any evaluations required pursuant to paragraph (D) of this rule and the home modification provider.

(2) The provider shall be reimbursed for the actual cost of material and labor for the home modification as identified in the home modification proposal. Reimbursement may be adjusted only if the job specifications are modified pursuant to the requirements in paragraph (D) of this rule.

(3) The provider will not be the owner of the individual's home where the modification is being performed.

(F) Provider requirements.

(1) The provider will:

(a) Know and understand information contained in the individual's person-centered services plan related to the modification and personal preferences about the home modification services to be furnished.

(b) Obtain final written approval from the individual and ODM, Ohio department of aging or their designee after completion of the home modification.

(2) The provider record will include evidence the provider obtained and maintained:

(a) The written consent of the property owner to modify the property, including acknowledgment that the owner understands that the waiver is not responsible for returning the property to its prior condition.

(b) All permits required by law, including building permits, prior to commencing work on each job order.

(c) Any necessary inspections and inspection reports required by federal, state and local laws upon completion of each job to verify that the repair, modification or installation was completed. The provider will obtain these inspections, inspection reports, and permits prior to billing for the completed job.

(d) Documentation that the home modification was completed in accordance with the agreed upon specifications.

(e) Documentation that the home modification was tested, is in proper working order and is functional for use by the individual.

(f) Documentation that the home modification meets all applicable federal, state and local building codes and accessibility codes.

(g) Appropriate qualifications to perform jobs requiring specialized skills such as electrical work, heating/ventilation and plumbing to ODM, Ohio department of aging or their designee upon request.

(h) Licensure, insurance, and bonding for general contracting services of applicable jurisdictions to ODM, Ohio department of aging or their designee upon request.

(i) All permits and pre-job inspections required by law, home owners' association, or both.

(j) All necessary post-inspections and post-inspection reports required by law, a HOA, or both to verify whether each episode of service meets federal, state, and local laws or HOA requirements. Proof will be obtained prior to billing,

(G) The authorization of home modification services may be bundled with other waiver services to meet the assessed needs of the individuals. In such instances, individual waiver service limits as described in paragraph (A) of this rule still apply.

Last updated April 17, 2026 at 8:03 AM

History

Effective: April 17, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-44-14 Nursing facility-based level of care home and community-based services programs: community integration services.

(A) "Community integration" means independent living assistance and community support coaching activities that are necessary to enable an individual to live independently and have access to, choice of, and an opportunity to participate in, a full range of community activities.

(B) "Independent living assistance" means help for individuals to manage their households and personal affairs, self-administer medications, and retain their community living arrangements. Independent living assistance can be furnished through telephone support, in-person support or travel attendant activities, as applicable to the tasks performed. Activities may include:

(1) Reminding an individual to take their medications;

(2) Contacting individuals at times no other in-home services are being provided to confirm the individual is functioning safely in their home;

(3) Assisting with banking;

(4) Organizing and coordinating health records;

(5) Assisting with applications for public programs including homestead exemption, the home energy assistance program, and subsidized housing;

(6) Monitoring and replenishing needed groceries (does not include cost of groceries);

(7) Assisting with business and personal correspondence;

(8) Accompanying an individual to their medical and other appointments; and

(9) Accompanying an individual on their errands and to other activities in the community.

(C) "Community support coaching" includes providing information and training to an individual so the individual can achieve the community integration goals identified in his or her person-centered services plan. Skills training topics include:

(1) How to manage finances;

(2) How to manage an individual's own health and wellness;

(3) How to identify and access community and legal resources, and leisure, educational, and recreational activities;

(4) How to find a job;

(5) How to manage an individual's own home;

(6) How to navigate community-based transportation systems; and

(7) How to build interpersonal, social, and communication skills.

(D) Community integration provider requirements.

(1) Community integration will be furnished by Ohio department of medicaid (ODM) -approved agencies or Ohio department of aging (ODA) -certified agencies.

(2) The provider will comply with the requirements set forth in rule 5160-44-31 of the Administrative Code for an ODM-administered waiver program, or Chapter 173-39 of the Administrative Code for the pre-admission screening system providing options and resources today (PASSPORT) waiver program.

(3) The provider will develop, implement, and maintain evidence of a training plan that includes initial orientation and annual continuing education.

(a) The provider will ensure anyone who furnishes community integration receives orientation on topics relevant to the person's job duties before they perform those duties.

(b) The provider will ensure anyone who furnishes community integration completes a minimum of twelve hours of continuing education annually on topics relevant to the person's job duties.

(4) Community integration staff will have:

(a) A high school diploma, general education diploma (GED), or a minimum of one year of relevant, supervised work experience with a public health, human services, or other community service agency.

(b) The ability to understand written activity plans (description of interventions and the dates/times the provider will provide the interventions), execute instructions, document activities provided, and the ability to perform basic mathematical operations.

(c) Experience advocating on behalf of individuals with chronic illnesses, behavioral health conditions, physical disabilities, or developmental disabilities.

(5) Supervisors of community integration staff will possess at least one of the following:

(a) A current and valid license to practice in the state of Ohio as a registered nurse (RN), licensed practical nurse (LPN), licensed social worker (LSW), or licensed independent social worker (LISW);

(b) A bachelor's degree or an associate's degree in human ecology, dietetics, counseling, gerontology, social work, nursing, public health, health education, or another related field; or

(6) Supervisory responsibilities include:

(a) Collaborating with the individual to identify, develop and document a specific activities plan, including the type of intervention(s) provided, prior to initiation of services that is consistent with the individual's approved person-centered services plan.

(b) Conducting evaluations of community integration staff every ninety days to ensure staff compliance with the activities plan, and the individual's satisfaction.

(E) All providers will maintain a record at their place of business for each individual served in accordance with the requirements set forth in rule 5160-44-31 of the Administrative Code for an ODM-administered waiver program, or with the requirements set forth in Chapter 173-39 of the Administrative Code for the PASSPORT program. The record will include:

(1) The individual's name;

(2) A copy of the individual's initial, and all subsequent person-centered services plans;

(3) A copy of the individual's approved activity plan;

(4) Date(s) of service;

(5) A detailed description of each task or activity performed and the staff person who performed it; and

(6) The individual's signature to verify receipt of the service.

Last updated January 2, 2024 at 8:32 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-44-16 Nursing facility-based level of care home and community-based services programs: personal emergency response systems.

(A) "Personal emergency response systems" (PERS) is a service with a monitoring, reminder and/or reporting component available to support individuals' independence in the community. PERS include telecommunications equipment, a central monitoring station (station), and a medium for two-way, hands-free communication between the individual and the station. Personnel at the station respond to an individual's alarm signal via the individual's PERS equipment.

(B) "PERS equipment" means equipment that is appropriate to meet the assessed needs of the individual as authorized on the individual's person-centered services plan and that meets all of the following characteristics:

(1) Includes an activation device that is wearable and water-resistant according to a generally-accepted industry standard for water resistance to a level matching the individual's assessed needs and preferences.

(2) Has an internal battery providing at least twenty-four hours of power without recharging.

(3) Accommodates the individual's needs and preferences.

(1) Remote video monitoring of the individual in his or her home.

(2) Systems that connect the individual to only emergency service personnel.

(D) PERS provider requirements. The provider will:

(1) Ensure and maintain a record of the successful completion of training on how to respond to alarm signals by each staff member whose job duties include responding to alarm signals at the station.

(2) Ensure each individual is able to choose the PERS device that meets his or her assessed needs and preferences as authorized by the individual's person-centered services plan.

(3) Install and activate the individual's PERS equipment no later than seven days after the date PERS has been authorized on the individual's person-centered services plan by the Ohio department of medicaid (ODM), the Ohio department of aging (ODA) or their designee.

(4) Train each individual receiving PERS with the following:

(a) An initial demonstration on how to use their PERS equipment. The demonstration can be conducted by telephone or electronically, unless the individual's needs necessitate an in-person visit.

(b) A successful return demonstration by the individual of all components of the PERS equipment and monthly testing.

(5) Ensure the availability of language assistance in the event the individual has limited English language proficiency.

(6) Consult with the individual and case manager before activating PERS equipment to develop an initial written response plan regarding how to proceed when an alarm is signaled within the following parameters.

(a) The written response plan includes a summary of the individual's information regarding medical diagnosis, treatment and preferences, as well as the contact information for the individual's designated responder.

(i) For the purpose of this rule, a designated responder is a person or organization identified in an individual's written response plan who the station contacts if the individual signals an alarm and requires assistance from the designated responder.

(ii) The provider identifies emergency service personnel on the written response plan only if the individual does not designate a responder or only designates one responder.

(b) The provider notifies each person the individual designated when activating the individual's PERS equipment and on an annual basis thereafter as part of the monthly service that, at a minimum, the individual designated the person as a responder and to provide instructions on how to respond when an alarm is signaled.

(c) The provider consults with the individual and ODM, ODA or their designee to identify a new designated responder in the written response plan whenever the person the individual chooses to be a designated responder refuses to participate or stops participating.

(7) Replace any malfunctioning PERS equipment at no additional cost to the individual, ODM, ODA, or their designee no later than twenty-four hours after it is notified of the malfunction, or no later than twenty-four hours after the malfunction is detected through the monthly testing of equipment, unless the malfunction is due to the individual's apparent misuse, abuse, or negligence of the equipment.

(8) Provide ongoing customer support to the individual, designated responder, ODM, ODA and its designee upon request of one or more of those parties as part of the monthly service.

(9) The provider will notify ODM, ODA, or their designee, in writing, if at any time, the provider determines inability to meet the individual's assessed needs, as identified through the individual's person-centered services plan.

(10) Employ staff to comprise a central monitoring station located in the United States or may subcontract with another company to use a station located in the United States to provide the station component of the PERS.

(11) Maintain a primary system to receive and respond to alarm signals from individuals twenty-four hours a day, every day of the year;

(12) Maintain a secondary system to respond to all incoming alarm signals in case the primary system is unable to respond to alarm signals;

(13) Respond to each alarm signal no more than sixty seconds after it receives the alarm signal;

(14) Notify ODM, ODA or their designee of any emergency involving an individual no more than twenty-four hours after the individual sends the alarm signal;

(15) Notify ODM, ODA or their designee when a pattern of frequent false alarms has been established for an individual;

(16) Contact emergency service personnel in the event a provider receives an alarm signal, but the station cannot reach a designated responder; and

(17) Remain in communication with the individual in the event of a personal emergency through the two-way communication feature of the PERS equipment until a designated responder or emergency service personnel arrives in the individual's home, the personal emergency subsides, or after it is determined there is no personal emergency (e.g. false alarm).

(E) PERS providers will maintain the following documentation for each individual receiving PERS:

(1) Date and time of equipment delivery and installation;

(2) A copy of the individual's initial and all subsequent written response plans;

(3) Date the individual and designated responder received initial and annual notification from the PERS provider as required by paragraph (D)(6)(b) of this rule;

(4) Date, time and results of monthly testing; and

(5) Date, time and summary of actions taken regarding service-related contacts.

Last updated January 2, 2024 at 8:33 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-44-17 Nursing facility-based level of care home and community-based services programs: out-of-home respite services.

(A) "Out-of-home respite" are services delivered to an individual in an out-of-home setting to allow a period of rest or relief for caregivers normally providing care. The service will include an overnight stay.

(1) An out-of-home respite provider will make available the following:

(a) Waiver nursing services as set forth in rule 5160-44-22 of the Administrative Code;

(b) Personal care services as set forth in rule 5160-46-04 of the Administrative Code if the individual is enrolled on an Ohio department of medicaid (ODM) -administered waiver, or rule 173-39-02.11 of the Administrative Code if the individual is enrolled in the PASSPORT program administered by the Ohio department of aging (ODA); and

(2) All services set forth in paragraph (A)(1) of this rule delivered during the provision of out-of-home respite will not be reimbursed as separate services.

(B) To qualify for submitting claims, providers of out-of-home respite will:

(1) Comply with all applicable rules set forth in Chapter 5160-44 of the Administrative Code, and:

(a) Chapters 5160-45, and as appropriate, either 5160-46 or 5160-58 of the Administrative Code, if the individual is enrolled on an ODM-administered waiver program; or

(b) Chapter 173-39 of the Administrative Code, if the individual is enrolled in the PASSPORT program.

(2) Be either:

(a) An intermediate care facility for individuals with an intellectual disability (ICF-IID) that has an active medicaid provider agreement in accordance with sections 5124.06 and 5124.07 of the Revised Code; or

(b) A nursing facility (NF) certified in accordance with rule 5160-3-02.3 of the Administrative Code; or

(1) Provide for coverage of an individual's loss due to theft, property damage and/or personal injury; and maintain a written procedure identifying the steps an individual takes to file a liability claim. Upon request, the provider will verify their coverage with ODM, ODA or their designee.

(2) Maintain evidence of non-licensed staff's completion of twelve hours of in-service training within a twelve-month period, excluding agency and program-specific orientation for every employee with in-person contact with individuals. In-service training will be initiated immediately after the non-licensed direct care staff's first anniversary of employment with the provider, and will be completed annually thereafter.

(3) Ensure any waiver nursing services provided are within the nurse's scope of practice as set forth in rule 5160-44-22 of the Administrative Code.

(4) Provide task-based instruction to direct care staff providing personal care services as defined in rule 5160-46-04 of the Administrative Code, or rule 173-39-02.11 of the Administrative Code, as applicable.

(D) Providers of out-of-home respite will maintain a clinical record at their place of business for each individual served in accordance with the requirements set forth in rule 5160-44-31 of the Administrative Code.

(1) Storage will protect the confidentiality of these records.

(2) Each clinical record will include the following:

(a) Identifying information, including but not limited to name, address, date of birth, gender/gender identify, race, significant phone numbers and health insurance identification numbers of the individual.

(b) Information regarding medical diagnosis (es), treatment(s) and preferences.

(d) The individual's treatment administration record, as applicable.

(e) The name and contact information for the individual's primary care physician(s).

(f) The name and current contact information for the individual's parent/guardian/authorized representative and/or emergency contact.

(g) All known drug and food interactions, allergies and dietary needs, preferences and/or restrictions.

(h) A copy of the initial and all subsequent person-centered services plans.

(i) A copy of any advance directives including, but not limited to, a do-not-resuscitate order, or medical power of attorney, if they are provided.

(j) Documentation verifying the date of out-of-home respite service delivery, including tasks performed or not performed.

(3) If the individual is receiving waiver nursing services pursuant to paragraph (A)(1)(a) of this rule, the clinical record will also include the following;

(a) A copy of the initial and all subsequent plans of care, specifying the type, frequency, scope and duration of the nursing services being provided. When services are provided by a licensed practical nurse (LPN) at the direction of a registered nurse (RN), the clinical records will include documentation that the RN has reviewed the plans of care with the LPN. The plan of care will be recertified by the primary care physician at least every sixty days, or more frequently if there is a significant change in the individual's condition.

(b) Documentation of any verbal orders given by the primary care physician to the nurse. The nurse shall document, in writing, the physician's orders, the date and time the orders were given, and sign the entry in the clinical record. The nurse shall subsequently secure documentation of the verbal orders, signed and dated by the primary care physician.

(c) All communications with the individual, case manager, RN supervisor (if one exists) primary care physician and other members of the individual's team.

Last updated January 2, 2024 at 8:33 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-44-22 Nursing facility-based level of care home and community-based services programs: waiver nursing services.

(A) "Waiver nursing services" are defined as nursing tasks and activities provided to individuals who require the skills of a registered nurse (RN) or licensed practical nurse (LPN) at the direction of an RN.

(1) All nurses providing waiver nursing services to individuals will:

(a) Possess a current, valid and unrestricted license with the Ohio board of nursing; and

(b) Possess an active medicaid provider agreement or be employed by an entity that has an active medicaid provider agreement; and

(c) Provide services within the nurse's scope of practice as set forth in Chapter 4723. of the Revised Code and agency 4723 of the Administrative Code rules adopted thereunder.

(2) Nursing tasks and activities that will only be performed by an RN include, but are not limited to, the following:

(a) Intravenous (IV) insertion, removal or discontinuation;

(b) IV medication administration;

(c) Programming of a pump to deliver medications including, but not limited to, epidural, subcutaneous and IV (except routine doses of insulin through a programmed pump);

(d) Insertion or initiation of infusion therapies;

(e) Central line dressing changes; and

(f) Blood product administration.

(B) Limitations.

(1) Waiver nursing will not be used in lieu of similar services available through third-party insurers, community supports and available resources, including Ohio medicaid state plan services when it has been determined an individual's needs can be met by those services.

(2) If the provider cannot assist an individual with an assessed need, the provider will notify ODM, ODA or their designee, in writing, of the service limitation(s) before the provider is included on the individual's person-centered services plan.

(3) Waiver nursing services do not include:

(a) Services delegated in accordance with Chapter 4723. of the Revised Code and rules adopted thereunder and to be performed by providers who are not licensed nurses in accordance with Chapter 4723. of the Revised Code;

(b) Services that require the skills of a nurse with a psychiatric mental health nursing specialty as set forth in rule 4723-8-04 of the Administrative Code;

(c) Visits performed for the sole purpose of meeting the supervisory requirements (including any visit) set forth in 42 CFR 484 (as in effect on October 1, 2023);

(d) Visits performed for the sole purpose of directing LPNs pursuant to section 4723.01 of the Revised Code; or

(e) Visits performed for the sole purpose of meeting the home care attendant service RN visit requirements set forth in rule 5160-44-27 of the Administrative Code.

(4) Waiver nursing services are reimbursable when sequentially, but not concurrently, performed with any other service during a visit in which the RN is furnishing billable home health, private duty nursing, RN assessment, RN consultation, and/or any other similar service that is reimbursable through the Ohio medicaid program.

(1) An employee or contractor of a medicare-certified or otherwise-accredited home health agency approved by ODM or certified by ODA who meets the provider requirements set forth in paragraph (D) of this rule. For the purposes of this rule, medicare-certified home health agencies and otherwise-accredited agencies will ensure they and the nurses they employ or contract with, are in compliance with 42 CFR 484. (as in effect on October 1, 2023).

(a) Parent of minor children, spouses, and relatives appointed legal decision-making authority may serve as direct care worker in accordance with rule 5160-44-32 of the Administrative Code.

(b) Maximum weekly direct care hours set forth in rule 5160-44-32 of the Administrative Code do not apply to the parent of a minor child.

(2) A non-agency RN waiver nursing provider approved by ODM who meets the provider requirements set forth in paragraph (D) of this rule.

(3) A non-agency LPN waiver nursing provider approved by ODM who meets the provider requirements set forth in paragraphs (D) and (E) of this rule.

(D) All waiver nursing providers will:

(1) Understand and comply with all applicable rules governing the home and community-based services (HCBS) waiver(s) for which they are providing services including, but not limited to those rules set forth in Chapters 5160-44, 5160-45, 5160-46, and/or 5160-58, of the Administrative Code, as applicable, for ODM-administered HCBS waiver programs, and Chapters 173-39, 5160-31, 5160-33, and/or 5160-58 of the Administrative Code, as applicable, for ODA-administered HCBS waiver programs.

(2) Provide the service to either one individual, or in a group setting as defined in rule 5160-46-06 of the Administrative Code during a face-to-face nursing visit in an ODM-administered HCBS waiver program, or in a group setting as defined in rule 5160-31-07 of the Administrative Code during a face-to-face nursing visit in an ODA-administered HCBS waiver program.

(3) Complete training about individual rights and responsibilities as set forth in rule 5160-45-03 of the Administrative Code for ODM-administered HCBS waiver programs.

(4) Not be the individual's legally responsible family member, as that term is defined in rule 5160-45-01 of the Administrative Code, unless the legally responsible family member is employed by a medicare-certified or otherwise-accredited home health agency and the individual is enrolled on an ODM-administered waiver.

(5) Not be the individual's legally responsible family member, as that term is defined in rule 173-39-02 of the Administrative Code, when the individual is enrolled on the ODA-administered waiver.

(6) Not be the foster caregiver of the individual.

(E) Non-agency LPNs, at the direction of an RN, will:

(1) Conduct a visit with the directing RN at least every sixty days after the initial visit to evaluate the provision of waiver nursing services and LPN performance, and to ensure that waiver nursing services are being provided in accordance with the approved plan of care and within the LPN's scope of practice. The visit may be conducted via telehealth.; and

(2) Conduct an in-person visit with the individual and the directing RN before initiating services and at least every one hundred and twenty days for the purpose of evaluating the provision of waiver nursing services, the individual's satisfaction with care delivery and LPN performance, and to ensure that waiver nursing services are being provided in accordance with the approved plan of care and within the LPN's scope of practice.

(3) When the RN performs an RN assessment visit, the RN will bill the state plan nursing assessment code set forth in appendix A to rule 5160-12-08 of the Administrative Code.

(F) All waiver nursing service providers will maintain a clinical record at their place of business for each individual served in accordance with the requirements set forth in rule 5160-44-31 of the Administrative Code.

(1) Storage will be in a manner that protects the confidentiality of these records.

(2) For the purposes of this rule, the place of business will be a location other than the individual's residence or primary location where the individual receives services.

(3) Each clinical record will include the following:

(a) Identifying information, including but not limited to, name, address, date of birth, gender, gender identity, race, phone numbers and health insurance identification numbers of the individual.

(b) Information regarding medical diagnoses, treatment and preferences.

(d) The individual's treatment administration record, as applicable.

(e) The name of and contact information for the individual's primary care physician(s).

(f) The name of and contact information for the individual's parent/guardian/authorized representative and/or emergency contact.

(g) All known drug and food interactions, allergies and dietary needs, preferences and/or restrictions.

(h) A copy of the initial and all subsequent person-centered services plans.

(i) Nurse assignments.

(j) A copy of any advance directives including, but not limited to, a do-not-resuscitate (DNR) order and/or medical power of attorney, if they are provided by the individual.

(k) A copy of the initial and all subsequent plans of care, specifying the type, frequency, scope and duration of the nursing services being performed. When services are performed by an LPN at the direction of an RN, the clinical record will include documentation that the RN has reviewed the plans of care with the LPN. The plan of care will be recertified by the primary care physician at least every sixty days, or more frequently if there is a significant change in the individual's condition.

(l) Documentation of any verbal orders given by the primary care physician to the nurse. The nurse will document, in writing, the physician's orders, the date and time the orders were given, and sign the entry in the clinical record. The nurse will subsequently secure documentation of the verbal orders, signed and dated by the primary care physician.

(m) In all instances when a non-agency LPN is providing waiver nursing services, clinical notes, signed and dated by the LPN, documenting all consultations between the LPN and the directing RN, the face-to-face visits between the LPN and the directing RN, and the face-to-face visits between the LPN, the individual, and the directing RN.

(n) Clinical notes, signed and dated by the nurse, documenting the general condition of the individual, any unusual events occurring during the visit and the service tasks performed or not performed.

(o) All communications with the individual, case manager, RN supervisor if one exists, primary care physician and other members of the individual's team.

(G) All waiver nursing providers will also maintain a record at the individual's residence or primary service location in order to encourage sharing of information between caregivers and enhance person-centered care.

(1) Storage will be in a manner that protects the confidentiality of these records.

(2) The record may include a communication log, treatment record and/or medication administration record, if they exist.

(3) Documents in the record will reflect a minimum of at least the past sixty calendar days, with the individual's right to maintain more if he or she so chooses.

(4) The individual will identify the location in his or her residence or the primary service location where the record will be safely maintained.

Last updated January 2, 2024 at 8:33 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-44-26 Nursing facility-based level of care home and community-based services programs: community transition services.

(A) "Community transition" pays for non-recurring start-up living expenses for individuals transitioning from an institutional setting to a home and community-based services (HCBS) setting that is compliant with rule 5160-44-01 of the Administrative Code. Community transition:

(1) Community transition includes the following:

(a) Expenses necessary to enable an individual to establish a basic household. Examples include:

(i) Security deposits and rental fees needed to obtain a lease on an apartment or home and rental expenses required to obtain a residential lease;

(ii) Essential household items such as furnishings and moving expenses required to occupy and use a community home, including furniture needed to occupy and maintain housing, including window coverings, food preparation items, and linens;

(iii) Set-up fees and deposits for utility and service access, including telephone/cellphone, electricity, gas, garbage, and water;

(iv) Services necessary for the individual's health and safety such as pest eradication and one-time cleaning prior to occupancy;

(v) Pre-transition transportation necessary to secure housing and benefits, etc.;

(vi) Initial cleaning and household supplies;

(vii) Activities to arrange for and to procure other non-recurring set-up expenses; and

(viii) Essential personal hygiene and clothing items needed to transition safely.

(b) The provider's administrative cost associated with providing community transition under this rule. Such fees will be included in the authorization described in paragraph (A)(2)(b) of this rule.

(2) Is payable only to the extent:

(a) They are determined reasonable and necessary through the person-centered services planning process described in rule 5160-44-02 of the Administrative Code and are clearly identified in an individual's person-centered services plan; and

(b) They are authorized by the Ohio department of medicaid (ODM), the Ohio department of aging (ODA) or their designee in an individual's person-centered services plan, which will only occur if no other person, including a landlord, has a legal or contractual responsibility to fund the expense, and if family, neighbors, friends, or community resources are unavailable to fund the expense.

(3) May be authorized up to one hundred eighty consecutive days before an individual's transition from an institutional setting into an HCBS setting. The date of service for purposes of payment is the date the individual leaves the institutional setting. If the individual fails to transition to an HCBS setting, the service is still payable if all other requirements are met.

(4) Is provided no later than thirty days after the date on which an individual enrolls on the waiver program.

(B) Community transition does not include:

(1) Room and board, ongoing monthly rental, or mortgage expenses;

(2) Grocery expenses;

(3) Ongoing utility or service expenses;

(4) Ongoing cable or internet expenses;

(5) Electronic and other household appliances and items intended to be used for entertainment or recreational purposes;

(6) Tobacco products or alcohol; and

(7) Furnishing living arrangements that are owned or leased by a waiver provider where the provision of these items and services are inherent to the service they are already providing.

(1) Community transition will only be used one time per individual per waiver enrollment.

(2) Community transition will not exceed two thousand dollars per individual per waiver program enrollment.

(D) Providers will:

(1) Be either:

(a) An ODM-approved or ODA-certified waiver agency provider;

(b) An ODM-approved or ODA-certified non-agency provider;

(c) A transition coordination service provider under contract with ODM that also meets the requirements set forth in paragraph (E)(1) of this rule; or

(d) An ODA-certified assisted living provider.

(2) Comply with the requirements set forth in rule 5160-44-31 of the Administrative Code for an ODM-administered waiver program, or Chapter 173-39 of the Administrative Code for the pre-admission screening system providing options and resources today (PASSPORT) or assisted living programs.

(3) The provider will involve the individual and/or caregiver(s) in the selection of items to be purchased on the individual's behalf.

(E) All providers will maintain a record at their place of business for each individual served in accordance with the requirements set forth in rule 5160-44-31 of the Administrative Code, or with the requirements set forth in Chapter 173-39 of the Administrative Code for the PASSPORT program. For each service provided, the record will include:

(1) The individual's name;

(2) Date of service;

(3) A detailed description of each expense;

(4) A receipt for each expense;

(5) Verification the individual was involved in the selection of all items; and

(6) The individual's signature to verify receipt of the service.

Last updated January 2, 2024 at 8:34 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-44-27 Nursing facility-based level of care home and community-based services programs: home care attendant services.

(A) The following definitions are applicable to this rule:

(1) "Adult" means an individual at least eighteen years of age.

(2) "Authorizing health care professional" means a health care professional who, pursuant to section 5166.307 of the Revised Code, authorizes a home care attendant to assist an individual enrolled on a nursing facility (NF)-based level of care waiver with self-administration of medication, nursing tasks, or both.

(3) "Controlled substance" has the same meaning as in section 3719.01 of the Revised Code.

(4) "Custodian" has the same meaning as in section 2151.011 of the Revised Code.

(5) "Gastrostomy tube" means a percutaneously inserted catheter that terminates in the stomach.

(6) "Group setting" means a situation in which a home care attendant service provider furnishes home care attendant services in accordance with this rule and as authorized by the Ohio department of medicaid (ODM), or certified by the Ohio department of aging (ODA), to two or three individuals who reside at the same address.

(7) "Guardian" has the same meaning as in section 2111.01 of the Revised Code.

(8) "Health care professional" means a physician or registered nurse who holds a current, valid unrestricted license.

(9) "Home care attendant" means a provider, holding a valid medicaid provider agreement in accordance with section 5166.301 of the Revised Code and paragraph (G) of this rule, who is authorized to provide home care attendant services to a specific individual enrolled on a NF-based level of care waiver.

(10) "Individual enrolled on a NF-based level of care waiver" and "individual" mean the same as "consumer" as defined in section 5166.30 of the Revised Code.

(11) "Jejunostomy tube" means a percutaneously inserted catheter that terminates in the jejunum.

(12) "Medication" means a drug as defined in section 4729.01 of the Revised Code.

(13) "Minor" means an individual under eighteen years of age.

(14) "Nursing facility (NF) -based level of care waiver" and "waiver" mean the MyCare Ohio and Ohio home care waivers administered by ODM and the PASSPORT waiver administered by ODA.

(15) "Nursing tasks" means skilled tasks that would otherwise be performed by a registered nurse (RN), or a licensed practical nurse (LPN) at the direction of an RN.

(16) "Oral medication" means any medication that can be administered through the mouth, through a gastrostomy tube or jejunostomy tube if through a pre-programmed pump, or through a syringe. Oral medication may include medication administered through a metered dose inhaler.

(17) "Physician" means an individual authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery.

(18) "Practice of nursing as a registered nurse," "practice of nursing as a licensed practical nurse (LPN)", and "registered nurse (RN)" have the same meanings as in section 4723.01 of the Revised Code. "Registered nurse" includes an advance practice nurse as defined in section 4723.01 of the Revised Code.

(19) "RN home care attendant service visit" means the visit every ninety days between the RN and the individual receiving home care attendant services as required by paragraph (G)(8) of this rule. The visit may be conducted by via telehealth, unless the individual's needs necessitate in-person visit.

(20) "Schedule II, " "schedule III," "schedule IV" and "schedule V" have the same meaning as in section 3719.01 of the Revised Code.

(21) "Topical medication" means any medication applied to the outer skin, including transdermal medications and eye, ear and nose drops. Topical medication may also include vaginal or rectal suppositories.

(B) Home care attendant services are services provided to an individual enrolled on a waiver by an unlicensed non-agency provider in accordance with this rule. Home care attendant services are tasks that would otherwise be performed by an RN or an LPN at the direction of an RN. Home care attendant services include:

(1) Assistance with self-administration of medications as set forth in paragraph (E) of this rule.

(2) Assistance with the performance of nursing tasks as set forth in paragraph (F) of this rule.

(3) Tasks performed as part of personal care aide services as described in rule 5160-46-04 or 173-39-02.11 of the Administrative Code when performed during a home care attendant service visit. Personal care aide tasks are not reimbursable separately as personal care aide services when they are performed during a home care attendant service visit.

(1) In the individual's home or in the community; and

(2) To assist an individual to function in the workplace without duplicating workplace accommodations.

(D) If the individual has an authorized representative as 5166.3010 of the Revised Code, the authorized representative will be present and awake during the delivery of home care attendant services.

(E) Assistance with self-administration of medication.

(1) A home care attendant will only assist an individual enrolled on a waiver with the self-administration of the following medication:

(a) Oral medications;

(b) Topical medications;

(d) Programming of a pump only used to deliver a routine dose of insulin;

(e) Medication administered via stable, labeled gastrostomy or jejunostomy tubes using pre-programmed pumps; and

(f) Doses of schedule II, schedule III, schedule IV and schedule V drugs only when administered orally or topically.

(2) Medication will be maintained in its original container and the attached label will match the dosage and means of administration set forth on the ODM 02389 "Home Care Attendant Medication Authorization" form. The label on the container will display all of the following information for the individual enrolled on a waiver:

(a) The individual's full name;

(b) A dispensing date within the prior twelve months; and

(3) For schedule II, schedule III, schedule IV and schedule V drugs, all of the following apply:

(a) Medication(s) will have a warning label on the bottle;

(b) During the first visit, the home care attendant will count the medication(s) in the presence of the individual enrolled on a waiver or the authorized representative and will record the count on a log located in the individual's clinical record.

(c) The medication(s) will be recounted by the home care attendant in the presence of the individual enrolled on a waiver or the authorized representative at least monthly, and the count will be reconciled on a log located in the individual's clinical record. The home care attendant will notify the authorizing health care professional, in writing, within twenty-four hours if:

(i) Medication is missing; or

(ii) The count of medication(s) cannot be reconciled.

(d) The medication(s) will be stored separately from all other medications, and secured and locked at all times when not being administered in order to prevent access by unauthorized persons.

(F) Assistance with the performance of nursing tasks.

(1) A home care attendant may assist with the performance of nursing tasks not expressly excluded in accordance with paragraph (F)(2) of this rule.

(2) A home care attendant may not assist an individual who is receiving home care attendant services with the performance of any of the following nursing tasks:

(a) Intravenous (IV) insertion, removal or discontinuation;

(b) Intramuscular injections;

(d) Subcutaneous injections, except for routine doses of insulin pursuant to paragraph (E)(1)(c) of this rule;

(e) Programming of a pump used to deliver medications (including, but not limited to epidural, subcutaneous and IV), except for routine doses of insulin pursuant to paragraph (E)(1)(d) of this rule;

(f) Insertion or initiation of infusion therapies; and

(g) Central line dressing changes.

(3) Performance of nursing tasks will be summarized and submitted on the ODM 02390 "Home Care Attendant Skilled Task Authorization" form.

(G) In order to provide services to an individual enrolled on a waiver and to submit a claim for reimbursement, home care attendants will meet all of the following requirements:

(1) As part of the medicaid provider agreement application process, provide ODM, ODA or their designee with evidence to its satisfaction of the following:

(a) Submission of the ODM 02389 "Home Care Attendant Medication Authorization" form and/or ODM 02390 "Home Care Attendant Skilled Task Authorization" form as prescribed by paragraph (H) of this rule.

(b) Successful completion of at least one of the following:

(i) A competency evaluation program or training and competency evaluation program approved or conducted by the director of health under section 3721.31 of the Revised Code, and registration as active or in good standing on the Ohio nurse aide registry maintained by the director of health under section 3721.32 of the Revised Code; or

(ii) A training program and competency evaluation program for home health aides as specified in 42 C.F.R. 484.4 and 484.36, if the person met those standards as they existed on or before January 12, 2018, or 42 C.F.R. 484.80 and 484.115, if the person met those standards since they were adopted on January 13, 2018. A person is not considered to have completed a training and competency evaluation program, or a competency evaluation program if, since the person's most recent completion of this program(s), there has been a continuous period of twenty-four consecutive months during none of which the person furnished services described in 42 C.F.R. 409.40 (as in effect on October 1, 2023); or

(iii) A certified vocational program in a health care field, and written testing and skills testing by return demonstration; or

(iv) A written attestation of training, instruction, and as appropriate, skills testing by return demonstration prior to initiation of service provision on:

(a) Appropriate and safe techniques in personal hygiene and grooming that include: bed, tub, shower and partial bath techniques, shampoo in sink, tub or bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer and ambulation, normal range of motion and positioning, and adequate nutrition and fluid intake.

(b) The maintenance of a clean, safe and healthy environment, including but not limited to, house cleaning and laundry, dusting furniture, sweeping, vacuuming and washing floors, kitchen care (including dishes, appliances and counters), bathroom care, emptying and cleaning bedside commodes and urinary catheter bags, changing bed linens, washing inside windows within reach from the floor, removing trash and folding, ironing and putting away laundry.

(d) The physical, emotional and developmental needs of individuals, including the need for privacy and respect for individuals and their property.

(e) Universal precautions for the prevention of disease transmission, including hand-washing and proper disposal of bodily waste and medical instruments that are sharp or may produce sharp pieces if broken.

(f) Basic elements of body functioning and changes in body function that should be reported to a supervisor.

(g) Basic safety requirements and knowledge of emergency procedures.

(h) Reading and recording temperature, pulse and respiration.

(i) Observation, reporting and documentation of individual status and services provided.

(j) Communication skills, including the ability to read, write and make brief and accurate oral or written reports.

(c) Completion of training and instruction, prior to the provision of home care attendant services, regarding the delivery of the home care attendant services authorized by the individual's authorizing health care professional. The training will be specific to the individual enrolled on a waiver and may be provided by the individual's authorizing health care professional, the individual receiving services or the authorized representative in cooperation with the individual's health care professional as indicated on the ODM 02389 "Home Care Attendant Medication Authorization" form and/or ODM 02390 "Home Care Attendant Skilled Task Authorization" form, as appropriate.

(d) Performance of a successful return demonstration of the home care attendant service to be provided if requested by the individual enrolled on a waiver or the authorizing health care professional.

(e) Completion and maintenance of first aid certification from a class that is not solely internet-based and that includes hands-on training by a certified first aid instructor and a successful return demonstration of what was learned in the course, and certification that education was received from the authorizing health care professional about health and welfare considerations appropriate for an individual or group setting.

(f) Completion and maintenance of cardiopulmonary resuscitation (CPR) certification from a class that is not solely internet-based and that includes hands-on training by a certified CPR instructor and a successful return demonstration of what was learned in the course. Current providers and those provider-applicants whose applications are pending as of the effective date of this rule shall have one hundred and eighty days from the effective date of this rule to meet this requirement.

(2) Be a non-agency provider who holds an active medicaid provider agreement as a home care attendant and who maintains compliance with sections 5166.30 to 5166.3010 of the Revised Code and applicable rules set forth in Chapters 173-39, 5160-44, 5160-45 and 5160-46 of the Administrative Code.

(3) Request reimbursement for the provision of home care attendant services in accordance with rule 5160-1-06.1 of the Administrative Code for Ohio department of aging certified providers or 5160-46-06.1 of the Administrative Code for providers of Ohio department of medicaid administrated waiver programs.

(4) Not be the authorizing health care professional of the individual receiving services.

(5) Not be an authorized representative of the individual receiving services.

(6) Not be the legally responsible family member as that term is defined in rule 5160-45-01 of the Administrative Code of the individual receiving services.

(7) Not be the legal guardian or foster caregiver of the individual receiving services.

(8) In collaboration with the individual receiving services, secure the services of an RN and participate in an in-person visit with the individual receiving services, the authorized representative, and the RN for the purpose of answering any questions the home care attendant and/or individual receiving services, or authorized representative have about meeting care needs, medications and other issues.

(a) At least twice per year, the RN will conduct RN home care attendant service visits in-person.

All other RN home care attendant service visits may be conducted via telehealth, unless the individual's needs necessitate an in-person visit.

(b) The RN performing an RN home care attendant service visit will:

(i) Possess a current, valid and unrestricted license with the Ohio board of nursing;

(ii) Possess an active Ohio medicaid provider agreement;

(iii) Comply with the conditions of participation as set forth in rule 5160-44-31 of the Administrative Code.

(c) The RN will be present at the first visit between the home care attendant and individual upon the initiation of home care attendant services. ODM, ODA, or their designee will also be present at the first visit.

(d) The home care attendant and the RN will document the activities of each visit in the clinical record of the individual receiving services.

(e) The home care attendant will discuss the results of the RN visit with ODM, ODA or their designee, the individual receiving services and/or the authorized representative.

(f) When the RN performs an RN home care attendant service visit, the RN may bill the state plan nursing assessment code set forth in appendix A to rule 5160-12-08 of the Administrative Code.

(H) If authorized on the person-centered services plan, a home care attendant may provide services to two or three individuals enrolled on a waiver in a group setting.

(I) The ODM 02389 "Home Care Attendant Medication Authorization" form and/or the ODM 02390 "Home Care Attendant Skilled Task Authorization" form, as appropriate, will contain all of the following:

(1) Written consent from the individual enrolled on a waiver or the authorized representative, as applicable, allowing the home care attendant to provide home care attendant services, and assuming responsibility for directing the home care attendant.

(2) A written statement from the authorizing health care professional attesting that the individual enrolled on a waiver or the authorized representative has demonstrated the ability to direct the home care attendant. The written statement will also indicate whether the home care attendant has demonstrated the ability to furnish the home care attendant service to the individual enrolled on a waiver. The statement will include all of the following:

(a) The name and address of the individual receiving home care attendant services;

(b) A description of the specific nursing task or self-administration of medication that the home care attendant will assist with, including, in the case of assistance with self-administration of medication, the name, dosage, and route of administration of the medication;

(c) The times or intervals when the home care attendant is to assist the individual receiving services with the self-administration of each dosage of the medication or with the performance of nursing tasks;

(d) The dates on which the home care attendant is to begin and cease providing assistance;

(e) A list of severe adverse reactions that the home care attendant will report to the individual's health care professional should the individual experience one or more reactions;

(f) At least one telephone number at which the home care attendant can reach the individual's health care professional in an emergency for consultation after contacting emergency personnel;

(g) At least one contact number at which the home care attendant can reach the authorizing health care professional when the home care attendant observes that scheduled medication(s) is missing or cannot be reconciled; and

(h) Instructions the home care attendant will follow when assisting the individual receiving services with the performance of a nursing task or the self-administration of medications, including, instructions for maintaining sterile conditions and for the storage of task-related equipment and supplies.

(J) The individual enrolled on a waiver will participate with ODM, ODA, or their designee in the development and maintenance of a written back-up plan prior to initiation of services. The authorizing health care professional and/or the home care attendant may also participate in the development and maintenance of the back-up plan.

(1) The back-up plan will meet the needs of the individual enrolled on a waiver in the event:

(a) The regularly scheduled home care attendant cannot or does not meet his or her obligation to provide services to the individual receiving services; or

(b) The individual receiving services and/or the authorized representative is not able to direct home care attendant services.

(2) As authorized by ODM, ODA, or their designee,

(a) Waiver nursing as set forth in rule 5160-44-22 of the Administrative Code, and/or private duty nursing or home health nursing as set forth in Chapter 5160-12 of the Administrative Code, may be used as back-up to assist with self-administration of medications and the performance of nursing tasks;

(b) Personal care aide services as set forth in rule 5160-46-04 of the Administrative Code may be used as back-up for personal care aide tasks in an ODM-administered waiver;

(c) Personal care services as set forth in rule 173-39-02.11 of the Administrative Code may be used as back-up for personal care tasks in the PASSPORT waiver; and

(d) Back-up may include informal caregivers.

(K) All home care attendants service providers will maintain a clinical record for each individual served in accordance with the requirements set forth in rule 5160-44-31 of the Administrative Code.

(1) Storage of the clinical record will be in a manner that protects the confidentiality of these records and will be in a secure location that may be the individual's residence or primary location where the individual receives services.

(2) Each clinical record will include:

(a) Identifying information including name, address, date of birth, gender/gender identity, race, significant phone numbers and health identification numbers of the individual.

(b) Information regarding the individual's medical diagnoses, treatment and preferences.

(d) The individual's treatment administration record, as applicable.

(e) The name and contact information for all of the licensed health care professionals serving the individual.

(f) The name of and current contact information for the individual's parent/guardian/authorized representative and/or emergency contact.

(g) A copy of the initial and all subsequent person-centered services plans.

(h) All known drug and food interactions, allergies and dietary needs, preferences and/or restrictions.

(i) A copy of any advance directives including, but not limited to, a "do not resuscitate order" (DNR) or a "medical power of attorney," if they exist.

(j) The ODM 02389 "Home Care Attendant Medication Authorization" form and/or the ODM 02390 "Home Care Attendant Skilled Task Authorization" form, as appropriate. The ODM 02389 "Home Care Attendant Medication Authorization" form and/or the ODM 02390 "Home Care Attendant Skilled Task Authorization" form will be updated and reflected in the clinical record should any changes in home care attendant service provisions be needed.

(k) Documentation of home care attendant services performed or not performed, arrival and departure times, and the dated signature of the provider, and individual receiving services or the authorized representative, verifying the service delivery upon its completion and arrival and departure times. The signature method of choice for the individual receiving services or the authorized representative will be documented on the person-centered services plan, and will include, but not be limited to, any of the following: a handwritten signature, initials, a stamp or mark, or an electronic signature. If the individual is unable to provide the signature at the time of service, the individual is to submit an electronic signature or standard signature via regular mail, or otherwise provide a signature in no instance any later than within three business days of the completion of the service delivery that requires signature.

(l) A copy of the log detailing the count and reconciliation of schedule II, schedule III, schedule IV and schedule V drugs for which assistance with self-administration is provided.

(m) Service notes, signed and dated by the home care attendant, documenting all communications with ODM, ODA or their designee, health care professionals including the authorizing health care professional, and other members of the individual's team, and documenting the general condition of the individual, any unusual events occurring during the visit, and the service tasks performed.

(n) Documentation of the RN home care attendant service visits every ninety days between the home care attendant, individual enrolled on a waiver and RN, and of any resulting activities, in accordance with paragraph (G)(8) of this rule.

(L) Unless the clinical record described in paragraph (K) of this rule is maintained in the home of the individual and accessible to team members, the home care attendant will maintain another record which:

(1) Includes communication logs going back no less than sixty calendar days in a format agreed upon by the individual and provider for the purpose of promoting communication between team members.

(2) Any other documentation required by the individual.

(3) Is maintained in a place and manner that is accessible to the individual and other team members chosen by the individual at the individual's residence or primary service location.

(4) Is maintained in a manner that protects the confidentiality of the individual.

(M) If ODM, ODA, or their designee determines that the individual enrolled on a waiver cannot meet the requirements of this rule, or the health and welfare of the individual receiving home care attendant services cannot be ensured, then ODM, ODA, or their designee, at its discretion, may prohibit the individual from receiving home care attendant services. The individual will be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

Last updated January 2, 2024 at 8:34 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-44-31 Ohio department of medicaid (ODM)-administered waiver programs: provider conditions of participation.

(A) An ODM-administered waiver service provider will maintain a professional relationship with the individuals to whom they provide services. Providers will furnish services in a manner that is in accordance with the individual's approved person-centered services plan, is attentive to the individual's needs, and maximizes the individual's independence. A provider will refrain from any behavior that may detract from the goals, objectives and services outlined in the individual's approved person-centered services plan and/or that may jeopardize the individual's health and welfare.

(B) An ODM-administered waiver service provider will:

(1) Maintain an active, valid medicaid provider agreement as set forth in rule 5160-1-17.2 of the Administrative Code.

(2) Comply with all provider requirements set forth in Chapters 5160-44 and 5160-45 of the Administrative Code, and Chapter 5160-46 or 5160-58 of the Administrative Code, depending upon the waiver(s) for which the provider is rendering services. Provider requirements include:

(a) Provider enrollment as set forth in rule 5160-45-04 of the Administrative Code;

(b) Criminal record checks as set forth in rule 5160-45-07 or 5160-45-08, as applicable, and rule 5160-45-11 of the Administrative Code;

(d) Provider monitoring, reviews and oversight as set forth in rules 5160-45-06 and 5160-45-09 of the Administrative Code.

(3) Be at least eighteen years of age, including the provider and its employees, if applicable.

(4) Be able to read, write, and understand English at a level that enables the provider to comply with all applicable program requirements.

(5) Be able to effectively communicate with the individual.

(6) Deliver services professionally, respectfully and legally.

(7) Ensure that individuals to whom the provider is rendering ODM-administered waiver services are protected from abuse, neglect, exploitation and other threats to their health, safety and well-being. Upon entering into a medicaid provider agreement, and annually thereafter, all providers including all employees who have direct contact with individuals enrolled on an ODM-administered waiver, must acknowledge in writing they have reviewed rule 5160-44-05 of the Administrative Code regarding incident management and related procedures.

(8) Work with the individual and case manager to coordinate service delivery, including:

(a) Agreeing to provide and providing services in the amount, scope, location and duration they have capacity to provide, and as specified on the individual's approved person-centered services plan.

(b) Participating in the development of a back-up plan in the event that providers are unable to furnish services on the appointed date and time.

(c) Contacting the individual and the case manager in the event the provider is unable to render services on the appointed date and time.

(i) In the case of an emergency or unplanned absence, the provider will immediately activate the back-up plan as set forth in the individual's approved person-centered services plan, verify with the individual and notify the case manager with information about the absence.

(ii) In the event of a planned absence, the provider will verify with the individual and notify the case manager no later than seventy-two hours prior to the absence with information about the absence.

(9) Upon request and within the timeframe prescribed in the request, provide information and documentation to ODM, its designee and/or the centers for medicare and medicaid services (CMS).

(10) Successfully complete ODM-mandated new provider training within ninety days after a new provider's medicaid enrollment date.

(11) Participate in all appropriate provider trainings mandated or sponsored by ODM or its designees, including but not limited to those set forth in Chapters 5160-44, 5160-45, 5160-46 and 5160-58 of the Administrative Code.

(12) Be knowledgeable about and comply with all applicable federal and state laws, including the "Health Insurance Portability and Accountability Act of 1996" (HIPAA) regulations set forth in 45 C.F.R. parts 160 and 164 (as in effect on October 1, 2023), and the medicaid safeguarding information requirements set forth in 42 C.F.R. 431.300 to 431.306 (as in effect on October 1, 2023), along with sections 5160.45 to 5160.481 of the Revised Code.

(13) Ensure that the provider's contact information, including but not limited to address, telephone number, fax number and email address, is current. In the event of a change in contact information, the provider will notify ODM via the provider network management (PNM) portal and its designee, no later than seven calendar days after such changes have occurred.

(14) Maintain and retain all required documentation related to the services delivered during each visit, including but not limited to: an individual-specific description and details of the tasks performed or not performed in accordance with the approved person-centered services plan and when required, the individual's plan of care.

(a) Verification of service delivery will include, but not be limited to, the date and location of service delivery, service start and end times, and the signatures of the provider and the individual or authorized representative.

(b) Acceptable signatures include, but are not limited to a handwritten signature, initials, a stamp or mark, or an electronic signature. Any accommodations to the individual's or authorized representative's signature will be documented on the person-centered services plan.

(c) If the individual is unable to provide the signature required by this paragraph at the time of the service, the individual is to submit an electronic signature or standard signature via regular mail, or otherwise provide a signature in no instance any later than within three business days of the completion of the service delivery that requires signature.

(15) Retain all records of service delivery and billing for a period of six years after the date of receipt of the payment based upon those records, or until any initiated audit is completed, whichever is longer.

(16) Cooperate with ODM and its designee during all provider monitoring and oversight activities by being available to answer questions during reviews, and by assuring the availability and confidentiality of individual information and other documents that may be requested as part of provider monitoring activities.

(17) To the extent not otherwise required by rule 5160-44-05 of the Administrative Code, notify ODM or its designee within twenty-four hours when the provider is aware of issues that may affect the individual and/or provider's ability to render services as directed in the individual's person-centered services plan, including when:

(a) The individual consistently declines services;

(b) The individual plans to or has moved to another residential address;

(d) There are changes in the individual's environmental conditions;

(e) The individual's caregiver status has changed;

(f) The individual no longer requires medically necessary services as defined in rule 5160-1-01 of the Administrative Code;

(g) The individual's actions toward the provider are threatening or the provider feels unsafe or threatened in the individual's environment;

(h) The individual is consistently noncompliant with physician orders, or is noncompliant with physician orders in a manner that may jeopardize his or her health and welfare;

(i) The individual's requests conflict with his or her person-centered services plan and/or may jeopardize his or her health and welfare; or

(j) Any other situation that affects the individual's health and welfare.

(18) Make arrangements to accept all correspondence sent by ODM or its designee, including but not limited to, certified mail.

(19) Maintain a current e-mail address with ODM and its designee in order to receive electronic notification of any rule adoption, amendment or rescission, and any other communications from ODM or its designee

(20) Submit written notification to the individual and ODM or its designee at least thirty calendar days before the anticipated last date of service if the provider is terminating the provision of ODM-administered waiver services to the individual. Exceptions include:

(a) The provider will submit verbal and written notification to the individual and ODM or its designee at least ten days before the anticipated last date of service if the individual has been:

(i) Admitted to a hospital;

(ii) Placed in an institutional setting; or

(iii) Incarcerated.

(b) ODM may waive advance notification for a provider upon request and on a case-by-case basis.

(21) Be identified as the provider, and have specified on the individual's person-centered service plan that is prior approved by ODM or its designee, the amount of services the provider is authorized to furnish to the individual.

(22) Have a valid social security number and at least one of the following current, government-issued photographic identification cards:

(a) Driver license;

(b) State of Ohio identification card; or

(C) A provider of nursing, personal care and home care attendant services under an ODM-administered waiver program will verify service delivery using an ODM-approved electronic visit verification (EVV) system in accordance with rule 5160-1-40 of the Administrative Code.

(D) At no time, will an ODM-administered waiver service provider:

(1) Engage in any behavior that causes or may cause physical, verbal, mental or emotional abuse or distress to the individual.

(2) Engage in any other behavior that may compromise the health and welfare of the individual.

(3) Engage in any activity or behavior that may take advantage of or manipulate the individual or his or her authorized representative, family or household members or which may result in a conflict of interest, exploitation, or any other advantage for personal gain, including:

(a) Misrepresentation;

(b) Accepting, obtaining, attempting to obtain, borrowing, or receiving money or anything of value including, but not limited to gifts, tips, credit cards or other items;

(d) Using real or personal property of another;

(e) Using information of another;

(f) Lending or giving money or anything of value;

(g) Engaging in the sale or purchase of products, services or personal items; and

(h) Engaging in any activity that takes advantage of or manipulates ODM-administered waiver program rules.

(4) Falsify the individual's signature, including using copies of the signature.

(5) Make fraudulent, deceptive or misleading statements in the advertising, solicitation, administration or billing of services.

(6) Submit a claim for waiver services rendered while the individual is hospitalized, institutionalized or incarcerated. The only exception is when the individual is receiving out-of-home respite as set forth on his or her person-centered services plan.

(E) While rendering services, an ODM-administered waiver service provider will not:

(1) Take the individual to the provider's place of residence.

(2) Bring children, animals, friends, relatives, other individuals or anyone else to the individual's place of residence.

(3) Provide care to persons other than the individual.

(4) Smoke without the consent of the individual.

(5) Sleep.

(6) Engage in any activity that is not related to the provision of services to the extent the activity distracts from, or interferes with, service delivery. Such activities include, but are not limited to the following:

(a) Using electronic devices for personal or entertainment purposes including, but not limited to watching television, using the computer or playing games.

(b) Making or receiving personal communications.

(7) Deliver services when the provider is medically, physically or emotionally unfit.

(8) Use or be under the influence of the following while providing services:

(a) Alcohol.

(b) Illegal drugs.

(d) Controlled substances that may adversely affect the provider's ability to furnish services.

(9) Engage in any activity or conduct that may reasonably be interpreted as sexual in nature, regardless of whether or not it is consensual.

(11) Consume the individual's food and/or drink without his or her offer and consent.

(F) Parents of minor children, spouse, and other individual's designated legal decision-making authority:

(1) Unless otherwise permitted by rule 5160-44-32 of the Administrative Code, an ODM-administered waiver service provider will not be designated to serve or make decisions for the individual in any capacity involving a declaration for mental health treatment, general power of attorney, health care (medical) power of attorney, financial power of attorney, legal custody of a minor child, guardianship pursuant to court order, as an authorized representative, or as a representative payee.

(2) A provider may be designated as an authorized representative or pursuant to a declaration for mental health treatment, general power of attorney, health care (medical) power of attorney, financial power of attorney or guardianship for the individual if:

(a) The provider was serving in that capacity prior to September 1, 2005; and

(b) The provider was the individual's paid medical provider prior to September 1, 2005; and

(G) An agency provider will pay applicable federal, state and local income and employment taxes in compliance with federal, state and local requirements. Federal employment taxes include medicare and social security.

(H) Non-agency providers will pay applicable federal, state and local income and employment taxes in compliance with federal, state and local requirements. Federal employment taxes include medicare and social security. On an annual basis, non-agency providers will submit an ODM-approved affidavit stating that they paid their applicable federal, state and local income and employment taxes.

(I) Failure to meet the requirements set forth in this rule may result in any of the actions set forth in rules 5160-44-05, 5160-45-06 and 5160-45-09 of the Administrative Code including termination of the medicaid provider agreement in accordance with rule 5160-1-17.6 of the Administrative Code. In the event ODM proposes termination of the medicaid provider agreement, the provider may be entitled to a hearing or review in accordance with Chapter 5160-70 of the Administrative Code.

Last updated January 2, 2024 at 8:34 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-44-32 Home and community based medicaid waiver program provider and direct care worker relationships.

(A) This rule is applicable to the following waiver programs and services:

(1) Individual options services, as described in Chapter 5123-9 of the Administrative Code:

(a) Homemaker/personal care, participant-directed and provided through an agency; and

(b) Waiver nursing, provided through an agency.

(2) Level one homemaker/personal care services, participant-directed and provided through an agency, as described in Chapter 5123-9 of the Administrative Code.

(3) MyCare Ohio services, as described in Chapter 5160-58 of the Administrative Code:

(a) Choices home care attendant, participant-directed;

(b) Homemaker services provided through an agency;

(d) Waiver nursing services provided through an agency.

(4) Ohio home care services, as described in Chapter 5160-46 of the Administrative Code:

(a) Personal care aide services provided through an agency; and

(b) Waiver nursing services provided through an agency.

(5) Pre-admission screening system providing options and resources today (PASSPORT) services, as described in Chapter 173-39 of the Administrative Code:

(a) Choices home care attendant, participant-directed;

(b) Homemaker services provided through an agency;

(d) Waiver nursing services provided through an agency.

(6) Self-empowered life funding participant-directed homemaker/personal care services, as described in Chapter 5123-9 of the Administrative Code.

(B) For the purpose of this rule, the following definitions apply:

(1) "Agency" refers to the following:

(a) A home health agency provider of Ohio home care waiver services, as described in Chapter 5160-46 of the Administrative Code;

(b) An Ohio department of aging (ODA) agency provider certified under section 173.391 of the Revised Code; and

(c) A department of developmental disabilities (DODD) agency provider certified under section 5123.045 of the Revised Code.

(2) "Appendix K" refers to a standalone appendix that may be utilized by states during emergency situations to request amendment to approved 1915(c) waivers. It includes actions that states can take under the existing section 1915(c) home and community-based waiver authority in order to respond to an emergency.

(3) "Care management agency" and "service and support administration entity" refers to an agency or entity delegated or contracted by ODA, ODM, or DODD to perform care coordination activities and related functions for individuals enrolled on a fee for service or managed care waiver program.

(4) "Direct care worker" refers to the person providing hands on care to an individual receiving a medicaid 1915(c) waiver program service.

(5) "Extraordinary care" refers to hands-on assistance with activities of daily living, incidental activities of daily living, and supervisory monitoring care exceeding the range of activities a parent of a minor child would ordinarily perform in the household on behalf of an individual without a disability or chronic illness of the same age, or on behalf of a spouse without a disability or chronic illness.

(6) "Financial Management Service (FMS)" refers to the entity contracted with ODA, Ohio department of medicaid (ODM), DODD, or their designee to process payment of participant-directed waiver services.

(7) "Home and community-based services (HCBS)" refers to services available to individuals to help maintain their health and safety in a community setting in lieu of institutional care as described in 42 C.F.R. 440 subpart A (October 1, 2023). Programs which provide HCBS include the assisted living waiver, the individual options waiver, the level one waiver, the MyCare Ohio waiver, the Ohio home care waiver, pre-admission screening system providing options and resources today (PASSPORT), and the self-empowered life funding waiver.

(8) "Individual" refers to a medicaid recipient receiving services through an HCBS waiver program authorized under 1915(c) of the Social Security Act.

(9) "Legal representative" refers to a person or entity who has a legal standing to make decisions on behalf of another person (e.g., a guardian who has been appointed by the court or an individual who has power of attorney granted by the individual).

(10) "Non-agency provider" refers to the following:

(a) A non-agency provider of Ohio home care waiver services, as described in Chapter 5160-46 of the Administrative Code;

(b) An ODA certified non-agency provider, certified under section 173.391 of the Revised Code; and

(11) "Parent" refers to an adoptive, biological, or step-parent of an individual.

(12) "Relative" refers to children, grandparents, grandchildren, great-grandparents, great grand-children, brothers, sisters, aunts, uncles, nephews, nieces, and step-relations and parents of an individual above the age of seventeen.

(C) Unless otherwise permitted in this rule or other home and community based services (HCBS) waiver program rules or other ODM rules, a parent of a minor child, a spouse, and other legal representatives are not eligible to bill for medicaid reimbursable waiver services to an individual for whom they serve as legal representative.

(D) Unless otherwise permitted in other HCBS waiver program rules, an agency fully or partially owned by an individual's legal representative is not eligible to bill for medicaid reimbursable waiver services to an individual for whom they serve as legal representative.

(E) Parents of minor child and spouse of an individual:

(1) A parent of a minor child, or the spouse of an individual may only provide HCBS waiver services to an individual if both of the following conditions are met:

(a) There is no other willing and able provider or direct care worker available to provide the HCBS waiver services to the individual.

(b) ODM, ODA, DODD, or their designee has determined the health and safety needs of the individual can be ensured.

(2) When conditions set forth in paragraph (E)(1) of this rule are present, a parent of a minor child, or the spouse of an individual may serve as a direct care worker, within the following parameters:

(a) The parent of a minor child is employed through an agency provider or provides an eligible participant-directed service through an FMS.

(b) The spouse is employed through an agency provider or provides an eligible participant-directed service through an FMS.

(c) Unless otherwise permitted in HCBS waiver program rules, or determined by ODM, DODD or their designee, as necessary to ensure the health and safety of the individual and authorized on the PCSP, an individual who is a minor child may receive a maximum of forty hours per week of paid care from a parent or combination of parents and may not exceed the amount of service the individual is assessed to need. ODM, ODA, DODD or their designee may grant an exception to this limitation, in accordance with departmental program operational processes.

(d) Unless otherwise permitted in HCBS waiver program rules, or determined by ODM, ODA, DODD or their designee, as necessary to ensure the health and safety of the individual and authorized on the PCSP, an individual may receive a maximum of forty hours per week of paid care from their spouse and may not exceed the amount of service the individual is assessed to need. ODM, ODA, DODD or their designee may grant an exception to this limitation, in accordance with departmental program operational processes.

(e) HCBS waiver services provided by a parent of a minor child or by a spouse must meet extraordinary care requirements, as determined through prescribed form, ODM 10372 "Ohio Extraordinary Care Instrument";

(f) Services provided by a parent of a minor child or by a spouse may not be provided for respite purposes;

(g) Individuals agree to and cooperate with monthly care management agency or services and supports administrator contacts. Contacts may be a combination of telephonic and in-person visits, with no more than sixty calendar days between in-person visits.

(h) The parent of a minor child or spouse participates in contact and visit requirements described in the individual's person-centered services plan (PCSP).

(3) HCBS waiver services may not be provided to an individual by the foster parent of the individual or by an agency in which the foster parent of the individual has an ownership interest.

(4) A spouse appointed as a legal guardian of an individual must maintain evidence of the guardian's ability to be a direct care worker for the individual in accordance with Rule 66.04 of the Rules of Superintendence for the Courts of Ohio.

(F) Relatives of an individual above the age of seventeen years with a legal representative designation:

(1) A parent of an individual above the age of seventeen years may provide the services described in paragraph (A) of this rule while holding the designation of:

(a) Authorized representative,

(b) Declaration for mental health treatment,

(d) Healthcare (medical) power of attorney,

(e) Representative payee, or

(f) Guardian appointed by the probate court who is authorized by the court to be a direct service provider for the individual under court order as permitted by Rule 66.04 of the Rules of Superintendence for the Courts of Ohio.

(2) Unless otherwise permitted in HCBS waiver program rules, adult children, grandparents, grandchildren, great-grandparents, great-grandchildren, brothers, sisters, aunts, uncles, nephews, nieces, and step-relations may provide the services described in paragraph (A) of this rule while holding the designation of:

(a) Authorized representative,

(b) Declaration for mental health treatment,

(d) Healthcare (medical) power of attorney, or

(e) Guardian appointed by the probate court who is authorized by the court to be a direct service provider for the individual under court order as permitted by Rule 66.04 of the Rules of Superintendence for the Courts of Ohio.

(3) Unless otherwise permitted in HCBS waiver program rules or determined by ODM, ODA, DODD or their designee, as necessary to ensure the health and safety of the individual and authorized on the PCSP, paid care is limited to forty hours per week per relative with legal decision-making authority, and may not exceed the amount of service the individual is assessed to need.

(G) Limitations

(1) A direct care worker providing services described in paragraph (A) of this rule may not verify service provision on behalf of the individual.

(2) A direct care worker may not receive payment from any source for activity other than the direct care for the individual during the time authorized to provide HCBS waiver services.

(3) A direct care worker may not provide care to a person other than the authorized individual(s) during medicaid billed hours.

(4) Participant directed services: if an individual chooses to designate a representative through the FMS, the FMS designated representative(s) may not serve as a direct care worker.

(H) The PCSP will document that the conditions set forth in paragraphs (E) and (F) of this rule are met.

(I) Within ninety days of the effective date of this rule, parents of minor children and spouses of individuals who were authorized to provide paid services under the Appendix K authority will be assessed by care management agencies or service and support administration entities, as appropriate, to determine whether they meet the requirements outlined in this rule in order to continue to provide services. The authorized parents of minor children and spouses of individuals may continue to provide paid services until the assessment has been completed or the ninety-day period has expired, whichever comes first.

(J) A decision by ODM, ODA, DODD, or their designee related to whether someone qualifies under this rule to serve as a provider or a direct care worker for an individual is not subject to notice and appeal rights under division 5101:6 of the Administrative Code.

Last updated January 2, 2024 at 9:03 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-44-33 Nursing facility-based level of care home and community-based services programs: structured family caregiving.

(A) "Structured Family Caregiving (SFC)" is a service in which an individual at least eighteen years of age who is enrolled on either the MyCare Ohio, Ohio home care, or pre-admission screening system providing options and resources today (PASSPORT) waiver program, resides with a caregiver who provides daily care and support to the individual when the individual meets the following criteria:

(1) The caregiver resides with the individual in the individual's private home or resides with the individual in the caregiver's private home.

(2) The individual needs assistance with daily personal care and household support, and assistance with activities needed to promote independence and integration into the community.

(3) The individual chooses to receive SFC.

(B) The waiver service provider will:

(1) Be an agency provider as defined in rule 5160-45-01 of the Administrative Code meeting the following criteria:

(a) For the Ohio home care waiver program, providers will be a medicare-certified home health agency, otherwise-accredited agency, or hold an accreditation from an organization recognized by the centers for medicare and medicaid services (CMS) or the United States department of health and human services (HHS) and operate in accordance with Chapter 5160-45 of the Administrative Code.

(b) For the PASSPORT program, providers will be an Ohio department of aging (ODA) certified provider and operate in accordance with Chapter 173-39 of the Administrative Code.

(c) For MyCare waiver program, providers will operate in accordance with either paragraph (B)(1)(a) or paragraph (B)(1)(b) of this rule, as appropriate.

(2) Complete caregiver training.

(a) For medicare-certified home health agencies, the caregiver will successfully meet the trainings specified in 42 C.F.R. 484.80 (as in effect on October 1, 2023).

(b) For otherwise-accredited and Ohio department of aging certified agencies, the caregiver will successfully complete at least eight hours of initial training that the individual determines the provider needs to meet the individual's specific needs by the deadline the individual establishes.

(c) The provider will ensure the caregiver receives structured training tailored to support the caregiver to meet the individual's assessed needs.

(d) The provider will maintain documentation that demonstrates the training described in paragraph (B)(2) of this rule has been completed.

(3) Ensure SFC is provided as authorized and that any modifications needed in settings adhere to the individual's approved person-centered services plan (PCSP). Settings where the individual resides in a private residence owned or leased by a caregiver who is not related by blood or marriage are considered provider-owned or controlled settings and are subject to compliance with the conditions described in paragraph (C) of rule 5160-44-01 of the Administrative Code.

(4) Ensure that the caregiver employed by or contracted with the agency provider is able to meet the individual's need for assistance with daily care as assessed by the waiver program case management entity for the relevant waiver program.

(5) Employ coaching and support professional staff.

(a) The provider's coaching and support professional staff will include:

(i) A registered nurse (RN), in accordance with Chapter 4723. of the Revised Code,

(ii) A licensed practical nurse (LPN), at the direction of an RN, in accordance with Chapter 4723. of the Revised Code,

(iii) A licensed social worker (LSW), in accordance with Chapter 4757. of the Revised Code, or

(iv) A licensed independent social worker (LISW), in accordance with Chapter 4757. of the Revised Code.

(b) The provider's coaching and support professional staff will:

(i) Conduct an initial in-person home visit with the individual and the caregiver of SFC to review the roles and responsibilities of the caregiver and the provider, applicable rules of ODM and ODA, and relevant policies of the provider which apply to provider staff.

(ii) Conduct monthly contact with the individual and caregiver to provide individualized coaching to the caregiver to increase the caregiver's competencies to provide care to the individual, help the caregiver identify signs of change in the individual's general condition and how to manage such circumstances. Monthly contact will also be made to ensure the caregiver is attending to self-care needs, assess the provision of SFC, review the caregiver's goals and needs, share relevant educational content, assess the individual's satisfaction with care delivery and relationship with the caregiver. Contacts may be a combination of telephonic and in-person visits, with no more than sixty calendar days between in-person visits.

(6) Maintain a record for each individual served, in accordance with the criteria outlined in:

(a) Paragraph (A)(9) of rule 5160-46-04 of the Administrative Code if providing SFC to an individual enrolled on the Ohio home care waiver program.

(b) Rule 173-39-02 of the Administrative Code if providing SFC to an individual enrolled on the PASSPORT program.

(c) Paragraph (B)(6)(a) or paragraph (B)(6)(b) of this rule if providing services to an individual enrolled on the MyCare waiver program, as appropriate.

(1) SFC will not be authorized for individuals who are medically unstable or medically complex as a substitute for skilled care provided by an RN, LPN, licensed nurse, or other licensed health care professional.

(2) SFC will not be provided on the same calendar day as out-of-home respite as described in rules 5160-44-17 and 173-39-02.23 of the Administrative Code.

(3) SFC will not be provided on the same calendar day when a combination of more than two hours of the following services are authorized on the individual's PCSP:

(a) Choices home care attendant service as described in rules 5160-58-04 and 173-39-02.4 of the Administrative Code.

(b) Home care attendant service as described in rules 5160-44-27 and 173-39-02.24 of the Administrative Code.

(d) Personal care services as described in rule 5160-46-06 of the Administrative Code or personal care as described in rule 173-39-02.11 of the Administrative Code.

(D) Spouses and other relatives with legal decision-making authority may only provide SFC in accordance with the criteria outlined in rule 5160-44-32 of the Administrative Code.

(E) Authorization process.

(1) SFC may be authorized for individuals who are eligible and choose to access the service.

(2) The maximum allowable payment rates and procedure codes for SFC are listed in rule 5160-46-06 of the Administrative Code. SFC may be authorized as a full day, or a half day as indicated in the individual's PCSP.

(a) SFC will be authorized as a full day, unless the individual is assessed to need additional services described in paragraph (C) of this rule to be provided on the same calendar day as SFC.

(b) SFC will only be authorized as a half day when the individual is assessed to need additional services described in paragraph (C) of this rule to be provided on the same calendar day as SFC.

(3) The caregiver will provide SFC for no more than three individuals who reside at the same address. When SFC is provided to more than one individual at the same address, the provider will be reimbursed at a group rate as defined in:

(a) Paragraph (A)(5) of rule 5160-46-06 of the Administrative Code if providing SFC to individuals enrolled on the Ohio home care waiver program.

(b) Paragraph (C)(3) of rule 5160-31-07 of the Administrative Code if providing SFC to individuals enrolled on the PASSPORT program.

(c) Paragraph (C) of rule 5160-58-04 of the Administrative Code if providing SFC to individuals enrolled on the MyCare waiver program.

(F) As a condition of receiving SFC, individuals will agree to and cooperate with monthly waiver program care management agency contacts. Contacts may be a combination of telephonic and in-person visits, with no more than sixty calendar days between in-person visits.

Last updated August 13, 2025 at 7:40 AM

History

Effective: August 12, 2025
Promulgated Under: 119.03

Chapter 5160-45 ODM Administered Waiver Services

Ohio Adm.Code 5160-45-01 Ohio department of medicaid (ODM) -administered waiver program: definitions.

The following terms apply to Ohio department of medicaid (ODM) -administered waiver programs:

(A) "Abuse" has the same meaning as set forth in rule 5160-44-05 of the Administrative Code.

(B) "Accreditation commission for health care" or "(ACHC)" is a national organization that evaluates and accredits agencies seeking to participate in the medicare and medicaid programs. For the purpose of providing services to individuals enrolled on an ODM-administered waiver, ACHC-accredited agencies are "otherwise-accredited agencies" that can provide the same ODM-administered waiver services that community health accreditation program (CHAP) -accredited and the joint commission-accredited agencies provide.

(D) "Agency provider" is an entity that is eligible to furnish services in the medicaid program upon execution of a medicaid provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code.

(E) "Applicant" is a person who is requesting a determination of eligibility for enrollment in an ODM-administered waiver.

(F) "Authorized representative" is a person the individual appoints to act on his or her behalf in accordance with rule 5160-1-33 of the Administrative Code.

(G) "Case management contractor" is the entity designated by ODM to provide case management services to individuals enrolled on an ODM-administered waiver. This may include a contracted case management agency, a MyCare Ohio plan and/or ODM itself.

(H) "Case management services" are the administrative activities that link, coordinate and monitor the services, supports and resources provided to an individual enrolled on an ODM-administered waiver.

(I) "Case manager" is a registered nurse (RN), licensed social worker (LSW) or licensed independent social worker (LISW) employed by the case management contractor who provides case management services to individuals enrolled on an ODM-administered waiver. The case manager is responsible for developing and monitoring the individual's person-centered services plan as described in rule 5160-44-02 of the Administrative Code.

(J) "Case manager contact" is a phone conversation, email exchange or other electronic communication with an individual or provider that ensures the exchange of information between the case manager and the individual. Electronic communications without response are not considered a case manager contact.

(K) "Case manager visit" is an in-person encounter between an individual and a case manager in the individual's residence. Meetings and encounters at locations other than the individual's place of residence are only considered visits when completed in an institutional or other service delivery location for the purpose of completing an assessment for waiver eligibility and/or developing a discharge plan. Case managers will interact (i.e., converse, make visual contact and otherwise engage the individual at his or her functional ability) during every case manager visit.

(L) "Clinical record" is a record containing written documentation that will be maintained by each ODM-administered waiver service provider.

(M) "Community health accreditation program" or "(CHAP)" is a national organization that evaluates and accredits agencies seeking to participate in the medicare and medicaid programs. For the purpose of providing services to individuals enrolled on an ODM-administered waiver, CHAP-accredited agencies are "otherwise-accredited agencies" that can provide the same ODM-administered waiver services that ACHC-accredited and the joint commission-accredited agencies provide.

(N) "Comprehensive assessment" is an evaluation of an individual's long-term service and support needs that is used to determine level of care and eligibility for enrollment in an ODM-administered waiver, and to inform service planning. The comprehensive assessment includes an in-person evaluation and examines an individual's activities of daily living, instrumental activities of daily living, natural supports, cognition, health status, behavioral health status, safety and environment.

(O) "Electronic Visit Verification" or "EVV" has the same meaning as set forth in rule 5160-1-40 of the Administrative Code.

(P) "Group rate" has the same meaning as set forth in rules 5160-46-06 and 5160-46-06.1 of the Administrative Code.

(Q) "Group setting" has the same meaning as set forth in rules 5160-44-22, 5160-44-27, 5160-46-04, 5160-46-06, and 5160-46-06.1 of the Administrative Code.

(R) "Health and safety action plan" or "HSAP" is the document created between ODM and its designee and an individual enrolled on an ODM-administered waiver that identifies the interventions recommended by the case management contractor to remedy risks to the health, safety and welfare of the individual.

(S) "Health and welfare" is the basis for an assurance to CMS made by ODM that necessary safeguards are taken to protect the health, safety and welfare of individuals enrolled on an ODM-administered waiver. CMS will not grant an ODM-administered waiver, and may terminate an existing ODM-administered waiver, if ODM fails to assure compliance with this requirement. Health and welfare safeguards include policies and procedures that direct the following:

(1) Risk and safety evaluations and planning;

(2) Incident management;

(3) Housing and environmental safety evaluations and planning;

(4) Restraint, seclusion and restrictive intervention evaluations and planning;

(5) Medication management; and

(6) Natural disaster and public emergency response planning.

(T) "Helping Ohioans move, expanding (HOME) choice" mean Ohio's money follows the person program described in Chapter 5160-51 of the Administrative Code that assists individuals with transferring from an institutional long term care setting to a home setting.

(U) "Intermediate care facility for individuals with intellectual disabilities (ICF-IID) level of care" has the same meaning as that term is set forth in rule 5123-8-01 of the Administrative Code.

(V) "Incident" has the same meaning as set forth in rule 5160-44-05 of the Administrative Code.

(W) "Individual" is a person who is enrolled on an ODM-administered waiver.

(X) "Individual waiver agreement" is the ODM-approved agreement signed by an individual and the case manager that assures the individual is voluntarily enrolling in an ODM-administered waiver as an alternative to receiving medicaid long term services and supports in an institutional setting. The responsibilities an individual will understand and agree to as a condition of waiver enrollment are set forth in the agreement.

(Y) "Institutional setting" is any nursing facility, intermediate care facility for individuals with intellectual disabilities (ICF-IID) or hospital.

(Z) "Instrumental activity of daily living" has the same meaning as set forth in rule 5160-3-05 of the Administrative Code.

(AA) "Intermediate level of care" has the same meaning as set forth in rule 5160-3-08 of the Administrative Code.

(BB) "Legally responsible family member," as that term is used in ODM-administered waivers, is an individual's spouse, or in the case of a minor, the individual's birth or adoptive parent.

(CC) "Medical necessity" and "medically necessary" have the same meaning as set forth in rule 5160-1-01 of the Administrative Code.

(DD) "Medicare-certified home health agency" is any entity, agency or organization that has and maintains medicare certification as a home health agency, and is eligible to participate in the medicaid program upon execution of a medicaid provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code.

(EE) "MyCare Ohio plan" has the same meaning as set forth in rule 5160-58-01 of the Administrative Code.

(FF) "Natural supports" are unpaid caregivers who provide care to an individual.

(GG) "Neglect" has the same meaning as set forth in rule 5160-44-05 of the Administrative Code.

(HH) "Non-agency provider" means an RN, a licensed practical nurse (LPN) at the direction of an RN, a non-agency personal care aide, or a non-agency home care attendant who is eligible to participate in the medicaid program upon execution of a medicaid provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code.

(II) "Nursing facility-based level of care" has the same meaning as set forth in rule 5160-3-05 of the Administrative Code.

(JJ) "ODM-administered waiver programs" are home and community-based services waivers administered by ODM in accordance with Chapters 5160-44, 5160-45, 5160-46 and/or 5160-58 of the Administrative Code, as applicable.

(KK) "ODM-administered waiver provider" is any entity or non-agency provider eligible to furnish ODM-administered waiver services upon execution of a medicaid provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code.

(LL) "Otherwise-accredited agency" is an entity that has and maintains accreditation by a national accreditation organization for the provision of services upon execution of a medicaid provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code. The national accreditation organization will be approved by CMS.

(MM) "Person-centered services plan" is the document that identifies person-centered goals, objectives and interventions selected by the individual and team to support the individual in their community of choice. The plan addresses the assessed needs of the individual by identifying medically-necessary services and supports provided by natural supports, medical and professional staff and community resources.

(NN) "Person-centered planning" is a process directed by the individual, that identifies his or her strengths, values, capacities, preferences, needs and desired outcomes. The process includes team members who assist and support the individual to identify and access medically necessary services and supports needed to achieve his or her defined outcomes in the most inclusive community setting. The individual and team identify goals, objectives and interventions to achieve these outcomes which are documented on the person-centered services plan by the case manager. The person-centered service planning process is described in rule 5160-44-02 of the Administrative Code.

(OO) "Provider" means a person or agency that has entered into a medicaid provider agreement for the purpose of furnishing ODM-administered waiver services. In the case of an agency, provider includes the agency's respective staff who have direct contact with individuals.

(PP) "Provider oversight contractor" is the entity designated by ODM to perform quality assurance, monitoring and oversight functions related to the ODM-administered waiver program.

(QQ) "Plan of care" is the medical treatment plan that is established, approved and signed by the treating physician. The plan of care is not the same as the person-centered services plan.

(RR) "Reportable incident" has the same meaning as set forth in rule 5160-44-05 of the Administrative Code.

(SS) "Restraint" is any of the following:

(1) "Chemical restraint," i.e., the use of any sedative psychotropic drug exclusively to manage or control behavior; or

(2) "Mechanical restraint," i.e., the use of any device to restrict an individual's movement or function, or that is used for any purpose other than positioning and/or alignment; or

(3) "Physical restraint," i.e., any hands-on or physical method that is used to restrict the movement or function of the individual's head, neck, torso, one or more limbs or entire body.

(TT) "Restrictive intervention" is any action or activity that limits an individual's rights for a period of time to assure an individual's health, safety or welfare. Restrictive intervention may only be used to safeguard individuals from accident or injury, or to help promote optimal health and welfare. Restrictive interventions include, but are not limited to, locking cabinets, using door alarms or limiting access to a desired item contingent upon a behavior or activity.

(UU) "Seclusion" or "time-out" is any restriction that is used to address a specified behavior and that prevents the individual from leaving a location for any period of time. Seclusion may include, but is not limited to, preventing an individual from leaving an area until he or she is calm.

(VV) "Significant change" is a variation in the health, care or needs of an individual that warrants further evaluation to determine if changes to the type, amount or scope of services are needed. Significant changes include, but are not limited to, differences in health status, caregiver status, residence/location of service delivery and service delivery that result in the individual not receiving waiver services for thirty days.

(WW) "Skilled level of care" has the same meaning as set forth in rule 5160-3-08 of the Administrative Code.

(XX) "Team" is a group of persons freely chosen by the individual to assist and support him or her in the development and implementation of his or her person-centered services plan. The team is led by the individual and will include the case manager. It can also include, but is not limited to, the individual's friends, family and natural supports, the physician and other professionals and providers.

(YY) "The joint commission" is a national organization that evaluates and accredits agencies that seek to participate in the medicare and medicaid programs. For the purpose of providing services to individuals enrolled on an ODM-administered waiver, the joint commission-accredited agencies are "otherwise-accredited agencies" that can provide the same ODM-administered waiver services that ACHC-accredited and CHAP-accredited agencies provide.

(ZZ) "Time away" is a restrictive intervention during which an individual is directed away from a location or activity using only verbal prompting to address a specified behavior. The individual is able to return to the location or activity at his or her choosing. Time away will never include the use of a physical prompt or escort. The use of a physical prompt or required timeline for re-engaging in an activity will elevate the intervention to seclusion.

(AAA) "Unexplained death" has the same meaning as set forth in rule 5160-44-05 of the Administrative Code.

Last updated January 2, 2024 at 8:35 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-45-03 Ohio department of medicaid (ODM) -administered waiver program: individual rights and responsibilities.

Enrollment on an Ohio department of medicaid (ODM) -administered waiver is voluntary. Individuals enrolled on an ODM-administered waiver in accordance with rule 5160-46-02 of the Administrative Code will be informed of their rights and responsibilities. Individuals also have choice and control over the arrangement and provision of home and community-based waiver services, and the selection and control over the direction of approved waiver service providers.

(A) Individual rights.

An individual enrolled in an ODM-administered waiver has the right to:

(1) Be treated with dignity and respect.

(2) Be protected from abuse, neglect, exploitation and other threats to personal health, safety and well-being.

(3) Appoint an authorized representative to act on their behalf in accordance with 5160-1-33 of the Administrative Code.

(4) Receive waiver services in a person-centered manner that is in accordance with an approved person-centered services plan, is attentive to the individual's needs and maximizes personal independence.

(5) Conduct person-centered training of their waiver service providers.

(6) Choose his or her case management agency (CMA) and case managers, and

(a) Have the case manager explain what the ODM-administered waiver is, how it will assist the individual and what the individual's rights and responsibilities are;

(b) Participate with the case manager and the team in the person-centered services plan development process, and when possible, lead the process;

(d) Be able to effectively communicate with the case manager and team and receive information in a manner that is easy to understand;

(e) Be able to meet privately with the case manager;

(f) Receive ongoing assistance from the case manager; and

(g) Be able to request changes in CMA, as necessary, subject to ODM's approval.

(7) Make informed choices regarding the services and supports he or she receives and from whom, including provider-managed agency providers, non-agency providers, or participant-directed providers as those terms are defined in rule 5160-45-01 of the Administrative Code.

(8) Obtain the results of criminal records checks about current agency providers or provider applicants pursuant to section 5164.342 of the Revised Code and rules 5160-45-07 and 5160-45-11 of the Administrative Code.

(9) Obtain the results of criminal records checks about current non-agency providers or provider applicants pursuant to section 5164.341 of the Revised Code and rules 5160-45-08 and 5160-45-11 of the Administrative Code.

(10) Access files, records or other information related to the individual's health care.

(11) Be assured of confidentiality of personal and sensitive health care information pursuant to relevant confidentiality and information disclosure laws.

(12) Request assistance with problems, concerns and issues, and suggest changes without fear of repercussion.

(13) Be fully informed about how to contact the case manager and ODM with problems, concerns, issues or inquiries.

(14) Be informed of the right to appeal decisions made by ODM or its designee about waiver eligibility or services pursuant to division 5101:6 of the Administrative Code.

(B) Individual responsibilities.

(1) Upon enrollment in an ODM-administered waiver, the individual will sign an ODM-approved waiver agreement accepting responsibility to:

(a) Participate in, and cooperate during assessments to determine eligibility and enrollment in the waiver and service needs.

(b) Decide who, besides the case manager, will participate in the service planning process.

(c) Participate in, and cooperate with, the case manager and team in the development and implementation of person-centered services plans and plans of care.

(d) Participate in the recruitment, selection and dismissal of his or her providers.

(e) Participate in the development and maintenance of back-up plans that meet the needs of the individual.

(f) Work with the case manager and/or physician and the provider to identify and secure additional training within the provider's scope of practice in order to meet the individual's specific needs.

(g) Not direct the service provider to act in a manner that is contrary to relevant ODM-administered waiver program requirements, medicaid rules and regulations and all other applicable laws, rules and regulations.

(h) Verify service delivery in a manner that includes, but is not limited to; the date and location of service delivery, start and end times, and the signatures of the provider and the individual or authorized representative. All signatures will be obtained within three business days of the completion of service delivery.

(i) Notify the case manager when any change in provider is necessary. Notification will include the end date of the former provider, and the start date of the new provider.

(j) Authorize the exchange of information for development of the person-centered services plan with all of the individual's service providers, and in compliance with the "Health Insurance Portability and Accountability Act of 1996" (HIPAA) regulations set forth in 45 C.F.R. parts 160 and 164 (October 1, 2023) and the medicaid safeguarding information requirements set forth in 42 C.F.R. 431.000 to 431.306 (October 1, 2023) along with sections 5160.45 to 5160.481 of the Revised Code.

(k) Provide accurate and complete information including, but not limited to medical history.

(l) Utilize services in accordance with the approved person-centered services plan.

(m) Communicate to the provider personal preferences about the duties, tasks and procedures to be performed, and when appropriate, about provider performance concerns.

(n) Report to the case manager any service delivery issues including, but not limited to, service disruption, complaints and concerns about the provider, and/or health and safety issues.

(o) Keep scheduled appointments and notify the provider and case manager if he or she is going to miss a scheduled visit or service.

(p) Treat the case manager, team and providers with respect.

(q) Report to the case manager any significant changes, as defined in rule 5160-45-01 of the Administrative Code, that may affect the provision of services.

(r) Report to the case manager, in accordance with rule 5160-44-05 of the Administrative Code, incidents that may impact the health and welfare of the individual.

(s) Work with the case manager and team to resolve problems and concerns.

(t) Refuse to participate in dishonest or illegal activities involving providers, caregivers and team members.

(2) When an individual receives services from an agency provider, the individual will identify a location in his or her residence where a record containing a copy of his or her medication profile, if one exists, will be safely maintained. The record may also include the individual's medication administration record, treatment administration record, aide assignment, person-centered services plan and plans of care.

(3) When an individual receives services from a non-agency provider, the individual will identify a location in his or her residence where a copy of the clinical record will be safely maintained.

(C) If the individual fails to meet the requirements set forth in paragraph (B) of this rule, and/or the health and welfare of the individual receiving services from a non-agency provider cannot be assured, then the individual may be required to receive services from only agency providers. The individual will be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

Last updated January 2, 2024 at 8:35 AM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-45-03.2 ODM-administered waiver services: self-direction, and self-directed caregivers.

(A) An individual may choose how waiver services are delivered pursuant to the person-centered planning process outlined in rule 5160-44-02 of the Administrative Code.

(B) For purposes of this rule and rule 5160-45-03.5 of the Administrative Code:

(1) Home and community-based services (HCBS) are services available under the "Ohio Home Care" and "MyCare" waiver programs as described in chapters 5160-46 and 5160-58 of the Administrative Code.

(2) Individuals are people enrolled on or applying for an HCBS waiver. In self-directed services, the individual is the employer.

(3) Self-directed representatives (representatives) are people an individual may choose to assist with self-directing their services.

(4) Self-directed caregivers (caregivers) are employees of individuals using self-directed services.

(5) Financial management service (FMS) is an Ohio department of medicaid (ODM)-contracted agency that enrolls caregivers and processes payments for self-directed services.

(6) Employer-authority allows the individual to hire, manage, and dismiss their caregivers.

(7) Budget-authority allows the individual to manage the funds for self-directed waiver services.

(8) Self-directed budgets include the total cost of all waiver services that are or could be self-directed.

(9) Self-direction reviews are opportunities for an individual to discuss caregiver performance and to self-direction review compliance with required program rules.

(1) Personal care aide services in accordance with rule 5160-46-04 of the Administrative Code;

(2) Home care attendant services in accordance with rule 5160-44-27 of the Administrative Code; and

(3) Waiver nursing services in accordance with rule 5160-44-22 of the Administrative Code.

(D) Services that can be self-directed with budget-authority include:

(1) All services identified in paragraph (C) of this rule;

(2) Home modifications as described in rule 5160-44-13 of the Administrative Code; and

(3) Self-directed goods and services as described in rule 5160-45-03.5 of the Administrative Code.

(E) Individuals enrolled on an HCBS waiver who self-direct their services work with ODM's designated FMS and the waiver case manager to coordinate the authorized service delivery. Individuals need to be willing and able to:

(1) Understand the service the caregiver furnishes.

(2) Understand how to direct the caregiver.

(3) Enrolls in self-direction through the waiver case manager and FMS.

(4) Complete employer-authority related tasks, which may include:

(a) Identifying, selecting, and dismissing caregivers;

(b) Entering into written agreements with caregivers for specific activities and training expectations;

(d) Scheduling services;

(e) Supervising the caregiver's performance; and

(f) Approving the caregiver's time sheets and other documents needed for payment as determined by the FMS.

(5) Perform budget-authority related tasks within the self-directed budget, including:

(a) Determining wages for caregivers;

(b) Deciding spending for other self-directed services in accordance with paragraphs (D) and (E) of this rule and the person-centered services plan; and

(F) Representatives.

(1) The individual may choose a representative to assist in self-directing services.

(2) Representatives help with employer tasks identified in paragraph (E)(4) of this rule.

(3) A representative cannot be the employer or caregiver.

(G) Caregivers.

(1) Before providing paid services, the caregiver will need to enroll with the FMS as a caregiver. Caregivers qualify to supply the services as follows:

(a) Personal care aide services:

(i) Completion of training as determined and verified by the individual;

(ii) Completion of training identified in paragraph (A)(8) of rule 5160-46-04 of the Administrative Code; or

(iii) Enrollment with ODM as a non-agency personal care aide provider.

(b) Home care attendant services:

(i) Completion of training identified in paragraph (A)(9) of rule 5160-44-27 of the Administrative Code; or

(ii) Enrollment with ODM as a home care attendant provider and having completed training for the individual served.

(i) Maintain an active, unrestricted Ohio nursing license, as identified in rule 5160-44-22 of the Administrative Code; or

(ii) Enrollment with ODM as a non-agency waiver nursing provider.

(2) All caregivers enrolled with individual-specific training as identified in paragraph (G)(1)(a)(i) of this rule will be trained by each individual they serve.

(3) At enrollment, caregivers will complete all tasks and submit documentation to the FMS, including:

(a) Proof of the following:

(i) Training or qualifications as noted in paragraph (G)(1) of this rule;

(ii) Review of the applicable Ohio Administrative Code requirements for the service being provided; and

(iii) Training in incident management reporting responsibilities as required in rule 5160-44-05 of the Administrative Code.

(b) Completed forms, including

(i) Self-direction enrollment, including disclosure of any indictment or conviction of a violation of state or federal law;

(ii) Federal and state employment and tax forms, including for the Ohio bureau of workers' compensation;

(iii) Medicaid provider agreement (ODM form 10283); and

(iv) Consent for screening and criminal record checks in accordance with rule 5160-1-17.8 of the Administrative Code;

(4) Caregivers who are a parent, spouse, or other relative and meet the conditions set forth in rule 5160-44-32 of the Administrative Code and may deliver any self-directed service identified in paragraph (C) of this rule.

(5) Caregivers will use the FMS time-keeping system for recording all service time for which the caregiver expects to be reimbursed. This system will include electronic visit verification as outlined in Chapter 5160-32 of the Administrative Code.

(6) Caregivers will at all times meet the requirements of ODM's provider conditions of participation as outlined in rule 5160-44-31 of the Administrative Code except paragraph (B)(2)(a) of that rule.

(7) Caregivers maintain documentation of services delivered as required for each service type identified in paragraph (C) of this rule. Parents, spouses, or other relatives who deliver self-directed home care attendant services in accordance with rule 5160-44-32 of the Administrative Code are not required to obtain the signature of the individual or authorized representative to verify service delivery if the individual is unable to provide verification and there is no authorized representative present during service delivery.

(8) Caregivers will participate in self-direction reviews led by the individual with assistance from ODM's contracted review team. Caregivers are not required to participate in structural reviews as described in rule 5160-45-06 of the Administrative Code. Self-direction reviews are conducted as follows:

(a) Individuals and/or representatives will participate, by leading or at least being present during the self-direction reviews;

(b) Both the individual and caregiver will be notified by ODM's contracted self-direction review team when a self-direction review is due and will be scheduled prior to the due date at the individual's and caregiver's convenience;

(c) Initial self-direction reviews are conducted within the first twelve to twenty-four months of the caregiver's employment with the individual and are intended to provide guidance and technical assistance on compliance with applicable Administrative Code requirements;

(d) Additional self-direction reviews are conducted as requested by the individual or caregiver with no more than three years between self-direction reviews; and

(e) Self-direction reviews are educational and an opportunity to provide feedback on positive performance and areas for improvement including the following:

(i) Accountability: following the conditions of participation and documenting services that support the plan; and

(ii) Performance: supplying the services requested and submitting payroll on time; and

(iii) Individual satisfaction.

(f) Outcomes of the self-direction reviews are documented and signed by the individual and the caregiver.

(g) If any issues are identified during the self-direction review process, the caregiver will work with the individual on an opportunity for improvement plan. The improvement plan needs to include:

(i) Area(s) where improvement is needed;

(ii) Action(s) expected to meet the expectation; and

(iii) Timeline for completing the action(s).

(H) The FMS assists the caregiver to complete enrollment. The FMS conducts caregiver enrollment activities, including but not limited to:

(1) Validating employment, including:

(a) complete, file, and execute IRS and Ohio state forms necessary for employment; and

(b) conduct limited-risk screening and criminal record checks in accordance with rule 5160-1-17.8 of the Administrative Code. Criminal record checks will be conducted at initial enrollment and at least once every five years or as requested by the individual.

(2) Verifying caregiver eligibility as outlined in paragraph (C) of this rule.

(3) Reviewing with or ensuring that the caregiver completes a review of the applicable Administrative Code responsibilities for the service being provided.

(I) Caregivers will be enrolled when all required documentation as identified in paragraph (G) of this rule has been submitted. Enrollment will be completed within:

(1) Fourteen calendar days, or

(2) One business day of an expedited enrollment request from the case manager.

(J) Conditional employment.

(1) A caregiver who is not yet enrolled as a provider with ODM may be conditionally employed by the individual prior to obtaining the results of the criminal record check identified in paragraph (G) of this rule. Conditional employment can be in effect for up to sixty days. The FMS will:

(a) Conduct a review of the databases listed in rule 5160-1-17.8 of the Administrative Code to determine whether the caregiver is barred from rendering self-directed services; and

(b) Begin the criminal records check no later than five business days after conditional employment begins.

(2) The FMS agency will notify the individual, case manager, and ODM when the results of the criminal records check request:

(a) Are not obtained within sixty days of the criminal records check request, other than the results of any request for information from the federal bureau of investigation; or

(b) Reveal a disqualifying offense and the caregiver is not able to supply paid services.

(3) The FMS agency will advise the individual if a caregiver has a criminal offense on their record which is not disqualifying. The individual can choose to continue employing the caregiver or discontinue employment.

(K) If the FMS determines that a caregiver cannot be enrolled or maintain enrollment for any reason, the FMS will notify ODM. If a caregiver cannot be enrolled or maintain enrollment due to a disqualifying offense on a criminal record check, the FMS, with consent of the caregiver, will provide a copy of the criminal record check to ODM. ODM will review these results and issue a final decision to the caregiver, including information on how to appeal the decision.

(L) Individuals who cannot meet the requirements set forth in paragraph (E) of this rule, or whose the health and welfare cannot be ensured with the delivery of self-directed services will not be able to self-direct their services. The individual will be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

Last updated October 1, 2024 at 9:08 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-45-03.5 ODM-administered waiver program: self-directed goods and services.

(A) Scope. This rule sets forth provisions governing coverage for self-directed goods and services provided as part of an Ohio department of medicaid-(ODM) administered waiver program.

(B) "Self-directed goods and services" are services, equipment, or supplies that:

(1) Are not available through the medicaid state plan benefit or a home and community-based services (HCBS) waiver program;

(2) Address an individual's assessed need and are included on the person-centered services plan; and

(3) Supplement the medicaid state plan benefit and HCBS waiver services to help the individual successfully remain in the community.

(C) The ODM contracted financial management services (FMS) entity is the provider of self-directed goods and services. The FMS completes the purchase and reimbursement of self-directed goods and services approved in the person-centered services plan.

(D) Coverage.

(1) Self-directed goods and services are covered through self-direction budget authority, as described in rule 5160-45-03.2 of the Administrative Code.

(2) Self-directed goods and services may be approved if it is determined they will:

(a) Increase the individual's independence, safety, and/or community participation;

(b) Decrease the individual's need for other medicaid services; or

(c) Support the individual who does not have funds to purchase the services, equipment, or supplies, and they are not available through another source.

(3) Self-directed goods and services are individualized; therefore an exhaustive list cannot be developed. Goods and services include any needed equipment, supplies or services not covered by medicaid or another approved HCBS waiver service. This may include but is not limited to:

(a) Community classes, memberships, training or coaching;

(b) Household related items or devices;

(d) Art, music, or other alternative therapies.

(E) Limitations.

(1) The following items cannot be purchased as self-directed goods and services:

(a) Experimental treatments as outlined in rule 5160-1-61 of the Administrative Code;

(b) Items used solely for entertainment or recreational purposes;

(d) Items that are illegal or otherwise prohibited through federal or state regulations.

(2) Self-directed goods and services are limited to two thousand five hundred dollars within three hundred sixty-five days.

(3) The individual, representative, or self-directed caregiver cannot be a vendor of supplies or items purchased with the self-directed goods and services funds.

(F) Service documentation for self-directed goods and services will include each of the following to validate reimbursement for medicaid services:

(1) Receipts to validate purchase of items are submitted to the case manager containing all the following:

(a) Item or service description;

(b) Vendor name;

(d) Paid amount.

(2) An invoice for payment to a vendor is submitted to the FMS containing all the following:

(a) Individual's name and medicaid identification number;

(b) Item or service description;

(d) Purchaser of service if not the individual;

(e) Purchase date, delivery or service date; and

(f) Paid amount.

Last updated October 1, 2024 at 9:08 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-45-04 Ohio department of medicaid (ODM) -administered waiver program: provider enrollment process.

(A) Ohio department of medicaid (ODM) -administered waiver provider applicants must successfully complete the provider enrollment process set forth in this rule and receive approval from ODM before furnishing services to an individual enrolled on an ODM-administered waiver. Services furnished before ODM approves and enrolls the provider applicant and before the provider is added to the approved person-centered services plan are not reimbursable.

(B) The provider applicant completes and submits a provider application to ODM in accordance with rule 5160-1-17 of the Administrative Code.

(C) Upon receipt of the provider application, ODM or its designee shall verify the provider applicant has submitted and meets all applicable ODM-administered waiver provider regulations set forth in Chapters 5160-1, 5160-44, 5160-45, 5160-46, and 5160-58 of the Administrative Code.

(D) ODM or its designee shall notify the provider applicant if the application does not contain all of the required documentation. The provider applicant shall have thirty calendar days from the date of written notification to submit the requested documentation. If the provider applicant does not submit the documentation within the prescribed time frame, ODM or its designee may reject the provider application.

(E) ODM shall enroll or deny enrollment of the provider applicant based upon its own review and the review and recommendation of its designee.

(F) ODM shall notify the provider applicant in writing of its decision. If ODM denies enrollment, it shall either issue the provider applicant appeal rights in accordance with Chapter 119. of the Revised Code, or reconsideration rights in accordance with rule 5160-70-02 of the Administrative Code.

(G) When a current ODM-administered waiver service provider submits its medicaid provider agreement revalidation application, or applies for a specialty under their current provider type, ODM shall ensure that criminal record check requirements set forth in Chapter 5160-45 of the Administrative Code are satisfied. ODM shall also review the provider's history, including but not limited to medicaid program compliance and performance. ODM may approve or deny revalidation based on its findings and in accordance with rule 5160-1-17.6 of the Administrative Code.

(H) When a former medicaid provider applies for enrollment to become an ODM-administered waiver provider, in addition to following the process outlined in paragraphs (A) to (F) of this rule, ODM shall also review the provider applicant's history including, but not limited to medicaid program compliance and performance. ODM may approve or deny enrollment based on its findings and in accordance with rules 5160-1-17.6 and 5160-1-17.7 of the Administrative Code.

Last updated October 12, 2021 at 12:28 PM

History

Effective: October 11, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5160-45-06 Ohio department of medicaid (ODM) -administered waiver program: structural reviews of providers and investigation of provider occurrences.

(A) The Ohio department of medicaid (ODM) or its designee shall continuously monitor every ODM-administered waiver provider. Monitoring activities shall include, but not be limited to:

(1) A structural review of compliance with all ODM-administered waiver provider requirements in accordance with paragraph (B) of this rule.

(2) Investigation of provider occurrences in accordance with paragraph (C) of this rule.

(B) Structural reviews.

(1) Medicare-certified and otherwise accredited agency providers as defined in rule 5160-45-01 of the Administrative Code are subject to reviews in accordance with their certification and accreditation bodies and may be exempt from a regularly scheduled structural review as determined by ODM. Upon request by ODM or its designee, medicare-certified and otherwise-accredited agency providers, shall make available within ten business days, all review reports and accepted plans of correction from the certification and/or accreditation bodies.

(2) All other agency providers are subject to structural reviews by ODM or its designee every two years after the provider begins furnishing billable services.

(3) All non-agency ODM-administered waiver providers are subject to structural reviews by ODM or its designee during each of the first three years after a provider begins furnishing billable services. Thereafter, and unless otherwise prescribed by either paragraph (B)(4) or (B)(5) of this rule, structural reviews shall be conducted annually.

(4) ODM or its designee may conduct biennial structural reviews of a non-agency ODM-administered waiver provider, when all the following apply:

(a) There were no findings against the provider during the provider's most recent structural review;

(b) The provider was not substantiated to be the violator in an incident described in rule 5160-44-05 of the Administrative Code;

(d) The provider does not live with an individual receiving ODM-administered waiver services.

(5) All ODM-administered waiver providers may be subject to an announced or unannounced structural review at any time as determined by ODM or its designee.

(6) Structural reviews may be conducted in person between the provider and ODM or its designee or via desk review, and in a manner consistent with paragraph (B)(3) of rule 5160-45-09 of the Administrative Code.

(7) All structural reviews use an ODM-approved structural review tool.

(8) Structural reviews shall not occur while the provider is furnishing services to an individual.

(9) The structural review process consists of the following activities:

(a) Except for unannounced structural reviews, the provider shall be notified in advance of the review to arrange a mutually acceptable time, date and location for the review. Advance notification shall also include identification of the time period for which the review is being conducted and a list of the type of documents required for the review.

(b) The provider shall ensure the availability of required documents and maintain the confidentiality of information about individuals enrolled on the ODM-administered waiver.

(c) ODM or its designee shall examine all substantiated incident reports or provider occurrences related to the provider. Documented findings of noncompliance shall be addressed during the review.

(d) The structural review shall include an evaluation of compliance with Chapter 5160-45 of the Administrative Code and Chapter(s) 5160-44, 5160-46, and/or 5160-58 of the Administrative Code, depending upon the waiver(s) under which the provider is furnishing services.

(e) A unit of service verification shall be conducted by ODM or its designee to ensure all waiver services are authorized, delivered and reimbursed in accordance with the approved person-centered services plan for the individual receiving waiver services.

(f) The provider's compliance with the home and community-based settings requirements set forth in rule 5160-44-01 of the Administrative Code will be evaluated, which will include interviews with individuals served in the setting.

(g) An evaluation shall be conducted to determine whether the provider has implemented all plans of correction approved since the last review. Failure to successfully complete all plans of correction and/or the existence of repeat violations may lead to additional sanctions including, but not limited to termination of their provider agreement.

(h) A final exit interview summarizing the overall outcome of the review will occur between the non-agency provider, or in the case of an agency provider, the agency administrator or his or her designee, and ODM or its designee at the conclusion of the review.

(10) The exit interview will be followed up with a written report to the provider from ODM or its designee. The report shall summarize the overall outcome of the structural review, specify the Administrative Code rules that are the basis for which noncompliance has been determined, and outline the specific findings of noncompliance. When findings are indicated, the provider shall respond in writing to the report in a plan of correction, including any individual remediation.

(11) ODM, at its sole discretion, may choose to suspend a provider's structural review.

(1) "Provider occurrence" means any alleged, suspected or actual performance or operational issue by a provider furnishing ODM-administered waiver services that does not meet the definition of an incident as set forth in rule 5160-44-05 of the Administrative Code. Provider occurrences include, but are not limited to alleged violations of provider eligibility and/or service specification requirements, provider conditions of participation, billing issues including overpayments, and medicaid fraud.

(2) Upon discovery, ODM or its designee shall investigate provider occurrences including requesting any documentation required for the investigation.

(3) If ODM or its designee substantiates the provider occurrence, it shall notify the provider. The notification shall specify:

(a) The provider's action or inaction that constituted the provider occurrence;

(b) The Administrative Code rule(s) that support the finding(s) of noncompliance;

(c) What the provider must do to correct the finding(s) of noncompliance, including acknowledgement of technical assistance, required training, and any individual remediation;

(D) Plans of correction for structural reviews and provider occurrences.

(1) The provider must submit to ODM or its designee a plan of correction for all identified findings of noncompliance, including any individual remediation, within forty-five calendar days after the date on the written report.

(2) If ODM or its designee finds the provider's plan of correction acceptable, it shall acknowledge, in writing, to the provider that the plan addresses the findings outlined in the written report. If ODM or its designee determines that it cannot approve the provider's plan of correction, it shall inform the provider of this determination, in writing, require that the provider submit a new plan of correction and specify the required actions that must be included in the plan of correction. The provider must submit the new plan of correction within the prescribed timframes, not to exceed forty-five calendar days.

(3) ODM permits flexibility with the required timeframes for submission of plans of correction required in this paragraph, so long as it is documented in the provider's file.

(E) If the possibility of an overpayment is identified through the structural review and/or provider occurrence processes, ODM will conduct a final review, and as appropriate, issue all payment adjustments in accordance with rule 5160-1-19 of the Administrative Code.

(F) ODM may take action against the provider in accordance with rule 5160-45-09 of the Administrative Code for failure to comply with any of the requirements set forth in this rule.

Last updated January 5, 2026 at 8:50 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-45-07 ODM-administered waiver programs: criminal records checks involving agency providers.

(A) Unless otherwise stated in paragraphs (A)(1) and (A)(2) of this rule, this rule sets forth the process and requirements for the criminal records checks of persons under final consideration for subcontract or employment with a waiver agency, and existing subcontractors or employees with a waiver agency in a full-time, part-time or temporary position who are providing home and community-based services (HCBS) in an Ohio department of medicaid (ODM) -administered waiver. This rule does not apply to:

(1) Any individual who is subject to a database review or a criminal records check under section 3740.11 of the Revised Code and rules adopted thereunder.

(2) Applicants, subcontractors, and employees of a waiver agency that is also a community-based long term care provider who are subject to database reviews and criminal records checks in accordance with section 173.38 of the Revised Code and rules adopted thereunder.

(B) For the purposes of this rule,

(1) "Applicant" means a person who is under final consideration for employment with a waiver agency in a full-time, part-time or temporary position that involves providing HCBS.

(2) "Anniversary date" means the day and month of each year, which corresponds to the employee hire date.

(3) "Chief administrator" means the head of a waiver agency, or his or her designee.

(4) "Community-based long term care provider" has the same meaning as in section 173.39 of the Revised Code.

(5) "Criminal records check" has the same meaning as in section 109.572 of the Revised Code.

(6) "Department" means the Ohio department of medicaid (ODM).

(7) "Disqualifying offense" means any of the offenses listed or described in divisions (A)(3)(a) to (A)(3)(e) of section 109.572 of the Revised Code.

(8) "Employee" means a person employed by a waiver agency in a full-time, part-time, or temporary position that involves providing HCBS.

(9) "Home and community-based services medicaid waiver component" has the same meaning as in section 5166.01 of the Revised Code.

(10) "Retained applicant fingerprint database" or "RAPBACK" means the database maintained by the bureau of criminal investigation (BCI) pursuant to section 109.5721 of the Revised Code that contains the fingerprints of individuals on whom BCI has conducted criminal record checks to determine whether an applicant is ineligible for the medicaid provider agreement pursuant to this rule.

(11) "Subcontractor" means a person or entity who has a formal agreement with a waiver agency to provide HCBS direct-care services.

(12) "Waiver agency" means an entity that provides HCBS under an ODM-administered waiver program, other than such an entity that is certified under the medicare program. "Waiver agency" does not mean an independent provider as defined in section 5164.341 of the Revised Code or rule 5160-45-08 of the Administrative Code.

(C) No waiver agency shall employ an applicant, continue to employ an employee, or utilize a subcontractor in a position that involves providing HCBS in an ODM-administered waiver program if the applicant, employee, or subcontractor:

(1) Is included on one or more of the following databases:

(a) The system for award management (SAM) maintained by the United States general services administration;

(b) The list of excluded individuals and entities maintained by the office of inspector general in the United States department of health and human services pursuant to section 1128 of the "Social Security Act," 94 Stat. 2619 (1980), 42 U.S.C. 1320a-7, as amended, and section 1156 of the "Social Security Act," 96 Stat. 388 (1982), 42 U.S.C. 1320c-5, as amended, or if using ODM's automated registry check system (ARCS), the medicare exclusion database pursuant to 42 C.F.R. 455.436 (October 1, 2024);

(c) The Ohio department of developmental disabilities (DODD) online abuser registry established under section 5123.52 of the Revised Code;

(d) The internet-based sex offender and child-victim offender database established under division (A)(11) of section 2950.13 of the Revised Code;

(e) The internet-based database of inmates established under section 5120.66 of the Revised Code;

(f) The state nurse aide registry established under section 3721.32 of the Revised Code, and a statement detailing findings by the director of health that the applicant, employee, or subcontractor neglected or abused a long-term care facility or residential care facility resident or misappropriated property of such a resident; or

(g) The Ohio medicaid provider exclusion and suspension list found at: http://medicaid.ohio.gov.

(2) Fails to:

(a) Submit to a criminal records check conducted by the bureau of criminal investigation (BCI), including failing to access, complete and forward to the superintendent the form or the standard fingerprint impression sheet; or

(b) Instruct the superintendent of BCI to submit the completed report of the criminal records check directly to the chief administrator of the waiver agency.

(3) Except as provided for in paragraphs (F) and (G) of this rule, the applicant, employee, or subcontractor has been convicted of, or pleaded guilty to, a disqualifying offense, regardless of the date of the conviction or date of entry of the guilty plea.

(D) Process for conducting criminal records checks.

(1) At the time of each applicant's initial application for employment in a position that involves providing HCBS in an ODM-administered waiver program, the chief administrator of the waiver agency shall conduct a review of the databases listed in paragraph (C)(1) of this rule to determine whether the waiver agency is prohibited from employing the applicant in that position. The chief administrator of the waiver agency shall provide the applicant with a copy of any disqualifying information disclosed in the review of the databases.

(2) Except as otherwise noted in paragraph (C)(1) of this rule, the chief administrator of a waiver agency shall require each applicant request the BCI superintendent conduct a criminal records check with respect to the waiver agency applicant, and pursuant to sections 109.572 and 5164.342 of the Revised Code. The applicant must provide a set of fingerprints as part of the criminal records check.

(a) If an applicant does not present proof of having been a resident of the state of Ohio for the five-year period immediately prior to the date the criminal records check is requested, or provide evidence that within that five-year period the superintendent has requested information about the applicant from the federal bureau of investigation (FBI) in a criminal records check, the chief administrator shall require the applicant request the superintendent obtain information from the FBI as part of the criminal records check.

(b) Even if an applicant presents proof of being a resident of the state of Ohio for the five-year period, the chief administrator may require the applicant request the superintendent obtain information from the FBI in the criminal records check.

(3) The chief administrator of a waiver agency shall provide the following to each applicant for whom a criminal records check is required by this rule:

(b) Written notification that the applicant is to instruct the superintendent to submit the completed report of the criminal records check directly to the chief administrator of the waiver agency.

(4) Conditional employment.

(a) A waiver agency may conditionally employ an applicant for whom a criminal records check is required by this rule prior to obtaining the results of that check, provided that the waiver agency has conducted a review of the databases listed in paragraph (C)(1) of this rule and has determined the waiver agency is not prohibited from employing the applicant in that position. The chief administrator must require the applicant request a criminal records check no later than five business days after he or she begins conditional employment.

(b) The waiver agency shall terminate conditional employment if the results of the criminal records check request, other than the results of any request for information from the FBI, are not obtained within sixty days of the criminal records check request.

(5) If the results of the criminal records check indicate that the individual has been convicted of, or has pleaded guilty to any of the disqualifying offenses set forth in paragraph (B)(7) of this rule, and regardless of the date of conviction or the date of entry of the guilty plea, the waiver agency shall either:

(a) Terminate his or her employment; or

(b) Choose to employ the individual because he or she meets the conditions set forth in paragraph (F) of this rule.

(6) If the waiver agency determines that two or more convictions or guilty pleas result from or are connected with the same act or result from offenses committed at the same time, they shall be counted as one conviction or guilty plea.

(7) A waiver agency shall pay to BCI the fee prescribed pursuant to division (C)(3) of section 109.572 of the Revised Code for any criminal records check required by this rule. However, a waiver agency may require an applicant pay to BCI the fee for a criminal records check of the applicant. If the waiver agency pays the fee for an applicant, it may charge the applicant a fee not exceeding the amount the waiver agency pays to BCI pursuant to this rule if the waiver agency notifies the applicant at the time of application for employment of the amount of the fee and that, unless the fee is paid, he or she will not be considered for employment.

(8) Reports of any criminal records checks conducted by BCI in accordance with this rule are not public records for the purposes of section 149.43 of the Revised Code and shall not be made available to any person other than the following:

(a) The person who is the subject of the criminal records check or the individual's representative;

(b) The chief administrator of the waiver agency that requires the applicant to request the criminal records check or the administrator's representative;

(c) The director of ODM and the staff of the department who are involved in the administration of the Ohio medicaid program;

(d) The director of ODA or the director's designee if the waiver agency also is a community-based long-term care agency;

(e) An individual who receives, or may receive, waiver services from the person who is the subject of the criminal records check; and

(f) Any court, hearing officer or other necessary individual involved in a case dealing with a denial of employment of the applicant, termination of the employee, or termination of a contract with a subcontractor; employment or unemployment benefits of the applicant, employee, or subcontractor; or a civil or criminal action regarding the Ohio medicaid program.

(E) As a condition of continued employment or renewal of a subcontract in a position that involves providing HCBS in an ODM-administered waiver program, the chief administrator of the waiver agency shall conduct a criminal records check at least once every five years.

(1) The chief administrator of the waiver agency may conduct a criminal records check on any employee or subcontractor more frequently than every five years.

(2) If the chief administrator of the waiver agency enrolls an employee or subcontractor in RAPBACK, the criminal records check requirements of this rule are considered to have been met for that employee or subcontractor.

(F) A waiver agency may choose to employ an applicant, continue to employ an employee, or continue to contract with a subcontractor who has been convicted of, or has pleaded guilty to, a disqualifying offense set forth in paragraph (B)(7) of this rule if:

(1) The applicant, employee, or subcontractor has satisfied the conditions associated with the exclusionary periods set forth in rule 5160-45-11 of the Administrative Code; or

(2) The applicant. employee, or subcontractor has obtained a certificate of qualification for employment issued by a court of common pleas with competent jurisdiction pursuant to section 2953.25 of the Revised Code, and in accordance with rule 5160-45-11 of the Administrative Code; or

(3) The applicant, employee, or subcontractor has obtained a certificate of achievement and employability in an HCBS-related field, issued by the Ohio department of rehabilitation and corrections pursuant to section 2961.22 of the Revised Code, and in accordance with rule 5160-45-11 of the Administrative Code; and

(4) The applicant, employee, or subcontractor has agreed, in writing, to have the waiver agency inform each potential consumer of the disqualifying offense, and has acknowledged, in writing, that the potential consumer has the right to select or reject to receive services from the applicant, employee, or subcontractor, prior to commencing service delivery.

(G) A waiver agency may choose to continue to employ an employee or utilize a subcontractor who is otherwise excluded by paragraph (B)(7) of this rule if:

(1) The offense is a tier IV offense as set forth in paragraph (F) of rule 5160-45-11 of the Administrative Code;

(2) The employee or subcontractor was hired prior to January 1, 2013;

(3) The conviction or guilty plea occurred prior to January 1, 2013; and

(4) The waiver agency has considered the nature and seriousness of the offense(s), and attests in writing prior to April 1, 2013, to the character and fitness of the employee or subcontractor based on their demonstrated work performance. The required written attestation shall be maintained in the employee or subcontractor's personnel record.

(H) Pardons.

A conviction of, or a plea of guilty to, an offense as set forth in paragraph (B)(7) of this rule shall not prevent an agency from considering an applicant for employment, employee, or subcontractor for continued employment if any of the following circumstances apply:

(1) The applicant,employee, or subcontractor has been granted an unconditional pardon for the offense pursuant to Chapter 2967. of the Revised Code;

(2) The applicant,employee, or subcontractor has been granted an unconditional pardon for the offense pursuant to an existing or former law of the state of Ohio, any other state, or the United States, if the law is substantially equivalent to Chapter 2967. of the Revised Code;

(3) The applicant,employee, or subcontractor has been granted a conditional pardon for the offense pursuant to Chapter 2967. of the Revised Code, and the condition(s) under which the pardon was granted have been satisfied; or

(4) The applicant's, employee's, or subcontractor's conviction or guilty plea has been set aside pursuant to law.

(I) Documentation of compliance. Each waiver agency shall maintain a roster of applicants, employee, and subcontractor's, accessible by the director, which includes, but is not limited to:

(1) The name of each applicant,employee, and subcontractor;

(2) The date the applicant, employee, or subcontractor started work;

(3) The date the criminal records check request is submitted to BCI;

(4) The date the criminal records check is received; and

(5) A determination of whether the results of the check revealed that the applicant, employee, or subcontractor committed a disqualifying offense(s).

Last updated January 5, 2026 at 8:50 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-45-08 ODM-administered waiver programs: criminal records checks involving independent providers.

(A) This rule sets forth the process and requirements for the criminal records checks of independent providers of home and community-based services (HCBS) in Ohio department of medicaid (ODM) -administered waiver programs.

(B) For the purposes of this rule:

(1) "Applicant" means a person who has applied for a medicaid provider agreement to provide HCBS as an independent provider under an ODM-administered waiver program.

(2) "Criminal records check" has the same meaning as in section 109.572 of the Revised Code.

(3) "Disqualifying offense" means any of the offenses listed or described in divisions (A)(3)(a) to (A)(3)(e) of section 109.572 of the Revised Code.

(4) "Effective date of provider agreement" means the month in which the initial provider agreement was entered into between ODM and the independent provider.

(5) "Home and community-based services medicaid waiver component" has the same meaning as in section 5166.01 of the Revised Code.

(6) "Independent provider" means a person who has a medicaid provider agreement to provide HCBS as an independent provider in an ODM-administered waiver program. The term "independent provider" is interchangeable with the term "non-agency provider" in Chapters 5160-44, 5160-46 and 5160-58 of the Administrative Code.

(7) "Retained applicant fingerprint database" or "RAPBACK" means the database maintained by the bureau of criminal investigation (BCI) pursuant to section 109.5721 of the Revised Code that contains the fingerprints of individuals on whom BCI has conducted criminal record checks to determine whether an applicant is ineligible for a medicaid provider agreement pursuant to this rule.

(8) "Superintendent" means superintendent of the BCI.

(C) ODM or its designee shall deny an applicant's application for a medicaid provider agreement, and shall immediately take steps to terminate an independent provider's medicaid provider agreement, if any of the following applies:

(1) After the applicant is given the information and notification required by paragraph (D)(6) of this rule, the applicant fails to do any of the following:

(a) Access, complete, and forward to the superintendent of BCI the form prescribed pursuant to division (C)(1) of section 109.572 of the Revised Code, or the standard impression sheet prescribed pursuant to division (C)(2) of that section;

(b) Instruct the superintendent to submit the completed report of the criminal records check directly to ODM or its designee.

(2) Except as provided in paragraph (F) of this rule, the applicant or independent provider is found by a criminal records check to have been convicted of, or pleaded guilty to, a disqualifying offense, regardless of the date of the conviction, or the date of entry of the guilty plea. If ODM determines that two or more convictions or guilty pleas result from or are connected with the same act or result from offenses committed at the same time, they shall be counted as one conviction or guilty plea.

(3) The applicant or independent provider fails to comply with the provisions of this rule.

(D) Process for conducting criminal records checks.

(1) Each applicant, at the time of initial application for a medicaid provider agreement, shall provide a set of his or her fingerprints, and a criminal records check shall be conducted as a condition of ODM's approving the application.

(2) Each applicant and independent provider shall be subject to the database check requirements set forth in rule 5160-1-17.8 of the Administrative Code.

(3) If the applicant or independent provider does not present proof of having been a resident of the state of Ohio for the five-year period immediately prior to the date the criminal records check is requested, or provide evidence that within that five-year period the superintendent has requested information about the applicant or independent provider from the federal bureau of investigation (FBI) in a criminal records check, ODM or its designee shall request that the superintendent obtain a criminal records check from the FBI as part of the criminal records check.

(4) Even if an applicant or independent provider presents proof of having been a resident of the state of Ohio for the five-year period, ODM or its designee may request the superintendent obtain information from the FBI in the criminal records check.

(5) In order to maintain active provider status, each independent provider must have his or her fingerprints submitted to BCI to be maintained in RAPBACK. ODM shall pay BCI any reasonable fees associated with receiving notifications under division (D) of section 109.5721 of the Revised Code.

(6) ODM or its designee shall provide the following to each applicant and independent provider for whom a criminal records check is required by this rule:

(a) Information about accessing, completing and forwarding to the superintendent the form prescribed pursuant to division (C)(1) of section 109.572 of the Revised Code and the standard fingerprint impression sheet prescribed pursuant to division (C)(2) of that section;

(b) Information about accessing, completing and forwarding to the superintendent the information required for RAPBACK pursuant to section 109.5721 of the Revised Code.

(c) Written notification that the applicant or independent provider is to instruct the superintendent to submit the completed report of the criminal records check directly to ODM or its designee.

(7) Each applicant and independent provider shall pay BCI the fee prescribed pursuant to division (C)(3) of section 109.572 of the Revised Code for each criminal records check conducted on his or her behalf pursuant to paragraphs (D)(1), (D)(3) and (D)(4) of this rule.

(a) The person who is the subject of the criminal records check or his or her representative;

(b) The director of ODM and the staff of ODM involved in the administration of the Ohio medicaid program;

(d) An individual who receives, or may receive, waiver services from the person who is the subject of the criminal records check; and

(e) A court, hearing officer or other necessary individual involved in a case dealing with either a denial or termination of a medicaid provider agreement related to the criminal records check, or a civil or criminal action regarding the Ohio medicaid program.

(E) An individual may choose to receive waiver services from an applicant or independent provider who has been convicted of, or pleaded guilty to, a disqualifying offense if:

(1) The applicant or independent provider has satisfied the conditions associated with the exclusionary periods set forth in rule 5160-45-11 of the Administrative Code; or

(2) The applicant or independent provider has obtained a certificate of qualification for employment issued by a court of common pleas with competent jurisdiction pursuant to section 2953.25 of the Revised Code, and in accordance with rule 5160-45-11 of the Administrative Code; or

(3) The applicant or independent provider has obtained a certificate of achievement and employability in an HCBS-related field issued by the Ohio department of rehabilitation and corrections pursuant to section 2961.22 of the Revised Code, and in accordance with rule 5160-45-11 of the Administrative Code.

(F) Pardons.

A conviction of, or a plea of guilty to, an offense as set forth in paragraph (B)(3) of this rule shall not prevent a consumer from choosing to receive services from an applicant or independent provider if any of the following circumstances apply:

(1) The applicant or independent provider has been granted an unconditional pardon for the offense pursuant to Chapter 2967. of the Revised Code;

(2) The applicant or independent provider has been granted an unconditional pardon for the offense pursuant to an existing or former law of the state of Ohio, any other state, or the United States, if the law is substantially equivalent to Chapter 2967. of the Revised Code;

(3) The applicant or independent provider has been granted a conditional pardon for the offense pursuant to Chapter 2967. of the Revised Code, and the condition(s) under which the pardon was granted have been satisfied; or

(4) The applicant's or independent providers' conviction or guilty plea has been set aside pursuant to law.

Last updated January 5, 2026 at 8:56 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-45-09 ODM-administered waiver program: program compliance, monitoring and oversight of ODM-administered waiver service providers and ODM-administered waiver program contractors.

(A) The Ohio department of medicaid (ODM) is responsible for the ongoing monitoring and oversight of all ODM-administered waiver service providers and all ODM-administered waiver contractors in order to ensure providers' and contractors' compliance with ODM-administered waiver program requirements.

(B) Monitoring and oversight of ODM-administered waiver service providers.

(1) ODM and its designee, as applicable, shall conduct ongoing monitoring and oversight of ODM-administered waiver service providers to verify that each provider is:

(a) Complying with the terms and conditions of its medicaid provider agreement, the ODM-administered waiver program, and all applicable federal, state and local laws and regulations.

(b) Ensuring the health and welfare of individuals to whom they are providing services.

(2) Monitoring and oversight includes, but is not limited to the following:

(a) Interviews with individuals enrolled on the ODM-administered waivers and/or their authorized representative or legal guardian, providers, and contractor staff.

(b) Visits to the provider's place of business or another agreed upon location for the purpose of examining or collecting records, reviewing documentation, and conducting structural reviews.

(3) Providers shall fully cooperate with all requests made by ODM, and/or its designee as part of the monitoring and oversight process. This includes, but is not limited to the following:

(a) Upon request, arranging for or otherwise furnishing an adequate workspace for ODM and/or its designee to conduct visits as described in paragraph (B)(2)(b) of this rule. This workspace must be in a secure location which protects sensitive and confidential information from being disclosed contrary to relevant confidentiality and information disclosure laws.

(b) Making all requested information available at the time of review.

(c) Ensuring the availability of supervisors and/or other staff who may possess relevant information to answer questions.

(4) At the conclusion of a provider's monitoring and oversight review:

(a) ODM or its designee shall notify the provider in writing of its findings. ODM or its designee may do any of the following:

(i) Request that the provider prepare and submit to ODM or its designee a plan of correction within the prescribed time frame. The plan of correction shall set forth the action(s) that must be taken by the provider to correct each finding, and establish a target date by which the corrective action must be completed. If ODM or its designee does not approve the submitted plan of correction, ODM or its designee may request a new plan of correction or take other action as deemed appropriate by ODM.

(ii) Provide technical assistance to the provider.

(iii) Refer the provider to other entities for further investigation. Such entities include, but are not limited to:

(a) The surveillance and utilization review section (SURS) or other program area(s) within ODM;

(b) The Ohio attorney general;

(d) The Ohio board of nursing (OBN);

(e) Other licensing, certification or credentialing bodies, as appropriate; and

(f) Law enforcement.

(b) ODM may:

(i) Issue the provider a notice of operational deficiency (NOD) based upon its or its designee's review findings.

(ii) Propose suspension or termination of the provider's medicaid provider agreement pursuant to section 5164.38 of the Revised Code and rules 5160-1-17.5 and 5160-1-17.6 of the Administrative Code.

(1) ODM shall conduct ongoing monitoring and oversight of the ODM-administered waiver contractors to verify that each contractor is:

(a) Complying with the terms and conditions of its contract and all applicable federal, state and local laws and regulations.

(b) Ensuring the health and welfare of individuals to whom they are providing services.

(2) Monitoring and oversight may include, but are not limited to the following:

(a) Interviews with individuals enrolled on the ODM-administered waivers and/or their authorized representative or legal guardian, providers and contractor staff.

(b) Visits to the contractor's place of business or another agreed upon location for the purpose of examining or collecting records, reviews of documentation, structural reviews.

(3) Contractors shall fully cooperate with all requests made by ODM as part of the monitoring and oversight process. This includes, but is not limited to the following:

(a) Upon request, arranging for or otherwise furnishing an adequate workspace for ODM to conduct visits as described in paragraph (C)(2)(b) of this rule. This workspace must be in a secure location which protects sensitive and confidential information from being disclosed contrary to relevant confidentiality and information disclosure laws.

(b) Making all requested information available at the time of review, and in accordance with the terms of compliance with contracts.

(c) Ensuring the availability of supervisors and/or other staff who may possess relevant information to answer questions.

(4) At the conclusion of a contractor's monitoring and oversight review, ODM shall notify the contractor of its findings. Additionally, if determined appropriate, ODM may do any of the following:

(a) Request that the contractor prepare and submit to ODM a plan of correction within the prescribed time frame. The plan of correction shall set forth the action(s) that must be taken to correct each finding, and establish a target date by which the corrective action must be completed. If ODM does not approve the submitted plan of correction, ODM may request a new plan of correction or take other action as deemed appropriate by ODM.

(b) Provide technical assistance to the contractor.

(i) SURS;

(ii) The Ohio attorney general;

(iii) ODH;

(iv) OBN;

(v) Other licensing, certification or credentialing bodies, as appropriate; and

(vi) Law enforcement.

(d) Issue the contractor a NOD based upon review findings.

(e) Terminate the contractor's contract pursuant to its terms.

Last updated January 5, 2026 at 8:51 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-45-11 ODM-administered waiver programs: exclusionary periods for disqualifying offenses; certificates; and pardons.

(A) Except as set forth in paragraph (H) of this rule, a waiver agency may only employ an applicant, or continue to employ an employee, or continue to contract with a subcontractor who has been convicted of or pleaded guilty to an offense listed in divisions (A)(3)(a) to (A)(3)(e) of section 109.572 of the Revised Code in a position providing home and community-based services (HCBS) to an individual enrolled on an Ohio department of medicaid (ODM) -administered waiver pursuant to the exclusionary timeframes set forth in this rule.

(B) Except as set forth in paragraph (H) of this rule, an applicant, independent provider, or subcontractor who has been convicted of or pleaded guilty to an offense listed in divisions (A)(3)(a) to (A)(3)(e) of section 109.572 of the Revised Code may be selected by an individual enrolled on an ODM-administered waiver program to provide them with HCBS pursuant to the timeframes set forth in this rule.

(1) No waiver agency shall employ an applicant, continue to employ an employee, or utilize a subcontractor in a position that involves providing HCBS to an individual, nor shall an independent provider provide HCBS to an individual, if the applicant, employee, or subcontractor or independent provider has been convicted of or pleaded guilty to, an offense in any of the following sections of the Revised Code:

(a) 2903.01 (aggravated murder);

(b) 2903.02 (murder);

(d) 2903.11 (felonious assault);

(e) 2903.15 (permitting child abuse);

(f) 2903.16 (failing to provide for a functionally-impaired person);

(g) 2903.34 (patient abuse or neglect);

(h) 2903.341 (patient endangerment);

(i) 2905.01 (kidnapping);

(j) 2905.02 (abduction);

(k) 2905.32 (trafficking in persons);

(l) 2905.33 (unlawful conduct with respect to documents);

(m) 2907.02 (rape);

(n) 2907.03 (sexual battery);

(o) 2907.04 (unlawful sexual conduct with a minor, formerly corruption of a minor);

(p) 2907.05 (gross sexual imposition);

(q) 2907.06 (sexual imposition);

(r) 2907.07 (importuning);

(s) 2907.08 (voyeurism);

(t) 2907.12 (felonious sexual penetration, as that offense existed prior to September 3, 1996);

(u) 2907.31 (disseminating matter harmful to juveniles);

(v) 2907.32 (pandering obscenity);

(w) 2907.321 (pandering obscenity involving a minor or impaired person);

(x) 2907.322 (pandering sexually-oriented matter involving a minor or impaired person);

(y) 2907.323 (illegal use of a minor in nudity-oriented material or performance);

(z) 2909.22 (soliciting or providing support for act of terrorism);

(aa) 2909.23 (making terroristic threats);

(bb) 2909.24 (terrorism);

(cc) 2913.40 (medicaid fraud);

(dd) If related to another offense under paragraph (C)(1) of this rule, 2923.01 (conspiracy), 2923.02 (attempt), or 2923.03 (complicity); or

(2) A conviction related to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct involving a federal or state-funded program, excluding the disqualifying offenses set forth in section 2913.46 of the Revised Code and paragraph (D)(1)(m) of this rule; or.

(3) A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations described in paragraph (C)(1) or (C)(2) of this rule.

(D) Tier II. Ten-year exclusionary period.

(1) No waiver agency shall employ an applicant, continue to employ an employee, or utilize a subcontractor in a position that involves providing HCBS to an individual, nor shall an independent provider provide HCBS to an individual, for a period of ten years from the date the applicant, employee, subcontractor, or independent provider was fully discharged from all imprisonment, probation or parole, if the applicant, employee, subcontractor, or independent provider has been convicted of or pleaded guilty to, an offense in any of the following sections of the Revised Code:

(a) 2903.04 (involuntary manslaughter);

(b) 2903.041 (reckless homicide);

(d) 2905.05 (criminal child enticement);

(e) 2905.11 (extortion and sexual extortion);

(f) 2907.21 (compelling prostitution);

(g) 2907.22 (promoting prostitution);

(h) 2907.23 (enticement or solicitation to patronize a prostitute; procurement of a prostitute for another);

(i) 2909.02 (aggravated arson);

(j) 2909.03 (arson);

(k) 2911.01 (aggravated robbery);

(l) 2911.11 (aggravated burglary);

(m) 2913.46 (illegal use of SNAP or WIC program benefits);

(n) 2913.48 (worker's compensation fraud);

(o) 2913.49 (identity fraud);

(p) 2917.02 (aggravated riot);

(q) 2923.12 (carrying concealed weapons);

(r) 2923.122 (illegal conveyance or possession of deadly weapon or dangerous ordnance in a school safety zone, illegal possession of an object indistinguishable from a firearm in a school safety zone);

(s) 2923.123 (illegal conveyance, possession, or control of deadly weapon or ordnance into courthouse);

(t) 2923.13 (having weapons while under a disability);

(u) 2923.161 (improperly discharging a firearm at or into a habitation or school);

(v) 2923.162 (discharge of firearm on or near prohibited premises);

(w) 2923.21 (improperly furnishing firearms to minor);

(x) 2923.32 (engaging in a pattern of corrupt activity);

(y) 2923.42 (participating in a criminal gang);

(z) 2925.02 (corrupting another with drugs);

(aa) 2925.03 (trafficking, aggravated trafficking in drugs);

(bb) 2925.04 (illegal manufacture of drugs, illegal cultivation of marijuana or methamphetamine offenses);

(cc) 2925.041 (illegal assembly or possession of chemicals for the manufacture of drugs);

(dd) 3716.11 (placing harmful or hazardous objects in food or confection); or

(ee) If related to an offense under paragraph (D)(1) of this rule, 2923.01 (conspiracy), 2923.02 (attempt), or 2923.03 (complicity); or

(2) A violation of an existing or former municipal ordinance or law of this state, any other state or the United States that is substantially equivalent to any of the offenses or violations described under paragraph (D)(1) of this rule.

(3) If an applicant, employee, subcontractor, or independent provider has been convicted of multiple disqualifying offenses, including an offense listed in paragraph (D)(1) or (D)(2) of this rule, and another offense or offenses listed in paragraph (D)(1), (D)(2), (E)(1), (E)(2), (F)(1) or (F)(2) of this rule, the applicant, employee, subcontractor, or independent provider is subject to a fifteen-year exclusionary period beginning on the date the applicant, employee, subcontractor, or independent provider was fully discharged from all imprisonment, probation or parole for the most recent offense.

(E) Tier III. Seven-year exclusionary period.

(1) No waiver agency shall employ an applicant, continue to employ an employee, or utilize a subcontractor in a position that involves providing HCBS to an individual, nor shall an independent provider provide HCBS to an individual, for a period of seven years from the date the applicant, employee, subcontractor, or independent provider was fully discharged from all imprisonment, probation or parole, if the applicant, employee, subcontractor, or independent provider has been convicted of or pleaded guilty to, an offense in any of the following sections of the Revised Code:

(a) 959.13 (cruelty to animals);

(b) 959.131 (prohibitions concerning companion animals);

(d) 2903.21 (aggravated menacing);

(e) 2903.211 (menacing by stalking);

(f) 2905.12 (coercion);

(g) 2909.04 (disrupting public services);

(h) 2911.02 (robbery);

(i) 2911.12 (burglary);

(j) 2913.47 (insurance fraud);

(k) 2917.01 (inciting to violence);

(l) 2917.03 (riot);

(m) 2917.31 (inducing panic);

(n) 2919.22 (endangering children):

(o) 2919.25 (domestic violence);

(p) 2921.03 (intimidation);

(q) 2921.11 (perjury);

(r) 2921.13 (falsification, falsification in a theft offense, falsification to purchase a firearm, or falsification to obtain a concealed handgun license);

(s) 2921.34 (escape);

(t) 2921.35 (aiding escape or resistance to lawful authority);

(u) 2921.36 (illegal conveyance of weapons, drugs or other prohibited items onto the grounds of a detention facility or institution);

(v) 2925.05 (funding drug trafficking);

(w) 2925.06 (illegal administration or distribution of anabolic steroids);

(x) 2925.24 (tampering with drugs);

(y) 2927.12 (ethnic intimidation); or

(z) If related to an offense under paragraph (E)(1) of this rule, 2923.01 (conspiracy), 2923.02 (attempt), or 2923.03 (complicity); or

(3) If an applicant, employee, subcontractor, or independent provider has been convicted of multiple disqualifying offenses, including an offense listed in paragraph (E)(1) or (E)(2) of this rule, and another offense or offenses listed in paragraph (E)(1), (E)(2), (F)(1) or (F)(2) of this rule, the applicant, employee, subcontractor, or independent provider is subject to a ten-year exclusionary period beginning on the date the applicant, employee, subcontractor, or independent provider was fully discharged from all imprisonment, probation or parole for the most recent offense.

(F) Tier IV. Five-year exclusionary period.

(1) No waiver agency shall employ an applicant, continue to employ an employee, or utilize a subcontractor in a position that involves providing HCBS to an individual, nor shall an independent provider provide HCBS to an individual, for a period of five years from the date the applicant, employee, subcontractor, or independent provider was fully discharged from all imprisonment, probation or parole, if the applicant, employee, subcontractor, or independent provider has been convicted of or pleaded guilty to, an offense in any of the following sections of the Revised Code:

(a) 2903.13 (assault);

(b) 2903.22 (menacing);

(d) 2907.24 (soliciting);

(e) 2907.25 (prostitution);

(f) 2907.33 (deception to obtain matter harmful to juveniles);

(g) 2911.13 (breaking and entering);

(h) 2913.02 (theft);

(i) 2913.03 (unauthorized use of a vehicle);

(j) 2913.04 (unauthorized use of computer, cable or telecommunication property);

(k) 2913.05 (telecommunication fraud);

(l) 2913.11 (passing bad checks);

(m) 2913.21 (misuse of credit cards);

(n) 2913.31 (forgery - forging identification cards or selling or distributing forged identification cards);

(o) 2913.32 (criminal simulation);

(p) 2913.41 (defrauding a rental agency or hostelry);

(q) 2913.42 (tampering with records);

(r) 2913.43 (securing writings by deception);

(s) 2913.44 (personating an officer);

(t) 2913.441 (unlawful display of law enforcement emblem);

(u) 2913.45 (defrauding creditors);

(v) 2913.51 (receiving stolen property);

(w) 2919.12 (unlawful abortion);

(x) 2919.121 (unlawful abortion upon minor);

(y) 2919.123 (unlawful distribution of an abortion-inducing drug);

(z) 2919.124 (unlawful performance of a drug-induced abortion);

(aa) 2919.23 (interference with custody);

(bb) 2919.24 (contributing to the unruliness or delinquency of a child);

(cc) 2921.12 (tampering with evidence);

(dd) 2921.21 (compounding a crime);

(ee) 2921.24 (disclosure of confidential information);

(ff) 2921.32 (obstructing justice);

(gg) 2921.321 (assaulting or harassing a police dog, horse, or service animal);

(hh) 2921.51 (impersonation of peace officer);

(ii) 2925.09 (illegal administration, dispensing, distribution, manufacture, possession, selling, or using of any dangerous veterinary drug);

(jj) 2925.11 (drug possession, other than a minor drug possession offense);

(kk) 2925.13 (permitting drug abuse);

(ll) 2925.22 (deception to obtain a dangerous drug);

(mm) 2925.23 (illegal processing of drug documents);

(nn) 2925.36 (illegal dispensing of drug samples);

(oo) 2925.55 (unlawful purchase of pseudoephedrine product);

(pp) 2925.56 (unlawful sale of pseudoephedrine product);

(qq) If related to an offense under paragraph (F)(1) of this rule, 2923.01 (conspiracy), 2923.02 (attempt), or 2923.03 (complicity); or

(3) If an applicant, employee, subcontractor, or independent provider has been convicted of multiple disqualifying offenses listed in paragraph (F)(1) or (F)(2) of this rule, the applicant, employee, subcontractor, or independent provider is subject to a seven-year exclusionary period beginning on the date the applicant, employee, subcontractor, or independent provider was fully discharged from all imprisonment, probation or parole for the most recent offense.

(G) Tier V. No exclusionary period.

(1) A waiver agency may employ an applicant, continue to employ an employee, or continue to utilize a subcontractor in a position that involves providing HCBS to an individual, and an independent provider may provide HCBS to an individual if the applicant, employee, subcontractor, or independent provider has been convicted of or pleaded guilty to, any of the following offenses:

(a) 2919.21 (non-support/contributing to non-support of dependents);

(b) 2925.11 (drug possession that is a minor drug possession offense); or

(d) 2925.141 (illegal use or possession of marihuana drug paraphernalia); or

(H) Certificates.

Except for individuals who have been convicted of or pleaded guilty to, a disqualifying offense set forth in paragraph (C) of this rule, a waiver agency may employ an applicant, continue to employ an employee, or utilize a subcontractor in a position involving providing HCBS to an individual, and an individual may choose to receive services from an applicant or independent provider, if the applicant, employee, subcontractor, or independent provider has been issued either of the following:

(1) A certificate of qualification for employment issued by a court of common pleas with competent jurisdiction pursuant to section 2953.25 of the Revised Code; or

(2) A certificate of achievement and employability in an HCBS-related field, issued by the Ohio department of rehabilitation and corrections pursuant to section 2961.22 of the Revised Code.

(I) Pardons.

(1) A conviction of, or plea of guilty to, an offense as set forth in paragraph (B)(6) of rule 5160-45-07 of the Administrative Code shall not prevent a waiver agency from considering an applicant for employment, an employee for continued employment, or a subcontractor if any of the following circumstances apply:

(a) The applicant, employee, or subcontractor has been granted:

(i) An unconditional pardon for the offense pursuant to Chapter 2967. of the Revised Code;

(ii) An unconditional pardon for the offense pursuant to an existing or former law of this state, any other state, or the United States, if the law is substantially equivalent to Chapter 2967. of the Revised Code; or

(iii) A conditional pardon for the offense pursuant to Chapter 2967. of the Revised Code, and the conditions under which the pardon was granted have been satisfied.

(b) The applicant's, employee's, or subcontractor's conviction or guilty plea has been set aside pursuant to law.

(2) A conviction of, or plea of guilty to, an offense as set forth in paragraph (B)(5) of rule 5160-45-08 of the Administrative Code shall not prevent an individual from choosing to receive services from an applicant or independent provider, if any of the following circumstances apply:

(a) The applicant or independent provider has been granted:

(i) An unconditional pardon for the offense pursuant to Chapter 2967. of the Revised Code;

(iii) A conditional pardon for the offense pursuant to Chapter 2967. of the Revised Code, and the conditions under which the pardon was granted have been satisfied.

(b) The applicant's or independent provider's conviction or guilty plea has been set aside pursuant to law.

Last updated January 5, 2026 at 8:56 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Chapter 5160-46 Ohio Home Care Waiver

Ohio Adm.Code 5160-46-02 Ohio home care waiver program: eligibility and enrollment.

(A) An individual is eligible for enrollment in the Ohio home care waiver program only if the individual meets all of the following criteria:

(1) The individual is between the ages of birth through age fifty-nine years.

(2) The individual is determined eligible for Ohio medicaid in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code.

(3) The individual participates in an in-person initial comprehensive assessment to determine if the individual has needs that can be met through the Ohio home care waiver program.

(4) The individual is determined to have a nursing facility (NF) -based level of care (i.e., intermediate or skilled) in accordance with rule 5160-3-08 of the Administrative Code.

(5) The individual in the absence of the Ohio home care waiver program, would require hospitalization or institutionalization in a NF to meet the individual's needs.

(6) The individual:

(b) Has a need for:

(i) Continuous nursing services for more than four hours in length;

(ii) At least one waiver service annually; and

(iii) Monthly monitoring of the individual's health and welfare through a combination of telephonic and in-person contacts with the case manager and agrees to cooperate with the monthly monitoring.

(7) The individual is able to establish residency in a place that possesses the home and community-based setting characteristics set forth in rule 5160-44-01 of the Administrative Code, and that is not a hospital, NF, intermediate care facility for individuals with an intellectual disability (ICF-IID) or another licensed or certified facility, any facility covered by section 1616(e) of the Social Security Act (42 U.S.C. 1382(e) (January 1, 2025)), residential care facility, adult foster home, or another group living arrangement subject to state licensure or certification.

(8) The individual's needs can be safely met through the Ohio home care waiver in a home or community setting as determined by the Ohio department of medicaid (ODM) or its designee.

(B) To be enrolled and maintain enrollment in the Ohio home care waiver program, the individual will meet all of the following criteria:

(1) The individual is determined eligible for the Ohio home care waiver program in accordance with paragraph (A) of this rule.

(2) The individual resides in a setting that possesses the home and community-based setting characteristics set forth in rule 5160-44-01 of the Administrative Code, and that is not a hospital, NF, intermediate care facility for individuals with an intellectual disability (ICF-IID) or another licensed or certified facility, any facility covered by section 1616(e) of the Social Security Act (42 U.S.C. 1382(e) (January 1, 2025)), residential care facility, or another group living arrangement subject to state licensure or certification.

(3) The individual's health and welfare can be ensured while enrolled on the waiver.

(4) The individual participates in the development and implementation of a person-centered services plan in accordance with the process and requirements set forth in rule 5160-44-02 of the Administrative Code.

(5) The individual agrees to and receives case management services from ODM or its designee including, but not limited to:

(a) Annual and other assessments, as needed;

(b) Home safety evaluations;

(6) The individual participates in telephonic and in-person quality assurance and participant satisfaction activities during their enrollment on the Ohio home care waiver program.

(7) The individual cooperates with the in-person eligibility comprehensive assessment at least annually, and more frequently if there is a significant change in the individual's situation that may impact the individual's health and welfare.

(8) The individual signs an agreement confirming the individual has been informed of service alternatives, choice of qualified providers available in the Ohio home care waiver program, and the options of institutional and community-based care, and elects to receive Ohio home care waiver services. If the individual is unable to provide a signature at the time of enrollment, the individual is to submit an electronic signature or standard signature via regular mail, or otherwise in no instance any later than at the next in-person visit with the case manager.

(9) The individual cost limit does not exceed fourteen thousand and seven hundred dollars per month for waiver services. Waiver services excluded from the cost limit are community transition, home maintenance and chore, home modification, self-directed goods and services, supplemental adaptive and assistive device, and vehicle modification.

(a) At the time of enrollment, the initial cost of waiver services in the person-centered services plan does not exceed the cost limit.

(b) The ongoing cost of waiver services in the person-centered services plan may not exceed the cost limit unless otherwise approved by ODM.

(10) There is an available Ohio home care waiver program slot that does not exceed the centers for medicare and medicaid (CMS)-authorized limit for individuals enrolled for the waiver program year.

(C) An individual is given priority for assessment to determine eligibility for enrollment in the Ohio home care waiver when ODM is made aware that the individual meets the criteria for any of the priority categories set forth in paragraphs (C)(1) to (C)(6) of this rule.

(1) The individual is under twenty-one years of age, and at the time of application:

(a) Received inpatient hospital services for at least fourteen consecutive days; or

(b) Had at least three inpatient hospital stays during the preceding twelve months.

(2) The individual is at least twenty-one but less than sixty years of age and received inpatient hospital services for at least fourteen consecutive days immediately preceding the date of application.

(3) The individual is under sixty years of age and received private duty nursing services in accordance with rule 5160-12-02 of the Administrative Code for at least twelve consecutive months immediately preceding application.

(4) The individual is under sixty years of age, lives in the community and is at imminent risk of institutionalization due to the documented loss of a primary caregiver. Written evidence is needed that substantiates the primary caregiver is unavailable to provide care and support, and the individual would need care in an inpatient hospital setting or a nursing facility (NF).

(5) The individual is under sixty years of age and resides in a medicaid-funded NF at the time of application.

(6) The individual is determined by ODM to be eligible for the HOME choice ("Helping Ohioans Move, Expanding Choice") program in accordance with Chapter 5160-51 of the Administrative Code.

(D) If at any time the individual does not meet the criteria in paragraph (A) or paragraph (B) of this rule, the individual will be denied enrollment or disenrolled from the Ohio home care waiver program. In such instances, the individual is notified of their hearing rights in accordance with division 5101:6 of the Administrative Code.

(E) Individuals will be disenrolled from the Ohio home care waiver program no later than one hundred twenty calendar days following their sixtieth birthday. Individuals are offered the opportunity to transition to the pre-admission screening system providing options and resources today (PASSPORT) waiver if all program eligibility criteria are met in accordance with rule 5160-31-03 of the Administrative Code.

Last updated September 30, 2025 at 10:10 AM

History

Effective: September 22, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-46-04 Ohio home care waiver: personal care aide service.

This rule sets forth the definition of personal care aide services and as well as the provider requirements and specifications for the delivery of the service. Providers are also subject to the conditions of participation set forth in rule 5160-44-31 of the Administrative Code. Services are reimbursed in accordance with rule 5160-46-06 of the Administrative Code.

(A) "Personal care aide services" are defined as services provided pursuant to the person-centered services plan (PCSP) that assist the individual with activities of daily living (ADL) and instrumental activities of daily living (IADL) needs. If the provider cannot perform IADLs, the provider will notify the Ohio department of medicaid (ODM) or its designee, in writing, of the service limitations before inclusion on the individual's PCSP. Personal care aide services include:

(1) Bathing, dressing, grooming, nail care, hair care, oral hygiene, shaving, deodorant application, skin care, foot care, feeding, toileting, assisting with ambulation, positioning in bed, transferring, range of motion exercises, and monitoring of intake and output;

(2) General homemaking activities, including but not limited to: meal preparation and cleanup, laundry, bed-making, dusting, vacuuming, washing floors, and waste disposal;

(3) Paying bills and assisting with personal correspondence as directed by the individual; and

(4) Accompanying or transporting the individual to Ohio home care waiver services, medical appointments, other community services, and running errands on behalf of that individual.

(B) Personal care aide services do not include tasks performed, or services provided as part of the home maintenance and chore services set forth in rule 5160-44-12 of the Administrative Code.

(C) Personal care aide services do not include services performed in excess of the number of hours approved pursuant to the PCSP.

(D) Personal care aides will not administer prescribed or over-the-counter medications to the individual, but may, unless otherwise prohibited by the provider's certification or accreditation status, pursuant to paragraph (C) of rule 4723-13-02 of the Administrative Code, help the individual self-administer medications by:

(1) Reminding the individual when to take the medication, and observing to ensure the individual follows the directions on the container;

(2) Assisting the individual by taking the medication in its container from where it is stored and handing the container to the individual;

(3) Opening the container for an individual who is physically unable to open the container;

(4) Assisting an individual who is physically-impaired, but mentally alert, in removing oral or topical medication from the container and in taking or applying the medication; and

(5) Assisting an individual who is physically unable to place a dose of medication in his or her mouth without spilling or dropping it, by placing the dose in another container and placing that container to the mouth of the individual.

(E) Personal care aide services will be delivered by one of the following:

(1) An employee of a medicare-certified, or otherwise-accredited home health agency; or

(2) A non-agency personal care aide.

(F) In order to be a provider and submit a claim for reimbursement, all personal care aide service providers will meet the following:

(1) Provide personal care aide services for one individual, or for up to three individuals in a group setting during a face-to-face visit.

(2) Comply with the additional applicable provider-specific criteria as specified in paragraph (G) or (H) of this rule.

(G) Medicare-certified and otherwise-accredited agencies will ensure that personal care aides meet the following criteria:

(1) Before commencing service delivery, the personal care aide will:

(a) Obtain a certificate of completion of either a competency evaluation program or training and competency evaluation program approved or conducted by the Ohio department of health under section 3721.31 of the Revised Code, or the medicare competency evaluation program for home health aides as specified in 42 C.F.R. 484.80 (as in effect on October 1, 2024), and

(b) Obtain and maintain first aid certification from a program that may be from a class that is not solely internet-based, and that includes hands-on training by a certified first aid instructor and a successful return demonstration of what was learned in the course.

(2) Maintain evidence of the completion of eight hours of in-service continuing education within a twelve-month period, excluding agency and program-specific orientation. Continuing education will be initiated immediately and will be completed annually thereafter.

(3) Receive supervision from a licensed RN or a licensed LPN at the direction of a medical professional in accordance with section 4723.01 of the Revised Code. The supervising RN or LPN will:

(a) Conduct a face-to-face individual home visit at least every sixty days while the personal care aide is present and providing care to evaluate the provision of personal care aide services and the individual's satisfaction with care delivery and personal care aide's performance.

Document each visit in the individual's record.

(b) Discuss the evaluation of personal care aide services with the case manager.

(4) Parents of minor children, spouses, and relatives appointed legal decision making authority for the individual may only serve as a direct care worker in accordance with rule 5160-44-32 of the Administrative Code.

(5) This rule sets the minimum standards for Ohio home care waiver agency personal care aide providers. Medicare-certified and otherwise-accredited agencies remain responsible for ensuring the requirements of applicable medicare certification or other accreditation standards are met.

(H) Non-agency personal care aides will meet the following criteria:

(1) Before commencing service delivery personal care aides will have:

(a) Obtained a certificate of completion within the last twenty-four months for either a competency evaluation program or training and competency evaluation program approved or conducted by the Ohio department of health in accordance with section 3721.31 of the Revised Code; or the medicare competency evaluation program for home health aides as specified in 42 C.F.R. 484.80 (as in effect on October 1, 2024); or other equivalent training program. The program will include training in the following areas:

(i) Personal care aide services as defined in paragraph (A) of this rule;

(ii) Basic home safety; and

(iii) Universal precautions for the prevention of disease transmission, including hand-washing, proper disposal of bodily waste, and medical instruments that are sharp or may produce sharp pieces if broken.

(b) Obtained and maintained first aid certification from a class that is not solely internet-based and that includes hands-on training by a certified first aid instructor and a successful return demonstration of what was learned in the course.

(2) Complete six hours of in-service continuing education annually that will occur on or before the anniversary date of their enrollment as a medicaid personal care aide provider. Continuing education topics include, but are not limited to, health and welfare of the individual, cardiopulmonary resuscitation (CPR), patient rights, emergency preparedness, communication skills, aging sensitivity, developmental stages, nutrition, transfer techniques, disease-specific trainings, and mental health issues.

(3) Comply with the individual's or the individual's authorized representative's specific personal care aide service instructions, and perform a return demonstration upon request of the individual or the case manager.

(4) Comply with ODM monitoring activities in accordance with rule 5160-45-06 of the Administrative Code.

(I) All personal care aide providers will maintain a clinical record for each individual served in a manner that protects the confidentiality of these records. Medicare-certified, or otherwise-accredited agencies, will maintain the clinical records at their place of business. Non-agency personal care aides will maintain the clinical records at their place of business and maintain a copy of the records in the individual's residence. For the purposes of this rule, the place of business will be a location other than the individual's residence. At a minimum, the clinical record will contain:

(1) Identifying information of the individual including but not limited to: name, address, age, date of birth, phone number(s) and health insurance identification numbers.

(2) The medical history of the individual.

(3) The name of individual's treating physician.

(4) A copy of the initial and all subsequent PCSP.

(5) Documentation of all drug and food interactions, allergies, and dietary restrictions.

(6) A copy of any advance directives including, but not limited to, a do not resuscitate (DNR) order or medical power of attorney, if they exist.

(7) Documentation of authorized tasks performed or not performed, arrival and departure times, and the dated signatures of the provider and individual or the individual's authorized representative, verifying the service delivery upon completion of the service delivery. The individual or the individual's authorized representative's signature of choice will be documented on the individual's PCSP and will include any of the following: a handwritten signature, initials, a stamp or mark, or an electronic signature.

(8) Progress notes signed and dated by the personal care aide, documenting all communications with the case manager, treating physician, other members of the team, and documenting any unusual events occurring during the visit, and the general condition of the individual.

(9) A discharge summary, signed and dated by the departing non-agency personal care aide or the RN supervisor of an agency personal care aide, at the point the personal care aide is no longer going to provide services to the individual, or when the individual no longer needs personal care aide services.

(a) The summary should include documentation regarding progress made toward achievement of goals as specified on the individual's PCSP and indicate any recommended follow-ups or referrals.

(b) The discharge summary is not needed in the event the individual dies.

(J) Personal care aide services will be provided in accordance with the individual's PCSP.

Last updated September 22, 2025 at 7:44 AM

History

Effective: September 22, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-46-06 Ohio home care waiver program: covered services, reimbursement rates, and billing procedures.

(A) The following waiver services are covered by the Ohio home care waiver:

(1) Home delivered meals as described in rule 5160-44-11 of the Administrative Code

(2) Home maintenance and chores as described in rule 5160-44-12 of the Administrative Code

(3) Home modification as described in rule 5160-44-13 of the Administrative Code

(4) Community integration as described in rule 5160-44-14 of the Administrative Code

(5) Personal emergency response systems as described in rule 5160-44-16 of the Administrative Code

(6) Out-of-home respite as described in rule 5160-44-17 of the Administrative Code

(7) Waiver nursing as described in rule 5160-44-22 of the Administrative Code

(8) Community transition as described in rule 5160-44-26 of the Administrative Code

(9) Home care attendant as described in rule 5160-44-27 of the Administrative Code

(10) Structured family caregiving as described in rule 5160-44-33 of the Administrative Code

(11) Personal care aide as described in rule 5160-46-04 of the Administrative Code

(12) Vehicle modifications as described in rule 5160-46-09 of the Administrative Code

(13) Supplemental transportation as described in rule 5160-46-10 of the Administrative Code

(14) Supplemental adaptive and assistive devices as described in rule 5160-46-11 of the Administrative Code

(15) Adult day health center as described in rule 5160-46-12 of the Administrative Code

(B) Definitions of terms used for billing and calculating rates.

(1) "Base rate," as used in table A, column 3 of paragraph (C) of this rule, means the amount reimbursed by the Ohio department of medicaid (ODM) for the first thirty-five to sixty minutes of service delivered.

(2) "Bid rate," as used in table B, column 3 of paragraph (C) of this rule, means the per job bid rate negotiated between the provider and the individual's case manager.

(3) "Billing unit," as used in table B, column 3 of paragraph (C) of this rule, means a single fixed item, amount of time or measurement (e.g., a meal, a day, or mile, etc.).

(4) "Caretaker relative" has the same meaning as in rule 5160:1-1-01 of the Administrative Code.

(5) "Group rate," as used in paragraph (E)(1) of this rule, means the amount that waiver nursing and personal care aide service providers are reimbursed when the service is provided in a group setting.

(6) "Group setting" means a setting in which:

(a) A personal care aide service provider furnishes the same type of services to two or three individuals at the same address. The services provided in the group setting can be either the same type of ODM-administered waiver service, or a combination of ODM-administered waiver services and similar non-ODM-administered waiver services.

(b) A waiver nursing service provider furnishes the same type of services to either:

(i) Two or three individuals at the same address. The services provided in the group setting can be either the same type of ODM-administered waiver service, or a combination of ODM-administered waiver services and similar non-ODM-administered waiver services.

(ii) Two to four individuals at the same address if all of the individuals receiving ODM-administered waiver nursing services are:

(a) Medically fragile children,

(b) Siblings, and

(c) Residing together in the home of their caretaker relative. The services provided in the group setting will be ODM-administered waiver nursing services.

(c) A structured family caregiving service provider furnishes the same type of services to two or three individuals at the same address. The services provided in the group setting can be either the same type of ODM-administered waiver service, or a combination of ODM-administered waiver services and similar non-ODM-administered waiver services.

(7) "Medicaid maximum rate" means the maximum amount that will be paid by medicaid for the service rendered.

(a) For the billing codes in table B of paragraph (C) of this rule, the medicaid maximum rate is set forth in column (4).

(b) For the billing codes in table A of paragraph (C) of this rule, the medicaid maximum rate is:

(i) The base rate as defined in paragraph (C)(1) of this rule, or

(ii) The base rate as defined in paragraph (C)(1) of this rule plus the unit rate as defined in paragraph (C)(7) of this rule for each additional unit of service delivered, or

(iii) The unit rate as defined in paragraph (C)(7)(b) of this rule.

(8) "Medically fragile child" means an individual who is under eighteen years of age, has intensive health care needs, and is considered blind or disabled under section 1614(a)(2) or (3) of the "Social Security Act," (42 U.S.C. 1382c(a)(2) or (3)) (as in effect on January 1, 2024).

(9) "Modifier," as used in paragraph (E) of this rule, means the additional two-alpha-numeric-digit billing codes that providers are required to use to provide additional information regarding service delivery.

(10) "Unit rate," as used in table A, column 4 of paragraph (C) of this rule, means the amount reimbursed by ODM for each fifteen minutes of service delivered when the visit is:

(a) Greater than sixty minutes in length.

(b) Less than or equal to thirty-four minutes in length. ODM will reimburse a maximum of only one unit if the service is equal to or less than fifteen minutes in length, and a maximum of two units if the service is sixteen through thirty-four minutes in length.

Table A

| Column 1 | Column 2 | Column 3 | Column 4 | | --- | --- | --- | --- | | Billing code | Service | Base rate | Unit rate | | T1002 | Waiver nursing services provided by an agency RN | $68.44 | $9.25 | | T1002 | Waiver nursing services provided by a non-agency RN | $56.26 | $7.46 | | T1002 | Waiver nursing services provided by a non-agency RN (overtime) | $84.39 | $11.19 | | T1003 | Waiver nursing services provided by an agency LPN | $58.72 | $7.82 | | T1003 | Waiver nursing services provided by a non-agency LPN | $48.00 | $6.24 | | T1003 | Waiver nursing services provided by a non-agency LPN (overtime) | $72.00 | $9.36 | | T1019 | Personal care aide services provided by an agency personal care aide | $28.96 | $7.24 | | T1019 | Personal care aide services provided by a non-agency personal care aide | $22.32 | $5.58 | | T1019 | Personal care aide services provided by a non-agency personal care aide (overtime) | $33.48 | $8.37 |

Table B

| Column 1 | Column 2 | Column 3 | Column 4 | | --- | --- | --- | --- | | Billing code | Service | Billing unit | Medicaid maximum rate | | H0045 | Out-of-home respite services | Per day | $199.82 | | S0215 | Supplemental transportation services | Per mile | $0.48 | | S5101 | Adult day health center services | Per half day | $53.11 | | S5102 | Adult day health center services | Per day | $106.26 | | S5136 | Structured family caregiving | Per day | $102.68 | | S5136 | Structured family caregiving | Per half day | $51.34 | | S5160 | Personal emergency response systems | Per installation and testing | $32.95 | | S5161 | Personal emergency response systems | Per monthly fee | $32.95 | | S5165 | Home modification services | Per item | Amount prior-authorized on the person-centered services plan, not to exceed $15,000$ in a twelve-month calendar year | | T2029 | Supplemental adaptive and assistive device services | Per item | Amount prior-authorized on the person-centered services plan, not to exceed $10,000 in a twelve-month calendar year | | S5170 | Home delivered meal services - standard meal | Per meal | $8.80 | | S5170 | Home delivered meal services - therapeutic or kosher meal | Per meal | $10.61 | | S5135 | Community integration services | Per fifteen-minute unit | $3.93 | | T2038 | Community transition services | Per job | $2,000 per waiver enrollment | | T2039 | Vehicle modification service | Per job | Amount prior-authorized on the person-centered services plan not to exceed $10,000 in a twelve-month calendar year | | S5121 | Home maintenance and chore services | Per job | Amount prior-authorized on the person-centered services plan, not to exceed $10,000 in a twelve-month calendar year |

(D) The amount of reimbursement for a service will be the lesser of the provider's billed charge or the medicaid maximum rate.

(E) Required modifiers.

(1) The "HQ" modifier will be used when a provider submits a claim for billing code S5136, T1002, T1003 or T1019 if the service was delivered in a group setting. Reimbursement as a group rate will be the lesser of the provider's billed charge or seventy-five per cent of the medicaid maximum.

(2) The "TU" modifier will be used when a provider submits a claim for billing code T1002, T1003 or T1019 and the entire claim is being billed as overtime.

(3) The "UA" modifier will be used when a provider submits a claim for billing code T1002, T1003 or T1019 and only a portion of the claim is being billed as overtime.

(4) The "UD" modifier will be used when a provider submits a claim for billing code S5136 for a half day of structured family caregiving.

(5) The "U1" modifier will be used when a provider submits a claim for billing code T1002 and the individual enrolled on the Ohio home care waiver is receiving infusion therapy.

(6) The "U2" modifier will be used when the same provider submits a claim for billing code T1002, T1003 or T1019 for a second visit to an individual enrolled on the Ohio home care waiver for the same date of service.

(7) The "U3" modifier will be used when the same provider submits a claim for billing code T1002, T1003 or T1019 for three or more visits to an individual enrolled on the Ohio home care waiver for the same date of service.

(8) The "U4" modifier will be used when a provider submits a claim for billing code T1002, T1003 or T1019 for a single visit that was more than twelve hours in length but did not exceed sixteen hours.

(9) The "U6" modifier will be used when a provider submits a claim for billing code S5170 for a therapeutic or kosher home delivered meal.

(F) Claims will be submitted to, and reimbursement will be provided by, ODM in accordance with Chapter 5160-1 of the Administrative Code.

Last updated April 17, 2026 at 8:03 AM

History

Effective: April 17, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-46-06.1 Ohio home care waiver program: home care attendant services reimbursement rates and billing procedures.

(A) Definitions of terms used for billing and calculating home care attendant services (HCAS) rates.

(1) "Base rate," as set forth in column 3 of tables A and B of this rule, means the amount reimbursed by Ohio medicaid for the first thirty-five to sixty minutes of assistance with self-administration of medications and the performance of nursing tasks provided during a single visit.

(2) "Continuous nursing" means nursing services (waiver nursing and/or private duty nursing) that are more than four hours in length and during which personal care aide service tasks as described in paragraph (A)(1) of rule 5160-46-04 of the Administrative Code may be provided incidental to nursing services.

(3) "Group rate" means the amount that HCAS providers will be reimbursed when the service is provided in a group setting.

(4) "Group setting" means a situation in which an HCAS provider furnishes HCAS in accordance with rule 5160-44-27 of the Administrative Code, and as authorized by the Ohio department of medicaid (ODM), to two or three individuals who reside at the same address.

(5) "HCAS visit" is a visit during which HCAS is provided in accordance with rule 5160-44-27 of the Administrative Code. An HCAS visit will not exceed twelve hours or forty-eight units in duration.

(6) "Intermittent nursing" means nursing services (waiver nursing and/or home health nursing) that are four hours or less in length.

(7) "Medicaid maximum rate" means the maximum amount that will be paid by the Ohio medicaid program for the service rendered. The base rate in column 3 and the unit rate in column 4 of table A of this rule, and the base rate in column 3 and the unit rates in column 5 of table B of this rule represent the medicaid maximum rates for HCAS.

(8) "Modifier", as set forth in column 4 of table A of this rule and column 4 of table B of this rule, means the additional two-alpha-numeric-digit billing code as set forth in paragraph (G) of this rule that HCAS providers will use to provide additional information regarding service delivery.

(9) "Unit rate," as set forth in column 5 of table A of this rule and column 5 of table B of this rule, means the amount reimbursed by Ohio medicaid for each fifteen minutes of HCAS delivered when the visit is:

(a) Greater than sixty minutes in length.

(b) Less than or equal to thirty-four minutes in length. Ohio medicaid will reimburse a maximum of only one unit if HCAS is equal to or less than fifteen minutes in length, and a maximum of two units if the service is sixteen through thirty-four minutes in length.

(B) Providers will bill for reimbursement using table A when HCAS is provided in lieu of continuous nursing as described in paragraph (A)(2) of this rule. Personal care aide tasks are included in the unit rate.

Table A

| Column 1 | Column 2 | Column 3 | Column 4 | Column 5 | | --- | --- | --- | --- | --- | | Billing code | Home care attendant service description | Base rate | Modifier | Unit rate | | S5125 | Assistance with self-administration of medications and/or the performance of nursing tasks (HCAS/N) | $27.53 | N/A | $6.39 per fifteen minute unit of HCAS/N delivered during visit | | S5125 | HCAS/N (overtime) | $35.11 | TU or UA | $9.81 |

(C) Providers will bill for reimbursement using table B when HCAS is provided in lieu of intermittent nursing as described in paragraph (A)(6) of this rule. The first four units of HCAS will be billed for at the base rate. Beginning with the fifth unit of HCAS, assistance with self-administration of medications and the performance of nursing tasks (HCAS/N) will be billed at the HCAS/N unit rate; and personal care aide service tasks (HCAS/PC) will be billed at the HCAS/PC unit rate using the U8 modifier. There is no base rate for HCAS/PC. The HCAS/PC service can only be rendered in conjunction with an HCAS/N service.

Table B

| Column 1 | Column 2 | Column 3 | Column 4 | Column 5 | | --- | --- | --- | --- | --- | | Billing code | Home care attendant service description | Base rate | Modifier | Unit rate | | S5125 | HCAS/N | $27.53 | N/A | $6.39 per fifteen minute unit of HCAS/N delivered during the visit | | S5125 | HCAS/PC | N/A | U8 | $4.70 per fifteen minute unit of HCAS/PC delivered during the visit | | S5125 | HCAS/N (overtime) | $35.11 | TU or UA | $9.81 | | S5125 | HCAS/PC (overtime) | N/A | either TU or UA, and U8 | $7.05 |

(D) The amount of reimbursement for a service will be the lesser of the provider's billed charge or the medicaid maximum rate.

(E) When HCAS/N and HCAS/PC are provided during an uninterrupted period of time, the visit will be considered a single HCAS visit. An HCAS provider is entitled to only one base rate during an HCAS visit.

(F) HCAS providers will be limited to a maximum of twelve hours or forty-eight units of HCAS during a twenty-four-hour period, regardless of the number of individuals enrolled on an ODM-administered waiver who are served.

(G) Required modifiers.

(1) The "HQ" modifier will be used when a provider submits a claim if HCAS was delivered in a group setting. Reimbursement at a group rate will be the lesser of the provider's billed charge or seventy-five per cent of the medicaid maximum rate.

(2) The "TU" modifier will be used when a provider submits a claim for billing code S5125 and the entire visit is being billed as overtime.

(3) The "UA" modifier will be used when a provider submits a claim for billing code S5125 and only a portion of the visit is being billed as overtime.

(4) The "U2" modifier will be used when a provider submits a claim for a second HCAS visit to an individual enrolled on the Ohio home care waiver for the same date of service.

(5) The "U3" modifier will be used when the same provider submits a claim for three or more HCAS visits to an individual enrolled on the Ohio home care waiver for the same date of service.

(6) The "U8" modifier will be used when a provider submits a claim for an HCAS visit that is in lieu of intermittent nursing as described in paragraph (A)(6) of this rule, and for units of service that are HCAS/PC.

(H) Claims will be submitted to, and reimbursement will be provided by, the ODM in accordance with Chapter 5160-1 of the Administrative Code.

Last updated April 7, 2026 at 4:16 PM

History

Effective: January 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-46-09 Ohio home care waiver: vehicle modification service.

This rule sets forth the definition of the vehicle modification service as well as the provider requirements and specifications for the delivery of the service. Providers are also subject to the conditions of participation set forth in rule 5160-44-31 of the Administrative Code. Services are reimbursed in accordance with rule 5160-46-06 of the Administrative Code.

(A) "Vehicle modifications" are adaptations or alterations to an automobile that is identified as the individual's primary means of transportation, that are needed in order to accommodate the needs of the individual. Vehicle modifications are authorized when necessary to enable the individual to function with greater independence, integrate more fully into the community, and to ensure the health, welfare, and safety of the individual.

(B) Vehicle modifications include but are not limited to:

(1) External handling devices and carriers.

(2) Operating aids, such as assistive equipment and technologies.

(3) Raised or lowered floors or roofs.

(4) Raised doors.

(5) Scooter/wheelchair hoists, hitches, and tie downs.

(6) Lifts.

(7) Maintenance, repair, or replacement of a previous vehicle modification funded by the individual's waiver that does not meet reimbursement criteria through another source.

(8) Transfers of adaptable equipment from one vehicle to another for use by the same individual in accordance with this rule.

(9) Factory-installed adaptations when documented on a separate, itemized invoice associated with the purchase of a new vehicle that is not pre-owned or pre-leased. Such modifications are payable upon proof of transfer of vehicle ownership from the dealer into the name of the allowable owner of the vehicle as described in this rule.

(1) Modifications that are available through another funding source.

(2) Routine auto care and maintenance of general utility unrelated to the vehicle's modification.

(3) Replacement or repair of previously approved vehicle modifications damaged because of apparent misuse, abuse, or negligence.

(4) Payment for purchase of a vehicle except as set forth in paragraph (B)(9) of this rule.

(5) Permanent modifications to leased vehicles.

(6) Vehicle insurance costs.

(7) Services performed which exceed what is specified on the individual's person-centered services plan.

(8) Removal of a modification except set forth in paragraph (B)(8) of this rule.

(9) Repairs needed to a vehicle before a modification can be installed.

(D) Limitations:

(1) Service authorization is limited to ten thousand dollars per calendar year per individual.

(2) Vehicle modifications will only be made to a vehicle owned by one of the following:

(a) The individual,

(b) A relative of the individual who provides primary long-term support, whether paid or non-paid, or

(3) Vehicle modifications are not allowed for vehicles owned by business entities or provider agencies.

(E) Service authorization process

(1) Prior to the service being authorized, the individual, and if applicable any person(s) who will operate the vehicle will provide the Ohio department of medicaid (ODM) or its designee with the following documentation:

(a) The valid driver's license for the person(s) who will be operating the vehicle, with appropriate endorsements;

(b) Proof of ownership and current title or registration of the vehicle to be modified;

(c) Written consent from the vehicle owner to modify the vehicle, including acknowledgment that the vehicle owner understands that ODM is not responsible for returning the vehicle to its prior condition;

(d) Written attestation from the individual or the individual's parent or guardian, as applicable, that identifies the vehicle to be modified as the individual's primary means of transportation; and

(e) Proof of active collision and liability insurance for the vehicle being modified.

(2) ODM or its designee may require the completion of an evaluation by an occupational therapist (OT) or physical therapist (PT). The evaluation will determine the appropriate vehicle modification and the individual's capacity to utilize the vehicle modification.

(3) In consultation with the individual and any person(s) who will be operating the vehicle, ODM or its designee, or the OT or PT will develop a vehicle modification referral that is intended to address the individuals needs.

(4) All submitted proposals will be reviewed by the individual, the individual's parent or guardian, as applicable, the owner of the vehicle if other than the individual, and ODM or its designee.

(5) The service will be awarded to the provider who proposes the lowest cost alternative that meets the individual's assessed need.

(F) Vehicle modification provider:

(1) Vehicle modification providers will submit a fixed cost proposal to ODM or its designee.

(a) The proposal is developed to meet the individual's needs as identified in the evaluation and includes the following:

(i) A description of the work to be performed;

(ii) A drawing or diagram of the modification(s);

(iii) Itemized materials and associated costs;

(iv) Year, make, and model of the vehicle being modified;

(v) Documentation from an automotive service excellence-certified professional stating the vehicle is in good operating condition including that it is structurally sound;

(vi) Estimated time needed to complete the modification;

(vii) A written statement of warranties provided, including a warranty lasting at least one year from date of final acceptance of work against defective workmanship; and

(viii) A written guarantee that all materials furnished and modifications installed perform their intended function.

(b) A fixed proposal may be adjusted with good cause only if the job specifications are modified in writing, and the adjustment is approved by ODM or its designee.

(2) Upon completion of a vehicle modification, but before submitting a claim, the vehicle modification provider will:

(a) Perform all necessary inspections and submit documentation to verify the repair, modification, or installation was completed in accordance with applicable federal, state, and local laws;

(b) Document that the vehicle modification was tested, is in proper working order, and is safe to be operated by the individual or his or her caregiver;

(c) Attest that the individual and if applicable, any other person(s) who will operate the vehicle modification, was instructed on the usage of the modification;

(d) Attest the vehicle modification was completed in accordance with the agreed upon specifications using all the materials and equipment described in the proposal; and

(e) Obtain final written confirmation from the individual, the individual's parent or guardian as applicable, and the owner of the vehicle if other than the individual, that the vehicle modification has been completed to their satisfaction.

(3) Request for reimbursements include:

(a) Itemized cost of material and labor as identified in the approved proposal and

(b) Any approved adjustments made per paragraph (F)(2)(b) of this rule.

(G) The authorization of vehicle modifications may be combined with other waiver services to meet the assessed needs of the individual. In such instances, individual waiver service limits as described in paragraph (D)(1) of this rule still apply.

Last updated September 22, 2025 at 7:45 AM

History

Effective: September 22, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-46-10 Ohio home care waiver: supplemental transportation service.

This rule sets forth the definition of the supplemental transportation service as well as the provider requirements and specifications for the delivery of the service. Providers are also subject to the conditions of participation set forth in rule 5160-44-31 of the Administrative Code. Services are reimbursed in accordance with rule 5160-46-06 of the Administrative Code.

(A) "Supplemental transportation services" are transportation services that are not available through any other resources that enable an individual to access waiver services and other community resources specified on the individual's person-centered services plan (PCSP). Supplemental transportation services include but are not limited to assistance in transferring the individual from the point of pick-up to the vehicle and from the vehicle to the destination point.

(B) Supplemental transportation services do not include services, performed in excess of what is specified on the individual's person-centered services plan.

(1) Maintain a current list of drivers.

(2) Ensure all drivers providing supplemental transportation services are age eighteen years or older.

(3) Maintain a copy of the valid driver's license for each driver.

(4) Maintain collision and liability insurance for each vehicle and driver used to provide supplemental transportation services.

(5) Obtain and exhibit evidence of a valid motor vehicle inspection from the Ohio highway patrol for each vehicle used in the provision of supplemental transportation services.

(6) Obtain and maintain a certificate of completion of a course in first aid for each driver used to provide supplemental transportation services, that is not solely internet-based, that includes hands-on training by a certified first aid instructor and a successful return demonstration of what was learned in the course. Obtain certification that education was received from the authorizing health care professional about health and welfare considerations appropriate for an individual or group setting.

(7) Ensure drivers are not the individual's foster caregiver or legally responsible family member as defined in rule 5160-45-01 of the Administrative Code.

(D) Non-agency supplemental transportation service providers will:

(1) Be age eighteen years or older.

(2) Possess a valid driver's license.

(3) Maintain collision and liability insurance for each vehicle used to provide supplemental transportation services.

(4) Obtain and exhibit evidence of a valid motor vehicle inspection from the Ohio highway patrol for each vehicle used in the provision of supplemental transportation services.

(5) Complete and maintain a certificate of completion of first aid from a class that is not solely internet-based, that includes hands-on training by a certified first aid instructor, and a successful return demonstration of what was learned in the course. Obtain certification that education was received from the authorizing health care professional about health and welfare considerations appropriate for an individual or group setting.

(6) Not be the individual's foster caregiver or legally responsible family member as defined in rule 5160-45-01 of the Administrative Code.

(E) All supplemental transportation service providers will:

(1) Maintain documentation that, at a minimum, includes a log identifying the individual transported, the date of service, pick-up point, destination point, mileage for each trip, and the signature of the individual receiving supplemental transportation services, or the individual's authorized representative. The individual's or authorized representative's signature of choice will be documented on the individual's PCSP and will include any of the following: a handwritten signature, initials, a stamp or mark, or an electronic signature.

(2) Maintain a daily vehicle inspection log.

(3) Ensure a fire extinguisher is in each vehicle.

(4) Ensure potentially harmful items (such as lighters, sharp objects, etc.) are not left in vehicles.

(F) Supplemental transportation services will be provided in accordance with the individual's person-centered services plan.

Last updated September 22, 2025 at 7:45 AM

History

Effective: September 22, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-46-11 Ohio home care waiver: supplemental assistive and adaptive device service.

This rule sets forth the definition of the supplemental assistive and adaptive devices service and provider requirements and specifications for the delivery of the service. Providers are also subject to the conditions of participation set forth in rule 5160-44-31 of the Administrative Code. Services are reimbursed in accordance with rule 5160-46-06 of the Administrative Code.

(A) "Supplemental adaptive and assistive device services" are medical equipment, supplies, and devices that not otherwise available through any other funding source and that are suitable to enable the individual to function with greater independence, avoid institutionalization, and reduce the need for human assistance. All supplemental adaptive and assistive device services will be prior-approved by the Ohio department of medicaid (ODM) or its designee. ODM or its designee will only approve the lowest cost alternative that meets the individual's needs as determined during the assessment process.

(1) Reimbursement for medical equipment, supplies, and devices will not exceed a combined total of ten thousand dollars within a calendar year per individual. Supplemental adaptive and assistive device services in excess of the limit can be approved by ODM or its designee when there is a documented need.

(2) Supplemental adaptive and assistive device services do not include:

(a) Items considered by the federal food and drug administration as experimental or investigational;

(b) Funding of down payments toward the purchase or lease of any supplemental adaptive and assistive devices;

(c) Equipment, supplies, or services furnished in excess of what is approved in the individual's person-centered services plan (PCSP);

(d) Replacement of equipment or supplies, or repair of previously approved equipment or supplies that have been damaged as a result of perceived misuse, abuse, or negligence.

(B) In order to submit a claim for supplemental adaptive and assistive device services, the provider will:

(1) Ensure all manufacturer's rebates have been deducted before requesting reimbursement.

(2) Ensure the supplemental adaptive and assistive device was tested and is in proper working order, and is subject to warranty in accordance with industry standards.

(C) Providers of supplemental adaptive and assistive device services will maintain a clinical record for each individual they serve in a manner that protects confidentiality of these records. At a minimum, the clinical record will include:

(1) Identifying information of the individual including but not limited to name, address, age, date of birth, phone number(s), and health insurance identification numbers.

(2) The name of the individual's treating physician.

(3) A copy of the initial and all subsequent PCSP.

(4) Documentation verifying the date the supplemental adaptive and assistive device service was provided.

(D) The authorization of supplemental adaptive and assistive device services may be combined with other waiver services to meet the assessed needs of the individual. In such instances, the individual waiver service limits as described in paragraph (A)(1) of this rule still apply.

(E) Supplemental adaptive and assistive device services will be provided in accordance with the individual's person-centered services plan.

Last updated September 22, 2025 at 7:45 AM

History

Effective: September 22, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-46-12 Ohio home care waiver: adult day health center service.

This rule sets forth the definition of the adult day health center service as well as the provider requirements and specifications for the delivery of the service. Providers are also subject to the conditions of participation set forth in rule 5160-44-31 of the Administrative Code. Services are reimbursed in accordance with rule 5160-46-06 of the Administrative Code.

(A) "Adult day health center services (ADHCS)" are regularly scheduled services delivered at an adult day health center to individuals who are age eighteen years or older. A qualifying adult day health center will be a freestanding building or a space within a building that is not a private residence and will not be used for other purposes during the provision of ADHCS.

(1) An adult day health center will provide:

(a) Waiver nursing services as set forth in rule 5160-44-22 of the Administrative Code or personal care aide services as set forth in rule 5160-46-04 of the Administrative Code;

(b) Recreational and educational activities; and

(2) An adult day health center may also provide:

(a) Skilled therapy services as set forth in rule 5160-12-01 of the Administrative Code; and

(b) Transportation of the individual to and from ADHCS. The ADHCS will ensure the following for all vehicles used for transportation:

(i) Maintain a daily vehicle inspection log.

(ii) Ensure a fire extinguisher is in each vehicle.

(iii) Ensure potentially harmful items (such as lighters, sharp objects, etc.) are not left in vehicles.

(3) ADHCS are reimbursable at a full-day rate when five or more hours are provided to an individual in a day. ADHCS are reimbursable at a half-day rate when less than five hours are provided in a day.

(4) Services set forth in paragraphs (A)(1) and (A)(2) of this rule and delivered by an adult day health center will not be reimbursed as separate services.

(B) ADHCS do not include services performed in excess of what is approved pursuant to, and specified on, the individual's person-centered services plan (PCSP).

(C) Providers of ADHCS will operate the adult day health center in compliance with all federal, state, and local laws, rules, and regulations.

(D) All providers of ADHCS will:

(1) Comply with federal nondiscrimination regulations set forth in 45 C.F.R. part 80 (as in effect on October 1, 2024).

(2) Maintain a minimum of one million dollars in commercial liability insurance, which includes coverage for individual's losses due to theft or property damage and a written procedure identifying the steps an individual takes to file a liability claim.

(3) Maintain evidence of non-licensed direct care staff's completion of twelve hours of in-service training every twelve months.

(4) Ensure that any waiver nursing services provided are within the nurse's scope of practice set forth in rule 5160-44-22 of the Administrative Code.

(5) Provide task-based instruction to direct care staff providing personal care aide services set forth in rule 5160-46-04 of the Administrative Code.

(6) At all times, maintain a minimum of a one to six ratio of paid direct care staff to individuals.

(7) Maintain working fire pull stations, fire extinguishers, smoke detectors, and carbon monoxide detectors on each level of the building. Smoke detectors will be tested at least monthly. Fire extinguishers will be serviced at least annually. The provider will maintain documentation which demonstrates testing and service was performed.

(8) Store all cleaning supplies, flammables, combustible, and other potentially hazardous chemicals in a secured location away from furnace, hot water heater, open flame, or food.

(9) Store potentially harmful items (such as tools, knives, etc.), medications, and medical waste disposable bins in a secured location inaccessible to individuals.

(10) Maintain sufficient environmental conditions to ensure the safety of individuals served, including electrical systems and wiring, heating and cooling systems, private well and sewer systems, and secured access to mechanical rooms. All damage to walls, ceilings, windows, doors, and screens which could present a health and safety risk should be promptly repaired.

(11) Maintain an emergency preparedness plan to be used in instances of weather-related (i.e. tornado), fire, and other emergencies. The plan includes a pre-determined tornado shelter area and evacuation site. Ad hoc emergency drills will be conducted at least quarterly, with no more than ninety days between drills. Documentation of the drills, the date, and type will be maintained by the provider. Emergency exits will be readily accessible and unobstructed.

(12) Maintain an elopement policy describing actions of staff responsibilities, including notification to law enforcement in the event of an elopement.

(13) Provide the individual with phone access in a private space.

(14) Maintain evidence of passing a fire inspection completed by the local or state fire marshal.

(a) New service providers as of July 1, 2025: upon application to become an ADHCS service provider.

(b) Current service providers as of July 1, 2025: no later than December 31, 2025 and at least annually, with no more than three hundred sixty-five days between inspections thereafter.

(15) Publicly display the building floor plan displaying the location of fire extinguishers and emergency exits.

(16) Maintain a smoking policy.

(17) Adhere to criteria set forth in paragraph (C) of rule 5160-46-10 of the Administrative Code when providing transportation to individuals.

(E) Providers of ADHCS will maintain a clinical record for each individual served in a manner that protects the confidentiality of these records. At a minimum, the clinical record will contain the following:

(1) Identifying information for the individual including but not limited to name, address, age, date of birth, phone number(s), and health insurance identification numbers.

(2) The medical history of the individual.

(3) The name of the individual's treating physician.

(4) A copy of the initial and all subsequent all service plans.

(5) A copy of any advance directive including, but not limited to, do not resuscitate (DNR) order or medical power of attorney, if they exist.

(6) Documentation of all drug and food interactions, allergies, and dietary restrictions.

(7) Documentation that clearly shows the date of ADHCS delivery, including authorized tasks performed or not performed, and the individual's arrival and departure times.

(8) A discharge summary, signed and dated by the departing ADHCS provider, at the point the individual no longer needs ADHCS. The summary should include documentation regarding progress made toward goal achievement and indicate any recommended follow-ups or referrals.

(9) Documentation of the information set forth in rule 5160-44-22 of the Administrative Code when the individual is provided waiver nursing or skilled therapy services, or both.

(F) Adult day health center services will be provided in accordance with the individual's person-centered services plan.

Last updated September 22, 2025 at 7:45 AM

History

Effective: September 22, 2025
Promulgated Under: 119.03

Chapter 5160-48 Targeted Case Management Services Provided to Individuals with Intellectual and Developmental Disabilities

Ohio Adm.Code 5160-48-01 Medicaid coverage of targeted case management services provided to individuals with developmental disabilities.

(A) Purpose.

(1) This rule specifies the conditions for medicaid payment of targeted case management (TCM), which is associated with activities described in section 5126.15 of the Revised Code and in rule 5123-4-02 of the Administrative Code, but only to the extent that they are listed in paragraph (D) of this rule as reimbursable activities for medicaid eligible individuals with intellectual and developmental disabilities.

(2) The department of developmental disabilities (DODD), through an interagency agreement with the department of medicaid (ODM), administers the TCM program on a daily basis in accordance with section 5162.35 of the Revised Code.

(B) Definitions.

(1) "IEP" means an individualized education program and has the same meaning as described in rule 3301-51-07 of the Administrative Code.

(2) "Institution" means a nursing facility, an intermediate care facility for individuals with intellectual disabilities (ICF/IID), a state-operated intermediate care facility for individuals with intellectual disabilities (ICF/IID) or a medical institution.

(3) "ISP" means an individual service plan as defined in rule 5123-4-02 of the Administrative Code.

(4) "Major unusual incident" (MUI) has the same meaning as defined in rule 5123-17-02 of the Administrative Code.

(5) "Service and support administration" has the same meaning as described in section 5126.15 of the Revised Code.

(6) "Targeted case management" means services which will assist individuals in gaining access to needed medical, social, educational and other services as described in this rule in accordance with section 1915(g) of the Social Security Act (42 U.S.C. 1396n(g)(2)) as effective October 1, 2023. TCM is also referred to as medicaid case management.

(7) "Unusual incident" has the same meaning as defined in rule 5123-17-02 of the Administrative Code.

(1) Individuals eligible for medicaid coverage of TCM services are:

(a) Medicaid eligible individuals, regardless of age, who are enrolled on home and community-based service (HCBS) waivers administered by the DODD, and

(b) All other medicaid eligible individuals, age three or above, who are determined to have an intellectual or developmental disability according to section 5126.01 of the Revised Code.

(D) Reimbursable activities.

(1) Medicaid services listed in paragraph (D) of this rule are reimbursable only if provided to or on behalf of a medicaid eligible individual as defined in paragraph (C) of this rule and by qualified providers as defined in paragraph (E) of this rule. Payment for TCM services will not duplicate payments made to public agencies or private entities under other program authorities for this same purpose. Medicaid reimbursable TCM services are:

(a) Assessment. Activities reimbursable under the assessment category are limited to the following:

(i) Activities performed to make arrangements to obtain from therapists and appropriately qualified persons the initial and on-going assessments of an eligible individual's need for any medical, educational, social, and other services which includes technology and employment-related.

(ii) Eligibility assessment activities that provide the basis for the recommendation of an eligible individual's need for HCBS waiver services administered by DODD.

(iii) Activities related to recommending an eligible individual's initial and on-going need for services and associated costs for those individuals eligible for HCBS waiver services administered by DODD.

(b) Care planning. Activities reimbursable under the care planning category are limited to the following:

Activities related to ensuring the active participation of the eligible individual and working with the eligible individual and others to develop goals and identify a course of action to respond to the assessed needs of the eligible individual. These activities result in the development, monitoring, and on-going revision of an ISP.

Activities that help link eligible individuals with medical, social, educational providers and/or other programs and services that can provide needed services including technology and employment-related providers and technology and employment-related programs and services.

(d) Monitoring and follow-up. Activities reimbursable under the monitoring and follow-up category are limited to the following:

(i) Activities and contacts that are necessary to ensure that the ISP is effectively implemented and adequately addresses the needs of the eligible individual.

(ii) Reviewing the individual trends and patterns resulting from reports of investigations of unusual incidents and MUIs and integrating prevention plans into amendments of an ISP.

(iii) Ensuring that services are provided in accordance with the ISP and ISP services are effectively coordinated through communication with service providers.

(iv) Activities and contacts that are necessary to ensure that guardians and eligible individuals receive appropriate notification and communication related to unusual incidents and MUIs.

(e) State hearings: Activities reimbursable under the state hearing category are limited to the following:

Activities performed to assist an eligible individual in preparing for a state hearing related to the reduction, termination, or denial of a service on an ISP.

(2) Coverage exclusions.

(a) Activities performed on behalf of an eligible individual residing in an institution are not billable for medicaid TCM reimbursement except for the last one hundred eighty consecutive days of residence when the activities are related to moving the eligible individual from an institution to a non-institutional community setting.

(b) Emergency response systems as described in paragraph (G) of rule 5123-4-02 of the Administrative Code. This does not preclude those activities covered in paragraph (D)(1) of this rule when responding to an emergency and provided by a certified service and support administrator.

(d) The provision of direct services (medical, educational, vocational, transportation, or social services) to which the eligible individual has been referred and with respect to the direct delivery of foster care services, including but not limited to those described in paragraph (A)(iii) of section 1915(g) of the Social Security Act (42 U.S.C. 1396n(g)(2)) as effective October 1, 2023.

(e) Services provided to individuals who have been determined to not have an intellectual or developmental disability according to section 5126.01 of the Revised Code, except for individuals eligible for coverage of TCM services pursuant to paragraph (C)(1)(a) of this rule.

(f) Payment or coverage for establishing budgets for services outside of the scope of individual assessment and care planning.

(g) Activities related to the development, monitoring or implementation of an IEP.

(h) Services provided to groups of individuals.

(i) Habilitation management.

(j) Eligibility determinations for county board of developmental disabilities (CBDD) services.

(E) Qualified providers.

Qualified providers of medicaid TCM services are CBsDD as established under Chapter 5126. of the Revised Code. Only those eligible activities as defined in this rule performed by CBsDD employees or CBsDD sub-contractors meeting the certification standards contained in rule 5123-5-02 of the Administrative Code are eligible for payment.

(F) Documentation requirements.

To receive medicaid reimbursement for TCM activities provided under this rule, documentation will include, but is not limited to, the following elements:

(1) The date that the activity was provided, including the year;

(2) The name of the person for whom the activity was provided;

(3) A description of the activity provided and location of the activity delivery (may be in case notes or a coded system with a corresponding key);

(4) The duration in minutes or time in/time out of the activity provided. Duration in minutes is acceptable if the provider's schedule is maintained on file;

(5) The identification of the activity provider by signature or initials on each entry of service delivery. Each documentation recording sheet will contain a legend that indicates the service provider's name (typed or printed), title, signature, and initials to correspond with each entry's identifying signature or initials.

(G) Reimbursement and claims submission.

(1) Each CBDD will maintain a current fee schedule of usual and customary charges. Records of fee schedules will be maintained for a period of six years. The CBDD will bill DODD its usual and customary charge for a TCM covered service. TCM services will be reimbursed the lesser of the CBDD's usual and customary charge or the rate found in appendix DD to rule 5160-1-60 of the Administrative Code. Without regard to the rate of reimbursement that may be identified in appendix DD to rule 5160-1-60 of the Administrative Code, no provider of TCM will receive reimbursement at a rate more than the rate in the federally approved state plan amendment.

(2) Each CBDD is responsible for instituting collection efforts against third parties liable for the payment of TCM services as required by rule 5160-1-08 of the Administrative Code. The CBDD will maintain sufficient documentation to substantiate collection activities and any payments received. Sufficient documentation includes a written confirmation every twelve months from any known possible third party, if applicable, which states that the TCM service is not covered under that program or policy.

(3) If any of the TCM services provided by a CBDD are paid or attributable to another federal program, the costs of such services should be allocated in accordance with 2 CFR Part 200 as in effect on January 1, 2023.

(4) A CBDD will not alter or adjust usual and customary rates charged to the medicaid program if such adjustments will result in a direct or indirect charge for costs of uncompensated care being charged to the medicaid program.

(5) A CBDD is required to submit claims to DODD within three hundred thirty days from the date of service in accordance with the format specified by DODD. Failure to submit claims within the specified three hundred thirty days may result in the CBDD not being reimbursed for such claims. The CBDD will have no recourse to recover such non-reimbursed claims.

(6) Medicaid reimbursement for TCM services will constitute payment in full. Medicaid recipients will not be billed for medicaid covered services.

(7) Payment for TCM services will not duplicate payments made to CBDD under other programs.

(8) To support the provision of providing TCM through fee for service, utilization review procedures will be incorporated to assure compliance with "42 C.F.R. Part 456" as in effect on October 1, 2023.

(9) Records relating to TCM services will be made available to DODD, ODM, centers for medicare and medicaid services (CMS) or any of their representatives to verify actual units of service provided comply with federal requirements and are adequately supported.

(10) For the purpose of this rule, a unit of service is equivalent to fifteen minutes. Minutes of service provided to a specific eligible individual can be accrued over one calendar day. The number of units that may be billed during a day is equivalent to the total number of minutes of TCM provided during the day for a specific individual divided by fifteen plus one additional unit if the remaining number of minutes is eight or greater minutes.

(11) Billable units of service are those tasks/contacts made with the eligible individual or on behalf of the eligible individual. Activities which are not performed on behalf of or are not specific to an eligible individual are not billable.

(H) Reimbursement on and after January 1, 2022.

(1) A CBDD will receive an interim rate as defined in the appendix DD to rule 5160-1-60 of the Administrative Code for each fifteen minute unit of providing TCM services to medicaid eligible individuals as defined in paragraph (C) of this rule.

(2) A CBDD will be reimbursed for the actual incurred costs of providing TCM to eligible medicaid recipients. Each CBDD will certify its expenditures as eligible for federal financial participation to settle the actual incurred costs for medicaid TCM.

(3) Each CBDD will submit their actual incurred costs as described in paragraph (G) (1) of this rule on an annual cost report as established in section 5126.131 of the Revised Code.

(4) DODD will conduct a final settlement once all cost reports are received and audited. Payments will be paid to each provider in an amount based on the provider's reconciled costs for providing TCM services to medicaid eligible recipients less any amounts previously paid to the provider for providing TCM services under the state plan.

(5) Reconciled costs will be calculated by using a methodology approved by the CMS.

(I) Record requests and retention.

(1) CBDD will make available all records including but not limited to work papers, supporting reports, medical reports, progress notes, charges, journals, ledgers, computer tapes, computer disks, and fiscal reports for review by representatives from ODM, ODM's designee, CMS, or DODD at the discretion and request of these representatives.

(2) Documentation will be retained for a period of six years from the date of receipt of final payment or until such time as a lawsuit or audit finding has been resolved, whichever is longer. The records will be provided to ODM or its designee upon request in a timely manner. Records produced electronically will be produced at the provider's expense, in the format specific by state or federal authorities. A retrospective program review will not be required on or after January 1, 2015.

(J) Monitoring, compliance, and sanctions.

(1) DODD will conduct periodic monitoring and compliance reviews related to TCM as authorized by the Revised Code. Reviews may consist of, but are not limited to, physical inspections of records and sites where services are provided, interviews of providers, recipients, and administrators. Qualified providers as defined in paragraph (E) of this rule, in accordance with the medicaid provider agreement and DODD, will furnish to DODD, ODM, CMS, and the medicaid fraud control unit or their designees any records related to the administration and/or provision of TCM services.

(2) ODM will monitor the activities of DODD, as necessary, to ensure that funding applicable to the TCM program is used for authorized purposes in compliance with laws, regulations, and the provisions of the interagency agreement.

(3) In the event a fiscal review reveals that an overpayment has been made, and/or there is a disallowance of medicaid payments, the amount of the overpayment and/or disallowance will be recovered from the CBDD.

(K) Due process.

(1) Medicaid eligible individuals whose TCM services either affect the provision of services or whose TCM services are affected by any decision may appeal that decision at a state hearing pursuant to division 5101:6 of the Administrative Code. CBsDD will provide notice to the individual of their right to request a state hearing pursuant to Chapter 5101:6-2 of the Administrative Code.

(2) If an eligible individual requests a hearing, as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code, the participation of DODD, and/or ODM and the CBDD is required during the hearing proceedings to justify the decision under appeal.

(3) All rules related to due process will be interpreted in a manner consistent with section 1.11 of the Revised Code, which requires that they be liberally construed in order to promote their objective and assist the individual in obtaining justice. All rules relating to the right to a hearing and limitations on that right will be interpreted in favor of the right to a hearing.

(L) Nonfederal share.

A CBDD is responsible for payment of the nonfederal share of medicaid expenditures in accordance with sections 5126.0510 and 5126.0511 of the Revised Code. A CBDD will provide this nonfederal share prior to the CBDD receiving payment.

Last updated July 31, 2024 at 8:41 AM

History

Effective: July 31, 2024
Promulgated Under: 119.03

Chapter 5160-51 HOME choice ("Helping Ohioans Move, Expanding Choice") demonstration program

Ohio Adm.Code 5160-51-10 Helping Ohioans move, expanding choice (HOME choice).

(A) Helping Ohioans move, expanding choice (HOME choice) assists individuals to transition from an institutional setting into a community setting.

(B) Definitions

(1) "Assessment" means an in-person meeting with the HOME choice applicant to determine eligibility for the program, conducted by the Ohio department of medicaid (ODM) or its designee.

(2) "Community setting" means a location that meets the home and community-based setting requirements set forth in rule 5160-44-01 of the Administrative Code or for those moving from an intermediate care facility for individuals with intellectual disabilities the requirements set forth in rule 5123:2-9-02 of the Administrative Code.

(3) "HOME choice participant" or "participant" means a person who is enrolled in HOME choice.

(4) "Institutional setting" means a hospital as described in Chapter 5160-2 of the Administrative Code, a nursing facility as described in Chapter 5160-3 of the Administrative Code, or an intermediate care facility for individuals with intellectual disabilities as described in Chapter 5123:2-7 of the Administrative Code.

(1) Be enrolled in medicaid in accordance with division 5160:1 of the Administrative Code at the time of HOME choice application and during the entire HOME choice enrollment period;

(2) Currently reside in an institutional setting in Ohio and have resided in an institutional setting in Ohio for a period of not less than sixty consecutive days;

(3) Be eighteen years of age or older;

(4) Complete the ODM 10239, "HOME Choice Application" (5/2021) which includes:

(a) Agreeing to adhere to the participant responsibilities outlined in the HOME choice application;

(b) Agreeing to move to a community setting in Ohio within one hundred eighty days of enrolling in the program.

(5) Participate in an assessment and be determined by ODM to have:

(a) A need for the program. Examples include:

(i) Requiring physical or emotional supports to successfully transition from an institutional setting to a community setting;

(ii) Lacking family or informal supports willing and capable of assisting with any of the following;

(a) Locating, securing or moving into a community setting;

(b) Acquiring household furnishings and supplies;

(d) Accessing community resources and supports; or

(e) Arranging necessary home adaptations required for community living.

(b) Health care needs that may be adequately met in a community setting; and

(c) Enough income or means to sustain community living at the time of HOME choice application and during the entire HOME choice enrollment period.

(6) Have not previously transitioned through the HOME choice program after July 1, 2019;

(7) Not be moving to another institutional setting.

(8) Work with a transition coordinator to develop a safe transition plan, and discharge in accordance with that plan.

(9) Not be a foster child, as defined in Chapter 5101:2-1 of the Administrative Code; and

(10) Not be eligible for both:

(a) Targeted case management, as defined in rule 5160-48-01 of the Administrative Code, and

(b) Community transition services, as defined in rule 5123-9-48 of the Administrative Code.

(D) An individual may be enrolled in HOME choice when all the criteria in paragraph (C) of this rule are met. ODM will notify the individual of enrollment in writing. The HOME choice enrollment period begins on the date of the enrollment letter and continues for up to one hundred eighty days pre-transition and up to thirty days post transition.

(E) Services available through HOME choice include activities approved by ODM or it's designee to assist the participant in their transition including:

(1) "Transition coordination" which includes:

(a) Working with facility discharge planners to determine what services and supports the participant will need in the community;

(b) Helping the participant obtain housing;

(d) Coordinating the use of community transition services;

(e) Collaborating with the participant's comprehensive care team and nursing facility or hospital to coordinate services at the time of discharge from the institutional setting, and after the transition into the community setting when applicable.

(2) "Community transition service" as set forth in rule 5160-44-26 of the Administrative Code.

(3) HOME choice services can not duplicate services available to a participant enrolled on a home and community-based services (HCBS) waiver.

(F) A participant may receive HOME choice services for up to thirty days post transition beginning on the date the participant moves from the institutional setting into the community setting.

(G) If an individual fails to meet any of the requirements set forth in paragraph (C) of this rule before the HOME choice enrollment period, the individual will be denied participation in the program and afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

(H) If an individual fails to meet any of the requirements set forth in paragraph (C) of this rule after the HOME choice enrollment period begins, the individual will be terminated from the program and afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

Last updated November 15, 2021 at 10:02 AM

History

Effective: November 15, 2021
Promulgated Under: 119.03

Chapter 5160-56 Medicaid Hospice Program

Ohio Adm.Code 5160-56-01 Hospice services: definitions.

This rule set forth terms used throughout Chapter 5160-56 of the Administrative Code.

(A) "Advance directive" refers to written instructions recognized under state law that are related to the provisions of health care when the individual is incapacitated. Samples of advance directive documents include a living will, a declaration as defined in Chapter 2133. of the Revised Code, and a durable power of attorney for health care as defined in Chapter 1337. of the Revised Code.

(B) "Advanced practice registered nurse (APRN)" refers to a registered nurse (RN) authorized to practice as a clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife or certified nurse practitioner in accordance with section 4723.43 of the Revised Code.

(C) "Attending physician" refers to a health professional identified by the individual at the time of the election of hospice, as having primary responsibility in the determination and delivery of the individual's medical care while under hospice, and one who is:

(1) A doctor of medicine or osteopathy licensed and legally authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery; or

(2) A "nurse practitioner" who meets the training, education, and experience requirements of a certified, advanced practice nurse in accordance with section 4723.43 of the Revised Code. APRNs are prohibited from certifying or recertifying a terminal diagnosis.

(3) A "physician assistant" (PA) who meets the training, education, and other specifications of a licensed physician assistant in accordance with Chapter 4730. of the Revised Code. PAs are prohibited from certifying or recertifying a terminal diagnosis.

(D) "Authorized representative" has the same meaning as rule 5160-1-33 of the Administrative Code.

(E) "Beginning date of service" means the first billable date on which a designated hospice provider delivers hospice services to an individual.

(F) "Benefit period" or "election benefit period" refers to a span for which the individual is enrolled in the hospice benefit. Benefit periods consist of two ninety day benefit periods, followed by an unlimited number of sixty day benefit periods. The benefit periods may be used consecutively or at intervals. The election benefit period is subject to the conditions set forth in this chapter to include revocation, and must be utilized in sequential order:

(1) An initial ninety-day period (limited to one during the individual's lifetime);

(2) A second subsequent ninety-day period (limited to one during the individual's lifetime);

(3) An unlimited number of subsequent sixty-day periods.

(G) "Bereavement counseling" refers to counseling services furnished to the individual's immediate family or caregiver before and after the individual's death, to assist the family with issues related to grief, loss, and adjustment. Bereavement counseling must be made available by the designated hospice for a period up to one year following the individual's death.

(H) "Certification of the terminal illness" refers to the clinical judgment made by a medical director or physician member of the interdisciplinary group (IDG) and the individual's attending physician about the life expectancy of an individual should a terminal illness run its normal course. As a requirement pursuant to 42 C.F.R. 418.22 (October 1, 2023), in order to receive hospice care, the individual must be certified by a hospice medical director or physician member of the IDG and the individual's attending physician (if the individual has an attending physician) as being terminally ill with a medical prognosis that the individual's life expectancy is six months or less.

(I) "Concurrent care for children" refers to a federal provision which allows for curative treatment and hospice care to be covered simultaneously for individuals under age twenty-one.

(J) "Continuous home care" is a level of hospice care covered by medicaid in accordance with 42 C.F.R. 418.302 (October 1, 2023). A continuous home care day is one on which an individual who has elected to receive hospice care is at home and not in an inpatient facility, and when the care provided in the home consists predominantly of nursing care. Continuous home care may involve a home health aide (also known as a hospice aide) or homemaker services, or both. Continuous home care is only furnished during brief periods of crisis and only as necessary to maintain the terminally ill individual at home.

(K) "Core hospice services" are nursing care, medical social services, counseling services, and physician services that must routinely be afforded and/or provided directly to the individual by employees of the hospice.

(L) "Corresponding federal fiscal year" refers to the annual period from October first to September thirtieth, as set by the federal government for accounting and budgeting purposes.

(M) "Counseling services" are services provided to the terminally ill individual and the family members or other persons caring for the individual at home, including dietary counseling, training the individual's family or other caregiver to provide care, and for the purpose of helping the individual and the family members and/or caregiver with adjustment to the approaching death.

(N) "Designated hospice provider" refers to the hospice responsible for the professional management of care provided to the individual while enrolled in hospice.

(O) "Dietary counseling" means intervention and education regarding appropriate nutritional intake that is provided to the individual and/or the individual's family by a qualified professional including, but not limited to, a registered nurse, a dietitian and/or a physician.

(P) "Dietitian" means a person licensed to practice dietetics who meets the criteria set forth in Chapter 4759. of the Revised Code.

(Q) "Election statement," "election of hospice statement" and the "hospice election statement" refer to the required, written acknowledgment of the individual's decision to receive hospice care in lieu of curative care or treatment of the terminal illness.

(R) "Ending date of service" means the date on which a designated hospice stops delivering hospice services to the individual because of revocation of the medicaid hospice benefit, discharge from the hospice benefit, change by the individual of the designated hospice, or death of the individual in accordance with Chapter 5160-56 of the Administrative Code.

(S) "Episode of Care" or "Hospice Episode of Care" is a hospice election period or series of election periods separated by no more than a sixty day gap. Each episode is initiated by a start of care and is ended by a discharge to death or a gap in hospice services of more than sixty days. An episode of care may include multiple election benefit periods; however, a benefit period cannot span more than one episode of care.

(T) "General inpatient care" is a level of hospice care covered in accordance with 42 C.F.R. 418.302 (October 1, 2023). A general inpatient care day is a day on which an individual who has elected hospice care receives care in an inpatient facility for pain control or acute or chronic symptom management which cannot be managed in other settings.

(U) "Home and community based services (HCBS) waivers" refers to medicaid programs operated in accordance with Section 1915 (c) of the Social Security Act (the Act), 42 U.S.C. 1396n(c) (as in effect January 1, 2017) that allow individuals to receive covered services in their own home or community rather than institutions or other isolated settings. The HCBS waiver programs include those waivers administered by the Ohio department of medicaid (ODM), the Ohio department of aging (ODA), and the Ohio department of developmental disabilities (DODD).

(V) "Hospice" refers to a public agency, a private organization, or a subdivision of either, subject to the conditions of participation pursuant to 42 C.F.R. Part 418 (October 1, 2023), that is licensed in the state of Ohio and approved by the ODM to engaged in providing care to terminally ill individuals.

(W) "Hospice aide" refers to one who has successfully completed a training and competency evaluation program for hospice aide services, who meets the conditions of participation prescribed in 42 C.F.R. 418.76 (October 1, 2023), and who provides home care services pursuant to rule 3701-19-16 of the Administrative Code. For purposes of this chapter, hospice aide is interchangeable with the term, "home health aide".

(X) "Hospice care" refers to a comprehensive set of home based, inpatient and/or outpatient services coordinated by an interdisciplinary group of health professionals and volunteers as part of a written plan of care, to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill individual and/or the individual's family members. Hospice stresses palliative care as opposed to curative care.

(Y) "Hospice enrollment" refers to the process of entering hospice data, such as benefit periods pursuant to rule 5160-56-03.3 of the Administrative Code, into the ODM provider web portal for an individual in receipt of hospice care.

(Z) "Hospice quality reporting program" refers to a federal mandate pursuant to the Section 3004 of Affordable Care Act of 2010 (as in effect January 1, 2017). HQRP requires all Medicare-certified hospice providers to comply with data reporting requirements prescribed by the centers for medicare and medicaid services (CMS). Annually, by October 1, CMS publishes the quality measures a hospice must report. The act of submitting data is what determines compliance with HQRP requirements.

(AA) "Hospice provider span" refers to the date range (begin date to end date) that a valid provider is considered the designated hospice provider. It is an assignment in the ODM provider web portal that refers to the period of time during which an individual receives hospice services from the designated hospice.

(BB) "Individual" refers to the beneficiary eligible for medicaid, who is in need of, or under the care of the designated hospice, and who is considering and/or who has elected the hospice benefit. For decision making purposes, an individual may designate an authorized representative to act on his or her behalf, in place of the individual.

(CC) "Inpatient facility" refers to a facility that is either operated by or under contract with a hospice for the purpose of providing general inpatient and/or respite care to the individual.

(DD) "Inpatient respite care" is a level of hospice care covered in accordance with 42 C.F.R. 418.302 (October 1, 2023). An inpatient respite care day is a day on which the individual who has elected hospice care receives care in an approved facility on a short-term basis for the purpose of providing relief and respite for caregivers.

(EE) "Interdisciplinary group (IDG)" refers to a group of professionals and volunteer staff who provide or supervise the care and the services offered by the hospice in accordance with 42 C.F.R. 418.56 (October 1, 2023).

(FF) "Intermediate care facility for individuals with intellectual disabilities" has the same meaning as in section 5124.01 of the Revised Code.

(GG) "Licensed occupational therapist" means a person holding a valid license under Chapter 4755. of the Revised Code as an occupational therapist.

(HH) "Licensed occupational therapy assistant" means a person holding a valid license under Chapter 4755. of the Revised Code as an occupational therapy assistant (OTA).

(II) "Licensed physical therapist" means a person holding a valid license under Chapter 4755. of the Revised Code as a physical therapist.

(JJ) "Licensed physical therapy assistant" means a person holding a valid license under Chapter 4755. of the Revised Code as a physical therapist assistant (PTA).

(KK) "Licensed speech-language pathologist" means a person holding a valid license under Chapter 4753. of the Revised Code as a speech-language pathologist and who is eligible for or meets the educational requirements for a certificate of clinical competence in speech language pathology granted by the "American Speech-Language-Hearing Association."

(LL) "Licensed speech-language pathology aide" means a person holding a valid license under Chapter 4753. of the Revised Code as a speech-language pathology aide.

(MM) "Long Term Care Facility (LTCF)" as defined in section 3721.21 of the Revised Code is a term used interchangeably in the ODM provider web portal to refer to a nursing home, a facility or part of a facility that is certified as a skilled nursing facility or a nursing facility under Title XVIII or XIX of the "Social Security Act.

(NN) "Managed Care Organization" has the same meaning as in rule 5160-26-01 of the Administrative Code.

(OO) "Medical director" refers to the doctor of medicine or osteopathy employed by the designated hospice to assume overall responsibility for the medical component of the individual's plan of care, including consulting with other members of the interdisciplinary team and collaborating with the individual's attending physician if any.

(PP) "Medicare" is the federally financed medical assistance program operated under Title XVIII of the Social Security Act (as in effect January 1, 2017).

(QQ) "Non-core hospice services" are hospice services that are the responsibility of the hospice to ensure are provided directly to the individual by hospice employees or under a contractual arrangement made by the hospice.

(RR) "Nursing facility" (NF) has the same meaning as in section 5165.01 of the Revised Code.

(SS) "Nursing services" are services that require the skills of a RN, or a LPN under the supervision of an RN. Services provided by an advanced practice registered nurse (APRN) who is not the individual's attending physician or are not provided by a physician in the absence of an APRN are included under nursing services.

(TT) "Oral Physician Certification Date" refers to the date the verbal certification of the individual's terminal illness is obtained by the hospice medical director (or physician member of the IDG), and the patient's attending physician, if he/she has one.

(UU) "Palliative care" refers to patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care is at the core of hospice philosophy and care practices, and is a critical component of the medicaid hospice benefit.

(VV) "Physician" means an individual who is currently licensed and authorized under Chapter 4731. of the Revised Code to practice as a doctor of medicine and surgery or osteopathic medicine and surgery. An unlicensed individual who is authorized to practice under the laws of the state in which the services are performed is not a physician, even if the individual holds a staff or faculty appointment.

(WW) "Physician assistant" means an individual practicing in accordance with Chapter 4730. of the Revised Code.

(XX) "Physician services" refers to services as defined in Chapter 5160-4 of the Administrative Code. Physician services may be provided by a physician, or an advanced practice registered nurse acting within his or her scope of practice as defined in section 4723.01 of the Revised Code, or a physician assistant acting within his or her scope of practice under the supervision, control, and direction of one or more physicians as defined in section 4730.01 of the Revised Code.

(YY) "Plan of Care" refers to an individualized written plan established at the start of hospice care by the hospice interdisciplinary group in collaboration with the attending physician (if any), the individual and the primary caregiver (when feasible). The plan of care must specify the hospice care and services necessary to meet the individual and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions.

(ZZ) "Registered nurse" (RN) refers to a person licensed to practice as a RN in accordance with the criteria set forth in Chapter 4723. of the Revised Code.

(AAA) "Routine Home Care" is a level of hospice care covered in accordance with 42 C.F.R. 418.302 (as in effect October 1, 2023). Routine home care shall be afforded to an individual in the individual's residence when the individual is not receiving continuous home care.

(BBB) "Social worker" means a person registered under Chapter 4757. of the Revised Code to practice as a social worker or independent social worker.

(CCC) "Terminally ill" means that a physician has certified that the individual has a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course.

(DDD) "Written Physician Certification Date" refers to the date the completed certification of the individual's terminal illness is signed by the hospice medical director (or physician member of the IDG, and the patient's attending physician, if he or she has one.

Last updated October 1, 2024 at 9:09 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-56-02 Hospice services: eligibility and election requirements.

(A) To be covered under Ohio medicaid, the designated hospice will ensure the following criteria are met prior to furnishing hospice care:

(1) The designated hospice has a certification of the terminal illness on behalf of the individual, obtained in accordance with 42 C.F.R. 418.22 (October 1, 2023);

(2) A hospice election statement, completed by the individual, has been obtained by the designated hospice pursuant to paragraphs (B) and (C) of this rule;

(3) The individual has a hospice plan of care initiated, pursuant to paragraph (F) of this rule.

(B) The designated hospice will ensure an individual eligible for both medicare and medicaid hospice elects the hospice benefit under both programs. Hospice services furnished to individuals who are dual eligible should be billed to medicare first.

(C) If the individual has or later obtains third-party coverage of hospice, the individual should elect the third-party coverage of hospice to cover the same days the medicaid hospice benefit covers in order to ensure medicaid is the secondary payor. If the individual revokes his or her third-party coverage of hospice, the medicaid hospice benefit should be revoked at the same time.

(D) If the individual is a participant in the program of all-inclusive care for the elderly (PACE), the individual should access hospice services through the PACE site's network of providers.

(E) If the individual is enrolled in a medicaid managed care organization (MCO) , the individual should access hospice services through the MCO's network of providers.

(F) If the individual is enrolled in a home and community based services (HCBS) waiver, the designated hospice will assist the individual in coordinating concurrent care and waiver services in accordance with rule 5160-56-04 of the Administrative Code.

(G) At the time hospice is elected, the designated hospice will:

(1) Assist the individual with the election process; and

(2) Provide the individual with the following materials and written information:

(a) A copy of the agency's grievance procedures;

(b) Information regarding advance directives in accordance with Chapter 2133. of the Revised Code; and

(c) Any policies the hospice has regarding the implementation of advance directives, including ensuring the individual's right to formulate an advance directive, and the right to request a "do not resuscitate" order. The hospice should maintain the individual's advance directive in an accessible part of the individual's current hospice record and include a notation in the individual's plan of care.

(H) The designated hospice should maintain a record of the election statement completed by the individual.

(1) The election statement should be in writing and a notice of the election filed by the designated hospice in accordance with 42 C.F.R. 418.24 (October 1, 2023). The medicaid election statement may be combined with the medicare election statement or on a separate form, provided it is clear the form denotes medicaid hospice has been elected.

(2) The election statement should contain the following:

(a) Documentation that the individual elected the medicaid hospice benefit;

(b) The identity of the designated hospice responsible for providing hospice care to the individual;

(c) The individual's acknowledgment that he or she has been given a full explanation of the palliative rather than curative nature of hospice care as it relates to the individual's terminal illness and the provisions and limitations of services as specified in this chapter;

(d) Acknowledgment that the individual understands that certain medicaid services are waived by the election, except when the individual is under age twenty-one;

(e) The identification of the individual's attending physician (if any) with an acknowledgment that the identified attending physician was the individual's own choice;

(f) The individual's acknowledgment that the attending physician was the individual's choice;

(g) The effective date of the election which may be the first day of hospice care or a later date, but should not be earlier than the date of the election statement;

(h) The individual's signature; and

(i) The date the election statement was signed.

(3) A copy of the completed election statement shall be scanned and uploaded to the ODM provider web portal pursuant to rule 5160-56-03.3 of the Administrative Code. The original form as completed, should remain on file with the designated hospice.

(4) The election statement should remain in effect as long as the individual continues to meet all eligibility requirements of this rule.

(I) While a hospice election is in effect, the designated hospice should commence hospice care to the individual, beginning with enrolling the individual in the appropriate benefit period as defined in rule 5160-56-01 of the Administrative Code and pursuant to the remainder of this rule.

(1) The initial benefit period should commence with hospice care on or after the date of election and end on the ninetieth day, unless a discharge pursuant to rule 5160-56-03 of the Administrative Code disrupts hospice care.

(2) If at the end of the initial ninety day period, the individual is recertified as terminally ill, the designated hospice will ensure the individual is enrolled in the second subsequent ninety-day benefit period, continuing hospice services uninterrupted until the end the second ninety-period, to the one-hundred eightieth day, unless a discharge pursuant to rule 5160-56-03 of the Administrative Code disrupts hospice care.

(3) If at the end of the subsequent ninety day period, the individual is recertified as terminally ill, the designated hospice will ensure the individual is enrolled in a subsequent sixty day benefit period, and will continue hospice services uninterrupted for increments of sixty additional days as recertifications occur, unless a discharge pursuant to rule 5160-56-03 of the Administrative Code disrupts hospice care.

(J) For the duration of the election of hospice care, the individual should waive medicaid services if the services:

(1) Are provided by a hospice other than the hospice designated by the individual, unless provided under arrangement made by the designated hospice;

(2) Are related to the curative treatment of the terminal condition for which hospice care was elected or a related condition, except for the individual under age twenty-one; or

(3) Are equivalent to hospice care such as non-waiver services provided through home health and private duty nursing services.

(K) The designated hospice should follow the requirements as prescribed in this rule for an individual previously discharged from hospice, who has subsequently re-elected hospice care in accordance with paragraphs (C) and (D) of rule 5160-56-03 of the Administrative Code.

Last updated October 1, 2024 at 9:09 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-56-03 Hospice services: discharge requirements.

This rule sets forth the requirements for discharging an individual from the designated hospice's care and/or the hospice benefit.

(A) Discharge refers to the end the hospice benefit or the designated hospice's care:

(1) Discharge from the designated hospice's care should occur when the individual:

(a) Dies;

(b) No longer meets the hospice enrollment or eligibility criteria;

(d) Moves out of the designated hospice provider's service area;

(e) Enters a facility where the designated hospice has no access or cannot enter to provide care;

(f) Revokes the hospice benefit in accordance with paragraph (B) of this rule;

(g) Transfers to another hospice in accordance with paragraph (E) of this rule; or

(h) Is discharged for cause, such as compromising the safety of self or the safety of the hospice staff.

(2) The hospice provider should notify the Ohio department of medicaid (ODM) through the ODM provider web portal of the individual's discharge from the designated hospice's care so that the designated hospice's services and billings coincide with the date of the individual's discharge and/or so that hospice services may continue with the new hospice when applicable, e.g., following a transfer.

(3) Except for the reason cited in paragraph (A)(1)(a) of this rule, the designated hospice should complete a written summary statement which clearly states the reason(s) for the individual's discharge from the designated hospice's care. The original statement of discharge should be retained by the hospice for its records, with a copy provided to the individual. As a reason for discharge, a hospice provider cannot automatically or routinely discharge an individual at its "discretion" or request or demand that the individual revoke his or her election.

(4) With the exception of paragraph (A)(1)(g) of this rule, when an individual is discharged from a designated hospice's care, the current election period (as defined in rule 5160-56-01 of the Administrative Code) should end and the individual should be discharged from the hospice benefit entirely, making him or her no longer eligible to receive medicaid hospice services.

(B) The individual has the right to revoke the election of the hospice benefit at any time during any given election period.

(1) Upon notice of the individual's intent to revoke, the designated hospice should:

(a) Obtain a written statement, signed and dated by the individual, which states that the election of hospice care has been revoked by the individual for the remainder of the applicable benefit period. The designated hospice should not accept a verbal revocation of the hospice benefit;

(b) Discharge the individual from hospice care, such that hospice coverage for the remaining days in that election period is forfeited and medicaid coverage of the benefits waived when hospice care was elected may resume; and

(2) An individual will be permitted to re-elect the medicaid hospice benefit at any time after revocation pursuant to paragraph (C) of this rule, provided the individual meets all hospice eligibility requirements.

(C) The individual discharged from hospice care during the initial ninety-day period, who re-elects the hospice benefit, should be enrolled in the second ninety-day benefit period; or

(D) The individual who revoked the hospice benefit or who was discharged from hospice care during the second ninety-day benefit period, or any subsequent sixty-day benefit period, who re-elects the hospice benefit, should be enrolled in a subsequent sixty-day benefit period.

(E) The following requirements apply when an individual is discharged from the designated hospice's care due to individual's transfer to another hospice:

(1) The individual may change the designation of the hospice from which care is received once during each benefit period. The change of the designated hospice is not considered a revocation of the election from the period in which it is made.

(2) To change the designated hospice, the individual should file, with the hospice from which the individual has received care and the newly designated hospice, a signed statement which includes the following information:

(a) The name of the hospice from which the individual has received care;

(b) The name of the hospice from which the individual plans to receive care; and

(3) When an individual transfers from one hospice to another, his or her medicaid hospice benefit shall continue without interruption of care.

(F) The individual who has elected the hospice benefit and decided to revoke, terminate, or transfer his or her hospice benefit should do so on the same effective date for both the third-party covered or medicare hospice benefit and the medicaid hospice benefit. When the dual eligible individual revokes his or her medicare hospice benefit, the provider will ensure the medicaid hospice benefit is revoked by the individual at the same time.

(G) Any denial or termination of hospice care which is the result of an Ohio department of medicaid (ODM) decision will be subject to the notice and hearing rights contained in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.

Last updated October 1, 2024 at 9:09 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-56-03.3 Hospice services: reporting requirements.

This rule sets forth the requirement for recording the hospice provider span for individuals receiving medicaid hospice care in accordance with Chapter 5160-56 of the Administrative Code, including individuals who may be covered by third-party insurance, such as medicare, for which the hospice seeks reimbursement.

(A) The designated hospice should report the necessary enrollment information to the Ohio department of medicaid using the ODM provider web portal for the following:

(1) Individuals in fee-for-service (FFS) medicaid hospice under the designated hospice's care on the effective date of this rule; and

(2) Individuals in which the hospice seeks to file an original or adjusted claim to ODM for medicaid hospice services rendered under codes T2042 through T2046, including:

(a) All individuals with FFS claims for routine home care, code T2042, whether or not the claim has previously been submitted and paid.

(b) Individuals in the care of hospice prior to the effective date of this rule, if the provider is submitting an original FFS claim for hospice services other than the services specified in paragraph (A)(2)(a) of this rule.

(c) Individuals in the care of hospice prior to the effective date of this rule, if the provider is submitting an adjusted FFS claim or if ODM should adjust a FFS claim for hospice services other than the services specified in paragraph (A)(2)(a) of this rule.

(B) The designated hospice should ensure the following information is entered into the ODM provider web portal prior to submitting a claim for reimbursement:

(1) The individual's recipient identification number (also referred to as the medicaid billing number) as shown on the individual's medicaid card;

(2) The date the individual elected hospice;

(3) The begin date and end date of every benefit period recognized under paragraph (D) of rule 5160-56-02 of the Administrative Code. For each benefit period, the designated hospice should identify the benefit period as either the initial one time ninety-day period, the subsequent one time ninety-day period, or one of the subsequent unlimited sixty-day periods as applicable;

(4) The national provider identifier for the medical doctor who serves on the hospice interdisciplinary group (IDG) for each benefit period;

(5) The national provider identifier for the attending physician or the advanced practice registered nurse for each benefit period;

(6) The oral certification date(s), if applicable;

(7) The written physician certification date(s);

(8) The hospice terminal illness diagnosis code(s);

(a) At least one but not more than three terminal diagnosis codes for the individual;

(b) The effective dates (begin and ending date) that apply to the terminal diagnosis code(s) should be entered in the ODM provider web portal by the designated hospice;

(9) The county (or counties if more than one) where hospice services were or will be provided during the benefit period;

(10) The national provider identifier of the long term care facility (LTCF) and the corresponding effective date and end date, if the individual resides in a LTCF and provider will be billing for hospice room and board services;

(11) Supporting documentation, should be attached to the hospice enrollment, including:

(a) Copy of the current certification of the terminal illness;

(b) Copy of the individual's election statement;

(12) The date of death, when applicable; and

(13) Any updates or changes to be made to the benefit period as a result of a discharge pursuant to rule 5160-56-03 of the Administrative Code.

(C) The information specified in paragraph (B) of this rule should be submitted to ODM only through the system in accordance with the requirements of the ODM provider web portal.

Last updated October 1, 2024 at 9:10 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-56-04 Hospice services: provider requirements.

This rule sets forth the responsibilities, including the conditions of participation for a hospice engaged in the provision of medicaid hospice services. To be eligible to provide and to request reimbursement for hospice services, a designated hospice should:

(A) Meet the medicare guidelines in accordance with 42 C.F.R. part 418 (October 1, 2023).

(B) Be authorized to provide services under Ohio law in accordance with Chapter 3712. of the Revised Code by the Ohio department of health.

(C) Ensure that all hospice employees, volunteers, and contracted staff who provide direct services to hospice individuals are trained, licensed, certified, or registered in accordance with applicable federal and state law. ODM will allow hospices to utilize pseudo-patients, such as a person trained to participate in a role-play situation or a computer-based mannequin device instead of real patients, in competency testing of hospice aides and allow individuals who are competency tested only in the tasks for which they will be assigned to function as hospice aides.

(D) Not discontinue or diminish the hospice care provided to the individual because of the inability of the individual to pay or receipt of medicaid reimbursement for such care.

(E) Arrange for another individual or entity to furnish services to the individual in accordance with 42 C.F.R. 418.56 (October 1, 2023) when the designated hospice cannot provide services to the individual. This arrangement should include a signed agreement which shall remain on file at the hospice agency.

(F) Assume responsibility for the professional management of the individual's hospice care. Professional management involves the assessment, planning, monitoring, directing and evaluation of the individual's hospice care across all settings. The designated hospice should provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement.

(G) Facilitate concurrent care and services with other medicaid providers for which the individual under age twenty-one is eligible. As a responsibility for the professional management of the individual's hospice care, the designated hospice will:

(1) Ensure hospice services are maintained and coordinated with concurrent care services;

(2) Document the delineation in which services and the assessment process are coordinated between medicaid hospice and non-hospice providers to avoid the duplication of equivalent or similar scope of services; and

(3) Maintain up-to-date contact information for providers of concurrent care and services.

(H) Have a signed agreement with the nursing facility, the intermediate care facility for individuals with intellectual disabilities (ICF-IID), the general inpatient facility, and/or the inpatient respite care facility in which the individual resides and/or receives services. The terms of the agreement should not violate the medicaid provider agreement as set forth in rule 5160-1-17.2 of the Administrative Code and should not violate the individual's freedom of choice of providers. This agreement should remain on file at the hospice agency and contain, at a minimum, the following:

(1) A stipulation that the designated hospice maintains responsibility for the professional management of the individual's hospice care;

(2) A delineation of the manner in which contracted services are coordinated and supervised by the hospice;

(3) A delineation of the role of the hospice and the facility in the admissions process, patient/family assessments, and the interdisciplinary group conferences; and

(4) A stipulation that the facility should have a valid medicaid provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code and accept the payment from the hospice as payment in full as negotiated.

(I) Ensure all necessary care and services set forth in this chapter are furnished to the individual and that such care and services are specified in the individual's plan of care in accordance with the standards set forth in 42 C.F.R. 418.56 (October 1, 2023) for:

(1) Approaching service delivery;

(2) Care planning;

(3) Contents of the plan of care;

(4) Reviewing and revising the plan; and

(5) Coordinating hospice and non-hospice services.

(J) Designate a registered nurse who is a member of the interdisciplinary group to provide coordination of care and to ensure continuous assessment of each individual's and family's needs and implementation of the plan of care.

(K) Ensure hospice care is coordinated for an individual enrolled in a home and community based waiver program. A collaborative effort should occur between the designated hospice and the waiver case manager or the service and support administrator (SSA) as applicable to maintain a continuum of the overall care provided to the individual.

(1) Case management of hospice services will be provided by the designated hospice in accordance with this chapter;

(2) Case management of waiver services will be provided by the waiver case manager; and

(3) The hospice should provide services to a waiver individual in accordance with a comprehensive plan for the concurrent provision of waiver services by waiver and hospice providers. The administrating agency of the waiver or its designee will assist in the coordination of care by:

(a) Reviewing and approving the comprehensive plan for the concurrent provision of waiver services by waiver and hospice providers;

(b) Resolving any issues resulting from the comprehensive plan for the concurrent provision of waiver services by waiver and hospice providers;

(d) Applying any exceptions to the requirements of this chapter on a case-by-case basis.

Last updated October 1, 2024 at 9:10 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-56-05 Hospice services: covered services.

This rule sets forth medicaid covered services that hospice providers should furnish to individuals to the extent specified by the individual's plan of care.

(A) The designated hospice will ensure the hospice services furnished to an individual in accordance with this rule are reasonable and necessary for the palliation and management of the terminal illness and related conditions.

(B) Unless otherwise specified, covered services will be furnished to the individual in his or her residence, including the individual's home, a relative's home or any other type of living arrangement, a skilled nursing facility (SNF), a nursing facility (NF), an intermediate care facility for individuals with intellectual disabilities (ICF-IID), or a hospice inpatient unit.

(C) The designated hospice will ensure covered services provided to the individual are furnished by qualified personnel pursuant to 42 C.F.R. 418.114 (October 1, 2023), who are employed by the hospice, under an individual contract, or under arrangement with another provider.

(D) The following services are covered by medicaid when furnished or arranged by the designated hospice based on the individual's needs, appropriate level of care, and plan of care:

(1) Core hospice services:

(a) Nursing care;

(b) Medical social services, provided by a social worker under the direction of a physician or attending provider;

(c) Physicians' services, including attending physician services, and services rendered by advance nurse practitioners or physician assistants acting as attending physicians; and

(d) Counseling services, including but not limited to dietary counseling, bereavement counseling and spiritual counseling.

(2) Non-core hospice services:

(a) Physical therapy, occupational therapy, and speech-language pathology provided for symptom control or to enable the individual to maintain activities of daily living and basic functional skills;

(b) Hospice aide, home health aide and homemaker services that enable the individual to carry out the plan of care;

(d) Medical appliances and supplies, including drugs and biologicals;

(e) Short-term inpatient care provided in hospital, hospice inpatient unit, or a participating SNF or NF on an intermittent, non routine basis for relief of the individual's caregivers, or general inpatient care for the purpose of respite, pain control and acute or chronic symptom management that cannot feasibly be provided in other settings; and

(f) Any other item or service provided in relation to the terminal condition, when medically indicated, included in the plan of care and for which payment may otherwise be made under medicaid.

(3) Ambulance transports or an individual that are related to the terminal illness and that occur after the effective date of election, are covered to the extent specified by the individual's plan of care, when deemed the responsibility of the hospice as specified in section 40.1.9 of the "medicare benefit policy manual, chapter nine: coverage of hospice services under hospital insurance" under hospital insurance (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c09.pdf).

(a) Transports to an individual's home which occur on the effective date of the hospice election, the date of admission, prior to the initial assessment or prior to establishing the plan of care are not covered under the hospice benefit.

(b) If the hospice determines that the individual's need for transportation is for any reason other than receiving care related to the terminal illness, the hospice can make arrangements pursuant to paragraph (G) of this rule for the appropriate level or type of transportation and the service to be covered under the ambulance benefit for medicaid in accordance with Chapter 5160-15 of the Administrative Code.

(E) Coverage for individuals who reside in a NF or ICF-IID:

(1) Pursuant to rule 5160-56-06 of the Administrative Code, the room and board will be covered for the individual when all of the following applies:

(a) The individual has elected hospice and is receiving hospice care;

(b) The individual resides in a NF, SNF or ICF-IID; and

(2) The designated hospice will pay the facility per diem reimbursed to the designated hospice by the Ohio department of medicaid in accordance with rule 5160-56-06 of the Administrative Code. The following room and board services are covered pursuant to section 20.3 of the "medicare benefit policy manual, chapter nine: coverage of hospice services under hospital insurance" under hospital insurance (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c09.pdf).

(a) Performing personal care services;

(b) Assisting with ADLs;

(d) Socializing activities;

(e) Maintaining the cleanliness of the individual's room; and

(f) Supervising and assisting in the use of durable medical equipment and prescribed therapies.

(F) Hospice care for individuals enrolled in a home and community based services (HCBS) waiver program:

(1) Waiver services are provided by approved waiver providers in the amount and scope approved on the individual's plan of care.

(2) The designated hospice has the responsibility to cover hospice services pursuant to paragraph (M) of rule 5160-56-04 of the Administrative Code.

(G) For any medicaid services that are unrelated to the treatment of the terminal condition for which hospice care was elected, non-designated hospices and/or non-hospice providers should:

(1) Follow all applicable medicaid authorization policies and procedures; and

(2) Contact the designated hospice to coordinate the individual's care and to clarify provider payment responsibility.

Last updated October 1, 2024 at 9:10 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-56-06 Hospice services: reimbursement.

This rule sets forth the Ohio department of medicaid (ODM) payment for hospice services and care.

(A) ODM will directly pay the designated hospice to care for an individual enrolled in medicaid hospice. Payment to the designated hospice will cover the array of services listed in rule 5160-56-05 of the Administrative Code, except for:

(1) Services pursuant to paragraph (E) of this rule which are paid directly to the physician; and

(2) Services furnished by a non-hospice provider pursuant to paragraph (I) of this rule for the concurrent care of an individual under the age of twenty-one.

(B) Reimbursement rates paid by ODM to the designated hospice will be based on the level of care that is appropriate for the individual for each day while receiving hospice care. Based on the methodology set forth in 42 C.F.R. 418.302 (as in effect October 1, 2023), the medicaid payment for hospice care is made at predetermined rates in accordance with paragraph (C) of this rule for levels of care as defined in rule 5160-56-01 of the Administrative Code.

(1) The medicaid payment for hospice covers the cost of services rendered by the hospice either directly or under contractual arrangement.

(2) For designated hospices that are compliant with the hospice quality reporting program in accordance with 42 C.F.R. 418.312 (as in effect October 1, 2023), ODM will reimburse the full medicaid payment rate for hospice services, up to the maximum payment rate prescribed for the county where services were provided.

(3) For designated hospices that fail to comply with the hospice quality reporting program for federal fiscal years 2014 through 2024, ODM will reimburse the payment amount minus a two percentage point reduction for the corresponding federal fiscal year.

(4) For designated hospices that fail to comply with the hospice quality reporting program for federal fiscal year 2025 and subsequent fiscal years, ODM will reimburse the payment amount minus a four percentage point reduction for the corresponding federal fiscal year.

(1) Hospice providers should use code T2042 for one unit per day to bill for routine home care afforded to an individual in his or her home, who is not receiving continuous home care.

(a) Routine home care days will be paid using a two-tiered system, where the per diem for the first sixty days of hospice care is paid at a higher rate and days sixty-one and thereafter are paid at a lower rate for the duration of the individual's hospice episode of care. A minimum of a sixty day gap in hospice services is required to reset the counter that determines which per diem to apply.

(b) In accordance with 42 C.F.R 418.302 (as in effect October 1, 2023), routine home care may be eligible for an add-on payment for services provided by a registered nurse (RN) authorized to practice under Chapter 4723. of the Revised Code, or a social worker licensed to practice under Chapter 4757. of the Revised Code during the last seven days of an individual's life, when the discharge from hospice care is due to death.

The service intensity add-on (SIA) payment will be billed using code G0299 for the direct care provided in an in-person visit completed by an RN. The SIA payment will be billed using code G0155 for the direct care provided during an in-person visit completed by a social worker.

The reimbursement rate for the SIA payment will be equal to the continuous home care hourly rate converted into fifteen minute increments, up to a maximum of four hours (sixteen units) combined total per day for RN and social worker visits. Visits solely for the pronouncement of death should not be counted for the service intensity add-on payment.

(2) Hospice providers will use code T2043 for one unit per hour, with a minimum of eight hours per day, to bill for continuous home care.

(3) Hospice providers will use code T2044 for one unit per day to bill for inpatient respite care.

(4) Hospice providers will use code T2045 for one unit per day to bill for general inpatient care.

(D) When the individual is a resident of a nursing facility (NF) or an intermediate care facility for individuals with intellectual disabilities (ICF-IID), the hospice may be reimbursed for room and board. This additional per diem amount is reimbursable at ninety-five per cent of the rate that the long-term care facility would have otherwise received from ODM if the individual was not enrolled in hospice, and only on days where the individual receives routine home care or continuous home care. To receive reimbursement, the hospice:

(1) Will bill for room and bill using code T2046.

(2) Will bill patient liability until consumed to zero dollars.

(3) Will bill for days that the individual is residing in the NF or ICF-IID and is medicaid eligible, including the date of a live discharge from hospice.

(4) Will bill for individuals who are medicare and medicaid eligible, medicare for services provided under the medicare hospice benefit and medicaid for the individual's room and board.

(E) Separate payment may be made to a physician for services involving direct patient care. The physician may be an employee of the hospice, a practitioner under contractual arrangement with the hospice, or an attending practitioner who is not an employee of the hospice but is an eligible medicaid provider. Separate payment cannot be made, however, for the following services:

(1) A physician service furnished on a volunteer basis or on an administrative basis;

(2) A procedure classified as a technical service; or

(3) Laboratory or radiography services performed in connection with the physician service.

(F) After receipt of all third-party resources, including private insurance, and taking into account patient liability for room and board, ODM may be billed for the balance owed to the designated hospice, except for services covered by individuals receiving hospice through managed care. For each day the medicaid eligible individual is enrolled in hospice, the total reimbursement for hospice services cannot exceed the medicaid per diem reimbursement rate.

(G) Medicaid eligible residents of NFs or ICF-IIDs who are enrolled in a medicare or medicaid hospice program are not entitled to medicaid-covered bed-hold days. It is the hospice's responsibility to contract with and pay the NF in accordance with rule 5160-3-16.4 of the Administrative Code. It is the hospice's responsibility to contract with and pay the ICF-IID in accordance with rule 5123-7-08 of the Administrative Code.

(H) Pursuant to Section 1861(dd)(2)(A)(iii) of the Social Security Act, 42 U.S.C. 1395x(dd)(2)(A)(iii) (as in effect January 1, 2017) there should be a limitation on reimbursement for inpatient care during the hospice cap period.

(I) For any services related to the terminal illness, non-hospice providers will bill the designated hospice provider directly unless the services were for concurrent care of the terminal illness for individuals under age twenty-one. Providers billing for concurrent care will comply with, and will only be reimbursed according to, all the requirements for medicaid providers in Chapter 5160-1 of the Administrative Code.

Last updated October 1, 2024 at 9:10 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Chapter 5160-57 Medicaid Provider Incentive Program

Ohio Adm.Code 5160-57-01 Medicaid provider incentive program (MPIP): program eligibility requirements and payment.

(A) The medicaid provider incentive program (MPIP) is Ohio's program implementing section 4201 of the American Recovery and Reinvestment Act of 2009 (ARRA), Pub. L. No. 111-5, and the published regulations in 42 C.F.R. Part 495. Certain medicaid eligible professionals and hospitals are eligible to participate in MPIP. Funding for this program ends in 2021.

(B) An eligible professional participating in Ohio's MPIP program is a provider that meets eligibility requirements in 42 C.F.R. 495.304 (as in effect on October 1, 2018) and practices within his or her scope of practice as recognized under Ohio law for each type of professional. In addition, an advanced practice registered nurse (APRN) defined in rule 5160-4-04 of the Administrative Code with an appropriate scope of practice will be considered as an eligible provider for Ohio's MPIP program.

(C) Medicaid eligible hospitals participating in Ohio's MPIP program are subject to the program eligibility rules and regulations published in 42 C.F.R. Part 495 (as in effect on October 1, 2018).

(D) To be eligible for a year of participation in MPIP, each eligible professional and hospital must:

(1) Be an enrolled Ohio medicaid provider with an active Ohio medicaid provider agreement;

(2) Except for eligible hospitals, not have received an electronic health record (EHR) incentive payment within the current payment year from another state, MPIP, or the medicare EHR incentive payment program;

(3) Not have a current sanction or exclusion identified at the United States department of health and human services, office of inspector general, list of excluded individuals and entities, or the Ohio medicaid list of excluded providers.

(E) Patient volume requirements.

(1) Eligible professionals and hospitals participating in MPIP must meet annual patient volume requirements in accordance with 42 C.F.R. 495.304 (as in effect on October 1, 2018) with the exception of children's hospitals;

(2) Patient volume is calculated in accordance with the patient encounter methodology defined in 42 C.F.R. 495.306(c) (as in effect on October 1, 2018);

(F) Group practices or clinics patient volume proxy.

(1) A group practice or clinic will be permitted to calculate patient volume at the group practice or clinic level, but only in accordance with all of the limitations defined in 42 C.F.R. 495.306(h) (as in effect on October 1, 2018).

(2) Each group practice or clinic must confirm in writing and provide evidence of consent, in a manner specified by the Ohio department of medicaid (ODM) on the ODM website, www.medicaid.ohio.gov, from each eligible professional in the group practice or clinic that the eligible professional is consenting to one of the following:

(a) Attesting as a member of the group practice or clinic and permitting the group practice or clinic to use his or her encounters in the group practice or clinic patient volume proxy calculation; or

(b) Not attesting as a member of the group practice or clinic but will permit the group practice or clinic to use his or her encounters in the group practice or clinic patient volume proxy calculation.

(3) If an eligible professional is not attesting as a member of a group practice or clinic but will permit a group practice or clinic to use his or her encounters in the patient volume proxy calculation for the group practice or clinic, the non-participating eligible professional cannot use those encounters toward his or her individual patient volume calculation.

(4) If any eligible professional within the group practice or clinic does not provide written consent for the group practice or clinic to use his or her encounters in the patient volume proxy calculation for the group practice or clinic, the group practice or clinic is precluded from using a group practice or clinic patient volume proxy.

(5) Supporting documentation must be provided for processing through the MPIP system of the attested patient volume proxy and include the medicaid encounters, total encounters, name and medicaid ID of all medicaid practitioners used in the group practice or clinic patient volume proxy calculation. This information shall be provided in a manner specified by ODM.

(6) Eligible professionals must be employed by the group practice or clinic at the time of attestation in order to use the group practice's or clinic's patient volume proxy.

(G) Encounters.

(1) Encounters are defined in accordance with 42 C.F.R. 495.306(e) (as in effect October 1, 2018).

(2) "Out-of-state encounters" are services rendered by an eligible professional or hospital to a non-Ohio resident and may be used for calculating patient volume.

(a) If out-of-state medicaid encounters are included in the numerator of the calculation to determine patient volume, all out-of-state encounters for the same representative period should be included in the denominator.

(b) Eligible professionals and eligible hospitals are required to provide documentation to support the use of out-of-state encounters and must report out-of-state encounters from each state separately through the MPIP system, in a manner specified by ODM.

(H) Meaningful use (MU).

(1) Eligible professionals and hospitals must:

(a) Meet all activities required to receive an incentive payment in accordance with 42 C.F.R. 495.314 (as in effect on October 1, 2018), in addition to all program eligibility requirements.

(b) Report which certified EHR technology they have adopted, implemented or upgraded to by providing supporting documentation through the MPIP system at the time of registration and attestation, in a manner specified by ODM.

(c) Demonstrate that meaningful use objectives and measures are met, in accordance with 42 C.F.R. 495.40 (as in effect on October 1, 2018).

(2) Demonstration of MU is subject to review by both ODM and the centers for medicare and medicaid services (CMS).

(3) Dual eligible hospitals meeting MU criteria for the medicare EHR incentive program will be deemed meaningful users for MPIP, but will be required to meet MPIP program eligibility requirements.

(I) Incentive payments.

(1) MPIP incentive payments are calculated in accordance with 42 C.F.R. 495.310 and 42 C.F.R. 495.312 (as in effect on October 1, 2018). Payment will be disbursed to the payee tax identification number selected at the time of attestation.

(2) Eligible professionals and hospitals must meet all requirements set forth in this rule to be eligible for payment.

(3) Eligible professionals may reassign incentive payments in accordance with 42 C.F.R. 495.60(f) (as in effect on October 1, 2018) and other applicable federal and state medicaid laws, rules, and regulations.

(a) The employer or entity for which payment is reassigned must be an Ohio medicaid provider with an active Ohio medicaid provider agreement.

(b) In cases where eligible professionals are associated with more than one practice, the eligible professional must select one tax identification number to receive any applicable EHR incentive payment.

(J) Eligible hospital incentive payments.

(1) All data used to calculate the hospital EHR incentive payment amount must be provided through the MPIP system at the time of the eligible hospital's application and attestation.

(2) All eligible hospital calculations of the aggregate EHR hospital incentive payment made at the time of MPIP application are subject to review and may be adjusted based on review findings.

(3) An eligible hospital may be paid up to one hundred per cent of the calculated aggregate EHR incentive amount over a four-year period, if it meets all MPIP eligibility requirements: forty per cent in year one; thirty per cent in year two; twenty per cent in year three; and ten per cent in year four.

(4) An eligible hospital may not alter or modify data elements used to calculate the hospital EHR incentive payment after MPIP has processed an application for payment and payment has been disbursed for the payment year.

(K) Offsets, adjustments and recoupment of payment.

(1) MPIP payments are subject to offsets, adjustments and recoupments. These and other collection methods will be applied to the medicaid EHR incentive payments to reimburse or pay for medicaid overpayments, fines, penalties, or other debts owed by the provider or its assignee(s) to ODM, Ohio county or local governments, the United States department of health and human services, or any other federal agency.

(2) ODM will identify and recoup overpayments made under the incentive program that result from incorrect or fraudulent attestations, quality measures, cost data, patient data, or any other submission required to establish eligibility or qualify for a payment.

(3) Eligible professionals and eligible hospitals must report any suspected overpayments of an incentive payment to ODM within sixty days of its discovery.

History

Effective: November 9, 2019
Promulgated Under: 119.03

Ohio Adm.Code 5160-57-04 Medicaid provider incentive program (MPIP): program integrity and provider appeals.

(A) Program integrity.

(1) MPIP legal notice.

(a) All eligible professionals and eligible hospitals submitting an application to receive an MPIP payment are required to sign the MPIP legal notice before confirming and submitting their application.

(b) All program applicants are bound by the requirements of the MPIP legal notice.

(2) Eligible professional and eligible hospital MPIP applications and attestations are subject to verification by the Ohio department of medicaid (ODM).

(3) For any given payment year an eligible professional and eligible hospital must register for MPIP by the end of the calendar year (CY) for an eligible professional and federal fiscal year (FFY) for an eligible hospital.

(4) An eligible professional and eligible hospital will have sixty days after the end of the CY for an eligible professional and FFY for and eligible hospital to complete attestation via the MPIP system for a given payment year.

(5) Post payment audits and record retention.

(a) An eligible professional's and eligible hospital's MPIP application and attestation are subject to a post payment audit.

(b) ODM or its designee, the state auditor's office, the state attorney general's office and the federal centers for medicare and medicaid services (CMS) may conduct reviews and audits of MPIP applications for the purpose of determining compliance with the requirements of this chapter as well as with applicable state and federal requirements.

(c) Audits and reviews may be conducted on-site as determined necessary based on periodic analysis of medical, financial, and other information.

(d) Records stored electronically must be produced at the eligible professional's or eligible hospital's expense, upon request, in the format specified by ODM.

(e) All records must be maintained for a minimum of seven years following the last day of the CY for eligible professionals or FFY for eligible hospitals in which payment related to the attestation has been received, or in the event that the eligible professional or eligible hospital has been notified that state or federal authorities have commenced an audit or investigation of their MPIP application, until such time as the matter under audit, appeal or investigation has been resolved.

(f) An eligible professional and eligible hospital must comply with all audit recoveries.

(6) Fraud, waste, and abuse.

(a) Suspicion or detection of fraud and abuse by ODM will be referred to the medicaid fraud control unit (MFCU) in the office of the attorney general (AG). Referrals to the MFCU will be investigated for prosecutorial merit.

(b) Substantiated cases of fraud and abuse will be prosecuted according to federal and state regulations.

(B) Provider appeals.

(1) An eligible professional or eligible hospital may appeal the following issues related to MPIP, by first requesting an informal review:

(a) Incentive payment amounts.

(b) Provider eligibility determinations (i.e. patient volume, hospital-based).

(2) Appeals filed after the deadlines specified in paragraphs (B)(3)(a) and (B)(4)(a) of this rule, will be dismissed without the ability to refile. If the deadline falls on a saturday, sunday, state or federal holiday, the period for requesting an appeal will be extended to the next business day.

(3) Informal review.

(a) If the MPIP system has made a preliminary determination that may be adverse regarding the incentive payment application of an eligible professional or eligible hospital, the eligible professional or eligible hospital may request an informal review of the preliminary determination via the MPIP system, within fifteen calendar days of notification of an adverse preliminary determination.

(b) A request for informal review shall be made via the MPIP system and may include supporting documentation to support the request.

(c) An eligible professional or eligible hospital will be notified of the informal review decision via email and will be advised to log into the MPIP system to see the details of the review decision.

(d) An eligible professional or eligible hospital may withdraw the request for an informal review via the MPIP system, without reason, at any time, after the initial filing and before an informal review decision is issued.

(4) Request for reconsideration.

(a) If the informal review upholds the preliminary adverse determination and the eligible professional or eligible hospital does not agree with the informal review decision, the eligible professional or eligible hospital may submit a written request for reconsideration no later than fifteen calendar days after the date of notification of determination via the MPIP system.

(b) The request for reconsideration shall be initiated via the MPIP system and must include a written and signed letter from the eligible professional or eligible hospital containing the following information:

(i) Clear identification of the affected eligible professional or eligible hospital;

(ii) The proposed action being contested;

(iii) The basis for requesting reconsideration; and

(iv) Supporting documentation being submitted.

(c) The written request for reconsideration must be signed, dated, include any supporting documentation and must be uploaded via the MPIP system.

(d) An eligible professional or eligible hospital will be notified in writing, by certified mail, of the reconsideration decision.

(5) In accordance with Chapter 2505. of the Revised Code, an eligible professional or eligible hospital may appeal the reconsideration decision by filing a notice of appeal with the court of common pleas of Franklin county. The notice shall identify the decision being appealed and the specific grounds for the appeal. The notice of appeal shall be filed not later than fifteen days after the department mails its notice of the reconsideration decision. A copy of the notice of appeal shall be filed with the department not later than three days after the notice is filed with the court.

History

Effective: November 9, 2019
Promulgated Under: 119.03

Chapter 5160-58 MyCare Ohio

Ohio Adm.Code 5160-58-01 MyCare Ohio plans: definitions.

(A) The general definitions set forth in rule 5160-26-01 of the Administrative Code regarding managed care entities (MCEs) apply to the MyCare Ohio rules set forth in Chapter 5160-58 of the Administrative Code.

(B) In addition to the definitions set forth in rule 5160-26-01 of the Administrative Code, the following definitions apply to Chapter 5160-58 of the Administrative Code:

(1) "Assessment" means a comprehensive evaluation of an individual's medical, behavioral health, long-term services and supports, and social needs. Results of the assessment process are used to develop the integrated, individualized care plan, inclusive of the waiver services plan.

(2) "Auto-assign" means the process for determining in which MyCare Ohio Plan (MCOP) a member is assigned. Auto-assignment uses preset rules to best match needs and preserve existing provider-patient relationships. The process does not include manual intervention for assignment.

(3) "Care management" means a collaborative, team based, and personalized approach that encompasses the full spectrum of care coordination activities, ranging from short term assistance to meet care gaps to long term, intensive and holistic care coordination for members with the most intensive needs, designed to assist members and their support systems in managing medical conditions and social determinants of health (SDOH) more effectively. Care management includes care coordination activities to deliberately organize and support an individual to address needs for the purpose of achieving better health outcomes.

(4) "Care coordinator" means a healthcare professional who works with individuals to create and manage their care plans. Care coordinators help individuals navigate the healthcare system, access resources, and advocate for the individuals'needs. They assess individuals' physical, psychological, and social needs, develop personalized care plans, coordinate care, monitor individuals' progress, provide education, connect individuals with community resources and other support services, and address individuals' social determinants of health.

(5) "Creditable insurance" or "creditable coverage" means health insurance coverage as defined in 42 U.S.C. 300gg-3(c) (January 1, 2026).

(6) "Critical incident" is defined in rule 5160-44-05 of the Administrative Code.

(7) "Dual benefits member" means an individual for whom a MyCare Ohio plan is responsible for the coordination and payment of both medicare and medicaid benefits.

(8) "Dual-eligible member" means an individual who is eligible for and enrolled in medicare parts a, b, and d, and full benefits under the medicaid program as defined in paragraph (B)(11) of this rule.

(9) "Dual special needs plan (D-SNP)" is defined in 42 CFR 422.2 (October 1, 2025).

(10) "Financial management service (FMS)" means a support that is provided to waiver individuals who direct some or all of their waiver services. When used in conjunction with the employer authority, this support includes, but is not limited to, operating a payroll service for staff who provide care and services for the individual and making required payroll withholdings. When used in conjunction with the budget authority, this support includes, but is not limited to, paying invoices for waiver goods and services and tracking expenditures against the self-directed budget.

(11) "Full benefits under the medicaid program" means the full scope of services covered by the medicaid state plan. Medicaid-enrolled individuals who have full benefits under the medicaid program exclude individuals whose medicaid enrollment is categorized as:

(a) Presumptive eligibility under rule 5160:1-2-13 of the Administrative Code;

(b) Non-citizen emergency medical assistance under rule 5160:1-5-06 of the Administrative Code;

(d) Medicare premium assistance program under rule 5160:1-3-02.1 of the Administrative Code;

(e) Inmates subject to restrictions on medicaid payment under rule 5160:1-1-03 of the Administrative Code.

(12) "Fully integrated dual-eligible special needs plan (FIDE SNP)" is defined in 42 CFR 422.2 (October 1, 2025).

(13) "Health and welfare" as described in 42 CFR 441.302 (October 1, 2025) refers to a federal requirement that necessary safeguards are taken to protect the safety and independence of individuals enrolled in a home and community-based services (HCBS) waiver. Examples of such safeguards includes, without limitation:

(a) Risk and safety planning and evaluations;

(b) Critical incident management;

(d) Behavioral interventions;

(e) Medication management; and

(f) Natural disaster and public emergency response planning.

(14) "Home and community-based services (HCBS)" means services available to individuals to help maintain their health and safety in a community setting in lieu of institutional care as described in 42 CFR 440 subpart A (October 1, 2025).

(15) "Hybrid services" are services which are covered by both medicare and medicaid.

(16) "Individual" is defined in rule 5160-1-04 of the Administrative Code.

(17) "Individual care plan" means an integrated, individualized, person-centered care plan developed by the individual and his or her MyCare Ohio plan's inter-disciplinary care management team that addresses clinical and non-clinical needs identified in the assessment and includes goals, interventions, and expected outcomes.

(18) "Interdisciplinary care management team" means a team made up of the member, the individual's authorized representative, the member's managed care team, other professionals, and information supports chosen by the member. The MCOP provides the member's care coordinator, and waiver service coordinator if the member is enrolled on the MyCare Ohio HCBS waiver, and internal support staff, such as social workers, mental health and substance use disorder licensed independent professionals, gerontologists, housing specialists, transportation specialists, and community health workers, to support the care coordinator.

(19) "Medicaid-only member" means an individual for whom a MyCare Ohio plan is responsible for coordination and payment of medicaid benefits, and, upon request, is responsible to assist with coordination of medicare benefits.

(20) "Member" is defined in rule 5160-26-01 of the Administrative Code.

(21) "MyCare Ohio plan (MCOP)" means a health insuring corporation (HIC), as defined in Chapter 1751. of the Revised Code, which is also a FIDE SNP, contracted to comprehensively manage medicaid benefits, including HCBS, for medicare and medicaid eligible members. An MCOP is also a managed care organization as defined in rule 5160-26-01 of the Administrative Code. For the purpose of this chapter, an MCOP does not include entities approved to operate as a program for the all-inclusive care of the elderly (PACE) site as defined in rule 5160-36-01 of the Administrative Code.

(22) "Nursing facility-based level of care" means the intermediate and skilled levels of care, as described in rule 5160-3-08 of the Administrative Code.

(23) "Person-centered services plan" is defined in rule 5160-44-02 of the Administrative Code.

(24) "Self-direction" means a service model that empowers individuals with choice and control over identifying, accessing, and managing the long-term services and supports needed to live at home while considering their personal preferences. Self-direction includes both self-directed services in accordance with rule 5160-45-03.2 of the Administrative Code and participant direction under rule 173-42-06 of the Administrative Code.

(25) "Significant change event" is a change experienced by a individual that warrants further evaluation. Significant changes include, but are not limited to, a change in health status, caregiver status, location, or residence; referral to or active involvement on the part of a protective service agency; institutionalization; and when the waiver-enrolled individual has not received MyCare Ohio waiver services for ninety calendar days.

(26) "Waiver services plan" is a component of the person-centered care plan that identifies specific goals, objectives, and measurable outcomes for a waiver-enrolled individual's health and functioning expected as a result of HCBS provided by both formal and informal caregivers, and that addresses the physical and medical conditions of the individual. At a minimum, the waiver services plan includes:

(a) Essential information needed to provide care to the individual that assures the member's health and welfare;

(b) Signatures indicating the individual's acceptance or rejection of the waiver services plan. If the member is unable to provide the signature when the services plan is initially developed, the individual submits an electronic signature or standard signature via regular mail, or otherwise provide a signature in no instance any later than at the next face-to-face visit with the care coordinator; and

Last updated January 5, 2026 at 8:56 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-58-01.1 MyCare Ohio plans: application of general managed care rules.

(A) MyCare Ohio plans must comply with all of the requirements applicable to managed care organizations (MCOs) and managed care entities (MCEs), as applicable, in the following rules:

(1) Rule 5160-26-05 of the Administrative Code;

(2) Rule 5160-26-05.1 of the Administrative Code;

(3) Rule 5160-26-06 of the Administrative Code;

(4) Rule 5160-26-08.3 of the Administrative Code;

(5) Rule 5160-26-09.1 of the Administrative Code;

(6) Rule 5160-26-10 of the Administrative Code;

(7) Rule 5160-26-11 of the Administrative Code;

(8) Rule 5160-26-12 of the Administrative Code; and

(9) Rule 5160-01-08 of the Administrative Code.

(B) For all rules listed in paragraph (A) of this rule, the following provisions apply to the MyCare Ohio program described in Chapter 5160-58 of the Administrative Code:

(1) All cross-references to rule 5160-26-01 of the Administrative Code are replaced by cross-references to rule 5160-58-01 of the Administrative Code.

(2) All cross-references to rule 5160-26-02 of the Administrative Code are replaced by cross-references to rule 5160-58-02 of the Administrative Code.

(3) All cross-references to rule 5160-26-02.1 of the Administrative Code are replaced by cross-references to rule 5160-58-02.1 of the Administrative Code.

(4) All cross-references to rule 5160-26-03 of the Administrative Code are replaced by cross-references to rule 5160-58-03 of the Administrative Code.

(5) All cross-references to rule 5160-26-03.1 of the Administrative Code are replaced by cross-references to rule 5160-58-03.1 of the Administrative Code.

(6) All cross-references to rule 5160-26-08.4 of the Administrative Code are replaced by cross-references to rule 5160-58-08.4 of the Administrative Code.

(C) The following rules in Chapter 5160-26 of the Administrative Code do not apply to MyCare Ohio, as they are replaced by corresponding rules in Chapter 5160-58 of the Administrative Code:

(1) Rule 5160-26-02 of the Administrative Code;

(2) Rule 5160-26-02.1 of the Administrative Code;

(3) Rule 5160-26-03 of the Administrative Code;

(4) Rule 5160-26-03.1 of the Administrative Code; and

(5) Rule 5160-26-08.4 of the Administrative Code.

(D) When an MCO holds provider agreements with the Ohio department of medicaid (ODM) for the MyCare Ohio and medicaid managed care programs or the Ohio resilience through integrated systems and excellence (OhioRISE) program, ODM may apply all of the applicable provisions in Chapter 5160-26 of the Administrative Code separately to each of the contracts.

Last updated January 5, 2026 at 8:56 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-58-02 MyCare Ohio plans: eligibility, ineligibility, and optional enrollment.

(A) Eligibility.

(1) An individual is enrolled in a MyCare Ohio plan (MCOP) if he or she meets all of the following criteria:

(a) Age twenty-one or older at the time of enrollment in the MCOP;

(b) Eligible for medicare parts A, B, and D, and full benefits under the medicaid program.

(2) The following individuals are not eligible for enrollment in an MCOP:

(a) Individuals enrolled in the program of all-inclusive care for the elderly (PACE);

(b) Individuals who have other verified third-party creditable health care coverage, except medicare coverage as authorized by 42 U.S.C. 1395 (January 1, 2026);

(d) Individuals with intellectual disabilities who have a level of care that meets the criteria specified in rule 5123-8-01 of the Administrative Code and receive services through a home and community-based services (HCBS) waiver administered by the Ohio department of developmental disabilities (DODD); and

(e) Individuals with intellectual disabilities who receive services through an intermediate care facility for individuals with intellectual disabilities (ICF-IID).

(3) Indians, who are members of federally recognized tribes, may voluntarily choose to enroll in an MCOP, and may choose not to enroll. Verification of membership in a federally recognized tribe is needed for request of enrollment exclusion.

(4) If an individual meets eligibility requirements in paragraph (A)(1) of this rule and does not meet an exclusion in paragraph (A)(2) of this rule or an optional enrollment in paragraph (A)(3) of this rule, then the individual is enrolled into an MCOP for medicaid benefits.

(5) Nothing in this rule should be construed to limit or in any way jeopardize an eligible individual's basic medicaid eligibility or eligibility for medicare or other non-medicaid benefits to which he or she may be entitled.

(B) MyCare Ohio plan enrollment.

(1) The following applies when the MyCare Ohio service area expands beginning January 1, 2026:

(a) When a service area is designated, in accordance with paragraphs (B)(1)(c) to (B)(1)(i) of this rule, by the Ohio department of medicaid (ODM) as mandatory for eligible individuals, ODM confirms the eligibility of each individual. Upon the confirmation of eligibility:

(i) Eligible individuals residing in the service area who are currently MCOP members are deemed participants in the mandatory program; and

(ii) All other eligible individuals residing in the mandatory service area may request MCOP membership at any time but must select a MCOP following receipt of a notification of mandatory enrollment (NME) issued by the Ohio department of medicaid (ODM).

(b) MyCare Ohio plan membership selection procedures for the mandatory program:

(i) A newly eligible individual who does not make a choice following issuance of a NME by ODM and one additional notice, is assigned to a MCOP by ODM, the medicaid consumer hotline, or other ODM-approved entity.

(ii) ODM or the medicaid consumer hotline assigns the individual to a MCOP based on prior medicaid fee-for-service, managed care organization, or MCOP membership history, whenever available, or at the discretion of ODM.

(c) Effective January 1, 2026, the mandatory service area includes the following twenty-nine counties: Butler, Clark, Clermont, Clinton, Columbiana, Cuyahoga, Delaware, Geauga, Greene, Franklin, Fulton, Hamilton, Lake, Lorain, Lucas, Madison, Mahoning, Medina, Montgomery, Portage, Pickaway, Ottawa, Stark, Summit, Trumbull, Union, Wayne, Warren, and Wood.

(d) Effective April 1, 2026, the following counties are added to the mandatory service area: Ashtabula, Defiance, Erie, Fairfield, Fayette, Henry, Licking, Paulding, Sandusky, and Williams.

(e) Effective May 1, 2026, the following counties are added to the mandatory service area: Allen, Ashland, Auglaize, Champaign, Crawford, Darke, Hancock, Hardin, Huron, Knox, Logan, Marion, Mercer, Miami, Morrow, Preble, Putnam, Richland, Seneca, Shelby, VanWert, and Wyandot.

(f) Effective June 1, 2026, the following counties are added to the mandatory service area: Adams, Brown, Gallia, Highland, Lawrence, Jackson, Pike, Ross, Scioto, and Vinton.

(g) Effective July 1, 2026, the following counties are added to the mandatory service area: Belmont, Carroll, Coshocton, Guernsey, Harrison, Holmes, Jefferson, Muskingum, and Tuscarawas.

(h) Effective August 1, 2026, the following counties are added to the mandatory service area: Athens, Hocking, Meigs, Monroe, Morgan, Noble, Perry, and Washington.

(i) The mandatory services area includes previously named counties from paragraph (B)(1)(c) of this rule, adding counties named in paragraphs (B)(1)(c) to (B)(1)(h) of this rule, until all eighty-eight counties are included.

(C) Commencement of coverage. Coverage of MCOP members is effective on the first day of the calendar month specified on the ODM-produced HIPAA compliant 834 daily or monthly enrollment file to the MCOP.

(D) All of the following apply to dual-benefits members in the MyCare Ohio program:

(1) Unless CMS implements a passive enrollment under 42 CFR 422.60 (October 1, 2025), an eligible individual's decision to enroll in the MCOP for medicare benefits is choice-based and ODM does not auto-assign MyCare Ohio members in an MCOP for medicare benefits.

(2) Any individual enrolled in MyCare Ohio may exercise the choice of MCOP for their medicare benefits during their initial medicare enrollment. medicare open enrollment, or subject to 42 CFR 422.62 (October 1, 2025), 42 CFR 423.38 (October 1, 2025) or other enrollment period allowable under federal rules.

(3) In accordance with 42 CFR 422.66(c)(2) (October 1, 2025), individuals who are enrolled in an MCOP or ODM-contracted MCO with an affiliated MCOP, who become eligible for the MyCare Ohio program, and do not choose to receive their medicare benefits through another medicare payer, are deemed to have elected the MCOP for both their medicare and medicaid benefits.

Last updated January 5, 2026 at 8:51 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-58-02.1 MyCare Ohio plans: termination of enrollment.

(A) Disenrollment from the MyCare Ohio program occurs for the following reasons:

(1) The member becomes ineligible for full benefits under the medicaid program or medicare parts A or B or D. Termination of MyCare Ohio plan (MCOP) enrollment is effective the end of the last day of the month in which the member became ineligible.

(2) The member's permanent place of residence is moved outside the plan's service area. MCOP disenrollment is effective the end of the last day of the month in which the member moved from the service area.

(3) The member dies, in which case plan enrollment ends on the date of death.

(4) The member is found by the Ohio department of medicaid (ODM), or their designee, to meet the criteria for the developmental disabilities (DD) level of care and has a stay in an intermediate care facility for individuals with intellectual disabilities (ICF-IID) or is enrolled in a DD waiver. After the MCOP notifies ODM this has occurred, MCOP disenrollment takes effect on the last day of the month preceding the ICF-IID facility stay or enrollment on the DD waiver.

(5) The member has creditable third party coverage, excepting medicare coverage. MCOP disenrollment is effective the end of the last day of the month in which ODM identified the third party coverage. Members report third party coverage to the county department of job and family services in accordance with rule 5160:1-2-08 of the Administrative Code.

(6) The member is not eligible for enrollment in an MCOP for one of the reasons set forth in rule 5160-58-02 of the Administrative Code.

(B) Individual disenrollments.

(1) An individual's enrollment with an MCOP is terminated when the provider agreement between ODM and the MCOP is terminated or not renewed. The effective date of disenrollment is the date of the provider agreement termination or nonrenewal. The individual is reassigned to a new MCOP without a break in coverage in such a circumstance.

(2) All of the following apply when enrollment in a MyCare Ohio plan ends for any of the reasons set forth in paragraph (A) of this rule:

(3) All disenrollments occur at the individual level;

(4) Disenrollments do not require completion of a consumer contact record (CCR);

(5) If ODM fails to notify the MCOP of a member's disenrollment from the plan, ODM continues to pay the MCOP the applicable monthly premium rate for the member. The MCOP remains liable for the provision of covered services as set forth in rule 5160-58-03 of the Administrative Code, until ODM provides the MCOP with documentation of the member's disenrollment; and

(6) ODM recovers from the MCOP any premium paid for retroactive disenrollment occurring as a result of paragraph (A) of this rule.

(1) As permitted in 42 CFR 422.38 (October 1, 2025) a dual-benefits member may request disenrollment from the MCOP and transfer to another MCOP on a month-to-month basis any time during the year. MCOP coverage continues until the end of the month of disenrollment.

(a) Members may also transfer medicare coverage during medicare open enrollment, a medicare special enrollment period under 42 CFR 422.62 (October 1, 2025), or when otherwise permitted by federal law.

(b) For members who choose disenrollment from a medicare plan to enroll with a MyCare Ohio plan, ODM will automatically align the member's medicaid enrollment to match the MyCare Ohio medicare selection.

(2) A medicaid-only member may request a different MCOP by contacting the Ohio medicaid consumer hotline as follows:

(a) From the date of initial enrollment through the first three months of plan enrollment, for medicaid-only enrollment periods;

(b) During an open enrollment month as described in paragraph (E) of this rule; or

(c) At any time, if the just cause request meets one of the reasons for just cause as specified in paragraph (C)(3)(e) of this rule.

(3) The following provisions apply when a member requests a different MCOP in a mandatory service area. Changes to the medicare coverage are made through medicare enrollment pathways (i.e. medicare.gov website, medicare call center, Ohio senior health insurance information program, licensed enrollment broker) and changes to medicaid-only enrollment are made through the Ohio medicaid consumer hotline:

(a) The request may be made by the member, or by the member's authorized representative as long as the authorized representative is not a provider for the member.

(b) All member-initiated changes must be voluntary. MCOPs are not permitted to encourage members to change enrollment due to a member's race, color, religion, gender, gender identity, sexual orientation, age, disability, national origin, veteran's status, military status, genetic information, ancestry, ethnicity, mental ability, behavior, mental or physical disability, use of services, claims experience, appeals, medical history, evidence of insurability, geographic location within the service area, health status or need for health services. MCOPs may not use a policy or practice that has the effect of discrimination on the basis of the listed criteria.

(c) If a member requests disenrollment because he or she meets any of the requirements in rule 5160-58-02 of the Administrative Code, the member is disenrolled after the member notifies the consumer hotline.

(d) Disenrollment takes effect on the last day of the calendar month as specified by an ODM-produced HIPAA compliant 834 daily or monthly file sent to the plan.

(e) In accordance with 42 CFR 438.56 ( October 1, 2025), a change of MCOP enrollment may be permitted for any of the following just cause reasons:

(i) The member moves out of the MCOP's service area and a non-emergency service must be provided out of the service area before the effective date of a disenrollment that occurs for one of the reasons set forth in paragraph (A) of this rule;

(ii) The MCOP does not, for moral or religious objections, cover the service the member seeks;

(iii) The member needs related services to be performed at the same time in a coordinated manner; however, not all related services are available within the MCOP network, and the member's primary care provider (PCP) or another provider determines that receiving services separately would subject the member to unnecessary risk;

(iv) The member has experienced poor quality of care and the services are not available from another provider within the MCOP's network;

(v) The member receiving long-term services and supports would have to change their residential, institutional, or employment supports provider based on that provider's change in status from an in-network to and out-of-network provider with the MCOP and, as a result, would experience a disruption in their residence or employment;

(vi) The member cannot access medically necessary medicaid-covered services, under rule 5160-58-03.1 of the Administrative Code, or cannot access the type of providers experienced in dealing with the member's health care needs;

(vii) ODM determines that continued enrollment in the MCOP would be harmful to the interests of the member.

(f) The following provisions apply when a member seeks a change in MCOP enrollment for just cause:

(i) The member or an authorized representative must contact the MCOP to identify providers of services before seeking a determination of just cause from ODM.

(ii) The member may make the request for just cause directly to ODM or an ODM-approved entity, either orally or in writing.

(iii) ODM reviews all requests for just cause within seven working days of receipt. ODM may request documentation as necessary from both the member and the MCOP. ODM makes a decision within ten working days of receipt of all necessary documentation, or forty-five days from the date ODM receives the just cause request. If ODM fails to make the determination within this timeframe, the just cause request is considered approved.

(iv) ODM may establish retroactive disenrollment dates and/or recover premium payments as determined necessary and appropriate.

(v) Regardless of the procedures followed, the effective date of an approved just cause request must be no later than the first day of the second month following the month in which the member requests change.

(vi) If the just cause request is not approved, ODM notifies the member or the authorized representative of the member's right to a state hearing.

(vii) Requests for just cause may be processed at the individual level or case level as ODM determines necessary and appropriate.

(g) A member who is in a medicare Part D drug management program and is in a potentially at-risk or at-risk status as defined in 42 CFR 423.100 (October 1, 2025) is precluded from changing MCOPs.

(D) The following provisions apply when a disenrollment in an MCOP is initiated by an MCOP for a medicaid-only member:

(1) An MCOP may submit a request to ODM for the disenrollment of a member for the following reasons:

(a) Fraudulent behavior by the member as defined in rule 5160-26-01 of the Administrative Code; or

(b) Uncooperative or disruptive behavior by the member or someone acting on the member's behalf to the extent that such behavior seriously impairs the MCOP's ability to provide services to either the member or other MCOP members.

(2) The MCOP may not request disenrollment due to a member's race, color, religion, gender, gender identity, sexual orientation, age, disability, national origin, veteran's status, military status, genetic information, ancestry, ethnicity, mental ability, behavior, mental or physical disability, use of services, claims experience, appeals, medical history, evidence of insurability, geographic location within the service area, health status or need for health services.

(3) The MCOP provides covered services to a disenrolled member through the last day of the month in which the MCOP enrollment ends.

(4) If ODM approves the MCOP's request for disenrollment, ODM notifies in writing the member, the authorized representative, and the member is then assigned to another MCOP for their medicaid benefits. For dual-benefits members, this results in the member being disenrolled from the MCOPs medicare coverage as well.

(E) Open enrollment

Open enrollment for medicaid occurs at least annually. At least sixty days prior to the designated open enrollment month, ODM notifies eligible individuals of the opportunity to change enrollment in an MCOP and explains how the individual can obtain further information.

(F) Members enrolled in MyCare Ohio may exercise the choice of MCOP for their medicare benefits during their initial medicare enrollment, medicare open enrollment, or subject to 42 CFR 422.62 (October 1, 2025), 42 CFR 423.38 (October 1, 2025), or other enrollment period allowable under federal rules.

Last updated January 5, 2026 at 8:56 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-58-02.2 MyCare Ohio waiver: eligibility and enrollment.

(A) To be eligible for enrollment in the MyCare Ohio waiver, a member meets all of the following requirements:

(1) Is enrolled in the MyCare Ohio program at the time of application for the MyCare Ohio waiver;

(2) Is determined to have a nursing facility-based level of care (i.e., intermediate or skilled) in accordance with rule 5160-3-08 of the Administrative Code;

(3) In the absence of the MyCare Ohio waiver, require hospitalization or institutionalization in a nursing facility to meet his or her needs;

(4) The member:

(a) Has a need for and agrees to receive at least one waiver service monthly that is otherwise unavailable through another source (including, but not limited to: private pay, community resources, and the medicaid state plan services) in an amount sufficient to meet the individual's assessed need; or

(b) Has a need for:

(i) Continuous nursing services more than four hours in length,

(ii) At least one waiver service annually, and

(iii) Monthly monitoring of the individual's health and welfare through a combination of telephonic and in-person contacts with the waiver service coordinator and agrees to cooperate with the monthly monitoring.

(5) Resides, or is able and agrees to reside, in a setting that possesses the home and community-based setting characteristics set forth in rule 5160-44-01 of the Administrative Code, and is not a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities (ICF-IID) or another licensed/certified facility, any facility covered by section 1616(e) of the Social Security Act ( January 1, 2026), residential care facility (except an assisted living facility as described in rule 173-39-02.16 of the Administrative Code), adult foster home or another group living arrangement subject to state licensure or certification; and

(6) Is able to have waiver services that can be identified in a person-centered care plan as described in rule 5160-44-02 of the Administrative Code that safely meets his or her assessed needs.

(B) To be enrolled, and maintain enrollment in the MyCare Ohio waiver, a member should be determined by the MyCare Ohio plan to meet all of the following requirements:

(1) Be determined eligible for the MyCare Ohio waiver in accordance with paragraph (A) of this rule;

(2) Be able to have his or her health and welfare ensured through the waiver as determined by the Ohio department of medicaid (ODM) or its designee;

(3) Participate in the development and implementation of an integrated, individualized care plan that includes a person-centered services plan, and waiver services plan, in accordance with the process and requirements set forth in rule 5160-44-02 of the Administrative Code, and sign and date the plan as a condition of its acceptance. If the individual is unable to sign the plan when initially developed, the individual submits an electronic signature or standard signature via regular mail, or otherwise provide a signature in no instance any later than at the next face-to-face visit with the waiver services coordinator;

(4) Agree to receive waiver service coordination from the MyCare Ohio plan or its designee;

(5) Agree to participate in quality management and evaluation activities during his or her enrollment on the MyCare Ohio waiver; and

(6) Sign an agreement prior to waiver enrollment confirming that the member was informed of service alternatives, choice of qualified providers available in the MyCare Ohio plan's provider panel and the options of institutional and community-based care, and he or she elects to receive MyCare Ohio services. If the member is unable to sign the agreement prior to waiver enrollment, the member submits an electronic signature and standard signature via regular mail, or otherwise provides a signature, in no instance any later than at the next face-to-face visit with the waiver services coordinator.

(C) If a member fails to meet any of the requirements set forth in paragraph (A) or paragraph (B) of this rule, the member is denied enrollment on the MyCare Ohio waiver.

(D) Once enrolled in the MyCare Ohio waiver, a member's level of care is reassessed at least annually, and more frequently if there is a significant change in the member's situation that impacts his or her health and welfare, including when the member is admitted to a hospital for inpatient services. If the reassessment determines the member no longer meets the requirements set forth in paragraph (A) or paragraph (B) of this rule, he or she is disenrolled from the MyCare Ohio waiver.

(E) If a member enrolled in the MyCare Ohio waiver who requires monthly waiver service does not receive at least one waiver service for ninety consecutive days, the MyCare Ohio plan , within ten days of the ninetieth day, reassesses the member's need for waiver services. If it is determined the member no longer meets the requirements set forth in paragraph (A) or paragraph (B) of this rule, he or she is disenrolled from the MyCare Ohio waiver.

(F) If, at any other time, it is determined that a member enrolled in the MyCare Ohio waiver no longer meets the requirements set forth in paragraph (A) or paragraph (B) of this rule, or fails to meet the member responsibilities set forth in rule 5160-58-03.2 of the Administrative Code, he or she is disenrolled from the MyCare Ohio waiver.

(G) If a member is denied enrollment in the MyCare Ohio waiver pursuant to paragraph (C) of this rule, or is disenrolled from the waiver pursuant to paragraph (D), (E) or (F) of this rule, the member is afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

Last updated January 5, 2026 at 8:57 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-58-03 MyCare Ohio plans: covered services.

(A) A MyCare Ohio plan (MCOP) ensures members have access to all medically-necessary medical, medicaid-covered over the counter drugs, behavioral health, nursing facility and home and community-based services (HCBS) covered by Ohio medicaid. Prescription drug coverage for members is provided under the medicare part d program. After consideration of verified third party liability including medicare coverage pursuant to rule 5160-26-09.1 of the Administrative Code, the MCOP ensures:

(1) Services are sufficient in amount, duration, and scope to reasonably be expected to achieve the purpose for which the services are provided;

(2) The amount, duration, and scope of a required service is not arbitrarily denied or reduced solely because of the diagnosis, type of illness, or condition;

(3) Prior authorization is available for services on which the MCOP places a pre-identified limitation to ensure the limitation may be exceeded when medically necessary, unless the MCOP's limitation is also a limitation for fee-for-service medicaid coverage;

(4) Medicaid coverage decisions are based on the coverage and medical necessity criteria published in agency 5160 of the Administrative Code; and practice guidelines specified in rules 5160-58-03.1 and 5160-26-05.1 of the Administrative Code; and

(5) If a member is unable to obtain medically-necessary medicaid services from an MCOP network provider, the MCOP adequately and timely covers the services out of network until the MCOP is able to provide the services from a network provider.

(B) The MCOP may place appropriate limits on a service;

(1) On the basis of medical necessity for the member's condition or diagnosis;

(2) Except as otherwise specified in this rule, to available network providers; or

(3) For the purposes of utilization control, provided the services furnished can be reasonably expected to achieve their purpose as specified in paragraph (A)(1) of this rule.

(1) The MCOP covers annual physical examinations for adults.

(2) At the request of a member, the MCOP provides for a second opinion from a qualified health care professional within the MCOP's network. If a qualified health care professional is not available within the MCOP's network, the MCOP arranges for the member to obtain a second opinion outside the MCOP's network, at no cost to the member.

(3) The MCOP ensures emergency services as defined in rule 5160-26-01 of the Administrative Code are provided and covered twenty-four hours a day, seven days a week. At a minimum, such services are provided and reimbursed in accordance with the following:

(a) The MCOP may not deny payment for treatment obtained when a member had an emergency medical condition as defined in rule 5160-26-01 of the Administrative Code.

(b) The MCOP cannot limit what constitutes an emergency medical condition on the basis of diagnoses or symptoms.

(d) The MCOP covers medicaid-covered services related to the member's emergency medical condition when the member is instructed to go to an emergency facility by a representative of the MCOP including but not limited to the member's primary care provider (PCP) or the MCOP's twenty-four-hour toll-free call-in-system.

(e) The MCOP cannot deny payment of emergency services based on the treating provider, hospital, or fiscal representative not notifying the member's PCP of the visit.

(f) The MCOP covers emergency services as defined in rule 5160-26-01 of the Administrative Code when the services are delivered by a non-contracting provider of emergency services. Claims for these services cannot be denied regardless of whether the services meet an emergency medical condition as defined in rule 5160-26-01 of the Administrative Code. Such services are reimbursed by the MCOP at the lesser of billed charges or one hundred per cent of the Ohio medicaid program fee-for-service reimbursement rate (less any payments for indirect costs of medical education and direct costs of graduate medical education that is included in the Ohio medicaid program fee-for-service reimbursement rate) in effect for the date of service. If an inpatient admission results, the MCOP reimburses at this rate only until the member can be transferred to a provider designated by the MCOP. Pursuant to section 5167.10 of the Revised Code, the MCOP may not compensate a hospital for inpatient capital costs in an amount that exceeds the maximum rate established by the Ohio department of medicaid (ODM).

(g) The MCOP covers emergency services until the member is stabilized and can be safely discharged or transferred.

(h) The MCOP must adhere to the judgment of the attending provider when the attending provider requests a member's transfer to another facility or discharge. The MCOP may establish arrangements with hospitals whereby the MCOP may designate one of its contracting providers to assume the attending provider's responsibilities to stabilize, treat and transfer the member.

(i) A member who has had an emergency medical condition may not be held liable for payment of any subsequent screening and treatment needed to diagnose the specific condition or stabilize the member.

(4) The MCOP establishes, in writing, the process and procedures for the submission of claims for services delivered by non-contracting providers, including non-contracting providers of emergency services. These written policies and procedures are made available to non-contracting providers, including non-contracting providers of emergency services, on request. The MCOP may not establish claims filing and processing procedures for non-contracting providers, including non-contracting providers of emergency services, that are more stringent than those established for their contracting providers.

(5) The MCOP ensures post-stabilization care services as defined in rule 5160-26-01 of the Administrative Code are provided and covered twenty-four hours a day, seven days a week.

(a) The MCOP must designate a telephone line to receive provider requests for coverage of post-stabilization care services. The line is available twenty-four hours a day, seven days a week. The MCOP documents the telephone number and process for obtaining authorization was provided to each emergency facility in the service area. The MCOP maintains a record of any request for coverage of post-stabilization care services that is denied including, at a minimum, the time of the provider's request and the time the MCOP communicated the decision in writing to the provider.

(b) At a minimum, post-stabilization care services are provided and reimbursed in accordance with the following:

(i) The MCOP covers services obtained within or outside the MCOP's network that are not pre-approved in writing by an MCOP provider or other MCOP representative.

(ii) If the MCOP does not respond within one hour of a provider's request for preapproval of further services administered to maintain the member's stabilized condition, the MCOP covers the services, whether or not they were provided within the MCOP's network.

(iii) The MCOP covers services obtained within or outside the MCOP's network that are not pre-approved by an MCOP provider or other MCOP representative but are administered to maintain, improve or resolve the member's stabilized condition if:

(a) The MCOP fails to respond within one hour to a provider request for authorization to provide such services.

(b) The provider documented an attempt to contact the MCOP to request authorization, but the MCOP cannot be contacted.

(c) The MCOP's representative and treating provider cannot reach an agreement concerning the member's care and a network provider is not available for consultation. In this situation, the MCOP gives the treating provider the opportunity to consult with a network provider and the treating provider may continue with care until a network provider is reached or one of the criteria specified in paragraph (C)(5)(c) of this rule is met.

(i) A network provider with privileges at the treating hospital assumes responsibility for the member's care;

(ii) A network provider assumes responsibility for the member's care after the member is transferred to another facility;

(iii) An MCOP representative and the treating provider reach an agreement concerning the member's care; or

(iv) The member is discharged.

(6) The MCOP permits members to self-refer to Title X services provided by any qualified family planning provider (QFPP). The MCOP is responsible for payment of claims for Title X services delivered by QFPPs not contracting with the MCOP at the lesser of one hundred per cent of the Ohio medicaid program fee-for-service reimbursement rate or billed charges, in effect for the date of service.

(7) The MCOP permits members to self-refer to any women's health specialist within the MCOP's network for covered care necessary to provide women's routine and preventative health care services. This is in addition to the member's designated primary care provider (PCP) if that PCP is not a women's health specialist.

(8) The MCOP ensures access to covered services provided by all federally qualified health centers (FQHCs) and rural health clinics (RHCs).

(9) Where available, the MCOP ensures access to covered services provided by a certified nurse practitioner.

(10) Pharmacy services are covered in accordance with rule 5160-9-03 of the Administrative Code and are limited to items in paragraph (A)(2) of this rule. All other prescription drugs are covered by medicare part D.

(D) MCOP service exclusions.

(1) The MCOP is not required to cover services provided to members outside the United States.

(2) When a member is determined to be no longer eligible for enrollment in an MCOP during a stay in an institution for mental disease (IMD), the MCOP is not responsible for payment of that IMD stay after the date of disenrollment from the MCOP.

Last updated January 5, 2026 at 8:51 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-58-03.1 MyCare Ohio plans: primary care and utilization management.

(A) A MyCare Ohio plan (MCOP) ensures each member has a primary care provider (PCP) who serves as an ongoing source of primary care and assists with care coordination appropriate to the member's needs.

(1) The MCOP ensures PCPs are in compliance with the following triage requirements. Members with:

(a) Emergency care needs are triaged and treated immediately on presentation at the PCP site;

(b) Persistent symptoms are treated no later than the end of the following working day after their initial contact with the PCP site; and

(2) PCP care coordination responsibilities include at a minimum the following:

(a) Assisting with coordination of the member's overall care, as appropriate for the member;

(b) Providing services which are medically necessary as described in rule 5160-1-01 of the Administrative Code;

(d) Recommending referrals to specialists, if necessary; and

(e) Triaging members as described in paragraph (A)(1) of this rule.

(B) The MCOP operates a utilization management (UM) program with clearly defined structures and processes designed to maximize the effectiveness of the care provided to the member. The MCOP ensures decisions rendered through the UM program are based on medical necessity.

(1) The UM program, based on written policies and procedures, includes, at a minimum:

(a) The information sources used to make determinations of medical necessity;

(b) The criteria, based on sound clinical evidence, to make UM decisions and the specific procedures for appropriately applying the criteria;

(d) A description of how the MCOP monitors the impact of the UM program to detect and correct potential under- and over-utilization;

(e) The MCOP cannot implement additional UM criteria for any MyCare Ohio waiver services which were identified and approved though the person-centered service planning process in accordance with rule 5160-44-02 of the Administrative Code.

(2) The MCOP's UM program ensures and documents the following:

(a) An annual review and update of the UM program.

(b) The involvement of a designated senior physician in the UM program.

(c) The use of appropriate qualified licensed health professionals to assess the clinical information used to support UM decisions.

(d) The use of board-certified consultants to assist in making medical necessity determinations, as necessary.

(e) That UM decisions are consistent with clinical practice guidelines as specified in rule 5160-26-05.1 of the Administrative Code. The MCOP cannot impose conditions on the coverage of a medically necessary medicaid-covered service unless they are supported by such clinical practice guidelines.

(f) The reason for each denial of a service, based on sound clinical evidence.

(g) That compensation by the MCOP to individuals or entities that conduct UM activities does not offer incentives to deny, limit, or discontinue medically necessary services to any member.

(h) Compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA) requirements outlined in 42 CFR Part 438 Subpart K (October 1, 2025).

(3) The MCOP processes requests for initial and continuing authorizations of services from their providers and members. The MCOP has written policies and procedures to process initial requests and continuing authorizations. Upon request, the MCOP's policies and procedures for initial and continuing authorizations are made available for review by the Ohio department of medicaid (ODM). The MCOP's written policies and procedures for initial and continuing authorizations of services are also made available to contracting and non-contracting providers. The MCOP ensures and documents the following occurs when processing requests for initial and continuing authorizations of services:

(a) Consistent application of review criteria for authorization decisions.

(b) Consultation with the requesting provider, when necessary.

(c) Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested, is made by a health care professional who has appropriate clinical expertise in treating the member's condition or disease.

(d) That a written notice is sent to the member and the requesting provider of any decision to reduce, suspend, terminate, or deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice to the member has to meet the requirements of division 5101:6 and rule 5160-58-08.4 of the Administrative Code.

(e) For standard authorization decisions, the MCOP provides notice to the provider and member as expeditiously as the member's health condition requires but no later than seven calendar days following receipt of the request for service. If requested by the member, provider, or MCOP, standard authorization decisions may be extended up to fourteen additional calendar days. If requested by the MCOP, the MCOP submits to ODM for prior-approval, documentation as to how the extension is in the member's interest. If ODM approves the MCOP's extension request, the MCOP gives the member written notice of the reason for the decision to extend the time frame and inform the member of the right to file a grievance if he or she disagrees with that decision. The MCOP carries out its determination as expeditiously as the member's health condition requires and no later than the date the extension expires.

(f) If a provider indicates or the MCOP determines that following the standard authorization timeframe could seriously jeopardize the member's life or health or ability to attain, maintain, or regain maximum function, the MCOP makes an expedited authorization decision and provide notice of the authorization decision as expeditiously as the member's health condition requires but no later than forty-eight hours after receipt of the request for service. If requested by the member or MCOP, expedited authorization decisions may be extended up to fourteen additional calendar days. If requested by the MCOP, the MCOP submits to ODM for prior-approval, documentation as to how the extension is in the member's interest. If ODM approves the MCOP's extension request, the MCOP will give the member written notice of the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if he or she disagrees with that decision. The MCOP carries out its determination as expeditiously as the member's health condition requires and no later than the date the extension expires.

(g) For prior authorization of covered outpatient drugs as defined in 42 U.S.C. 1396r-8(k)(2) (January 1, 2026), the MCOP has to make a decision within the timeframes specified in 42 CFR 423.568(b) (October 1, 2025) for standard decisions and 42 CFR 423.572(a) (October 1, 2025) for expedited decisions. If the prior authorization request is for an emergency situation, a seventy-two hour supply of the covered outpatient drug that was prescribed must be authorized while the MCOP reviews the prior authorization request.

(h) The MCOP maintains and submits as directed by ODM, a record of all authorization requests, including standard and expedited authorization requests and any extensions granted. The MCOP's records includes member identifying information, service requested, date initial request received, any extension requests, decision made, date of decision, date of member notice, and basis for denial, if applicable.

(4) Turnaround times for authorization decisions in paragraph (B)(3) of this rule also apply to organization determinations as described in 42 CFR 422.631 (October 1, 2025) for covered services by the medicare benefit for dual-benefits members enrolled with the MCOP.

(5) The MCOP may, subject to ODM approval, develop other UM programs.

Last updated January 5, 2026 at 8:57 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-58-03.2 MyCare Ohio waiver: member choice, control, responsibilities and participant direction.

(A) A member may choose to receive MyCare Ohio waiver services from any combination of providers on the provider panel of the MyCare Ohio plan selected by the member pursuant to paragraph (B) of rule 5160-58-04 of the Administrative Code.

(B) A member receiving waiver services from any MyCare Ohio waiver provider :

(1) Participates with the waiver service coordinator in the development of the person-centered services plan as defined in rule 5160-44-02 of the Administrative Code.

(2) Decides who from their interdisciplinary care management team participates in the development of the person-centered services plan.

(3) Communicates to the service provider and, as appropriate, the provider's management staff, personal preferences about the way duties, tasks and procedures are to be performed.

(4) Works collaboratively with the waiver service coordinator and the provider to identify and secure additional service provider orientation, training and/or continuing education within the provider's scope of practice to meet the member's specific needs.

(5) Does not direct the provider to act in a manner that is contrary to any relevant MyCare Ohio waiver requirements, medicaid rules and regulations, or the provider's policies and procedures.

(6) Understands and adheres to the incident management and reporting responsibilities of the member as set forth in rule 5160-44-05 of the Administrative Code.

(7) Communicates to the waiver service coordinator and MyCare Ohio plan care manager any significant changes, as applicable, as defined in rule 5160-58-01 of the Administrative Code, that may affect service provision or result in a need for more or fewer hours of service.

(8) Signs a complete and accurate timesheet or other documentation, as appropriate, to verify services have been furnished. The member cannot approve blank timesheets, or timesheets that were completed before services were furnished. Verification may be written or electronic at the discretion of the MyCare Ohio plan. If the individual is unable to provide the signature required to verify a service at the time of the service, the individual submits an electronic signature or standard signature via regular mail, or otherwise provides a signature in no instance any later than at the next face-to-face visit with the provider.

(9) Participates in the recruitment, selection and dismissal of providers in collaboration with the interdisciplinary care management team.

(10) Notifies the provider if the member is going to miss a scheduled visit in the manner specified by the waiver services coordinator.

(11) Notifies the waiver service coordinator if the assigned provider misses a scheduled visit.

(12) Notifies the waiver service coordinator when any change in provider is necessary. Notification includes the desired end date of the current provider.

(13) Participates in the monitoring of the performance of the provider.

(14) Understands and abides by the rules governing the MyCare Ohio program.

(C) Members who choose to exercise self-direction for their waiver services, as outlined in paragraph (F) of rule 5160-58-04 of the Administrative Code have the following additional requirements as appropriate to the service being furnished:

(1) Taking a proactive role in the delivery of their MyCare Ohio waiver services. This includes identifying and recruiting prospective providers, training on tasks to meet the member's needs and preferences, and scheduling and managing the delivery of services.

(2) Designating a location in their home in which the member and, as appropriate, the provider can safely store a copy of the member's records in a manner that protects the confidentiality of the records, and for the purpose of contributing to the continuity of the member's care.

(3) Working with ODM's designated financial management service and the waiver service coordinator and MyCare Ohio care , as applicable, to coordinate the authorized service delivery.

(D) Members who elect self-directed services demonstrate the ability and willingness to:

(1) Understand the service elements the provider furnishes;

(2) Understand how to direct the provider; and

(3) Perform employer-related responsibilities, including:

(a) Completing required training;

(b) Selecting and dismissing self-directed service providers;

(d) Training self-directed service providers to meet the member's specific needs;

(e) Supervising and monitoring the self-directed service provider's performance of specific activities, including written approval of the provider's time sheets;

(f) Managing the self-directed service provider when they furnish a service.

(E) If the waiver service coordinator, in consultation with the interdisciplinary care management team, determines that the member or the member's authorized representative cannot meet the requirements set forth in paragraph (C) or (D) of this rule, or the health and welfare of the member cannot be ensured, the waiver service coordinator may require the member to receive services from agency or non-agency providers. The member is afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

Last updated January 5, 2026 at 8:52 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-58-04 MyCare Ohio waiver: covered services and providers.

(A) The purpose of this rule is to establish both the services covered by the MyCare Ohio home and community based services (HCBS) waiver program and the providers eligible to furnish those services to members enrolled in the MyCare Ohio waiver.

(B) Providers seeking to furnish services in the MyCare Ohio waiver program meet the requirements in Chapter 173-39, 5160-45, 5160-46, or 5160-44 of the Administrative Code, as appropriate.

(1) Waiver services can be furnished to MyCare Ohio waiver members, or if the services are document on the members' services plans as described in rule 5160-44-02 of the Administrative Code. Individuals who are not enrolled on the waiver are unable to receive waiver services.

(2) In order to be eligible for payment of claims for services provided to MyCare Ohio waiver members, providers need to enroll with ODM and the MyCare Ohio plan, or enroll with the financial management services (FMS), if the member participates in self direction.

(C) MyCare Ohio waiver covered services are limited to the following and exclude any reimbursement provisions in the Ohio Administrative Code rules cited therein:

(1) Adult day health services as set forth in rule 173-39-02.1 or 5160-46-04 of the Administrative Code;

(2) Alternative meal services as set forth in rule 173-39-02.2 of the Administrative Code;

(3) Assisted living services as set forth in rule 173-39-02.16 of the Administrative Code;

(4) Choices home care attendant services as set forth in rule 173-39-02.4 of the Administrative Code except MyCare waiver providers are not required to submit task sheets to the FMS, as identified in rule 173-39-02.4 of the Administrative Code;

(5) Community integration services as set forth in rule 173-39-02.15 or 5160-44-14 of the Administrative Code;

(6) Community transition services as set forth in rule 173-39-02.17 or 5160-44-26 of the Administrative Code;

(7) Enhanced community living services as set forth in rule 173-39-02.20 of the Administrative Code.

(8) Homemaker services as set forth in rule 173-39-02.8 of the Administrative Code;

(9) Home care attendant services as set forth in rule 173-39-02.24 or 5160-44-27 of the Administrative Code;

(10) Home delivered meal services as set forth in rule 173-39-02.14 or 5160-44-11 of the Administrative Code;

(11) Home maintenance and chore services as set forth in rule 173-39-02.5 or 5160-44-12 of the Administrative Code.

(12) Home medical equipment and supplemental adaptive and assistive devices services as set forth in rule 173-39-02.7 of the Administrative Code;

(13) Home modification services as set forth in rule 173-39-02.9 or 5160-44-13 of the Administrative Code;

(14) Nutrition consultation services as set forth in rule 173-39-02.10 of the Administrative Code;

(15) Out-of- home respite services as set forth in rule 173-39-02.23 or 5160-44-17 of the Administrative Code;

(16) Personal care aide services as set forth in rule 173-39-02.11 or 5160-46-04 of the Administrative Code;

(17) Personal emergency response services as set forth in rule 173-39-02.6 or 5160-44-16 of the Administrative Code;

(18) Self-directed goods and services as set forth in rule 5160-45-03.5 of the Administrative Code;

(19) Social work counseling services as set forth in rule 173-39-02.12 of the Administrative Code;

(20) Supplemental adaptive and assistive devices as set forth in rule 5160-46-04 of the Administrative Code;

(21) Structured family caregiving services as set forth in rule 5160-44-33 of the Administrative Code;

(22) Vehicle modifications as set forth in rule 5160-46-04 of the Administrative Code;

(23) Waiver nursing services as set forth in rule 173-39-02.22 or 5160-44-22 of the Administrative Code;

(24) Non-medical transportation services as set forth in rule 173-39-02.18 or 5160-46-04 of the Administrative Code; and

(25) Any other HCBS waiver services included in Chapter 5160-44, 5160-45, 5160-46 or Chapter 173-39 of the Administrative Code, if not specifically mentioned in this rule.

(D) If a member enrolled in the MyCare Ohio waiver is also a participant in the helping ohioans move, expanding (HOME) choice demonstration program pursuant to Chapter 5160-51 of the Administrative Code, the member may use the HOME choice community transitions service in lieu of, but not in addition to, the community transition service available through the MyCare Ohio waiver.

(E) If a member receives enhanced community living services, the member shall not also receive personal care or homemaker services available through the MyCare Ohio waiver.

(F) The following services may be self-directed using budget or employer authority. To exercise these authorities, members must demonstrate the ability to direct providers in accordance with paragraph (D) of rule 5160-58-03.2 of the Administrative Code:

(1) Employer authority which includes, but is not limited to, the ability of the member to hire, fire, and train employees is available for the following services:

(a) Choices home care attendant services provided by a self-directed individual provider;

(b) Home care attendant services provided by a self-directed provider;

(d) Waiver nursing provided by a self-directed provider; and

(e) Any additional services that are permitted to be self-directed under an ODM-administered waiver in Chapter 5160-45 of the Administrative Code.

(2) Budget authority which includes the ability of the member to negotiate rates of reimbursement is available in the following services:

(a) Alternative meals;

(b) Choices home care attendant services;

(d) Home maintenance and chore services;

(e) Home modification services;

(f) Home medical equipment and supplemental adaptive and assistive devices;

(g) Self-directed goods and services;

(h) Waiver nursing; and

(i) Any additional services that are permitted to be self-directed under an ODM-administered waiver in rule 5160-45-03.2 of the Administrative Code.

Last updated January 5, 2026 at 8:57 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-58-05 MyCare Ohio: care coordination.

(A) Member care coordination.

(1) All MyCare Ohio members are assigned a care coordinator to assist with management of their care and navigation of services in accordance with 42 CFR 422.101, as applicable. MyCare Ohio members who are not receiving long-term care services through the MyCare Ohio waiver or in a nursing facility may choose not to participate in care coordination.

(a) Care coordinator outreach frequency may vary based on a member's needs.

(b) Members may request a change in care coordinator through their MyCare Ohio plan (MCOP).

(2) MyCare Ohio members are assured of access to medical advice, behavioral health crisis, and care management support through a centralized, toll-free telephonic system.

(a) Calls are answered by or forwarded to members' care coordinators or other team members designated to act on behalf of the care coordinator.

(b) The MyCare Ohio plan (MCOP) ensures the care coordinator or designee can access to the member's person-centered care plan, ensures the member's health welfare, and safety is considered when determining resolution and completion in address of the member's needs or concerns, including in-person support, if warranted.

(3) MyCare Ohio members are assigned a waiver services coordinator if enrolled in the MyCare Ohio home and community-based services waiver in accordance with rule 5160-58-04 of the Administrative Code. In some situations, the care coordinator and waiver services coordinator may be the same person.

(B) Interdisciplinary care team.

(1) The interdisciplinary team works together to achieve common health care goals with the member.

(2) The interdisciplinary team creates comprehensive individualized care plans that consider all aspects of the member's medical, social, and behavioral needs and preferences.

(3) The care coordinator may be part of a member's interdisciplinary care team for the purpose of providing support with care coordination activities and assisting the member with navigation of the healthcare system.

(1) The MCOP may choose to delegate all or some care coordination activities to the area agency on aging (AAA) for all members, or to another entity for members under the age of sixty years. If a member selects or requests a change in their waiver services coordination entity, or if the MCOP of the Ohio department of medicaid (ODM) identifies a performance issue affecting the member's health, safety, or welfare, the MCOP then assists by linking the member with another waiver service coordination entity or performs the function themselves, if the member so chooses.

(2) For waiver services coordination the MCOP:

(a) Contracts with the area agency on aging (AAA). The AAA acts as the primary waiver service coordination entity for members aged sixty years and older who are also enrolled in the MyCare Ohio HCBS program;

(b) May contract with the AAA for members under the age of sixty years who are enrolled in the MyCare Ohio HCBS program or with other entities which have experience working with people who have disabilities; or

(c) May contract with another care coordination entity if the member requests that care coordination activities are not provided by the AAA.

(d) MCOPs are responsible for ensuring that members' waiver services meet members' needs through delegation oversight activities regardless of the delegation model.

Last updated January 5, 2026 at 8:52 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-58-08.4 Grievances, appeals, and state fair hearings for MyCare Ohio.

(A) Grievances and appeals vary depending on the MyCare Ohio enrollment of the member.

(1) If the member is enrolled as a dual-benefits member, as defined in rule 5160-58-01 of the Administrative Code, then all grievances and appeals are conducted by the MyCare Ohio plan (MCOP).

(2) If the member is enrolled as a medicaid-only member, as defined in rule 5160-58-01 of the Administrative Code, then the grievances and appeals for medicare benefits are conducted by the organization(s) that provide(s) the member's medicare services in accordance with 42 CFR 422 Subpart M (October 1, 2025):

(3) If the member is enrolled as a medicaid-only member, then appeals for hybrid services, as defined in rule 5160-58-01 of the Administrative Code, the services are first appealed to medicare and then to the MyCare Ohio plan. Grievances may be made to both medicare and medicaid.

(4) If the member is enrolled as a medicaid-only member, then grievances and appeals for all services which are not covered by medicare, but which are covered by medicaid, are handled by the MCOP.

(B) Grievances are defined in rule 5160-26-01 of the Administrative Code. Members may contact their MCOP to submit a grievance.

(1) A member may file a grievance with an MCOP orally or in writing at any time. An authorized representative needs the member's written consent to file a grievance on the member's behalf.

(2) An MCOP acknowledges the receipt of each grievance to the member filing the grievance. Oral acknowledgment by an MCOP is acceptable. If the grievance is filed in writing, written acknowledgment is made within three business days of receipt of the grievance.

(3) An MCOP reviews and resolves all grievances as expeditiously as the member's health condition requires. Grievance resolutions, including member notification, meet the following time frames:

(a) Within two business days of receipt if the grievance is regarding access to services.

(b) Within thirty calendar days of receipt for all other grievances that are not regarding access to services.

(4) At a minimum, an MCOP provides oral notification to the member of a grievance resolution. If an MCOP is unable to speak directly with the member, or the resolution includes information that needs confirmed in writing, the resolution is provided in writing simultaneously with the MCOP's resolution.

(5) If an MCOP's resolution to a grievance is to affirm the denial, reduction, suspension, or termination of a service, or billing of a member due to the MCOP's denial of payment for that service, the MCOP notifies the member of his or her right to request a state hearing, if the member was not previously notified.

(C) A notice of action (NOA) is sent by an MCOP to a member when an MCOP adverse benefit determination occurs or has occurred.

(1) The NOA explains:

(a) The adverse benefit determination the MCOP has taken or intends to take;

(d) Information related to exhausting the MCOP appeal;

(e) The member's right to request a state hearing through the state's hearing system upon exhausting the MCOP appeal process;

(f) Procedures for exercising the member's rights to appeal the adverse benefit determination;

(g) Circumstances under which expedited resolution is available and how to request it;

(h) If applicable, the member's right to have benefits continue, pending the resolution of the appeal, how to request that benefits be continued, and the circumstances under which the member may be required to pay for the cost of those services; and

(i) The date the notice is issued.

(2) The following language and format requirements apply to a NOA issued by an MCOP.

(a) It is provided in a manner and format that may be easily understood by the member;

(b) It explains that oral interpretation is available for any language, written translation is available in prevalent non-English languages, as applicable, and written alternative formats may be available, as needed;

(c) It explains how to access the MCOP's interpretation and translation services, as well as, alternative formats that can be provided by the MCOP;

(d) As directed by ODM, it is printed in the prevalent non-English languages of members in the MCOP's service area; and

(e) It is available in alternative formats, and in an appropriate manner, taking into consideration the special needs of members, including, but not limited to, members who are limited visually or members who have limited reading proficiency.

(3) An MCOP issues a NOA within the following time frames:

(a) For a decision to deny or limit authorization of a requested service, the MCOP issues a NOA simultaneously with the MCOP's decision.

(b) For reduction, suspension, or termination of services prior to the member receiving the services previously authorized by the MCOP, the MCOP gives notice at least fifteen calendar days before the effective date of the adverse benefit determination except:

(i) If probable recipient fraud, as defined in rule 5160-26-01 of the Administrative Code, is verified, the MCOP gives notice five calendar days before the effective date of the adverse benefit determination.

(ii) Under the circumstances set forth in 42 CFR 431.213 (October 1, 2025), the MCOP gives notice on or before the effective date of the adverse benefit determination.

(c) For denial of payment for a non-covered service, the MCOP gives notice simultaneously with the MCOP's action to deny the claim, in whole or part, for a service that is not covered by medicaid, including a service determined through the MCOP's prior authorization process as not medically necessary.

(d) For untimely prior authorization, appeal, or grievance resolution, the MCOP gives notice simultaneously with the MCOP becoming aware of untimely resolution. Service authorization decisions not received within the time frames specified in rules 5160-58-01.1 and 5160-58-03.1 of the Administrative Code constitute a denial and is thus considered to be an adverse benefit determination. Notice is given on the date the authorization decision time frame expires.

(e) There are two NOA documents in MyCare Ohio:

(i) The CMS-10003 "Notice of Denial of Medical Coverage/Payment" (NDMCP) is used for services that are covered by medicare and hybrid services.

(ii) The ODM 04043 "Notice of Denial of Medical Services by Your Managed Care Entity" is used for services covered only by medicaid.

(D) Standard medicaid appeals to an MCOP may be made by a member, a member's authorized representative, or a provider. An appeal may be made orally or in writing within sixty calendar days from the date that the NOA was issued.

(1) An oral appeal filing must be followed by a written appeal. An MCOP will:

(a) Immediately convert an oral appeal filing to a written appeal on behalf of the member; and

(b) Consider the date of the oral appeal filing as the filing date.

(2) Any provider acting on the member's behalf will provide the member's written consent to file an appeal. MCOPs will begin processing the appeal upon receipt of the written consent.

(3) An MCOP acknowledges receipt of each appeal to the member filing the appeal. At a minimum, acknowledgment is made in the same manner the appeal was filed. If an appeal is filed in writing, written acknowledgment is made by an MCOP within three business days of receipt of the appeal.

(4) An MCOP provides members a reasonable opportunity to present evidence and allegations of fact or law, in person as well as in writing, and inform the member of this opportunity sufficiently in advance of the resolution time frame. Upon request, the member or member's authorized representative is provided, free of charge and sufficiently in advance of the resolution time frame, the case file, including medical records, and any other documents and records, and any new or additional evidence considered, relied upon or generated by an MCOP, or at the direction of an MCOP, in connection with the appeal of the adverse benefit determination.

(5) An MCOP considers the member, the member's authorized representative, and an estate representative of a deceased member as parties to the appeal.

(6) An MCOP reviews and resolves each appeal as expeditiously as the member's health condition requires, but the resolution time frame may not exceed fifteen calendar days from the receipt of the appeal unless the resolution time frame is extended.

(7) An MCOP provides written notice of the appeal's resolution to the member, and to the member's authorized representative, if applicable. At a minimum, the written notice includes the resolution decision and date of the resolution.

(8) For medicaid appeal resolutions not resolved wholly in the member's favor, the written notice to the member also includes the following information:

(a) The right to request a state hearing through the state's hearing system;

(b) How to request a state hearing; and if applicable:

(i) The right to continue to receive benefits pending a state hearing; and

(ii) How to request the continuation of benefits.

(d) Written translation is available in prevalent non-English languages as applicable;

(e) Written alternative formats may be available as needed; and

(f) How to access the MCOP's interpretation and translation services as well as alternative formats that can be provided by the MCOP.

(9) For medicare or hybrid services, the MCOP provides information explaining the steps involved for a second level appeal in accordance with 42 CFR 422.633, as applicable.

(10) For appeal resolutions decided in favor of the member, an MCOP:

(a) Authorizes or provides the disputed services promptly and as expeditiously as the member's health condition requires, but no later than seventy-two hours from the appeal resolution date, if the services were not furnished while the appeal was pending.

(b) Pays for the disputed services if the member received the services while the appeal was pending.

(11) Standard appeals for integrated services are determined in accordance with 42 CFR 422.633, as applicable.

(E) Expedited appeals to an MCOP.

(1) An MCOP establishes and maintains an expedited review process to resolve appeals when the member requests and the MCOP determines, or the provider indicates in making the request on the member's behalf or supporting the member's request, that taking the time for a standard resolution could seriously jeopardize the member's life, physical or mental health, or ability to attain, maintain, or regain maximum function.

(2) In utilizing an expedited appeal process, an MCOP complies with the standard appeal process specified in paragraph (F) of this rule, except that the MCOP:

(a) Determines within one business day of the appeal request whether to expedite the appeal resolution;

(b) Makes reasonable efforts to provide prompt oral notification to the member of the decision to expedite or not expedite the appeal resolution;

(c) Informs the member of the limited time available for the member to present evidence and allegations of fact or law in person or in writing;

(d) Resolves the appeal as expeditiously as the member's health condition requires, but the resolution time frame cannot exceed seventy-two hours from the date the MCOP received the appeal unless the resolution time frame is extended as outlined in paragraph (F) of this rule;

(e) Makes reasonable efforts to provide oral notice of the appeal resolution in addition to the required written notification; and

(f) Ensures punitive action is not taken against a provider who requests an expedited resolution or supports a member's appeal.

(3) If an MCOP denies the request for expedited resolution of an appeal, the MCOP:

(a) Transfers the appeal to the standard resolution time frame of fifteen calendar days from the date the appeal was received unless the resolution time frame is extended as outlined in paragraph (F) of this rule; and

(b) Makes reasonable efforts to provide the member prompt oral notification of the decision not to expedite, and within two calendar days of the receipt of the appeal, provide the member written notice of the reason for the denial, including information that the member can grieve the decision.

(4) Expedited appeals for integrated services are processed in accordance with 42 CFR 422.633, as applicable.

(F) Grievance and appeal resolution extensions.

(1) A member may request the time frame for an MCOP to resolve a grievance or standard or expedited appeal be extended up to fourteen calendar days.

(2) An MCOP may request that the time frame to resolve a grievance, standard appeal, or expedited appeal be extended up to fourteen calendar days. The following requirements apply:

(a) The MCOP seeks such an extension from ODM prior to the expiration of the standard or expedited appeal or grievance resolution time frame;

(b) The MCOP request is supported by documentation of the need for additional information and that the extension is in the member's best interest; and

(c) If ODM approves the extension, the MCOP immediately gives the member written notice of the extension, and includes the following components in the notice:

(i) The MCOP's reason for needing the extension;

(ii) The date a decision will be made; and

(iii) Informs the member of their right to file a grievance if the member disagrees with the extension.

(3) The MCOP maintains documentation of any extension request.

(4) The MCOP processes extensions for Part B drugs in accordance with 42 CFR 422.590, as applicable.

(G) Access to state's hearing system.

(1) In accordance with 42 CFR 438.402 (October 1, 2025), members may request a state hearing only after exhausting the MCOP's appeal process for hybrid services or medicaid-only services. If an MCOP fails to adhere to the notice and timing requirements for appeals set forth in this rule, the member is deemed to have exhausted the MCOP appeal process and may request a state hearing.

(2) When required by paragraph (C)(3) of this rule, and in accordance with division 5101:6 of the Administrative Code, an MCOP notifies members, and any authorized representatives on file with the MCOP, of the right to a state hearing subject to the following requirements:

(a) If an MCOP appeal resolution upholds the denial of a request for the authorization of a service, in whole or in part, the MCOP simultaneously issues the "Notice of Denial of Medical Services By Your Managed Care Entity" (ODM 04043).

(b) If an MCOP appeal resolution upholds the decision to reduce, suspend, or terminate services prior to the member receiving the services as authorized by the MCOP, the MCOP issues the "Notice of Reduction, Suspension or Termination of Medical Services By Your Managed Care Entity" (ODM 04066).

(c) If an MCOP learns a member was billed for services received by the member due to the MCOP's denial of payment, and the MCOP upholds the denial of payment, the MCOP immediately issues the "Notice of Denial of Payment for Medical Services By Your Managed Care Entity" (ODM 04046).

(3) The member or the member's authorized representative may request a state hearing within ninety calendar days from the date of an adverse appeal resolution by contacting the ODJFS bureau of state hearings or local county department of job and family services (CDJFS).

(4) There are no state hearing rights for a member disenrolled from an MCOP pursuant to an MCOP-initiated membership disenrollment in accordance with rule 5160-58-02.1 of the Administrative Code.

(5) Following the bureau of state hearing's notification to an MCOP that a member requested a state hearing, the MCOP:

(a) Completes the "Appeal Summary for Managed Care Entities" (ODM 01959) with appropriate supporting attachments, and files it with the bureau of state hearings, at least three business days prior to the scheduled hearing date. The appeal summary includes all facts and documents relevant to the issue and is sufficient to demonstrate the basis for the MCOP's adverse benefit determination;

(b) Sends a copy of the completed ODM 01959 to the member and the member's authorized representative, if applicable, the CDJFS, and the designated ODM contact; and

(c) If benefits were continued through the appeal process then the MCOP continues or reinstates the benefit(s) if the MCOP is notified the member's state hearing request was received within fifteen calendar days from the date of the appeal resolution.

(6) An MCOP participates in the state hearing, in person or by telephone, on the date indicated on the "Notice to Appear for a Scheduled Hearing" (JFS 04002) sent to the MCOP by the bureau of state hearings.

(7) An MCOP complies with the state hearing decision provided to the MCOP via the "State Hearing Decision" (JFS 04005). If the state hearing decision sustains the member's appeal, the MCOP submits the information required by the "Order of Compliance" (JFS 04068) to the bureau of state hearings. The information, including applicable supporting documentation, is due to the bureau of state hearings, and the designated ODM contact by no later than the compliance date specified in the hearing decision. If applicable, the MCOP:

(a) Authorizes or provides the disputed services promptly and as expeditiously as the member's health condition requires, but no later than seventy-two hours from the date it receives notice reversing the adverse benefit determination if services were not furnished while the appeal was pending.

(b) Pays for the disputed services if the member received the services while the appeal was pending.

(H) Continuation of benefits while the appeal to an MCOP or state hearing is pending.

(1) Unless a member requests that previously authorized benefits not be continued, an MCOP continues a member's benefits when all the following conditions are met:

(a) The member requests an appeal within fifteen calendar days of the MCOP issuing the NOA;

(b) The appeal involves the termination, suspension, or reduction of services prior to the member receiving the previously authorized services;

(d) The authorization period has not expired.

(2) If an MCOP continues or reinstates the member's benefits while the appeal or state hearing are pending, the benefits are continued until one of the following occurs:

(a) The member withdraws the appeal or the state hearing request;

(b) The member fails to request a state hearing within fifteen calendar days after the MCOP issues an adverse appeal resolution; or

(c) The bureau of state hearings issues a state hearing decision upholding the reduction, suspension or termination of services.

(3) If the final resolution of the appeal or state hearing upholds an MCOP's original adverse benefit determination the MCOP may recover the cost of the services furnished to the member while the appeal and/or state hearing was pending.

(I) Other duties of an MCOP regarding appeals and grievances.

(1) An MCOP gives members all reasonable assistance filing a grievance, an appeal, or a state hearing request including but not limited to:

(a) Explaining the MCOP's process to be followed in resolving the member's appeal or grievance;

(b) Completing forms and taking other procedural steps as outlined in this rule; and

(c) Providing oral interpretation and oral translation services, sign language assistance, and access to the grievance system through a toll-free number with text telephone yoke (TTY) and interpreter capability.

(2) An MCOP ensures the individuals who make decisions on appeals and grievances are individuals who:

(a) Were neither involved in any previous level of review or decision-making nor a subordinate of any such individual; and

(b) Are health care professionals who have the appropriate clinical expertise in treating the member's condition or disease, if deciding any of the following:

(i) An appeal of a denial based on lack of medical necessity;

(ii) A grievance regarding the denial of an expedited resolution of an appeal; or

(iii) An appeal or grievance involving clinical issues.

(3) In reaching an appeal resolution, the MCOP takes into account all comments, documents, records, and other information submitted by the member and their authorized representative without regard to whether such information was submitted or considered in the initial adverse benefit determination.

Last updated January 5, 2026 at 8:52 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Chapter 5160-59 OhioRISE

Ohio Adm.Code 5160-59-01 OhioRISE: definitions.

(A) The definitions set forth in rule 5160-26-01 of the Administrative Code, with the exceptions noted in paragraphs (A)(1) and (A)(2) of this rule, apply to the Ohio resilience through integrated systems and excellence (OhioRISE) rules set forth in Chapter 5160-59 of the Administrative Code. Definitions that reference managed care organizations (MCOs) in Chapter 5160-26 of the Administrative Code apply to the OhioRISE plan.

(1) Definitions that reference rule 5160-26-03 of the Administrative Code are replaced by reference to rule 5160-59-03 of the Administrative Code.

(2) Definitions that reference rule 5160-26-03.1 of the Administrative Code are replaced by reference to rule 5160-59-03.1 of the Administrative Code.

(B) In addition to the definitions set forth in rule 5160-26-01 of the Administrative Code, the following definitions apply to Chapter 5160-59 of the Administrative Code:

(1) "Back-up waiver service plan" means a plan that is in place for substitute coverage of 1915(c) waiver services for a youth when a provider is unable to or unresponsive in providing scheduled services. A back-up plan can include natural supports or other certified providers as the substitute of coverage. The child and family team identifies possible back-up options and includes them in the child and family-centered care plan.

(2) "Care coordination" means the model described in rule 5160-59-03.2 of the Administrative Code.

(3) "Care management entity (CME)" means the agency described in rule 5160-59-03.2 of the Administrative Code.

(4) "Child and adolescent needs and strengths (CANS) assessment" means either the "Ohio Children's Initiative Brief CANS assessment" or the "Ohio Children's Initiative Comprehensive CANS assessment" found at https://www.medicaid.ohio.gov administered by an individual who has successfully completed training and is certified by the Ohio department of medicaid (ODM) designated entity to administer the CANS assessment.

(5) "Child and family-centered care plan" means the individualized, child-centered, strength-based and family-focused plan of services and supports developed by the child and family team (CFT), the care management entity (CME), the OhioRISE plan, or a combination thereof. When including OhioRISE 1915(c) waiver services described in rule 5160-59-05 of the Administrative Code, the child and family-centered care plan will be developed in accordance with rule 5160-44-02 of the Administrative Code for these services.

(6) "Child and family team (CFT)" means a group of people composed of natural supports (relatives, friends, neighbors, etc.) and formal helpers (teachers, therapists, other professionals, etc.), who are involved with the child and family and who play an important role in the child's life.

(7) "Electronic health record (EHR)" means a record in digital format that is a systematic collection of electronic health information. EHRs may contain a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics such as age and weight, and billing information.

(8) "Family" means any individual or caregiver related by blood or affinity whose close association with the person is the equivalent of a family relationship as identified by the person, including kinship and foster care.

(9) "Incident" has the same meaning as in rule 5160-44-05 of the Administrative Code.

(10) "Individual Crisis and Safety Plan" means a plan developed through care coordination and the child and family team (CFT) to determine specific steps to ensure child and family safety and reduce the risk of harm in the home and community. The individual crisis and safety plan should include individualized, trauma-informed, interventions and de-escalation strategies. The individual crisis and safety plan encompasses what is also referred to as a behavior support plan, which details when an individual's intensive behavior warrants the use of restraints, seclusion, or restrictive intervention to ensure the safety of the individual and those with whom they interact. For members with behaviors that pose safety concerns for the member or others, the interventions and de-escalation strategies should be designed with the goal of preventing the use of restraints, seclusion, or restrictive interventions.

(11) "Natural supports" means a uniquely identified network of individuals or groups upon which a primary caregiver or the member rely for voluntary assistance in addressing the member's behavioral health diagnosis, community integration, and management of typical activities of daily living.

(12) "OhioRISE plan" means a prepaid inpatient health plan (PIHP) as defined in C.F.R. 438.2 (October 1, 2021) and a health insuring corporation (HIC) as defined in section 1751.01 of the Revised Code which enters into an OhioRISE plan provider agreement with ODM.

(13) "System of care" means a spectrum of effective, community-based services and supports for children and youth with, or at risk for, mental health or other challenges and their families. The system of care is organized into a coordinated network, builds meaningful partnerships with families and youth, and addresses their cultural and linguistic needs in order to help them function better at home, in school, in the community, and throughout life.

(14) "Telehealth" has the same meaning as in rule 5160-1-18 of the Administrative Code.

Last updated March 25, 2024 at 9:30 AM

History

Effective: July 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-59-01.1 OhioRISE: application of general managed care rules.

(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan has to adhere to all of the requirements applicable to managed care organizations (MCOs) or managed care entities (MCEs) in the following rules:

(1) Rule 5160-26-05 of the Administrative Code with the exception of paragraphs (B)(4), (B)(5), (D)(21), (D)(25), and (D)(26);

(2) Rule 5160-26-05.1 of the Administrative Code with the exception of paragraph (B)(1);

(3) Rule 5160-26-06 of the Administrative Code;

(4) Rule 5160-26-08.3 of the Administrative Code with the exception of paragraphs (A)(19) and (A)(25);

(5) Rule 5160-26-08.4 of the Administrative Code;

(6) Rule 5160-26-09.1 of the Administrative Code;

(7) Rule 5160-26-10 of the Administrative Code with the exceptions of paragraphs (B)(2)(c), (B)(2)(d), and (B)(2)(e); and

(8) Rule 5160-26-11 of the Administrative Code.

(B) For all rules listed in paragraph (A) of this rule, the following provisions apply to the OhioRISE program described in Chapter 5160-59 of the Administrative Code:

(1) All references to rule 5160-26-01 of the Administrative Code are replaced by references to rule 5160-59-01 of the Administrative Code.

(2) All references to rules 5160-26-02 and 5160-26-02.1 of the Administrative Code are replaced by references to rule 5160-59-02 of the Administrative Code.

(3) All references to rule 5160-26-03 of the Administrative Code are replaced by references to rule 5160-59-03 of the Administrative Code.

(4) All references to rule 5160-26-03.1 of the Administrative Code are replaced by references to rule 5160-59-03.1 of the Administrative Code.

(1) Rule 5160-26-02 of the Administrative Code;

(2) Rule 5160-26-02.1 of the Administrative Code;

(3) Rule 5160-26-03 of the Administrative Code;

(4) Rule 5160-26-03.1 of the Administrative Code.

Last updated March 25, 2024 at 9:31 AM

History

Effective: July 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-59-02 OhioRISE: eligibility and enrollment.

(A) To be eligible for enrollment in the Ohio resilience through integrated systems and excellence (OhioRISE) program, an individual has to meet the criteria in paragraphs (A)(1) to (A)(3) along with either paragraph (A)(4), (A)(5), (A)(6) or (B) of this rule.

(1) Be twenty years of age or younger at the time of enrollment;

(2) Be determined eligible for Ohio medicaid in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code;

(3) Not be enrolled in a MyCare Ohio plan as described in Chapter 5160-58 of the Administrative Code;

(4) For youth age six through twenty years of age, have a submitted Ohio children's initiative brief or comprehensive "child and adolescent needs and strengths" (CANS) assessment, using the tool available on https://www.managedcare.medicaid.ohio.gov, and completed by a certified Ohio CANS assessor within ninety days prior to eligibility determination that indicates paragraph (A)(4)(a) and either paragraph (A)(4)(b) or (A)(4)(c) of this rule have been met:

(a) For behavioral/emotional needs domain items, at least one of the following items is dangerous or disabling and needs immediate action or at least one of the following items is interfering with functioning and needs action to ensure that the identified need is addressed:

(i) Psychosis;

(ii) Impulsivity/hyperactivity;

(iii) Depression;

(iv) Anxiety;

(v) Oppositional behavior;

(vi) Conduct;

(vii) Adjustment to trauma;

(viii) Anger control;

(ix) Substance use;

(x) Eating disturbance;

(xi) Attachment difficulties;

(xii) For youth age fourteen or older, interpersonal problems.

(b) For risk behavior domain items, at least one of the following items is dangerous or disabling and needs immediate action or at least one of the following items is interfering with functioning and needs action to ensure that the identified need is addressed:

(i) Suicide risk;

(ii) Non-suicidal self-injury behavior;

(iii) Other self-harm;

(iv) Danger to others;

(v) Delinquent behavior;

(vi) Runaway;

(vii) Intentional misbehavior;

(viii) Fire setting;

(ix) Victimization/exploitation;

(x) Sexually problematic behavior.

(c) For life functioning domain items, at least one of the following items is dangerous or disabling and needs immediate action or at least one of the following items is interfering with functioning and needs action to ensure that the identified need is addressed:

(i) Family functioning;

(ii) Living situation;

(iii) Social functioning;

(iv) Sleep;

(v) For Ohio children's initiative brief CANS school or for Ohio children's initiative comprehensive CANS school attendance or school behavior.

(5) For youth age birth through five years of age, have a submitted Ohio children's initiative brief or comprehensive CANS assessment, using the tool available on https://www.managedcare.medicaid.ohio.gov, and completed by a certified Ohio children's initiative CANS assessor within ninety days prior to eligibility determination that indicates paragraph (A)(5)(a) and either paragraph (A)(5)(b), (A)(5)(c), or (A)(5)(d) of this rule have been met:

(a) For early childhood challenge domain items, at least one of the following items is dangerous or disabling and needs immediate action or at least one of the following items is interfering with functioning and needs action to ensure that the identified need is addressed:

(i) Impulsivity/hyperactivity;

(ii) Depression;

(iii) Anxiety;

(iv) Oppositional behavior;

(v) Attachment difficulties;

(vi) Adjustment to trauma;

(vii) Regulatory.

(b) Meeting at least one of the following:

(i) For caregiver resources and needs domain items, at least one of the following items prevents the provision of care and needs immediate action or at least one of the following items is at least interfering with the provision of care and needs action to ensure that the identified need is addressed:

(a) Supervision;

(b) Residential stability;

(d) Mental health;

(e) Substance use;

(f) Developmental;

(g) Family stress;

(h) Caregiver post-traumatic stress reaction;

(i) Marital/partner violence;

(j) Family relationship with the system;

(k) Legal involvement.

(ii) For early childhood domain item developmental or intellectual, the need is dangerous or disabling and needs immediate action or is interfering with functioning and needs action to ensure that the need is addressed.

(c) The caregiver resources and needs domain item "safety" is identified as a need that at least needs monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.

(d) For early childhood domain items, at least one of the following items is dangerous or disabling and needs immediate action or at least one of the following items is interfering with functioning and needs action to ensure that the identified need is addressed:

(i) Sleep;

(ii) Family functioning;

(iii) Early education;

(iv) Social and emotional functioning;

(v) Medical/physical;

(vi) Failure to thrive.

(6) For youth who meet one of the following but do not meet the criteria in paragraph (A)(4) or (A)(5) of this rule;

(a) Meets the criteria for moderate care coordination as described in paragraph (A)(1) or (A)(3) of rule 5160-59-03.2 of the Administrative Code; or

(b) Meets the criteria to receive intensive home-based treatment (IHBT) service as described in rule 5122-29-28 of the Administrative Code.

(B) Youth who meet the criteria in paragraphs (A)(1) to (A)(3) of this rule are eligible for OhioRISE enrollment when they are admitted inpatient in a hospital, as defined in in Chapter 5160-2 of the Administrative Code, with a primary diagnosis of mental illness or substance use disorder, and will remain in OhioRISE until the youth meets the criteria for disenrollment in paragraph (D) of this rule.

(C) Enrollment in OhioRISE is mandatory for eligible youth who meet the criteria in paragraph (A) or (B) of this rule. Enrollment will be effective on the first day of the calendar month in which the eligibility criteria are met.

(D) Disenrollment from OhioRISE occurs upon the earliest of any of the following:

(1) The last day of the following month when:

(a) The youth reaches twenty-one years of age, except for as described in paragraph (D)(2) of this rule; or

(b) Two years have passed since the youth's enrollment in OhioRISE and the youth subsequently:

(i) Has not had a CANS assessment meeting the eligibility criteria in paragraph (A)(4), (A)(5), or (A)(6)(a) of this rule in the last two years;

(ii) Has not received IHBT services in the last three hundred sixty-five days; and

(iii) Has not experienced an inpatient hospital stay as described in paragraph (B) of this rule in the last three hundred sixty-five days.

(2) Youth who are receiving inpatient psychiatric services in a hospital or psychiatric residential treatment facility (PRTF), as described in rule 5160-59-03.6 of the Administrative Code, upon turning twenty-one years of age, will remain enrolled in OhioRISE until the last day of the following month of whichever occurs first:

(a) The youth is discharged; or

(b) The youth reaches twenty-two years of age.

(3) The date the youth begins enrollment in a MyCare Ohio plan, as described in Chapter 5160-58 of the Administrative Code.

(4) The date of the youth's death.

(5) The date the youth is no longer eligible for medicaid.

(E) Member initiated disenrollment.

(1) In accordance with 42 CFR 438.56(d)(2) (October 1, 2025), a termination of OhioRISE program enrollment may be permitted for any of the following just cause reasons:

(a) The OhioRISE plan does not, for moral or religious objections, cover the service the youth seeks;

(b) The youth needs related services to be performed at the same time, not all related services are available within the OhioRISE plan's network, and the youth's primary care provider or another provider determines that receiving services separately would subject the youth to unnecessary risk;

(c) The youth has experienced poor quality of care and the services are not available from another provider within the OhioRISE plan's network; or

(d) The youth cannot access medically necessary medicaid-covered services or cannot access the type of providers experienced in dealing with the youth's care needs.

(e) After three hundred sixty-five days of continuous enrollment in the OhioRISE plan, disenrollment may be requested if the youth:

(i) Has not had a CANS assessment meeting the eligibility criteria in paragraph (A)(4), (A)(5), or (A)(6)(a) of this rule: or

(ii) Has not utilized any of the covered services, excluding care coordination, as described in paragraph (B) of rule 5160-59-03 of the Administrative Code, provided through the OhioRISE plan.

(2) The following provisions apply when a youth seeks a termination in OhioRISE enrollment for just cause:

(a) The youth may make the request for just cause directly to ODM or an ODM-approved entity, either orally or in writing.

(b) ODM will review all requests for just cause within seven working days of receipt. ODM may request documentation as necessary from both the youth and the OhioRISE plan. ODM will make a decision within forty-five days from the date ODM receives the just cause request. If ODM fails to make the determination within this timeframe, the just cause request is considered approved.

(c) ODM may establish retroactive termination dates and recover capitation payments as determined necessary and appropriate.

(d) The effective date of an approved just cause request will be no later than the first day of the second month following the month in which the member requests change or termination.

(e) Requests for just cause may be processed at the individual level or case level as ODM determines necessary and appropriate.

(F) If a youth is denied enrollment in the program pursuant to paragraph (A) or (B) of this rule, is disenrolled from the program pursuant to paragraph (D) of this rule, or if the youth-initiated disenrollment is denied pursuant to paragraph (E) of this rule, the youth will be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

Last updated July 1, 2026 at 8:14 AM

History

Effective: July 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-59-02.1 OhioRISE: first day eligibility and enrollment.

(A) Scope. This rule sets forth the provisions for eligibility and enrollment into Ohio resilience through integrated systems and excellence (OhioRISE) on the first day the program is effective. Individuals that do not meet the OhioRISE first day eligibility criteria described in paragraph (B) of this rule will have the opportunity to be enrolled in OhioRISE as set forth in rule 5160-59-02 of the Administrative Code.

(B) Eligibility. For individuals who meet criteria in paragraphs (B)(1) to (B)(4) of this rule, enrollment will be mandatory in the OhioRISE program on the first day the program is in effect:

(1) Be twenty years of age or younger;

(2) Be determined eligible for Ohio medicaid in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code;

(3) Not enrolled in a MyCare Ohio plan as described in Chapter 5160-58 of the Administrative Code on the first day the program is in effect; and

(4) Meet one or more of the following criteria:

(a) Within six months prior to the effective date of the OhioRISE program had an admission into an out of state psychiatric residential treatment facility (PRTF) as defined in 42 C.F.R. 441.150 (October 1, 2021) to 42 C.F.R. 441.184 (October 1, 2021), or had an inpatient admission to a hospital, as defined in Chapter 5160-2 of the Administrative Code, with a primary diagnosis of mental illness or substance use disorder; or

(b) Within three months prior to the effective date of the OhioRISE program:

(i) Received intensive home-based treatment (IHBT) as described in rule 5160-27-05 of the Administrative Code; or

(ii) Met the criteria described in either paragraph (A)(4) or (A)(5) in rule 5160-59-02 of the Administrative Code; or

(iii) Received the intensive behavioral support rate add-on at an intermediate care facility for individuals with intellectual disabilities as described in rule 5123-7-28 of the Administrative Code; or

(iv) Be seventeen years of age or younger and receive services in a developmental center as defined in section 5124.01 of the Revised Code; or

(i) Received substance use disorder residential treatment services as described in rule 5122-29-09 of the Administrative Code; or

(ii) While in the custody of a Title IV-E agency as defined in rule 5101:2-1-01 of the Administrative Code, was placed in a children's residential center or was a parent in a residential parenting facility as described in rule 5101:2-9 of the Administrative Code.

(C) For individuals enrolled by meeting the criteria in paragraph (B) of this rule, the conditions for disenrollment from OhioRISE set forth in rule 5160-59-02 of the Administrative Code apply.

Last updated July 7, 2026 at 9:18 AM

History

Effective: July 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-59-03 OhioRISE: covered services.

(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan has to ensure:

(1) Services are sufficient in amount, duration, and scope to reasonably be expected to achieve the purpose for which the services are provided;

(2) The amount, duration, and scope of a medically necessary service is not arbitrarily denied or reduced solely because of the diagnosis, type of illness, or condition;

(3) Prior authorization is available for services on which the OhioRISE plan has placed a preidentified limitation to ensure the limitation may be exceeded when medically necessary;

(5) If a member is unable to obtain medically necessary services described in this rule through an OhioRISE plan network provider, the OhioRISE plan has to adequately and timely cover the services out of network, until the OhioRISE plan is able to provide the services from a network provider.

(6) Providers delivering services in the OhioRISE program will adhere to the incident management criteria set forth in rule 5160-44-05 of the Administrative Code.

(B) The OhioRISE plan has to ensure members have access to the following services when medically necessary:

(1) Care coordination as described in rule 5160-59-03.2 of the Administrative Code.

(2) Intensive home-based treatment (IHBT) as described in rule 5160-59-03.3 of the Administrative Code.

(3) Respite services for members twenty years of age or younger with behavioral health needs in accordance with rule 5160-59-03.4 of the Administrative Code.

(4) Inpatient hospital services provided in accordance with Chapter 5160-2 of the Administrative Code in a free-standing psychiatric hospital or a general acute care hospital that are:

(a) Inpatient psychiatric services; or

(b) Inpatient substance use disorder (SUD) services (including withdrawal management) provided in accordance with American society of addiction medicine (ASAM) level of care four.

(5) Psychiatric residential treatment facility (PRTF) services as described in 42 C.F.R. 441.150 (October 1, 2021) to 42 C.F.R 441.184 (October 1, 2021).

(6) Opioid treatment program (OTP) services delivered by community SUD programs licensed by Ohio department of mental health and addiction services and/or certified by the substance abuse and mental health services administration (SAMHSA) as an OTP.

(7) Behavioral health services provided in accordance with Chapter 5160-27 of the Administrative Code.

(8) Behavioral health services provided in accordance with rule 5160-8-05 of the Administrative Code.

(9) Behavioral health services rendered by psychiatrists and physician assistants under the supervision of psychiatrists in accordance with Chapter 5160-4 of the Administrative Code and psychiatric advanced practice registered nurses in accordance with rule 5160-4-04 of the Administrative Code.

(10) Behavioral health services rendered by outpatient hospital providers in accordance with Chapter 5160-2 of the Administrative Code except for emergency department services.

(11) Behavioral health services rendered in federally qualified health centers (FQHCs) and rural health clinics (RHCs) in accordance with Chapter 5160-28 of the Administrative Code.

(12) Physician administered drugs in accordance with rule 5160-4-12 of the Administrative Code for the treatment of mental health and SUD conditions.

(13) Primary flex funds as described in rule 5160-59-03.5 of the Administrative Code.

(14) Services and supports included in the OhioRISE 1915(c) home and community-based services waiver in accordance with rule 5160-59-05 of the Administrative Code.

(1) On the basis of medical necessity for the member's condition or diagnosis; or

(2) For the purposes of utilization control, provided the services can be reasonably expected to achieve their purpose as specified in paragraph (A)(1) of this rule.

(D) The OhioRISE plan has to ensure that the services described in paragraph (B) of this rule that are emergency services, as described in rule 5160-26-01 of the Administrative Code, are provided and covered twenty-four hours a day, seven days a week. At a minimum, covered services described in paragraph (B) of this rule that are emergency services have to be provided and reimbursed in accordance with the following:

(1) The OhioRISE plan will not deny reimbursement for treatment obtained when a member had an emergency medical condition.

(2) The OhioRISE plan cannot limit what constitutes an emergency medical condition on the basis of diagnoses or symptoms.

(3) The OhioRISE plan has to cover emergency services without requiring prior authorization.

(4) The OhioRISE plan has to cover services as described in paragraph (B) of this rule related to the member's emergency medical condition when the member is instructed to go to an emergency facility by a representative of the OhioRISE plan, the member's managed care organization (MCO), or the member's primary care provider (PCP).

(5) The OhioRISE plan cannot deny reimbursement of emergency services based on the treating provider, hospital, or fiscal representative not notifying the member's PCP of the visit.

(6) The OhioRISE plan has to cover the services described in paragraph (B) of this rule that are emergency services when the services are delivered by a non-contracting provider of emergency services. Such services will be reimbursed by the OhioRISE plan at the lesser of billed charges or one hundred per cent of the Ohio medicaid program fee-for-service reimbursement rate (less any reimbursements for indirect costs of medical education and direct costs of graduate medical education that is included in the Ohio medicaid program fee-for-service reimbursement rate) in effect for the date of service. If an inpatient admission results, the OhioRISE plan has to reimburse at this rate only until the member can be transferred to a provider designated by the OhioRISE plan.

(7) The OhioRISE plan has to cover the services as described in paragraph (B) of this rule that are emergency services until the member is stabilized and can be safely discharged or transferred.

(8) The OhioRISE plan has to adhere to the judgment of the attending provider when the attending provider requests a member's transfer to another facility or discharge. The OhioRISE plan may establish arrangements with hospitals whereby the OhioRISE plan may designate one of its contracting providers to assume the attending provider's responsibilities to stabilize, treat and transfer the member.

(9) A member who has had an emergency medical condition will not be held liable for reimbursement of any subsequent screening and treatment needed to diagnose the specific condition or stabilize the member.

(E) The OhioRISE plan has to establish, in writing, the process and procedures for the submission of claims for services delivered by non-contracting providers, including non-contracting providers of emergency services. Such information will be made available upon request to non-contracting providers, including non-contracting providers of emergency services. The OhioRISE plan will not establish claims filing and processing procedures for non-contracting providers, including non-contracting providers of emergency services, that are more stringent than those established for their contracting providers.

(F) The OhioRISE plan has to ensure any services described in paragraph (B) of this rule that are post-stabilization care services, as described in rule 5160-26-01 of the Administrative Code, are provided and covered twenty-four hours a day, seven days a week.

(1) The OhioRISE plan has to designate a telephone line that is available twenty-four hours a day to receive provider requests for coverage of post-stabilization care services. The OhioRISE plan has to document that the telephone number and process for obtaining authorization has been provided to each emergency facility in the service area. The OhioRISE plan has to maintain a record of any request for coverage of post-stabilization care services that is denied including, at a minimum, the time of the provider's request and the time the OhioRISE plan communicated the decision in writing to the provider.

(2) At a minimum, the services described in paragraph (B) of this rule that are post-stabilization care services have to be provided and reimbursed in accordance with the following:

(a) The OhioRISE plan has to cover services obtained within or outside the OhioRISE plan's network that are pre-approved in writing to the requesting provider by a plan provider or other OhioRISE plan representative.

(b) The OhioRISE plan has to cover services obtained within or outside the OhioRISE plan's network that are not pre-approved by a plan provider or other OhioRISE plan representative but are administered to maintain the member's stabilized condition within one hour of a request to the OhioRISE plan for pre-approval of further post-stabilization care services.

(c) The OhioRISE plan has to cover services obtained within or outside the OhioRISE plan's network that are not pre-approved by a plan provider or other OhioRISE plan representative but are administered to maintain, improve or resolve the member's stabilized condition if:

(i) The OhioRISE plan fails to respond within one hour to a provider request for authorization to provide such services;

(ii) The provider has documented an attempt to contact the OhioRISE plan to request authorization, but the OhioRISE plan cannot be contacted; or

(iii) The OhioRISE plan's representative and treating provider cannot reach an agreement concerning the member's care and a plan provider is not available for consultation. In this situation, the OhioRISE plan will give the treating provider the opportunity to consult with an OhioRISE plan provider and the treating provider may continue with care until a plan provider is reached or one of the criteria specified in paragraph (F)(3) of this rule is met.

(3) The OhioRISE plan's financial responsibility for services described in paragraph (B) of this rule that are post-stabilization care services not pre-approved ends when:

(a) An OhioRISE plan provider with privileges at the treating hospital assumes responsibility for the member's care;

(b) An OhioRISE plan provider assumes responsibility for the member's care through transfer;

(d) The member is discharged.

(G) OhioRISE plan responsibilities for reimbursement of other services.

(1) ODM may approve referral of the OhioRISE plan's members to certain OhioRISE plan non-contracting hospitals, as specified in rule 5160-26-11 of the Administrative Code, for non-emergency hospital services that are OhioRISE covered services as described in paragraph (B) of this rule. When ODM permits such authorization, ODM will notify the OhioRISE plan and the OhioRISE plan's non-contracting hospital of the terms and conditions of the approval, including the duration, and the OhioRISE plan will reimburse the OhioRISE plan's non-contracting hospital at one hundred per cent of the current Ohio medicaid program fee-for-service reimbursement rate in effect for the date of service for all medicaid-covered non-emergency hospital services delivered by the OhioRISE plan's non-contracting hospital. ODM will base its determination of when an OhioRISE plan's members can be referred to an OhioRISE plan non-contracting hospital pursuant to the following:

(a) The OhioRISE plan's submission of a written request to ODM for the approval to refer members to a hospital that has declined to contract with the OhioRISE plan. The request will document the OhioRISE plan's contracting efforts and why the OhioRISE plan believes it will be necessary for members to be referred to this hospital; and

(b) ODM consultation with the OhioRISE plan non-contracting hospital to determine the basis for the hospital's decision to decline to contract with the OhioRISE plan, including but not limited to whether the OhioRISE plan's contracting efforts were unreasonable and/or that contracting with the OhioRISE plan would have adversely impacted the hospital's business.

(2) Paragraph (G)(1) of this rule is not applicable when the OhioRISE plan and an OhioRISE plan non-contracting hospital have mutually agreed that the non-contracting hospital will provide non-emergency OhioRISE covered hospital services to the OhioRISE plan's members. The OhioRISE plan will ensure that such arrangements comply with rule 5160-26-05 of the Administrative Code.

(3) The OhioRISE plan is not responsible for reimbursement of services provided through the medicaid school program (MSP) pursuant to Chapter 5160-35 of the Administrative Code. The OhioRISE plan will ensure access to services described in paragraph (B) of this rule for members who are unable to timely access services or are unwilling to access services through MSP providers.

(4) The OhioRISE plan is not required to cover services provided to members outside the United States.

(5) The OhioRISE plan will ensure that eligible members receive all behavioral health early and periodic screening, diagnosis and treatment (EPSDT) services in accordance with rule 5160-1-14 of the Administrative Code.

Last updated March 25, 2024 at 9:32 AM

History

Effective: July 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-59-03.1 OhioRISE: utilization management.

(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan will have a utilization management (UM) program with clearly defined structures and processes designed to maximize the effectiveness of the care provided to the member.

(1) The OhioRISE plan has to ensure decisions rendered through the UM program are based on medical necessity.

(2) The UM program has to be based on written policies and procedures that include, at a minimum:

(a) The information sources used to make determinations of medical necessity;

(b) The criteria, based on sound clinical evidence, to make UM decisions and the specific procedures for appropriately applying the criteria;

(c) A specification that written UM criteria will be made available to both contracting and non-contracting providers; and

(d) A description of how the OhioRISE plan will monitor the impact of the UM program to detect and correct potential under-and over-utilization.

(3) The OhioRISE plan's UM program has to ensure and document the following:

(a) An annual review and update of the UM program;

(b) The involvement of a designated senior physician in the UM program;

(c) The use of appropriate qualified licensed health professionals to assess the clinical information used to support UM decisions;

(d) Review and consideration of the child and family centered care plan;

(e) The use of board-certified consultants to assist in making medical necessity determinations, as necessary;

(f) That UM decisions are consistent with clinical practice guidelines as specified in rule 5160-26-05.1 of the Administrative Code. The OhioRISE plan may not impose conditions around the coverage of a medically necessary-covered service unless they are supported by such clinical practice guidelines;

(g) The reason for each denial of a service, based on sound clinical evidence;

(h) That compensation by the OhioRISE plan to individuals or entities that conduct UM activities does not offer incentives to deny, limit, or discontinue medically necessary services to any member; and

(i) Adherence to the Mental Health Parity and Addiction Equity Act (MHPAEA) requirements outlined in 42 CFR Part 438 Subpart K (October 1, 2025).

(B) The OhioRISE plan has to process requests for initial and continuing authorizations of services from their providers and members.

(1) The OhioRISE plan has to have written policies and procedures to process requests. Upon request, the OhioRISE plan's policies and procedures have to be made available for review by the Ohio department of medicaid (ODM).

(2) The OhioRISE plan's written policies and procedures for initial and continuing authorization of services have to also be made available to contracting and non-contracting providers upon request.

(C) The OhioRISE plan has to ensure and document the following occurs when processing requests for initial and continuing authorizations of services:

(1) Consistent application of review criteria for authorization decisions.

(2) Consultation with the requesting provider, when necessary.

(3) Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested has to be made by a health care professional who has appropriate clinical expertise in treating the member's condition or disease.

(4) That a written notice will be sent to the member and the requesting provider of any decision to reduce, suspend, terminate, or deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice to the member has to meet the requirements of division 5101:6 and rule 5160-26-08.4 of the Administrative Code.

(5) For standard authorization decisions, the OhioRISE plan has to provide notice to the provider and member as expeditiously as the member's health condition requires but no later than seven calendar days following receipt of the request for service. If requested by the member, provider, or the OhioRISE plan, standard authorization decisions may be extended up to fourteen additional calendar days. If requested by the OhioRISE plan, the OhioRISE plan has to submit to ODM for prior-approval, documentation as to how the extension is in the member's interest. If ODM approves the OhioRISE plan's extension request, the OhioRISE plan has to give the member written notice of the reason for the decision to extend the time frame and inform the member of the right to file a grievance if the member disagrees with that decision. The OhioRISE plan has to carry out its determination as expeditiously as the member's health condition requires and no later than the date the extension expires.

(6) If a provider indicates or the OhioRISE plan determines that following the standard authorization timeframe could seriously jeopardize the member's life or health or ability to attain, maintain, or regain maximum function, the OhioRISE plan has to make an expedited authorization decision and provide notice of the authorization decision as expeditiously as the member's health condition requires but no later than forty-eight hours after receipt of the request for service. If requested by the member or OhioRISE plan, expedited authorization decisions may be extended up to fourteen additional calendar days. If requested by the OhioRISE plan, the OhioRISE plan has to submit to ODM for prior-approval, documentation as to how the extension is in the member's interest. If ODM approves the OhioRISE plan's extension request, the OhioRISE plan has to give the member written notice of the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if he or she disagrees with that decision. The OhioRISE plan has to carry out its determination as expeditiously as the member's health condition requires and no later than the date the extension expires.

(D) The OhioRISE plan has to maintain and submit as directed by ODM a record of all authorization requests, including standard and expedited authorization requests and any extensions granted. The OhioRISE plan's records have to include member identifying information, service requested, date initial request received, any extension requests, decision made, date of decision, date of member notice, and basis for denial, if applicable.

Last updated January 5, 2026 at 8:14 AM

History

Effective: January 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-59-03.2 OhioRISE: care coordination.

(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan will assign a care coordination tier for all youth eligible for enrollment in the OhioRISE plan. Tier assignment of limited, moderate, or intensive is based on assessed or indicated needs and may be modified to be based on individual circumstances or to best fit the youth or family capacity and choice.

(1) Moderate care coordination (MCC) is recommended for youth six years of age and older when paragraph (A)(1)(a) and either paragraph (A)(1)(b) or (A)(1)(c) of this rule are met:

(a) An Ohio children's initiative child and adolescent needs and strengths (CANS) assessment, the tool available on https://www.medicaid.ohio.gov (September 20, 2021), indicates for behavioral/emotional needs domain items, at least one of the following items is dangerous or disabling and needs immediate action or two or more of the following items are at least interfering with functioning and need action to ensure that the identified need is addressed:

(i) Psychosis;

(ii) Impulsivity/hyperactivity;

(iii) Depression;

(iv) Anxiety;

(v) Oppositional behavior;

(vi) Conduct;

(vii) Adjustment to trauma;

(viii) Anger control;

(ix) Substance use;

(x) Eating disturbance;

(xi) Interpersonal problems (for youth age fourteen and older);

(b) For risk behavior domain items, at least one of the following items is dangerous or disabling and needs immediate action or two or more of the following items are interfering with functioning and need action to ensure that the identified behavior is addressed:

(i) Suicide risk;

(ii) Non-suicidal self-injury behavior;

(iii) Other self-harm;

(iv) Danger to others;

(v) Delinquent behavior;

(vi) Runaway;

(vii) Intentional misbehavior;

(viii) Fire setting;

(ix) Victimization/exploitation;

(x) Sexually problematic behavior;

(c) For life functioning domain items, at least two of the following items are dangerous or disabling and needs immediate action or three or more of the following items are at least interfering with functioning and need action to ensure that the identified need is addressed:

(i) For the Ohio children's initiative brief CANS assessment:

(a) Family functioning;

(b) Living situation;

(d) Developmental/intellectual;

(e) Legal;

(f) Medical/physical;

(g) Sleep;

(h) Decision making;

(i) School.

(ii) For the Ohio children's initiative comprehensive CANS assessment:

(a) Family functioning;

(b) Living situation;

(d) Developmental/intellectual;

(e) Legal;

(f) Medical/physical;

(g) Sleep;

(h) Decision making;

(i) School attendance or school behavior.

(2) Intensive care coordination (ICC) is recommended for youth six years of age and older when:

(a) Criteria for MCC are met as described in paragraph (A)(1) of this rule; and

(b) An Ohio children's initiative CANS assessment, the tool available on https://www.medicaid.ohio.gov (September 20, 2021), indicates for caregiver resources and needs domain items, at least one of the following items prevents the provision of care and needs immediate action or two or more of the following items are interfering with the provision of care and need action to ensure that the identified need is addressed:

(i) Supervision;

(ii) Knowledge;

(iii) Residential stability;

(iv) Medical/ physical;

(v) Mental health;

(vi) Substance use;

(vii) Family stress;

(3) MCC is recommended for youth under six years of age when paragraphs (A)(3)(a), (A)(3)(b), and either paragraph (A)(3)(c) or (A)(3)(d) of this rule are met.

(a) An Ohio children's initiative CANS assessment, the tool available on https://www.medicaid.ohio.gov (September 20, 2021), indicates for early childhood domain items, at least one of the following items is dangerous or disabling and needs immediate action or two or more of the following items are at least interfering with functioning and need action to ensure that the identified behavior is addressed:

(i) Impulsivity/hyperactivity;

(ii) Depression;

(iii) Anxiety;

(iv) Oppositional behavior;

(v) Adjustment to trauma;

(vi) Regulatory;

(b) For caregiver resources and needs domain items, at least one of the following items prevents the provision of care and needs immediate or intensive action or at least one of the following items is interfering with the provision of care and action is needed to ensure that the identified need is addressed:

(i) Supervision;

(ii) Residential stability;

(iii) Medical/physical;

(iv) Mental health;

(v) Substance use;

(vi) Developmental;

(vii) Family stress;

(viii) Caregiver post-traumatic stress reaction;

(ix) Marital/partner violence;

(x) Family relationship with the system;

(xi) Legal involvement;

(xii) Early childhood domain item developmental/intellectual;

(c) For early childhood domain items, at least one of the following items is dangerous or disabling and needs immediate action or at two or more of the following items are at least interfering with functioning and need action to ensure that the identified need is addressed:

(i) Sleep;

(ii) Family functioning;

(iii) Early education;

(iv) Social and emotional functioning;

(v) Medical/physical;

(vi) Failure to thrive;

(i) Aggressive behaviors;

(ii) Atypical behaviors;

(iii) Self-harm;

(iv) Exploited;

(v) Problematic sexual behavior.

(4) ICC is recommended for youth under six years of age when paragraphs (A)(4)(a), (A)(4)(b) and either paragraph (A)(4)(c) or (A)(4)(d) of this rule are met.

(a) An Ohio children's initiative CANS assessment, the tool available on https://www.medicaid.ohio.gov (September 20, 2021) indicates for early childhood domain items, at least one of the following items is dangerous or disabling and needs immediate action or two or more of the following items are at least interfering with functioning and need action to ensure that the identified behavior is addressed:

(i) Impulsivity/hyperactivity;

(ii) Depression;

(iii) Anxiety;

(iv) Oppositional behavior;

(v) Adjustment to trauma;

(vi) Regulatory;

(b) For caregiver resources and needs domain items, two or more of the following items prevents the provision of care and needs immediate or intensive action or three or more of the following items are at least interfering with the provision of care and action is needed to ensure that the identified need is addressed:

(i) Supervision;

(ii) Residential stability;

(iii) Medical/physical;

(iv) Mental health;

(v) Substance use;

(vi) Developmental;

(vii) Family stress;

(viii) Caregiver post-traumatic stress reaction;

(ix) Marital/partner violence;

(x) Family relationship with the system;

(xi) Legal involvement;

(xii) Early childhood domain item developmental/intellectual;

(c) For early childhood domain items, at least one of the following items is dangerous or disabling and needs immediate action or two or more of the following items are at least interfering with functioning and need action to ensure that the identified behavior is addressed:

(i) Sleep;

(ii) Family functioning;

(iii) Early education;

(iv) Social and emotional functioning;

(v) Medical/physical;

(vi) Failure to thrive;

(i) Aggressive behaviors;

(ii) Atypical behaviors;

(iii) Self-harm;

(iv) Exploited;

(v) Problematic sexual behavior.

(5) MCC or ICC may also be recommended when the CANS assessment alone does not indicate MCC or ICC as described in paragraphs (A)(1) through (A)(4) of this rule, but other documentation supports the need for the frequency and intensity of MCC or ICC activities. Other supporting documentation that provides clinical justification may include a comprehensive assessment, psychological evaluation, biopsychosocial assessment, or documentation illustrating a history of unsuccessful past services.

(6) Limited care coordination delivered by the OhioRISE plan is recommended when:

(a) The youth's needs do not meet the ICC or MCC recommendations; or

(b) The youth meets criteria for ICC or MCC but declines or does not consent to participate in ICC or MCC.

(7) Denials of assignment to ICC or MCC are subject to the appeal process described in rule 5160-26-08.4 of the Administrative Code.

(B) Care management entities (CMEs).

(1) ICC and MCC are delivered by care management entities (CMEs) designated by the OhioRISE plan.

(2) CMEs will:

(a) Maintain an active, valid medicaid provider agreement as defined and set forth in rule 5160-1-17.2 of the Administrative Code;

(b) Comply with all applicable provider requirements set forth in this rule;

(c) Participate in initial and ongoing training, coaching, and supports from an independent validation entity recognized by the Ohio department of medicaid (ODM) to ensure consistency in delivering care coordination;

(d) Have documentation of completion of an initial readiness review by an independent validation entity recognized by ODM prior to providing ICC or MCC;

(e) Ensure that all child and family-centered care plans (including initial plans, changes to plans, and transition plans) are submitted to the OhioRISE plan for review and approval;

(f) Exchange electronic, bidirectional data and other information regarding the youth and family receiving ICC and MCC with the OhioRISE plan and the independent validation entity recognized by ODM;

(g) Report incidents in accordance with rule 5160-44-05 of the Administrative Code;

(h) Implement quality improvement activities related to the CME's performance consistent with ODM's population health management strategy;

(i) Provide all staff with training regarding cultural and trauma-informed care competency within three months of the date of hire and annually thereafter;

(j) Conduct virtual, in-person, or telephonic engagement to the youth's family within two business days of receipt of referral to ICC or MCC to explain the service and obtain consent;

(k) Have administrative and program staff, in sufficient quantity to meet all the CME requirements to achieve the quality, performance, and outcome measures set by ODM;

(l) Ensure care coordination staff and supervisors have the experience necessary to manage complex cases and the ability to navigate state and local child serving systems:

(m) Have sufficient care coordination staff to meet care coordinator-to-youth ratio requirements described in this rule;

(n) Have supervisory personnel to provide coaching and support for ICC and MCC care coordinators, not to exceed the supervisor ratio described in this rule;

(o) Provide real-time or on demand clinical and psychiatric consultation for youth engaged in ICC or MCC;

(p) Respond to the youth and family twenty-four hours a day;

(q) Ensure youth and family choice is incorporated regarding the services and supports they receive and from whom;

(r) Ensure that all care coordination services are provided in a conflict-free manner, with particular attention to ensuring care coordination services, functions, and staff are separated from the organization's function and staff related to other services. If the CME has multiple lines of business, the CME will establish firewalls between its care coordination services and staff and the functions and staff of its other services;

(s) Identify and inform the OhioRISE plan of unmet needs and barriers to effective care and assist in developing community resources to meet youth and families' needs; and

(t) Assist with required activities related to the OhioRISE 1915(b)/(c) waivers, including:

(i) Gather and submit information to assist ODM in determining OhioRISE 1915(c) waiver eligibility;

(ii) Assess the initial and ongoing settings where youth will receive 1915(c) home and community-based services for settings requirements using the review tool designated by ODM; and

(iii) Help youth and caregivers in determining the need for OhioRISE 1915(b)/(c) waiver services.

(1) CMEs delivering ICC will:

(a) Provide structured service planning and care coordination through high-fidelity wraparound as established by the national wraparound initiative, found at https://nwi.pdx.edu (October 1, 2021), including:

(i) Offering initial face-to-face contact within two calendar days of conducting initial engagement contact for ICC; and

(ii) Completing an initial supplemental assessment with the youth that includes:

(a) Information from a new Ohio children's initiative CANS assessment or existing Ohio children's initiative CANS assessment that was completed within the ninety calendar days prior to the supplemental assessment; and

(b) Other tools as determined necessary that inform and result in the development of the child and family-centered care plan;

(iii) Completing an Ohio children's initiative comprehensive CANS assessment with the youth if not already completed;

(iv) Updating the Ohio children's initiative CANS assessment at a minimum of every ninety calendar days or whenever there is a significant change in the youth's needs or circumstances;

(v) Convening and facilitating the child and family team that will:

(a) Develop and implement the initial child and family-centered care plan; and

(b) Review, and when appropriate, update, the child and family-centered care plan every thirty calendar days, and whenever there is a significant change in the youth's needs or circumstances. When a youth and their caregiver is unable to participate in the review of the child and family-centered care plan within thirty calendar days, the child and family-centered care plan will be reviewed, and when appropriate, updated, within sixty calendar days.

(i) Develop and implement the initial child and family-centered care plan within thirty calendar days of enrollment on the OhioRISE 1915(c) waiver;

(ii) Review, and when appropriate, update, the child and family-centered care plan at least every thirty calendar days. If there is a significant change in the youth's needs or circumstances, the child and family-centered care plan will be reviewed and updated within fourteen calendar days of identifying a change in the youth's needs and circumstances;

(iii) Develop the back-up waiver service plan, as described in rule 5160-59-01 of the Administrative Code, to be included in the child and family-centered care plan. The back-up waiver service plan should be updated when the child and family-centered care plan is updated; and

(iv) Submit the child and family-centered care plan to the OhioRISE plan within one business day of completion and signature from the youth, caregiver, and OhioRISE waiver providers.

(vi) Developing an individual crisis and safety plan as soon as possible. For youth with behaviors that pose safety concerns for the youth or others, a licensed clinician working within or for the CME will consult on the individual crisis and safety plan, recommend de-escalation strategies that can be learned and used by the youth, parents, other caregivers to support the youth and prevent the use of restrictive interventions, and approve of the crisis and safety plan prior to its submission to the OhioRISE plan;

(a) For youth following an established individual crisis and safety plan previously created through another mechanism, the crisis and safety plan created by another mechanism will be reviewed to ensure it contains the required plan elements. If the plan includes required elements, it can be used as a preliminary OhioRISE crisis and safety plan and be updated during a child and family team meeting. If it does not meet the required plan elements, a new individual crisis and safety plan will be developed as soon as possible.

(b) For youth who are enrolled in the OhioRISE 1915(c) waiver, the individual crisis and safety plan will need to be completed within fourteen calendar days following enrollment in the OhioRISE 1915(c) waiver. The individual crisis and safety plan will be reviewed, and when appropriate, updated, at least every ninety calendar days.

(vii) Monitoring the child and family-centered care plan to ensure that services are delivered in accordance with the plan;

(viii) Performing referrals and linkages to appropriate services and supports, including natural supports, along the continuum of care;

(ix) Facilitating discharge planning activities for youth admitted to a facility for behavioral health treatment or inpatient behavioral health treatment; and

(x) Facilitating transition planning and activities for youth exiting the OhioRISE program or the OhioRISE 1915(c) waiver. For youth receiving ICC who are enrolled in the OhioRISE 1915(c) waiver, transition planning will identify supports the youth will need for the ninety calendar days following disenrollment from the OhioRISE 1915(c) waiver.

(b) Have documentation of annual fidelity review, monitoring, and adherence to high-fidelity wraparound by an independent validation entity recognized by ODM. The fidelity review will assess for consistent use of high-fidelity wraparound standards established by the national wraparound initiative.

(2) CMEs delivering MCC will:

(a) Provide structured service planning and care coordination based on wraparound principles, as established by the national wraparound initiative, found at https://nwi.pdx.edu (October 1, 2021), including;

(i) Offering an initial face-to-face contact within seven calendar days of conducting initial engagement contact for MCC; and

(ii) Completing an initial supplemental assessment with the youth that includes:

(a) Information from a new Ohio children's initiative CANS assessment or existing Ohio children's initiative CANS assessment completed within the ninety calendar days prior to the supplemental assessment; and

(b) Other tools as determined necessary that inform and result in the development of the child and family-centered care plan.

(iii) Completing an Ohio children's initiative comprehensive CANS assessment with the youth if not already completed;

(iv) Updating the Ohio children's initiative CANS assessment at a minimum of every ninety calendar days or whenever there is a significant change in the youth's behavioral health needs or circumstances;

(v) Convening and facilitating the child and family team that will:

(a) Develop and implement the initial child and family-centered care plan; and

(b) Review, and when appropriate, update, the child and family-centered care plan every sixty calendar days, and whenever there is a significant change in the youth's needs or circumstances.

(i) Develop and implement the initial child and family-centered care plan within thirty days of enrollment on the OhioRISE 1915(c) waiver; and

(ii) Review, and when appropriate, update, the child and family-centered care plan at least every thirty days. If there is a significant change in the youth's needs or circumstances, the child and family-centered care plan will be reviewed and updated within fourteen calendar days of identifying a change in the youth's needs and circumstances; and

(iv) Submit the child and family-centered care plan to the OhioRISE plan within one business day of completion and signature from the youth, caregiver, and OhioRISE waiver providers.

(a) For youth following an established individual crisis and safety plan previously created through another mechanism, the crisis and safety plan created by another mechanism will be reviewed to ensure it contains the required plan elements. If the plan includes required elements, it will be used as a preliminary OhioRISE crisis and safety plan and be updated during a child and family team meeting. If it does not meet the required plan elements, a new individual crisis and safety plan will be developed as soon as possible.

(b) For youth who are enrolled in the OhioRISE 1915(c) waiver, the individual crisis and safety plan needs to be completed within fourteen calendar days following enrollment in the OhioRISE 1915(c) waiver. The individual crisis and safety plan will be reviewed, and when appropriate, updated, at least every ninety calendar days.

(vii) Monitoring the child and family-centered care plan to ensure that services are delivered in accordance with the plan;

(viii) Performing referrals and linkages to appropriate services and supports, including natural supports, along the continuum of care;

(ix) Facilitating discharge planning activities for youth admitted to a facility for behavioral health treatment or inpatient behavioral health treatment; and

(x) Facilitating transition planning and activities for youth exiting the OhioRISE program or the OhioRISE 1915(c) waiver. For youth receiving MCC who are enrolled in the OhioRISE 1915(c) waiver, transition planning will identify supports the youth will need for the ninety calendar days following disenrollment from the OhioRISE 1915(c) waiver.

(b) Have documentation of annual fidelity review, monitoring, and adherence to MCC by an independent validation entity recognized by ODM. The fidelity review will assess for consistent application of system of care principles adherence to the MCC planning process and service components.

(D) CME care coordinator qualifications.

(1) An ICC or MCC care coordinator will be a licensed or an unlicensed practitioner in accordance with rule 5160-27-01 of the Administrative Code, except that an ICC or MCC care coordinator will be employed by or under contract with a CME as described in this rule.

(2) ICC and MCC care coordinators will complete the high-fidelity wraparound training program provided by an independent validation entity recognized by ODM. Care coordinators will successfully complete initial skill and competency-based training to provide ICC and MCC.

(3) ICC and MCC care coordinators will:

(a) Have experience providing community-based services and supports to children and youth and their families or caregivers in areas of children's behavioral health, child welfare, intellectual and developmental disabilities, juvenile justice, or a related public sector human services or behavioral health care field for:

(i) Three years with a high school diploma or equivalent; or

(ii) Two years with an associate's degree or bachelor's degree; or

(iii) One year with a master's degree or higher; or

(iv) With ODM or its designee approval, partially meets years of experience in paragraph (D)(3)(a)(i), (D)(3)(a)(ii), or (D)(3)(a)(iii) of this rule and meets the following until experience requirements are met:

(a) Demonstrates specific skills and competencies needed for the care coordination activities described in paragraph (C) of this rule; and

(b) Receives additional supervision to monitor skills and competencies to ensure effective care coordination; and

(b) Have a background and experience in one or more of the following areas of expertise:

(i) Family systems;

(ii) Community systems and resources;

(iii) Case management;

(iv) Child and family counseling or therapy;

(v) Child protection; or

(vi) Child development.

(d) Have the qualifications and experience needed to work with children and families who are experiencing serious emotional disturbance (SED), trauma, co-occurring behavioral health disorders and who are engaged with one or more child-serving systems (e.g., child welfare, intellectual and developmental disabilities, juvenile justice, education).

(E) CME care coordinator supervisory qualifications.

(1) A supervisor of ICC or MCC will meet CME care coordinator qualifications described in paragraph (D), with exception of (D)(3)(a)(iv), of this rule.

(2) A supervisor that is an unlicensed practitioner will have regular supervision with a licensed practitioner and real-time access to a psychiatrist for case consultation.

(3) Supervisors of ICC or MCC will complete the high-fidelity wraparound training program provided by an independent validation entity recognized by ODM. Supervisors will successfully complete skill and competency-based training to supervise delivery of ICC and MCC.

(F) ICC and MCC staffing requirements.

(1) ICC will be facilitated by a care coordinator with a ratio of one full-time care coordinator to no more than ten OhioRISE youth receiving ICC.

(2) MCC will be facilitated by a care coordinator with a ratio of one full-time care coordinator to no more than twenty OhioRISE youth receiving MCC.

(3) Supervisory staffing ratios will not exceed one supervisor to eight care coordinators.

(G) Care coordination documentation will include:

(1) Care coordination activities set forth in paragraphs (C)(1) and (C)(2) of this rule will be identified on claims submitted in accordance with rule 5160-26-05.1 of the Administrative Code;

(2) Progress notes to document the care coordination activities described in this rule, including face-to-face and telehealth meetings with the youth and the youth's family or collateral contacts;

(3) An individual crisis and safety plan for each youth receiving ICC or MCC;

(4) A back-up plan for each youth receiving ICC or MCC who is enrolled in the OhioRISE 1915(c) waiver;

(5) Assessments and child and family-centered care plans, including specifications for standard assessment and plan elements in CME's electronic health records; and

(6) Upon transition of a youth from ICC or MCC to a different care coordination tier, the CME will document the circumstances regarding transition.

(H) Transition from ICC or MCC.

(1) A youth or the youth's guardian may request to transition out of ICC or MCC at their discretion. The CME will notify the OhioRISE plan of the transition request.

(2) The CME or OhioRISE plan may pursue transition of a youth to other care coordination tiers when a CANS assessment or the child and family-centered care plan indicates that the youth's needs are no longer appropriate for the current tier.

(I) Limitations.

(1) The following activities are not reimbursable as ICC or MCC:

(a) Transportation for the youth or family; and

(b) Direct services to which the youth has been referred such as medical, behavioral, educational, or social services.

(2) Reimbursement for substance use disorder targeted case management is not allowable when a youth is enrolled in ICC or MCC.

(J) Reimbursement for MCC and ICC services as described in the rule is listed in Appendix A of this rule.

(K) Reimbursement for a CANS assessment is listed in the Appendix to rule 5160-27-03 of the Administrative Code.

(L) Care coordination activities described in paragraph (C) of this rule may be provided via telehealth in accordance with rule 5160-1-18 of the Administrative Code.

(M) When a youth's OhioRISE eligibility is added for a month that has already passed, the established timeframes for CME activities in paragraph (B) of this rule and care coordination activities in paragraph (C) of this rule will be based on the date the CME receives the referral for care coordination of the youth from the OhioRISE plan.

View Appendix

Last updated January 18, 2024 at 8:35 AM

History

Effective: January 18, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-59-03.3 OhioRISE: intensive home-based treatment service.

(A) Scope. This rule sets forth provisions governing medicaid coverage of intensive home-based treatment (IHBT) services.

(B) Definition. IHBT is the service and activities as set forth by the Ohio department of mental health and addiction services (OhioMHAS) in rule 5122-29-28 of the Administrative Code.

(1) Providers eligible for medicaid payment for IHBT will:

(a) Meet the criteria in paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code; and

(b) Provide the service in accordance with rule 5122-29-28 of the Administrative Code.

(D) Coverage.

(1) Payment may be made for IHBT services rendered face-to-face in person or via telehealth in accordance with rule 5122-29-31 of the Administrative Code.

(2) Payment may be made for services rendered by IHBT staff described in rule 5122-29-28 of the Administrative Code that are eligible as a provider of behavioral health services in accordance with rule 5160-27-01 of the Administrative Code.

(3) Medicaid rates for services described in this rule are listed in the appendix A to this rule.

(E) Limitations.

(1) The following activities are not reimbursable as part of IHBT:

(a) Time spent doing, attending, or participating in recreational activities.

(b) Child care services or services provided as a substitute for the parent or other individual responsible for providing care or supervision.

(d) Transportation for the youth or family.

(e) Any art, movement, dance, drama, or animal therapies, unless incorporated into the IHBT treatment modality.

(f) Services provided to teach academic subjects or as a substitute for educational personnel including, but not limited to a teacher, teacher's aide, or an academic tutor.

(2) A separate medicaid payment will not be made for any of the following services or treatments while the youth is enrolled in IHBT services, unless the service is prior authorized by the OhioRISE plan, or is listed in the child and family-centered care plan:

(a) Behavioral health assessments, screenings, and diagnostic evaluations, except of an Ohio children's initiative "child and adolescent needs and strengths" (CANS) assessment completed in accordance with rule 5160-59-03.2 of the Administrative Code that is separately reimbursable.

(b) Individual, group, or family psychotherapy and counseling.

(c) Therapeutic behavioral services, except for therapeutic behavioral group service - hourly and per diem as defined in rule 5160-27-06 of the Administrative Code.

(d) Community psychiatric supportive treatment as described in rule 5122-29-17 of the Administrative Code.

(e) Psychosocial rehabilitation as described in rule 5160-27-08 of the Administrative Code.

(f) Substance use disorder (SUD) residential treatment services as described in rule 5160-27-09 of the Administrative Code.

(g) Assertive community treatment as described in rule 5160-27-04 of the Administrative Code.

(h) Stabilization services as defined in rule 5160-27-13 of the Administrative Code and rendered by a mobile response and stabilization service (MRSS) provider in accordance with rule 5160-27-13 of the Administrative Code.

(i) SUD targeted case management as described in rule 5160-27-10 of the Administrative Code.

(3) When the OhioRISE plan denies, reduces, terminates or suspends IHBT, this constitutes an adverse benefit determination, and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.

View Appendix

Last updated August 19, 2024 at 8:26 AM

History

Effective: August 16, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-59-03.4 OhioRISE: behavioral health respite service.

(A) This rule sets forth provisions governing coverage for behavioral health respite services delivered as part of the Ohio resilience through integrated systems and excellence (OhioRISE) program.

(B) Definitions. For this rule, the following definitions apply:

(1) "Behavioral health respite services" are services that provide short-term, temporary relief to the primary caregiver of an OhioRISE plan enrolled youth, in order to support and preserve the primary caregiving relationship.

(2) "Foster home" has the same meaning as "certified foster home" in rule 5101:2-1-01 of the Administrative Code.

(3) "Kin" has the same meaning as in rule 5101:2-1-01 of the Administrative Code.

(4) "Public children services agency" (PCSA) has the same meaning as in rule 5101:2-1-01 of the Administrative Code.

(5) "Treatment foster home" has the same meaning as in rule 5101:2-1-01 of the Administrative Code.

(1) Behavioral health respite services can be provided by the following individuals or organizations:

(a) Behavioral health entities operating in accordance with paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code. Rendering practitioners will meet the criteria to be an eligible provider of behavioral health services in accordance with rule 5160-27-01 of the Administrative Code.

(b) The Ohio department of developmental disabilities (DODD)-certified providers of community respite as set forth in rule 5123-9-22 of the Administrative Code;

(d) Family, who do not also meet the definition of "legally responsible family member" as defined in rule 5160-45-01 of the Administrative Code, and who do not reside in the home with the youth;

(e) Natural supports; or

(f) Foster care settings as described in rule 5101:2-47-16 of the Administrative Code that either:

(i) Are not currently fostering other youth; or

(ii) If currently fostering other youth, meets one of the criteria identified in paragraphs (C)(1)(f)(ii)(a) to (C)(1)(f)(ii)(c) of this rule, and the foster caregiver has determined that the youth in need of behavioral health respite services can be safely served together with the youth residing in the home:

(a) Has a relationship, established via a face-to-face meeting, a telephone call, or a video call, with the youth who will receive respite services in the foster home;

(b) Is fostering siblings or kin of the youth who will receive respite services in the foster home; or

(2) Behavioral health respite providers are subject to the criminal records check criteria set forth in rule 5160-45-07 or 5160-45-08 of the Administrative Code, as applicable.

(3) Behavioral health respite providers will obtain and maintain first aid certification from instruction which includes hands-on training by a certified first aid instructor. At its discretion, ODM may accept training conducted by a solely internet-based class as sufficient for the purposes of first aid certification.

(4) Behavioral health respite providers will complete training in trauma-informed care practices as set forth in rule 5101:2-9-42 of the Administrative Code.

(5) Behavioral health respite providers serving an OhioRISE youth with behaviors that pose safety concerns for the youth or others will have been trained in de-escalation strategies that can be used to support the youth and prevent the use of restrictive interventions.

(D) Coverage.

(1) Components of the behavioral health respite service may include:

(a) Assistance with activities of daily living;

(b) Transportation; and

(2) Reimbursement may be made for behavioral health respite when rendered to a youth enrolled in the OhioRISE plan in accordance with rules 5160-59-02, 5160-59-02.1, and 5160-59-04 of the Administrative Code who:

(a) Resides:

(i) With the youth's primary caregiver in a home that is not owned, leased, or controlled by a provider of any health-related treatment or support services;

(ii) In a foster home licensed by the Ohio department of job and family services (ODJFS);

(iii) In the home of kin; or

(iv) In a medically fragile or treatment foster home.

(b) Has behavioral health needs for the behavioral health respite service as determined by the OhioRISE plan.

(3) The behavioral health respite service may be provided either during normal awake hours or overnight. The provider of the behavioral health respite services will be awake when the youth is awake during the provision of behavioral health respite services. The child and family-centered care plan will document when a provider will need to be awake during overnight hours dependent on a youth's assessed needs.

(4) The behavioral health respite service may be provided on a planned or emergency basis. An emergency behavioral health respite service may be provided to address either a primary caregiver's unexpected need for behavioral health respite or to address an urgent need related to the youth's behavioral health diagnosis.

(5) The behavioral health respite service delivery may occur in the following locations:

(a) The primary caregiver's home that is not owned, leased, or controlled by a provider of any health-related treatment or support services;

(b) A qualifying provider's residential setting when approved by the youth's legal guardian;

(d) In the home of kin;

(e) In a treatment foster home certified by ODJFS; or

(f) A community setting in which the general public has access.

(6) Coverage of the behavioral health respite service is subject to authorization by the OhioRISE plan in accordance with rule 5160-59-03.1 of the Administrative Code.

(a) Behavioral health respite services may be authorized in an amount, scope, and duration consistent with the youth's needs and behavioral health history.

(b) Coverage of the behavioral health respite services is based on a determination that the youth's primary caregiver has a demonstrated need for temporary relief from the care of the youth as a result of the youth's behavioral health needs.

(c) The behavioral health respite service is identified on a youth's child and family-centered care plan developed by the care management entity or the OhioRISE plan.

(E) Limitations.

(1) Reimbursement is allowed for behavioral health respite delivered in a foster home or treatment foster home when:

(a) The behavioral health respite need is determined to meet the provisions set forth in this rule for behavioral health respite;

(b) The behavioral health respite service does not duplicate reimbursement for otherwise available respite services in a foster home or treatment foster home;

(d) Title IV-E funding is not used for coverage of the OhioRISE behavioral health respite service.

(2) Reimbursement for behavioral health respite is not allowable when the youth is receiving otherwise available respite services as defined in rules 5160-26-03.2, 5160-44-17, and 5160-59-05.1 of the Administrative Code, or in Chapter 5123-9 of the Administrative Code.

(3) Reimbursement for the behavioral health respite services is not allowable when delivered by the youth's "legally responsible family member" as defined in rule 5160-45-01 of the Administrative Code.

(4) Transportation activities that do not include the provision of behavioral health respite are not reimbursable as behavioral health respite.

(5) When the OhioRISE plan denies, reduces, terminates or suspends behavioral health respite services, this constitutes an adverse benefit determination, and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.

(F) Service documentation for behavioral health respite will include each of the following to validate reimbursement for medicaid services:

(1) Date of service;

(2) Place of service;

(3) Name of youth receiving services;

(4) Medicaid identification number of youth receiving services;

(5) Name of provider;

(6) Provider identifier;

(7) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider;

(8) A summary of the amount, scope, duration, and frequency of services delivered that directly relate to the services specified in the approved child and family-centered care plan to be provided; and

(9) A summary of when restrictive interventions were used including a date, time, the de-escalation techniques used to prevent the restrictive intervention, and whether or not the use of restrictive intervention was included on the individual crisis and safety plan.

Last updated March 18, 2024 at 11:44 AM

History

Effective: March 17, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-59-03.5 OhioRISE: primary flex funds.

(A) Scope. This rule sets forth provisions governing coverage for primary flex funds provided as part of the Ohio resilience through integrated systems and excellence (OhioRISE) program.

(B) Definitions.

(1) "Primary flex funds" are services, equipment, or supplies not otherwise provided through the medicaid state plan benefit or the OhioRISE program that address a youth's identified need as documented in the child and family-centered care plan. Primary flex funds are intended to enhance and supplement the array of services available to a youth enrolled in the OhioRISE program and are discussed, recommended, and implemented through the care coordination process as described in rule 5160-59-03.2 of the Administrative Code.

(2) "Financial management services" (FMS) means an entity contracted with the OhioRISE plan to perform necessary financial transactions on behalf of individuals enrolled in the OhioRISE program

(3) "Participant direction" means the opportunity for a youth enrolled in OhioRISE to exercise choice and control in managing a budget for the applicable service in accordance with their needs.

(4) "Participant-directed budget for primary flex funds" is the OhioRISE enrollee's maximum approved funding for the purchase of primary flex funds under the OhioRISE program.

(1) The provider of primary flex funds will be the FMS entity under contract with the OhioRISE plan to complete the purchase and reimbursement of primary flex funds approved by the OhioRISE plan.

(2) With the exception of paragraph (B)(14) of rule 5160-44-31 of the Administrative Code, the provider will comply with conditions of participation as set forth in rule 5160-44-31 of the Administrative Code.

(D) Coverage.

(1) Coverage of primary flex funds will occur through participant-direction and will incorporate discussion and education with the youth and their primary caregiver of their ability to exercise budget authority during the participant-directed process.

(2) The youth's care coordinator working within a care management entity (CME), or the OhioRISE plan, will assist the youth and their primary caregiver in determining the need for the use of primary flex funds.

(3) The youth's care coordinator working within the CME, or the OhioRISE plan, will document the recommendation for approval of the participant-directed budget for primary flex funds on the child and family-centered care plan as evidence of the necessity of primary flex funds to meet a youth's needs:

(a) The primary flex funds will decrease the need for other Ohio department of medicaid (ODM) services;

(b) The primary flex funds will promote the youth's inclusion in the community; or

(4) The OhioRISE plan will need to approve the youth's requested goods and services, and the participant-directed budget for primary flex funds as part of the child and family-centered care plan prior to use of the service.

(E) Limitations.

(1) The following items are excluded for primary flex funds purchase:

(a) Experimental treatments as outlined in rule 5160-1-61 of the Administrative Code;

(b) Items used solely for entertainment or recreational purposes;

(d) Tobacco or alcoholic products;

(e) Food;

(f) Internet service;

(g) Items of general utility;

(h) More than one of the same item for the same youth unless there is a documented change in the item's condition that warrants replacement;

(i) Home modifications that are of general utility or that add to the total square footage of the home;

(j) Items or treatments that are illegal or otherwise excluded through federal or state regulations; and

(k) The costs of room and board as described in 42 CFR 441.310 (October 1, 2023).

(2) The total available budget for primary flex funds is limited to one thousand five hundred dollars within three hundred sixty-five days.

(3) Approval for primary flex funds by the OhioRISE plan will not occur when:

(a) The youth or their primary caregiver has the funds to purchase the services, equipment, or supplies; or

(b) There is another available funding source for the services, equipment, or supplies.

(4) Primary flex funds will first be submitted for consideration under the medicaid state plan or other available OhioRISE plan services including, but not limited to, value-add services, when the primary flex funds provider is purchasing the item from an active ODM provider of like services.

(5) When the OhioRISE plan denies, reduces, terminates or suspends primary flex funds, this constitutes an adverse benefit determination, and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.

(6) Primary flex funds cannot be given directly to the youth or caregiver for purchase or reimbursement, and neither the youth nor caregiver can be a provider of goods and services purchased with flex funds.

(7) The youth will be the direct recipient of any goods or services purchased using primary flex funds.

(F) Service documentation for primary flex funds will include each of the following to validate reimbursement for medicaid services:

(1) Documentation on the child and family-centered care plan indicating at least one of the concepts in paragraphs (D)(3)(a) to (D)(3)(c) of this rule will be addressed by approving primary flex funds;

(2) An invoice containing the youth's name and medicaid identification number;

(3) A description of the item or service provided;

(4) Identification of the purchaser of service;

(5) The date the item or service was purchased and provided;

(6) The amount paid by the provider for primary flex funds.

Last updated March 18, 2024 at 11:44 AM

History

Effective: March 17, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-59-03.6 Psychiatric residential treatment facility (PRTF) service.

(A) This rule sets forth provisions governing coverage for the psychiatric residential treatment facility (PRTF) service furnished as part of the Ohio resilience through integrated systems and excellence (OhioRISE) program.

(B) Definitions. For purposes of this rule, the following definitions apply:

(1) "Bed hold day" means a day for which a bed is reserved for a resident of a PRTF through medicaid reimbursement while the resident is temporarily absent from the PRTF for hospitalization, therapeutic leave, or a family visit. A youth on bed hold day status is not considered discharged from the PRTF.

(2) "Direct care costs" are costs for services delivered to a resident of a PRTF through a PRTF employee or contractual arrangement with a PRTF. Direct care costs include wages, taxes, supervision, staff development, contracting, and consulting services.

(3) "Family visit" means an authorized overnight absence from the PRTF that allows the youth to spend time with friends or relatives.

(4) "Hospitalization" means transfer of a youth receiving PRTF services to a hospital as defined in Chapter 5160-2 of the Administrative Code. The youth is considered hospitalized if admitted to the hospital as an inpatient or is in an observation status in a hospital.

(5) "PRTF services" include the service and activities described in Chapter 5122-41 of the Administrative Code.

(6) "Therapeutic leave" means a youth is temporarily absent from the PRTF and is in a setting in which the youth is receiving a regimen of therapeutic services that is not duplicative of PRTF services or are services related to facilitating transition planning.

(1) A "PRTF provider" for purposes of Chapter 5160-59 of the Administrative Code is an entity covered in agency 5160 of the Administrative Code that provides psychiatric services to individuals twenty years of age or younger in an inpatient setting; and

(a) Meets the provisions in 42 CFR Part 441 Subpart D and 42 CFR Part 483 Subpart G (October 1, 2025), including participating in survey and certification activities with the Ohio department of health; and

(b) Has current behavioral health accreditation by the joint commission, the commission on accreditation of rehabilitation facilities, or the council on accreditation of services for families and children; and is one of the following:

(i) An entity that is certified as a PRTF in accordance with section 5119.36 of the Revised Code and Chapter 5122-41 of the Administrative Code.

(ii) An entity operating in another state and meeting the provisions set forth in rule 5160-1-11 of the Administrative Code. The entity has to:

(a) Maintain licensure to provide relevant services in the state where the entity operates; and

(b) Provide evidence that the facility is an eligible and enrolled PRTF provider with another state medicaid agency.

(2) A PRTF provider has to be an eligible provider, as defined in rule 5160-1-17 of the Administrative Code.

(a) A PRTF provider will notify the Ohio department of medicaid (ODM) if its license, certification, or accreditation is terminated, suspended, or not renewed within five business days of the action taken against its license or accreditation.

(i) The PRTF provider will be disenrolled as an ODM PRTF provider, effective the license termination date, at least until such time as the license, certification, or accreditation is restored.

(ii) Once the PRTF provider's license, certification, or accreditation is restored by the appropriate agency, the provider will notify ODM for potential reenrollment.

(iii) A PRTF provider will be held liable for recoupment of any monies paid for services during the time that the provider did not possess a valid license, certification, or accreditation.

(b) A provider enrolling or revalidating as an ODM PRTF provider will inform and make available to the department any cited deficiencies issued by, or plans of correction submitted to, any local, state, or federal licensure, accreditation, or certification authorities within the preceding three years.

(c) No facility can enroll or revalidate as an ODM PRTF provider or receive medicaid funds for services furnished before the date on which the facility director signs an attestation that the facility is in compliance with centers for medicare and medicaid services (CMS) provisions regarding restraint, seclusion, and death reporting policies, in accordance with 42 CFR Parts 441 and 483 (October 1, 2025).

(d) A PRTF provider, or its designee, will report incidents in ODM's incident management system. The PRTF will notify the department of any local, state, or federal civil (including licensure, accreditation, or certification) or criminal investigation of the provider related to allegations that, if true, would be an incident as defined in rules 5122-30-16 and 5122-26-13 of the Administrative Code.

(e) A PRTF provider will provide ODM, the resident and guardian (as applicable), and anyone designated by the resident or guardian, written notice at least ninety calendar days prior to a facility closure or voluntary termination of the provider agreement.

(D) Coverage.

(1) Services and activities provided in accordance with Chapter 5122-41 of the Administrative Code to individuals twenty years of age or younger in a PRTF are covered services.

(2) PRTF services do not include hospital services covered in Chapter 5160-2 of the Administrative Code.

(3) PRTF services may continue when a youth is receiving PRTF services upon turning twenty-one years of age until the individual meets discharge or transition criteria or reaches twenty-two years of age, whichever occurs first.

(E) Reimbursement.

(1) The medicaid base per diem reimbursement rate includes medically necessary PRTF services. The per diem rate includes the following:

(a) Room and board;

(b) Treatment, therapeutic, and other services described in rule 5122-41-07 of the Administrative Code;

(d) Staffing to support increases in acuity, extending to the provision of individual supports when necessary;

(e) The services of PRTF staff as attendants during transportation; and

(f) Transportation of the youth to and from family visits or community outings, as is included in the youth's individual plan of care.

(2) The PRTF per diem medicaid rate will be reimbursed for up to three consecutive bed hold days, as defined in paragraph (B) of this rule.

(a) Temporary absences will first be approved by the youth's treatment team, included in the individual plan of care, and planned in consultation with the youth's child and family team as described in rule 5160-59-01 of the Administrative Code.

(b) Payment for bed hold days may be made only if the youth has the intent and ability to return to the same PRTF.

(c) If the therapeutic leave is related to an acute need, the facility will notify the OhioRISE plan within twenty-four hours of the leave event.

(d) Extensions to bed hold days will be authorized in accordance with rule 5160-59-03.1 of the Administrative Code.

(3) Distinct base per diem rates are established for the following types of PRTFs:

(a) Serving youth with cooccurring behavioral health and intellectual or developmental disabilities.

(b) Serving youth in a separate, detached building of six or fewer beds.

(c) Serving youth with cooccurring behavioral health and intellectual or developmental disabilities in a separate, detached building of six or fewer beds.

(d) Serving youth in a facility that does not meet the provisions in paragraph (E)(3)(a), (E)(3)(b) or (E)(3)(c) of this rule.

(4) Services not included in the PRTF per diem reimbursement rate for which a separate medicaid payment may be made include, but are not limited to:

(a) Medical, ancillary, and specialty healthcare services that a nurse is unable to provide onsite rendered by providers who bill medicaid directly.

(b) Direct-care services provided by a practitioner of physician services or hospital services as described in Chapter 5160-2 of the Administrative Code when performed outside of the PRTF.

(c) Community behavioral health services, as defined in Chapter 5160-27 and rules 5160-59-03.3 and 5160-8-05 of the Administrative Code, rendered by a provider outside of the PRTF, when identified in the child and family-centered care plan as necessary for the youth's successful transition to a lower level of care.

(d) Care coordination activities, including administration of the CANS assessment, provided by a care management entity, in accordance with rule 5160-59-03.2 of the Administrative Code, will be reimbursed as described in Chapter 5160-59 of the Administrative Code.

(e) Mobile response and stabilization services provided by a behavioral health provider in accordance with rule 5160-27-13 of the Administrative Code will be reimbursed as described in Chapter 5160-27 of the Administrative Code when it is provided prior to admission to the PRTF or while the youth is on a family visit described in paragraph (B)(3) of this rule.

(f) Drugs and take-home drugs billed in accordance with Chapter 5160-9 of the Administrative Code.

(g) Dental services provided by licensed dentists in accordance with Chapter 5160-5 of the Administrative Code.

(h) Laboratory and x-ray procedures in accordance with Chapter 5160-11 of the Administrative Code.

(i) Vision care services, including examinations, dispensing, and the fitting of eyeglasses, are paid directly to vision care providers in accordance with Chapter 5160-6 of the Administrative Code.

(j) Transportation:

(i) Emergency and non-emergency transportation to and from other healthcare facilities.

(ii) Of the youth's family or guardian to and from the PRTF facility.

(iii) Of a youth transitioning into or out of a PRTF.

(5) Payments for PRTF services will be paid the lesser of billed charges or at the OhioRISE plan contracted per diem rate. The OhioRISE plan contracted per diem rate will be no less than the rate listed on the PRTF fee schedule in effect on the date of services rendered. The PRTF fee schedule is published on the department's website, http://medicaid.ohio.gov/.

(F) Limitations.

(1) PRTF admissions will:

(a) Be requested by the OhioRISE care coordinator upon recommendation of the child and family team;

(b) Document the certification of need described in 42 CFR 441.152; and

(2) Except as described in paragraph (E) of this rule, separate medicaid payment will not be made for community behavioral health services, as defined in Chapter 5160-27 and rule 5160-8-05 of the Administrative Code, by a provider outside of the PRTF, unless the service is prior authorized by the OhioRISE plan.

(3) A PRTF may not accept preadmission payment to reserve a bed from a medicaid-eligible prospective resident or from any other source on the prospective resident's behalf as a precondition for admission.

(4) Educational services and transportation to or from educational services are not reimbursable as a PRTF service.

(5) When the OhioRISE plan denies, reduces, terminates or suspends PRTF services, this constitutes an adverse benefit determination, and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.

Last updated August 10, 2026 at 7:52 AM

History

Effective: August 10, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5160-59-04 OhioRISE home and community-based services waiver: eligibility and enrollment.

(A) To be eligible for the Ohio resilience through integrated systems and excellence (OhioRISE) home and community-based services (HCBS) 1915(c) waiver (waiver), a youth will be determined by the Ohio department of medicaid (ODM) to meet all of the following:

(1) Meet eligibility criteria set forth in paragraphs (A)(1) to (A)(3) of rule 5160-59-02 of the Administrative Code;

(2) Be determined to meet the following level of care (LOC) criteria for an inpatient psychiatric (IP) services through an IP LOC assessment:

(a) For youth age six through twenty years of age have a comprehensive Ohio children's initiative child and adolescent needs and strengths (CANS) assessment, using the tool available on https://www.medicaid.ohio.gov (September 20, 2021), completed by a certified Ohio children's initiative CANS assessor employed by or under contract with the care management entity (CME) described in rule 5160-59-03.2 of the Administrative Code, indicating paragraphs (A)(2)(a)(i), (A)(2)(a)(ii), and either paragraph (A)(2)(a)(iii) or (A)(2)(a)(iv) of this rule are met:

(i) For behavioral/emotional needs domain items, at least two of the following items are dangerous or disabling and need immediate action or three or more of the following items are at least interfering with functioning and need action to ensure that the identified need is addressed:

(A) Psychosis;

(B) Impulsivity/hyperactivity;

(D) Anxiety;

(E) Oppositional behavior;

(F) Conduct;

(G) Adjustment to trauma;

(H) Anger control;

(I) Substance use;

(J) Eating disturbance;

(K) Attachment difficulties;

(L) or Interpersonal problems (for youth age fourteen and older).

(ii) For risk behaviors domain items, at least one of the following items are dangerous or disabling and need immediate action or two or more of the following items are at least interfering with functioning and need action to ensure that the identified need is addressed:

(A) Suicide risk;

(B) Non-suicidal self-injury behavior;

(D) Danger to others;

(E) Delinquent behavior;

(F) Runaway;

(G) Intentional misbehavior;

(H) Fire setting;

(I) Victimization/exploitation;

(J) Sexually problematic behavior.

(iii) For the caregiver resources and needs domain, at least one of the following items is dangerous or disabling and needs immediate action or two or more of the following items are at least interfering with functioning and need action to ensure that the identified need is addressed:

(A) Supervision;

(B) Residential stability;

(D) Mental health;

(E) Substance use;

(F) Family stress;

(G) Knowledge;

(H) Caregiver post-traumatic reactions.

(iv) The youth has no current viable caregiver.

(b) For youth age birth through five years of age, have a comprehensive Ohio children's initiative CANS assessment, using the tool available on https://www.medicaid.ohio.gov (September 20, 2021), completed by a certified Ohio children's initiative CANS assessor employed by or under contract with the CME described in rule 5160-59-03.2 of the Administrative Code, indicating paragraphs (A)(2)(b)(i), (A)(2)(b)(ii), and either paragraph (A)(2)(b)(iii) or (A)(2)(b)(iv) of this rule are met:

(i) For early childhood domain items, at least two of the following items are dangerous or disabling and need immediate action or three or more of the following items are at least interfering with functioning and need action to ensure that the identified need is addressed:

(A) Impulsivity/hyperactivity;

(B) Depression;

(D) Oppositional behavior;

(E) Adjustment to trauma;

(F) Regulatory;

(G) Sleep.

(ii) For risk behavior and functioning domain items, at least two of the following items are dangerous or disabling and need immediate action or three or more the following items are at least interfering with functioning and need action to ensure that the identified need is addressed:

(A) Self-harm;

(B) Exploited;

(D) Aggressive behavior;

(E) Family functioning;

(F) Social and emotional functioning;

(G) Early education.

(A) Supervision;

(B) Residential stability;

(D) Mental health;

(E) Substance use;

(F) Family stress;

(G) Knowledge;

(H) Caregiver post-traumatic reactions.

(iv) The youth has no current viable caregiver.

(c) Have a diagnosis of serious emotional disturbance (SED) as defined in rule 5122-24-01 of the Administrative Code, which needs to be documented through one of the following:

(i) A diagnostic assessment dated no more than two years prior to the date of application for the OhioRISE waiver with an applicable SED diagnosis performed by a licensed practitioner operating within their scope of practice; or

(ii) A treatment plan showing an applicable SED diagnosis signed by the licensed clinician that is the treating provider dated no more than two years prior to the date of application for the OhioRISE waiver, accompanied by the diagnostic assessment that resulted in the applicable SED diagnosis performed by a licensed clinician.

(d) Have documented functional impairment and behaviors that substantially interfere with or limit the youth's role or functioning in family, school, or community activities which result in recommended institutionalization and potential relinquishment of custody to the child welfare system. Documented functional impairment and behaviors are indicated by the youth's CANS scores or by separate documentation provided by the youth or caregiver, and needs to include one or more of the following:

(i) Youth's persistent physical abuse or violence that results in physical injury or emotional distress to caregivers, family members, others in the home and community; or physical destruction of property that impacts the youth's housing stability.

(ii) Youth's history of suicidal ideation with intent, or history of suicide attempts, within the past six months.

(iii) Youth's sexually problematic behavior that creates a safety risk for themselves or others without a high-level of direct supervision.

(iv) Youth's suspension or expulsion from school; or withdrawal from school, daycare, or preschool program as the result of the youth's actions/intensive behaviors.

(v) Law enforcement or child welfare contact or involvement due to the youth's intensive behaviors.

(vi) Youth has a history of victimization or exploitation, including human trafficking within the past twelve months, and re-victimization may be imminent. This may include physical or sexual abuse, sexual exploitation, or violent crime.

(3) Have a completed IP LOC assessment as follows:

(a) A LOC assessment determining a youth meets an IP LOC will be completed prior to initial enrollment on the waiver;

(b) A LOC assessment determining a youth meets an IP LOC will be completed within three hundred sixty-five calendar days of the previous LOC assessment for continued enrollment on the waiver; and

(c) Once enrolled in the waiver, all youth who experience a significant change in situation impacting health and welfare will receive an IP LOC assessment following the event to determine continued enrollment on the waiver.

(4) Be determined to have a need for, and agree to receipt of, at least one service available under the waiver that is otherwise unavailable through another source (including, but not limited to private pay, community resources, or the medicaid state plan). If a youth is anticipated to need waiver services less frequently than every thirty calendar days, the care coordinator is to indicate on the child and family-centered care plan the method of monitoring they will employ on at least a monthly basis to assure that the youth's health and welfare needs are met.

(5) Have waiver needs which are less than or equal to the waiver services cost cap of fifteen thousand dollars in a twelve-month period. Once enrolled in the waiver, youth may have access to additional emergency funding as described in rule 5160-59-05.3 of the Administrative Code.

(6) Have been informed of, as recorded during the course of an assessment or in an alternative manner at the discretion of ODM, all of the following:

(a) Service alternatives including the choice and election to receive services on an HCBS program in lieu of institutional services; and

(b) Choice of providers who meet provider qualifications as described in Chapter 5160-59 of the Administrative Code to provide services under the waiver.

(7) Have needs that can be safely met in an HCBS setting through the waiver as determined by ODM or its designee.

(8) Meet the following age criteria:

(a) Be between the ages of birth and twenty years of age at the time of initial enrollment; and

(b) Once enrolled, youth may continue enrollment on the waiver through the age of twenty-two, so long as the youth meets the other eligibility criteria set forth in paragraphs (A) and (B) of this rule.

(9) Agrees to participate in the waiver, and while enrolled in the waiver, will not be simultaneously enrolled in another HCBS 1915(c) waiver or the specialized recovery services program as defined in rule 5160-43-01 of the Administrative Code.

(B) Once eligibility to the OhioRISE waiver has been determined and before the OhioRISE waiver services described in rule 5160-59-05 of the Administrative Code can be provided, the youth will:

(1) Participate in the development and implementation of the child and family-centered care plan in accordance with the process and criteria set forth in rule 5160-44-02 of the Administrative Code. The youth or their authorized representative will consent to the child and family-centered plan by signing and dating it by the thirtieth calendar day of eligibility; and

(2) Reside, and will continue to reside, in a setting that possesses the home and community-based setting characteristics set forth in rule 5160-44-01 of the Administrative Code. The youth may reside in a setting that does not meet the characteristics of a home and community-based setting while the waiver assessment process is being conducted. The waiver assessment process can begin up to ninety days prior to the youth residing in a home and community-based setting, as follows:

(a) The youth needs to reside with family or friends in a private residence, including family foster homes as defined in rule 5101:2-1-01 of Administrative Code; or

(b) The youth needs to reside alone in a private residence, when living alone is appropriate in the context of the youth's developmental needs and family or caregiver needs.

(C) All youth enrolled into the OhioRISE waiver will be automatically enrolled with a managed care organization as defined in rule 5160-26-01 of the Administrative Code except for those excluded from managed care enrollment as defined in paragraph (B)(5) of rule 5160-26-02 of the Administrative Code.

(D) If, at any time, a youth does not meet any of the eligibility criteria set forth in paragraphs (A) and (B) of this rule, with the exception of paragraph (A)(8)(b) of this rule, the youth will be denied enrollment to, or be disenrolled from, the waiver.

(E) If a youth resides in an institution as described in rule 5160-44-01 of the Administrative Code:

(1) For more than ninety consecutive days, the following will occur:

(a) The OhioRISE plan will assess the youth for potential disenrollment from the OhioRISE waiver.

(b) If the institution is an intermediate care facility for individuals with intellectual disabilities, the OhioRISE plan will initiate disenrollment from the OhioRISE waiver.

(2) For longer than one hundred eighty consecutive days, the OhioRISE plan will initiate disenrollment from the OhioRISE waiver.

(F) When a youth is disenrolled from the waiver for any reason, the following will occur:

(1) Dependent in which care coordination tier a youth is enrolled, in accordance with rule 5160-59-03.2 of the Administrative Code, either the care management entity (CME) or the OhioRISE plan will work to develop a transition of care plan at least thirty calendar days prior to disenrollment.

(2) Either the CME or the OhioRISE plan will work to identify needed supports for the ninety calendar days following disenrollment from the OhioRISE program.

(G) When a youth is denied enrollment to, or disenrolled from, the waiver for failure to meet eligibility criteria as set forth in paragraph (A) or (B) of this rule, the youth or their authorized representative will be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

(H) The number of individuals enrolled in the waiver program will not exceed the centers for medicare and medicaid services authorized limit for the waiver program year.

Last updated June 23, 2025 at 1:35 PM

History

Effective: June 23, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-59-05 OhioRISE home and community-based services waiver: covered services and providers.

(A) This rule establishes the services available under the Ohio resilience through integrated systems and excellence (OhioRISE) home and community-based services (HCBS) waiver program (waiver) established in accordance with 1915(c) of the Social Security Act 42 U.S.C. 1396n (January 1, 2025), and the providers eligible to deliver those services to youth enrolled on the waiver.

(B) Providers seeking to deliver services in the waiver program will meet the criteria in Chapter 5160-59 and rules 5160-44-02 and 5160-44-31 of the Administrative Code, as appropriate. Upon prior approval by the Ohio department of medicaid (ODM), providers that have responsibility for developing the child and family-centered care plan for a youth can provide other direct OhioRISE 1915(c) waiver services to that youth.

(C) Prior to a qualified waiver provider delivering services to waiver recipients, the services will be documented on the youth's child and family-centered care plan as described in Chapter 5160-59 of the Administrative Code and approved by the OhioRISE plan. The child and family-centered care plan will be developed in accordance with person-centered practices as set forth in rule 5160-44-02 of the Administrative Code.

(D) Waiver covered services are limited to the following and are subject to any reimbursement provisions in the Ohio Administrative Code rules cited therein:

(1) Out-of-home respite as set forth in rule 5160-59-05.1 of the Administrative Code;

(2) Transitional services and supports as set forth in rule 5160-59-05.2 of the Administrative Code; and

(3) Secondary flex funds as set forth in rule 5160-59-05.3 of the Administrative Code. Secondary flex funds service is subject to participant-direction through budget authority.

(E) When the OhioRISE plan denies, reduces, terminates or suspends an OhioRISE waiver service, this constitutes an adverse benefit determination, and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.

Last updated November 5, 2025 at 8:40 AM

History

Effective: October 13, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-59-05.1 OhioRISE home and community-based services waiver: out-of-home respite.

(A) Scope. This rule sets forth provisions governing coverage for out-of-home respite services delivered as part of the Ohio resilience through integrated systems and excellence (OhioRISE) 1915(c) waiver program (waiver) established in accordance with 1915(c) of the Social Security Act, 42 U.S.C. 1396n (January 1, 2022).

(B) Definitions. For this rule, the following definitions apply:

(1) "Community respite" has the same meaning as set forth in rule 5123-9-22 of the Administrative Code.

(2) "Intermediate care facility for individuals with intellectual disabilities" (ICF/IID) has the same meaning as set forth in section 5124.01 of the Revised Code.

(3) "Out-of-home respite" is a service provided to youth unable to care for themselves who are enrolled on the waiver. The service is provided on a short-term basis because of the absence or need for relief of those persons who normally provide care for the youth.

(4) "Residential respite" has the same meaning as set forth in rule 5123-9-34 of the Administrative Code.

(1) The following providers are eligible to provide the out-of-home respite service available under the waiver program:

(a) An ICF/IID who is certified by the Ohio department of health (ODH), holds certification with the Ohio department of developmental disabilities (DODD) as a residential respite provider as set forth in rule 5123-9-34 of the Administrative Code, and has an active license with DODD.

(b) An agency provider holding certification for DODD community respite services as set forth in rule 5123-9-22 of the Administrative Code.

(c) A class one residential facility licensed by Ohio MHAS in accordance with Chapter 5122-30 of the Administrative Code.

(2) With the exception of paragraph (B)(14) of rule 5160-44-31 of the Administrative Code, out-of-home respite providers will comply with conditions of participation as set forth in rule 5160-44-31 of the Administrative Code.

(3) Out-of-home respite providers will obtain and maintain first aid certification from instruction which includes hands-on training by a certified first aid instructor. At its discretion, ODM may accept training conducted by a solely internet-based class as sufficient for the purposes of first aid certification.

(4) Out-of-home respite providers serving an OhioRISE youth with behaviors that pose safety concerns for the youth or others, will be trained in de-escalation strategies that can be used to support the youth and prevent the use of restraints, seclusion, and restrictive interventions.

(5) Out-of-home respite providers serving an OhioRISE youth with an individual crisis and safety plan including the use of restraints, seclusion, or restrictive intervention will have been trained in the appropriate use of restraints, seclusion, and restrictive interventions.

(6) Out-of-home respite providers will retain all initial and subsequent child and family-centered care plans.

(7) Out-of-home respite providers are subject to compliance reviews specific to their licensure or certification criteria in addition to ongoing monitoring conducted by the OhioRISE plan.

(D) Coverage.

(1) The out-of-home respite service may be provided on a planned or emergency basis. An emergency out-of-home respite service may be provided to address either a primary caregiver's unexpected need for out-of-home respite or to address an urgent need related to the youth.

(2) Service delivery is not permitted in the youth's primary residence.

(3) The out-of-home respite service available under the waiver program is additive to the behavioral health respite service as set forth in rule 5160-59-03.4 of the Administrative Code.

(4) The youth's care coordinator working within the care management entity (CME), as defined in rule 5160-59-01 of the Administrative Code, or OhioRISE plan, will assist the youth and their primary caregiver in determining the need for the use of planed and emergency out-of-home respite.

(5) The youth's care coordinator working within the CME, as defined in rule 5160-59-01 of the Administrative Code, or OhioRISE plan may recommend planned and emergency out-of-home respite, as well as the providers of out-of-home respite services, as part of the child and family-centered care plan.

(6) The OhioRISE plan will need to approve out-of-home respite service as part of the child and family-centered care plan prior to receipt and reimbursement of out-of-home respite service.

(E) Limitations.

(1) The out-of-home respite service will not be provided to a youth prior to establishment of initial or ongoing enrollment and eligibility criteria for the waiver as set forth in rule 5160-59-04 of the Administrative Code.

(2) The out-of-home respite service will be provided only to a youth enrolled on the waiver at the time of service delivery.

(3) The out-of-home respite service is available for a total of ninety calendar days within a three hundred-sixty-five day period while a youth is enrolled on the waiver. Dependent on the care coordination tier a youth is enrolled, in accordance with rule 5160-59-03.2 of the Administrative Code, either the CME care coordinator or the OhioRISE care coordinator is responsible for tracking and maintaining records for the purposes of tracking out-of-home respite utilization within each three hundred sixty-five -day period.

(4) Reimbursement for out-of-home respite is not allowable on the same day when the youth is receiving behavioral health respite as set forth in rule 5160-59-03.4 of the Administrative Code.

(5) When the OhioRISE plan denies, reduces or terminates or suspends out-of-home respite services, this constitutes an adverse benefit determination and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.

(F) Service documentation for out-of-home respite will include each of the following to validate reimbursement for medicaid services:

(1) Date of service;

(2) Place of service;

(3) Name of youth receiving services;

(4) Medicaid identification number of youth receiving services;

(5) Name of provider;

(6) Provider identifier;

(7) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider; and

(8) A summary of the amount, scope, duration, and frequency of services delivered that directly relate to the services specified in the approved child and family-centered care plan to be provided.

(9) A summary of when restraints, seclusion, and restrictive interventions were used including a date, time, the de-escalation techniques used to prevent the restraints, seclusion, and restrictive interventions and whether or not the use of restraints, seclusion, and restrictive interventions was included on the individual crisis and safety plan.

(G) Reimbursement.

(1) Only one provider may bill out-of-home respite for the same youth on any given day.

(2) Reimbursement for the out-of-home respite service does not include room and board.

(3) Reimbursement for the out-of-home respite service does not include transportation costs.

Last updated July 7, 2026 at 9:18 AM

History

Effective: March 17, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5160-59-05.2 OhioRISE home and community-based services waiver: transitional services and supports.

(A) Scope. This rule sets forth provisions governing coverage for transitional services and supports provided as part of the Ohio resilience through integrated systems and excellence (OhioRISE) waiver program (waiver) established in accordance with 1915(c) of the Social Security Act 42, U.S.C. 1396n (January 1, 2025).

(B) Definitions. For this rule, the following definitions apply:

(1) "Homemaker/personal care" has the same meaning as set forth in rule 5123-9-30 of the Administrative Code.

(2) "Transitional services and supports" (TSS) is a service designed to provide family stability supports for the youth, primary caregiver and family as a pathway to creating a stable environment for the youth and the family that lives in the home. It is meant to assist the youth, in conjunction with their family/primary caregiver, as a means to overcome the functional limitations as identified due to the result of the youth's intensive behaviors. TSS is used to support youth and their caregivers in understanding, mitigating, and transitioning to long term solutions for behavior challenges. TSS is used to support a youth and their caregiver to stabilize during a transition of care and is not intended to de-escalate crises. TSS is an additional service for OhioRISE 1915(c) waiver enrollees and is limited to care not otherwise covered under the state plan, including early and periodic screening, diagnostic, and treatment (EPSDT) covered services set forth in rule 5160-1-14 of the Administrative Code.

(1) The following providers are eligible to provide TSS under the waiver program:

(a) An entity operating in accordance with paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code. Eligible rendering practitioners employed by or under contract with the entity include those described in paragraph (A)(3), (A)(4), (A)(5), or (A)(6)(a) of rule 5160-27-01 of the Administrative Code.

(b) An agency provider holding certification for homemaker/personal care services in accordance with rule 5123-9-30 of the Administrative Code.

(c) An individual provider who meets the criteria of an independent practitioner or licensed psychologist as described in rule 5160-8-05 of the Administrative Code.

(d) An individual provider holding certification for homemaker/personal care services in accordance with rule 5123-9-30 of the Administrative Code.

(e) A care management entity (CME) acting in accordance with rule 5160-59-03.2 of the Administrative Code. Eligible rendering practitioners employed by or under contract with the entity include those described in paragraph (A)(3), (A)(4), (A)(5), or (A)(6)(a) of rule 5160-27-01 of the Administrative Code.

(2) Providers who hold certification for homemaker/personal care services, as designated in paragraphs (C)(1)(b) and (C)(1)(d) of this rule, will also complete behavioral health support trainings sponsored by the Ohio department of developmental disabilities (DODD) or an Ohio department of medicaid (ODM) approved behavioral health training prior to rendering the TSS service.

(3) With the exception of paragraph (B)(14) of rule 5160-44-31 of the Administrative Code, providers will comply with conditions of participation as set forth in rule 5160-44-31 of the Administrative Code.

(4) TSS providers will obtain and maintain first aid certification from an instruction which includes hands-on training by a certified first aid instructor. At its discretion, ODM may accept training conducted by a solely internet-based class as sufficient for the purposes of first aid certification.

(5) TSS providers serving an OhioRISE youth with behaviors that pose safety concerns for the youth or others will have been trained in de-escalation strategies that can be used to support the youth and prevent the use of restraints, seclusion, and restrictive interventions.

(6) TSS providers serving an OhioRISE youth with an individual crisis and safety plan including the use of restraints, seclusion, or restrictive intervention will be trained in the appropriate use of restraints, seclusion, and restrictive interventions.

(7) TSS providers will retain all initial and subsequent child and family-centered care plans.

(8) TSS providers are subject to compliance reviews specific to conditions of their licensure or certification in addition to ongoing monitoring conducted by the OhioRISE plan.

(9) For youth under age eighteen, authorized representatives, legal guardians, birth parents, adoptive parents, foster parents, and stepparents of the OhioRISE-enrolled youth are prohibited from providing or receiving payment for TSS services.

(D) Coverage.

(1) Primary components of the TSS service may include:

(a) Training the youth and family or caregivers in behavior stabilization techniques related to the youth's serious emotional disturbance diagnosis;

(b) Working with the youth and family or caregivers to identify triggers and develop person-centered approaches for preventing behavioral crisis prior to occurrence;

(d) Training and skill-building for families and caregivers regarding mitigation and support techniques for when crises occur;

(e) Training and skill-building for families and caregivers to understand and implement positive coping strategies to directly address crisis or escalation of risk behaviors;

(f) Acting as a conduit between the family or caregivers, the youth and the youth's care coordinator to assist in system navigation;

(g) Assistance to the youth with engagement in the broader community; and

(h) Assistance to the youth and family or caregivers with coping skills both in home and community settings.

(2) Other family stability supports activities related to youth and family or caregivers; stabilization and transition beyond those listed in paragraph (D)(1) of this rule may be considered as permissible tangential activities allowable under the TSS service only when approved by the OhioRISE plan as part of the child and family-centered care plan prior to a provider rendering and receiving reimbursement for the service.

(3) When there is a demonstrated need, staffing may be provided to a youth at a ratio of up to two to one when documented on the child and family-centered plan and approved by the OhioRISE plan.

(4) The TSS service may be made available within twenty-four hours upon a change in circumstance or qualifying condition as described in paragraph (E) of this rule.

(5) The youth's care coordinator working within the CME or OhioRISE plan will assist the youth and their primary caregiver in determining the need for the TSS service.

(6) The youth's care coordinator working within the CME or OhioRISE plan may recommend TSS services, as well as the providers of TSS, as part of the child and family-centered care plan.

(7) The OhioRISE plan will need to approve TSS services as part of the child and family-centered care plan prior to receipt and reimbursement of the TSS service.

(E) Limitations.

(1) The TSS service will only be provided to youth meeting eligibility criteria for the waiver as set forth in rule 5160-59-04 of the Administrative Code and who are enrolled on the waiver at the time of service delivery.

(2) The TSS service will not be provided to a youth prior to establishment of initial or ongoing enrollment and eligibility criteria for the waiver as set forth in rule 5160-59-04 of the Administrative Code.

(3) The TSS service will assist a youth who experiences changes in circumstances or qualifying conditions, which include but are not limited to:

(a) Within twenty-four hours of the youth enrolling on the waiver following a discharge from one of the following settings:

(i) A psychiatric residential treatment facility (PRTF) as described in 42 C.F.R. 441.150 (October 1, 2024) through 42 C.F.R 441.184 (October 1, 2024);

(ii) An intermediate care facility for individuals with an intellectual disability (ICF/IID) as defined in section 5124.01 of the Revised Code;

(iii) An inpatient psychiatric hospital as defined in 42 CFR 440.160 (October 1, 2024);

(iv) A residential facility as defined in rule 5122-30-03 of the Administrative Code; or

(v) A qualified residential treatment program (QRTP) as described in rule 5101:2-9-42 of the Administrative Code.

(b) Within twenty-four hours of when the youth is transitioning between custodians or caregivers, for example, following a transition into a kinship caregiver's home.

(4) Reimbursement may be made for the TSS service when rendered by a provider in accordance with paragraph (C) of this rule to a youth enrolled in the OhioRISE 1915(c) waiver program in accordance with rule 5160-59-04 of the Administrative Code.

(5) When determined eligible for the OhioRISE 1915(c) waiver, the initial seventy-two hours will be approved with the child and family-centered care plan, or until other appropriate behavioral health service provided under the OhioRISE plan are scheduled to begin, or whichever occurs first. When the TSS service is needed beyond a seventy-two hour period, the child and family-centered care plan will need to be updated, reviewed, and approved by the OhioRISE plan prior to additional TSS services being provided.

(6) When the OhioRISE plan denies, reduces, terminates or suspends TSS services, this constitutes an adverse benefit determination and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.

(F) Service documentation for TSS will include each of the following to validate reimbursement for medicaid services:

(1) Date of service;

(2) Place of service;

(3) Name of youth receiving service;

(4) Medicaid identification number of youth receiving service;

(5) Name of provider;

(6) Provider identifier;

(7) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider; and

(8) A summary of the amount, scope, duration, and frequency of services delivered that directly relate to the services specified in the approved child and family-centered care plan to be provided.

Last updated November 5, 2025 at 8:40 AM

History

Effective: October 13, 2025
Promulgated Under: 119.03

Ohio Adm.Code 5160-59-05.3 OhioRISE home and community-based services waiver: secondary flex funds.

(A) Scope. This rule sets forth provisions governing coverage for secondary flex funds delivered as part of the Ohio resilience through integrated systems and excellence (OhioRISE) 1915(c) waiver program (waiver) established in accordance with 1915(c) of the Social Security Act, 42 U.S.C. 1396n (January 1, 2022).

(B) Definitions. For this rule, the following definitions apply:

(1) "Emergency funds" are an additional allotment of waiver funding used for the purchase of approved secondary flex funds based on a youth's unmet needs as determined by the OhioRISE plan.

(2) "Participant direction" means the opportunity for an OhioRISE waiver youth to exercise choice and control in managing a budget for the applicable waiver service in accordance with their needs.

(3) "Participant-directed budget for secondary flex funds" is the waiver-enrolled youth's maximum approved, non-emergency funding allowable for the purchase of secondary flex funds under the OhioRISE 1915(c) waiver.

(4) "Secondary flex funds" is defined as the additional services, equipment, or supplies available through the waiver that are not otherwise provided through the medicaid state plan benefit or the OhioRISE program that address a youth's identified need as documented in the child and family-centered care plan. Secondary flex funds are intended to enhance and supplement the array of services available to a youth enrolled on the OhioRISE program and are discussed, recommended, and implemented through the care coordination process as described in rule 5160-59-03.2 of the Administrative Code. Secondary flex funds is inclusive of emergency funds and the participant-directed budget as described in this rule.

(5) "Waiver cost limit" is the maximum amount of funding, excluding emergency funds, available to a youth enrolled in the waiver. The waiver cost limit for the waiver is fifteen thousand dollars per twelve month period.

(C) With the exception of additional criteria defined in paragraph (D) of this rule, all provisions of rule 5160-59-03.5 of the Administrative Code apply to secondary flex funds provided under the waiver.

(D) The following additional criteria apply to secondary flex funds provided under the waiver:

(1) The total participant-directed budget for secondary flex funds is limited to three thousand dollars within three hundred sixty-five calendar days. The participant-directed budget is included in the waiver cost limit.

(2) The waiver enrolled youth may access up to the total participant-directed budget for secondary flex funds when all primary flex funds, described in rule 5160-59-03.5 of the Administrative Code, provided under the OhioRISE plan are exhausted.

(3) The total emergency funds available to a youth is limited to two thousand dollars within three hundred sixty-five days calendar days. Emergency funds are not included in the waiver cost cap.

(a) Emergency funds are only available to a youth when the youth has exhausted all primary flex funds, as described in rule 5160-59-03.5 of the Administrative Code, and all available funds in their participant-directed budget, and still have a demonstrated need which may be met through the emergency funds available under secondary flex funds.

(b) The youth's unmet need and desired outcome, resulting from the use of emergency funds, will be detailed in the child and family-centered care plan.

(4) Secondary flex fund services are additive to the primary flex funds described in rule 5160-59-03.5 of the Administrative Code.

(5) The OhioRISE plan will need to approve the waiver enrolled youth's participant-directed budget for secondary flex funds as part of the child and family care plan prior to use of the service.

(6) When the OhioRISE plan denies, reduces, terminates or suspends secondary flex funds services, this constitutes an adverse benefit determination, and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.

Last updated July 7, 2026 at 9:18 AM

History

Effective: July 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5160-59-07 Psychiatric residential treatment facility (PRTF): cost reports.

For cost reporting purposes, each eligible psychiatric residential treatment facility (PRTF), as defined in Chapter 5160-59 of the Administrative Code, is to submit cost reports that cover a consecutive twelve-month period of the provider's operations as designated by the department.

(A) Effective for medicaid cost reports filed for cost-reporting periods ending in state fiscal year (SFY) 2024, the PRTF will annually complete and submit the ODM 10278 "Ohio Medicaid Psychiatric Residential Treatment Facility (PRTF) Cost Report" that is applicable to the state fiscal year and each state fiscal year thereafter. The PRTF's cost report will:

(2) Be submitted in accordance with the cost report instructions.

(3) Include the cost report certification executed by an officer of the PRTF attesting to the accuracy of the cost report. In addition, all subsequent revisions to the cost report will include an executed certification.

(4) Unless waived by ODM, the reporting period begins July first of each year and ends as follows:

(a) On June thirtieth the following year; or

(b) On the last day of medicaid participation or when the facility closes in accordance with paragraph (A)(1) of rule 5160-3-02 of the Administrative Code; or

(5) The cost report is to be submitted on or before December thirty-first of the same calendar year the reporting period ends or ninety days after reporting periods that end as described in paragraphs (A)(4)(b) and (A)(4)(c) of this rule.

(B) Unless an extension is granted by the Ohio department of medicaid (ODM), PRTF cost reports should be filed via the electronic means designated by ODM.

(2) In the case of a PRTF that has a change of operator during a reporting year, the cost report by the new provider should cover the portion of the reporting year following the change of operator encompassed by the first day of participation up to and including June thirtieth.

(3) In the case of a PRTF that begins participation after July first and ceases participation before June thirtieth of the same reporting year, the reporting period should be the first day of participation to the last day of participation.

(4) If a cost report is not received by the original due date, or by an approved extension due date if applicable, the provider may be assessed a late file penalty for each day a complete and adequate cost report is not received. The late file penalty may be assessed even if ODM has provided written notice of termination to a facility. For the purposes of this paragraph, a PRTF will be treated the same as a nursing facility as defined in Chapter 5160-3 of the Administrative Code and the penalty assessed will be determined with the same methodology described in paragraph (B) of rule 5160-3-20 of the Administrative Code.

(C) The desk review is a process of reviewing information pertaining to the cost report without detailed verification and is designed to identify problems warranting additional review. Desk review procedures will take into consideration the relationship between the prior year's costs and the current year's reported costs.

(1) A facility may revise the cost report within sixty days after the original due date without the revised information being considered an amended cost report.

(2) The cost report is considered accepted after the cost report has passed the desk review process.

(3) Adjustments made by ODM do not preclude findings of additional cost exceptions issued as the result of an audit as described in paragraph (E) of this rule.

(D) Cost reports shall be completed using accrual basis accounting and generally accepted accounting principles.

(E) Audits.

ODM or its designee will perform field audits of the most current cost report for each PRTF at least once every three years or more often as determined by ODM. Cost reports for other periods may also be audited within three years from the fiscal year end, unless justified from previous audit findings. ODM will use a full or limited scope audit.

(1) The audits will be performed in accordance with auditing standards adopted by ODM.

(2) ODM will develop a risk-based methodology to determine which PRTFs are subject to audit.

(3) The audit scope will be determined by ODM and will be sufficient to determine if costs reflected in the cost report are accurate, made in compliance with pertinent regulations, and based on actual cost.

Last updated October 2, 2023 at 8:26 AM

History

Effective: October 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5160-59-09 The OhioRISE program: incident management.

This rule sets the standards and procedures for managing incidents that may have a negative impact on youths. The purpose of this rule is to establish the procedures for reporting and addressing critical incidents and reportable incidents and to prevent and reduce the risk of harm to youths.

(A) For the purposes of this rule, the following definitions apply:

(1) "Care management entity" or "CME" means the agency described in rule 5160-59-03.2 of the Administrative Code.

(2) "Incident" means as defined in rule 5160-44-05 of the Administrative Code.

(3) "Incident management system" means as defined in rule 5160-44-05 of the Administrative Code.

(4) "Youth" means a person enrolled in the Ohio resilience through integrated systems and excellence (OhioRISE) program.

(5) "Individual crisis and safety plan" means as defined in rule 5160-59-01 of the Administrative Code.

(6) "Restraint" means any of the following:

(a) Chemical restraint, which is the use of any sedative psychotropic drug exclusively to manage or control behavior;

(b) Mechanical restraint, which is the use of any device to restrict a youth's movement or function for any purpose other than positioning or alignment;

(c) Physical restraint, which is the use of a hands-on or physical method to restrict the movement or function of a youth's head, neck, torso, one or more limbs, or the entire body.

(7) "Restrictive intervention" means any action or activity that limits a youth's right for a period of time to assure a youth's health, safety, or welfare. Restrictive intervention may only be used to safeguard youths from accident or injury or to help promote optimal health and welfare.

(8) "Seclusion" means any restriction that is used to address a specified behavior and that prevents the youth from leaving a location for a period of time.

(9) "Substantiated" means as defined in rule 5160-44-05 of the Administrative Code.

(10) "Unauthorized restraint" means as defined in rule 5160-44-05 of the Administrative Code.

(11) "Unauthorized restrictive intervention" means as defined in rule 5160-44-05 of the Administrative Code.

(12) "Unauthorized seclusion" means as defined in rule 5160-44-05 of the Administrative Code.

(B) The following incidents defined in paragraph (B) or rule 5160-44-05 of the Administrative Code will be reported and investigated as described in paragraph (D) of this rule:

(1) Critical incidents:

(a) Abuse.

(b) Behavioral support misuse.

(d) Exploitation.

(e) Misappropriation.

(f) Unnatural or accidental death.

(g) Self-harm or suicide attempt.

(h) Medication error.

(i) The health and welfare of the youth is at risk due to the youth being lost or missing.

(2) Reportable incidents: natural death.

(C) This rule applies to youth enrolled in the OhioRISE program or the OhioRISE waiver who were not receiving treatment in a psychiatric residential treatment facility (PRTF) at the time the incident occurred, Incidents that occurred while a youth was receiving treatment in a PRTF are reported per rule 5160-59-03.6 of the Administrative Code.

(D) The following process will be followed upon the occurrence of an incident.

(1) Initial incident report.

(a) Upon discovering an incident, ODM, its delegates, CMEs, and providers of services under the OhioRISE program will:

(i) Take immediate action to ensure the health and welfare of the youth.

(ii) Report the incident to the OhioRISE plan immediately upon discovery of the incident, but no later than one business day after discovering the incident, unless bound by federal, state, or local law, or the requirements of professional licensure or certification to report sooner to the applicable statutory entity.

(b) All incident reports will include the following information when available:

(i) The facts relevant to the incident;

(ii) A description of what happened;

(iii) The incident type;

(iv) The date of the incident;

(v) The location of the incident;

(vi) The names and contract information of all persons involved; and

(vii) All actions taken to ensure the health and welfare of the youth.

(2) Receipt of report and documentation of the incident.

(a) Upon becoming aware of an incident, the OhioRISE plan, or its designee, will:

(i) Ensure immediate action was take to protect the health and welfare of the youth. If such action was not taken, take action immediately, but no later than twenty-four hours after the report was received.

(ii) Notify all of the appropriate entities with investigative or protective authority, and the appropriate additional regulatory, oversight, or advocacy agencies including but not limited to:

(a) Local law enforcement if the incident involves suspected criminal conduct;

(b) The local coroner's office when the death of a youth is reportable in accordance with section 313.12 of the Revised Code;

(d) The local child protective services agency (CPS);

(e) The local adult protective services agency (APS);

(f) The Ohio department health, or other licensure or certification board or accreditation body if the incident involves a provider regulated by that entity;

(g) The local probate court if the incident may involve the legal guardian of the recipient.

(iii) Enter all critical incidents into the incident management system within one business day of becoming aware of the incident.

(iv) Enter all reportable incidents into the incident management system within three business days of becoming aware of the incident.

(3) Critical incident investigation.

(a) The OhioRISE plan, or its designee, will investigate all critical incidents by doing the following:

(i) Within two business days of entering the incident in the incident management system, initiate an investigation.

(ii) Conduct a review of all relevant documents including person-centered care plans, service plans, assessments, clinical notes, communication notes, results from an investigation conducted by a third-party entity when available, provider documentation, provider billing records, medical reports, police and fire department reports, and emergency response system reports.

(iii) Conduct and document interviews with everyone who may have information relevant to the incident.

(iv) Identify, to the extent possible, all causes and contributing factors.

(v) Determine whether the incident is substantiated.

(vi) Document all investigative activities in the incident management system.

(vii) Conclude the investigation no later than forty-five business days after the documented start date of the investigation, unless a longer timeframe has been previously approved by ODM.

(4) Follow-up and closeout responsibilities.

(b) Except in the case of death, include any relevant information from the investigation when updating the individual crisis and safety plan to ensure the health and safety of the youth.

(c) For all substantiated critical incidents, except in the case of death, enter a prevention plan into the incident management system no later than seven business days after the conclusion of the investigation, indicating closure of the incident.

(d) For all reportable incidents, address and remediate the incident as determined appropriate, and close the incident in the incident management system no later than forty-five business days after submission of the incident in the incident management system.

(E) ODM may request further review of any incident, conduct a separate independent review or investigation of any incident, determine necessary additional action, or assume responsibility for conducting an investigation or review.

Last updated August 27, 2026 at 8:01 AM

History

Effective: August 27, 2026
Promulgated Under: 119.03

Chapter 5160-70 Hearing or Review for Providers

Ohio Adm.Code 5160-70-01 Chapter 119. Hearing or Administrative Reconsideration Procedures for Medicaid Providers.

(A) The following definitions apply to Chapter 5160-70 of the Administrative Code:

(1) "Appellant" means the party who requested an adjudication hearing pursuant to Chapter 119. of the Revised Code and is appealing the adjudication order to the Franklin county court of common pleas.

(2) "Certified mail" means the United States postal service mail service in which the delivery person obtains the signature of the recipient of the mail on a form as proof of delivery to the specified addressee. Pursuant to section 1.02 of the Revised Code, certified mail includes registered mail.

(3) "Department" means the Ohio department of medicaid ("ODM").

(4) "Depository agent" means the ODM office of legal services at its official mailing address for the purpose of receiving correspondence or filings for any hearing held under authority of Chapter 5160-70 of the Administrative Code.

(5) "Director" means the director of ODM.

(6) "Adjudication order" means the order made by the director after notice and an opportunity for a hearing is afforded pursuant to Chapter 119. of the Revised Code.

(7) "Final fiscal audit" means a medicaid final rate settlement or a medicaid hospital final settlement, including a final settlement in which Title V monies are offset against medicaid monies proposed for adjudication by ODM.

(8) "Hearing" means a hearing held by ODM in compliance with sections 119.06 to 119.13 of the Revised Code.

(9) "Last known address" means the most recent mailing address reported to ODM in compliance with reporting requirements.

(10) "Notice of intended action" means the written notice to the party of the department's intended action and notice of the right to a hearing pursuant to Chapter 119. of the Revised Code.

(11) "ODM" means the Ohio department of medicaid.

(12) "Participants in the hearing" means the party and the party's counsel in the hearing and ODM and ODM's counsel in the hearing.

(13) "Party" means a person whose interests are the subject of a notice of intended action by ODM.

(14) "Person" means an individual, corporation, whether nonprofit or for profit, a partnership, a limited liability company, and unincorporated society or association.

(15) "Medicaid provider" or "provider" means a person or governmental entity with a valid provider agreement to provide medical services or supplies to medicaid recipients. To the extent appropriate in the context, "medicaid provider" or "provider" includes a person or governmental entity applying for a provider agreement, a former medicaid provider, or both.

(16) "Notice by ordinary mail" means the service obtained by the agency after the party fails to claim the certified mail notice and the agency sends the notice by ordinary mail using a certificate of mailing to the party's last known address and the ordinary mail notice is not returned showing failure of delivery.

(17) "Provider agreement" means a contract between ODM and a person or governmental entity that allows the person or governmental entity to provide medical services and supplies for the Ohio medicaid program.

(18) "Take any action based on a final fiscal audit" means ODM issuing a notice of intended action seeking recovery of medicaid overpayments that were identified in the final fiscal audit.

(B) Computation of time deadlines

Section 1.14 of the Revised Code controls the computing of time deadlines imposed by Chapter 119. of the Revised Code and Chapter 5160-70 of the Administrative Code. The time within which an act is required by law to be completed is computed by excluding the first day and including the last day. When the last day falls on a Saturday, Sunday, or legal holiday, the act may be completed on the next succeeding day that is not a Saturday, Sunday, or legal holiday. When the last day to perform an act that is required by law to be performed in a public office occurs when that public office is closed to the public for the entire day, the act may be performed on the next succeeding day that is not a Saturday, Sunday, or legal holiday and on which the public office is open.

History

Effective: January 1, 2015
Promulgated Under: 119.03

Ohio Adm.Code 5160-70-02 Procedures for Providers Seeking Review of Department Actions or Proposed Department Actions.

(A) Chapter 5160-70 of the Administrative Code prescribes the procedures to be followed when medicaid providers seek review of actions or proposed actions of the department, except for any action taken or decision made by the department with respect to entering into or refusing to enter into a contract with a managed care organization pursuant to section 5167.10 of the Revised Code and any action taken under section 5165.60 to 5165.89 of the Revised Code. The rules in Chapter 5160-70 of the Administrative Code prevail over the provisions set forth in Chapter 5101:6-50 of the Administrative Code.

(B) Except as provided in paragraph (C) of this rule and section 5164.58 of the Revised Code, the department shall do the following by issuing an order pursuant to an adjudication conducted in accordance with Chapter 119. of the Revised Code:

(1) Pursuant to section 5164.38 of the Revised Code, refuse to enter into a provider agreement with a provider;

(2) Pursuant to section 5164.38 of the Revised Code, refuse to revalidate a medicaid provider's provider agreement;

(3) Pursuant to section 5164.38 of the Revised Code, suspend or terminate an existing medicaid provider's provider agreement;

(4) Pursuant to section 5164.38 of the Revised Code, take any action based upon a final fiscal audit;

(5) Pursuant to section 5165.46 of the Revised Code:

(a) Take any audit disallowance that the department makes as the result of a nursing facility cost report audit under section 5165.109 of the Revised Code;

(b) Make any adverse finding that results from an exception review of resident assessment data conducted for a nursing facility under section 5165.193 of the Revised Code after the effective date of the nursing facility's medicaid payment rate for direct care costs that is based on the resident assessment data;

(c) Recover any medicaid payment deemed an overpayment based upon the final cost report filed by an exiting nursing facility operator under section 5165.523 of the Revised Code;

(d) Impose any penalty under section 5165.42 of the Revised Code or section 5165.523 of the Revised Code.

(6) Pursuant to section 5165.525 of the Revised Code, issue a final debt summary report;

(7) Pursuant to division (A) of section 5165.77 of the Revised Code, terminate a nursing facility's participation in the medical assistance program, appoint a temporary manager of a nursing facility, or deny payment to a nursing facility for all medicaid eligible residents admitted after the effective date of the order.

(C) The Chapter 119. administrative procedures, including hearing rights, are not applicable to department actions that include, but are not limited to, the following:

(1) Pursuant to section 5164.38 of the Revised Code, the termination of the provider agreement because the terms of the provider agreement require the medicaid provider to hold a license, permit, or certificate or maintain a certification issued by an official, board, commission, department, division, bureau, or other agency of state or federal government other than the department of medicaid, and the license, permit, certificate, or certification has been denied, revoked, not renewed, suspended, or otherwise limited;

(2) Pursuant to section 5164.38 of the Revised Code, the termination of the provider agreement because the terms of the provider agreement require the medicaid provider to hold a license, permit, or certificate or maintain certification issued by an official, board, commission, department, division, bureau, or other agency of state or federal government other than the department of medicaid, and the provider has not obtained the license, permit, certificate, or certification;

(3) Pursuant to section 5164.38 of the Revised Code, the denial of the medicaid provider's application for a provider agreement or the provider's provider agreement is terminated or not revalidated, because of or pursuant to any of the following:

(a) The termination, refusal to renew, or denial of a license, permit, certificate, or certification by an official, board, commission, department, division, bureau, or other agency of this state other than the department of medicaid, notwithstanding the fact that the provider may hold a license, permit, certificate, or certification from an official, board, commission, department, division, bureau, or other agency of another state;

(b) Division (E)(3)(b) of section 5164.38 of the Revised Code and division (D) of section 5164.35 of the Revised Code, when a judgment has been entered in either a criminal or civil action against a medicaid provider or its owner, officer, authorized agent, associate, manager, or employee in an action brought pursuant to section 109.85 of the Revised Code, except if the provider or owner can demonstrate to the department that the provider or owner did not directly or indirectly sanction the action of its authorized agent, associate, manager, or employee which resulted in the entry of judgment;

(c) Division (E)(3)(b) of section 5164.38 of the Revised Code and division (E) of section 5164.35 of the Revised Code, when the attorney general on behalf of the state has commenced proceedings in any court of competent jurisdiction and settled or compromised any such case brought under section 5164.35 of the Revised Code;

(d) The provider's termination, suspension, or exclusion from the medicare program or from another state's medicaid program and, in either case, the termination, suspension, or exclusion is binding on the provider's participation in the Ohio medicaid program;

(e) The provider has pleaded guilty to or been convicted of a criminal activity materially related to the medicare or medicaid programs;

(f) The conviction of the provider or its owner, officer, authorized agent, associate, manager, or employee of one of the offenses that caused the provider's provider agreement to be suspended pursuant to section 5164.36 of the Revised Code; and

(g) The failure of the provider to provide the department the national provider identifier assigned to the provider by the national provider system pursuant to 45 C.F.R 162.408 (October 1, 2014). In this case, the department may take its action by sending a notice explaining the action to the provider. The notice shall be sent to the provider's last known address on record with the department. The notice may be sent by ordinary mail.

(4) Pursuant to section 5164.38 of the Revised Code, the denial of the provider's application for a provider agreement, or the provider's provider agreement is terminated or suspended, as a result of action by the United States department of health and human services and that action is binding on the provider's medicaid participation;

(5) Pursuant to section 5164.38 of the Revised Code, referencing sections 5164.36 and 5164.37 of the Revised Code, the suspension of the provider's provider agreement and payments pending indictment of the provider;

(6) Pursuant to section 5164.38 of the Revised Code, the denial of the application for a provider agreement because the application was not complete. In this case, the department may take its action by sending a notice explaining the action to the applicant. The notice shall be sent to the applicant's last known address on record with the department. The notice may be sent by ordinary mail;

(7) Pursuant to section 5164.38 of the Revised Code, the conversion of the provider's provider agreement under section 5164.32 of the Revised Code from a provider agreement that is not time-limited to a provider agreement that is time-limited. In this case, the department may take its action by sending a notice explaining the action to the provider. The notice shall be sent to the provider's last known address on record with the department. The notice may be sent by ordinary mail;

(8) Unless the provider is a nursing facility or ICF/IID, the non-revalidation of the provider's provider agreement pursuant to division (B)(1) of section 5164.32 of the Revised Code;

(9) The suspension, termination, or non-revalidation of the provider's provider agreement because of either of the following:

(a) Any reason authorized or required by one or more of the following: 42 C.F.R. 455.106, 455.23, 455.416, 455.434, or 455.450 (October 1, 2014);

(b) The provider has not billed or otherwise submitted a medicaid claim for two years or longer. In this case, the department may take its action by sending a notice explaining the action to the provider. The notice shall be sent to the provider's address on record with the department. The notice may be sent by ordinary mail.

(10) Acts of the director, agency employees or contractors of ODM that are ministerial in nature;

(11) Actions of ODM that are subject to public hearings under an administrative review procedure other than the review provided by Chapter 119. of the Revised Code;

(12) Rate calculations and interim settlements;

(13) Claims payment denial determinations and claims adjustments for reasons including, but not limited to, duplicate payments and payment for services not rendered;

(14) Notices of operational deficiency, and reviews and audits that are not subject to the Chapter 119. administrative procedure;

(15) Proceedings, authorized by section 5101.31 of the Revised Code and rules in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code, provided to applicants for, or recipients of, benefits administered by the department, its designees, or contractors;

(16) Personnel action appeals of employees of ODM or of a county department of job and family services;

(17) Disputes involving the issuance, denial, or termination of a contract, a grant, or an interagency agreement issued by ODM or a protest filed with regard to a request for proposals or a request for application issued by ODM;

(18) Administrative actions taken by ODM that involve program administration and funding affecting county departments of job and family services.

(D) Except as otherwise set forth in the Ohio Administrative Code, actions taken that meet the exceptions of paragraph (C) of this rule and other administrative actions regarding medicaid providers that are not subject to hearings under Chapter 119. of the Revised Code and those individuals or providers who do not have medicaid provider agreements and are proposed for exclusion from participation may be reconsidered by the director, assistant director, or the deputy director over the area where the contestation arose. The director, assistant director, or the deputy director may designate who conducts the reconsideration, provided that the designee was not involved in the original decision or contestation. If the department takes an action that is subject to reconsideration, the department may set deadlines by which the person affected by the action shall submit his or her written request for reconsideration and the documentation supporting the request. The deadline shall be no fewer than thirty days from the date appearing on the letter sent to the person. When the department sets a deadline for requesting reconsideration, reconsideration requests and supporting documentation received after the deadline may be considered at the department's discretion. ODM shall not reconsider its reconsideration decisions.

(1) See Chapter 5160-2 of the Administrative Code for additional provisions specific to hospital services.

(2) See Chapter 5160-3 of the Administrative Code for additional provisions specific to nursing facilities.

(3) See Chapter 5160-26 of the Administrative Code for additional provisions specific to managed care plans (MCPs).

(E) When the department takes an action under paragraph (B)(2) or (B)(3) of this rule and the provider requests an adjudication hearing pursuant to Chapter 119. of the Revised Code, the department may withhold payments to the provider if each of the following conditions is met:

(1) The department complies with the provisions of section 119.07 of the Revised Code;

(2) The department does not request a hearing continuance; and

(3) The department issues an adjudication order within thirty days after the hearing is completed.

(F) When the department takes an action under paragraph (B)(4) of this rule and the provider requests an adjudication hearing pursuant to Chapter 119. of the Revised Code, the department may withhold payment to the provider if each of the following conditions is met:

(1) The department complies with the provisions of section 119.07 of the Revised Code;

(2) The department does not request a hearing continuance;

(3) The department issues an adjudication order within thirty days after the hearing is completed; and

(4) The department withholds only an amount that does not exceed the amounts determined in the final fiscal audit.

(G) The provisions of paragraphs (E) and (F) of this rule do not apply to long-term care facilities (LTCFs). Nursing facility and ICF/IID providers whose provider agreements are terminated pursuant to paragraph (B)(5)(b) of this rule may continue to receive medicaid payments for up to thirty days after the effective date of the termination if the provider makes reasonable efforts to transfer medicaid recipients to another facility or to alternate care and if federal financial participation is provided for the payments. See Chapter 5160-3 of the Administrative Code for additional provisions specific to LTCFs.

History

Effective: January 1, 2015
Promulgated Under: 119.03

Ohio Adm.Code 5160-70-03 Chapter 119. hearings: department notice, making a hearing request, and failure to make a hearing request.

(A) Notice of intended action

(1) Whenever ODM proposes to take an action that the Ohio general assembly has expressly made subject to the administrative adjudication procedure outlined in Chapter 119. of the Revised Code, ODM shall give notice of the intended action to the party informing the party of the party's right to a hearing. Notice shall be given by certified mail, return receipt requested, and shall, at a minimum, include all of the following:

(a) The specific action or actions ODM intends to take;

(b) The charges or other reasons for the proposed action or actions;

(d) A statement informing the party that the party is entitled to a hearing if the party requests it within thirty calendar days of the time of mailing the notice;

(e) A statement informing the party that at the hearing the party may appear in person or through an attorney;

(f) A statement informing the party that the party or the party's attorney may present the party's position, arguments or contentions entirely in writing, and that at the hearing the party or the party's attorney may present evidence and examine witnesses appearing for and against the party; and

(g) A statement informing the party that rules governing hearings in accordance with Chapter 119. of the Revised Code are found in Chapter 5160-70 of the Administrative Code.

(2) ODM shall also mail a copy of the notice to the party's attorney or other representative of record. To qualify as an attorney or representative of record, the party or the attorney or representative shall notify ODM, in writing, that the attorney or representative is to be designated the attorney or representative of record. The notification shall include the address where ODM should mail the notice to the attorney or representative of record. The mailing of notice to the party's attorney or representative is not deemed to perfect service of the notice. Failure to mail a copy of the notice to the attorney or representative of record shall not result in failure of otherwise perfected service upon the party. In those instances where a party is a corporation doing business in Ohio or is incorporated in Ohio, the mailing of notice to the corporation's statutory agent pursuant to sections 1701.07 and 1703.19 of the Revised Code shall perfect service, provided that all the requirements of paragraph (A) of this rule are met.

(3) When any notice sent by certified mail pursuant to this rule is returned because the party fails to claim the notice, ODM shall send the notice by ordinary mail to the party at the party's last known address and shall obtain a certificate of mailing. Service by ordinary mail is complete when the certificate of mailing is obtained unless the notice is returned showing failure of delivery.

(4) If any notice sent by certified or ordinary mail is returned for failure of delivery, ODM either shall make personal delivery of the notice by an employee or agent of ODM or shall cause a summary of the substantive provisions of the notice to be published once a week for three consecutive weeks in a newspaper of general circulation in the county where the last known address of the party is located. When notice is given by publication, a proof-of-publication affidavit, with the first publication of the notice set forth in the affidavit, shall be mailed by ordinary mail to the party at the party's last known address and the notice shall be deemed received as of the date of the last publication. An employee or agent of ODM may make personal delivery of the notice upon a party at any time.

(5) Refusal of delivery by personal service or by mail is not failure of delivery, and service is deemed to be complete at the time of personal refusal or at the time of receipt by ODM of the refused mail as demonstrated by the ODM time and date stamp. Failure of delivery occurs only when a mailed notice is returned by the postal authority marked undeliverable, address or addressee unknown, or forwarding address unknown or expired.

(B) Making a request for a hearing

(1) Any request for a hearing made as the result of notice issued pursuant to paragraph (A) of this rule must be made in writing and mailed or delivered to the depository agent within thirty calendar days of the following, as applicable:

(a) The time of mailing the notice if notice is given pursuant to paragraph (A)(1) of this rule;

(b) The date that service is complete if notice is given pursuant to paragraph (A)(3) or (A)(5) of this rule;

(d) The date of personal service.

(2) If a request for a hearing is mailed to the depository agent, the request is deemed to have been made as follows:

(a) If the request is mailed by certified mail, as of the date stamped by the U.S. postal service on its receipt form (PS form 3800 or any future equivalent postal service form);

(b) If the request is mailed by ordinary U.S. mail, as of the date of the postmark appearing upon the envelope containing the request;

(c) If the request is mailed by ordinary U.S. mail and the postmark is illegible or fails to appear on the envelope, as of the date of its receipt by the depository agent as evidenced by the agent's time stamp.

(3) If a request for a hearing is made by facsimile transmission or by electronic mail to the depository agent, the request is deemed to have been made as of the date of its receipt as evidenced by the receipt date generated by the facsimile transmission or the date of receipt shown in the source code of the electronic mail received by the depository agent.

(4) If a request for a hearing is mailed, personally delivered, made by facsimile transmission, or made by electronic mail to a person or address other than the depository agent, the request is deemed to have been made as of the date of its receipt by the depository agent as evidenced by the depository agent's time stamp.

(5) If a request for a hearing is personally delivered to the depository agent, the request is deemed to have been made as of the date of its receipt as evidenced by the depository agent's time stamp.

(6) All requests for hearings must include a copy of the notice of intended action that is being contested and clearly identify the party who is making the request by providing the party's name, address, and phone number.

When a party fails to request a hearing or the request is not submitted timely, ODM shall issue an adjudication order adopting and implementing the notice of intended action.

History

Effective: January 1, 2015
Promulgated Under: 119.03

Ohio Adm.Code 5160-70-04 Chapter 119. hearings: initial scheduling, joinder of cases, attorney representation, authority of hearing examiners, prehearing conference, filing with depository agent, and withdrawal of notice of intended action.

(A) Initial scheduling of the hearing

(1) When a party timely requests a hearing, ODM shall set the date, time, and place for the hearing and notify the party of the scheduling. ODM shall initially schedule the hearing not earlier than seven calendar days but not later than fifteen calendar days after the hearing was requested. The first notification concerning a scheduled hearing shall be sent by certified mail, return receipt requested. All subsequent letters and notices shall be sent by ordinary United States mail.

(2) Nothing in this rule shall be construed as preventing ODM from postponing and rescheduling any hearing upon its own motion or upon the motion of a party who can show good cause for such a request.

(3) Nothing in this rule shall be construed as preventing ODM and the party from entering into a written agreement establishing the time, date, and place of the hearing.

(B) Joinder of individual cases

On its own motion or on motion of a party, ODM or the hearing examiner may join any individual cases where there exist incidents of common ownership or interest and where joinder would be appropriate for efficiency and economic fairness to the participants in the hearing.

(1) The attorney general, or assistants or special counsel designated by the attorney general, shall represent ODM.

(2) Any individual not appearing pro se and any corporation, partnership, association, or other entity must be represented by an attorney admitted to the practice of law in this state. Individuals authorized to practice law in any other jurisdiction may be permitted to represent a party before ODM upon compliance with the "Ohio Supreme Court Rules for the Government of the Bar of Ohio." When a party is represented by more than one attorney, one attorney must be designated by the party as "trial counsel," and that attorney is deemed the party's attorney of record and is primarily responsible for the party's case at the hearing. No attorney representing a party is permitted to withdraw from any hearing proceeding before ODM without prior notice being served upon ODM and prior approval by the hearing examiner.

(D) Authority of hearing examiners appointed by ODM

The director may assign a hearing examiner to conduct any hearing held subject to Chapter 5160-70 of the Administrative Code. Any person assigned to be a hearing examiner must be admitted to the practice of law in the state of Ohio and have such other qualifications as the director deems necessary. The hearing examiner may be an employee of ODM or under contract with ODM. The hearing examiner has the same powers as granted to ODM in conducting the hearing; however, nothing in this rule or in any other ODM rule is to be construed as granting a hearing examiner the authority to dismiss any hearing. These powers include, but are not limited to, the following:

(1) The general authority to regulate the course of the hearing and to issue orders governing the conduct of the hearing;

(2) The authority to administer oaths or affirmations, order the production of documents and the attendance of witnesses, call and examine witnesses in a reasonable and impartial manner, and determine the order in which the participants in the hearing present testimony and are examined in a manner consistent with essential fairness and justice;

(3) The authority to rule on the admissibility of evidence, objections, procedural motions, and other procedural matters provided, however, that the hearing examiner shall not consider or admit into evidence documentation or information that the provider failed, upon request, to furnish to ODM or its contractor during the final fiscal audit process unless ODM agrees to the admissibility of such post final fiscal audit production of documentation or information;

(4) The authority to hold pre-hearing conferences for the purpose of resolving issues that can be resolved by the participants in the hearing, including facilitation of a settlement, identifying the witnesses to be presented and the subjects of their testimony, discussing possible admissions or stipulations regarding the authenticity of records, identifying and marking exhibits, ruling on any procedural motions of the participants in the hearing, resolving outstanding discovery claims, clarifying the issues to be addressed at the hearing, and discussing any other matters deemed appropriate by the hearing examiner for the thorough and expeditious preparation and disposition of the case;

(5) The authority to take such other actions as might be necessary to avoid unnecessary delay, prevent presentation of irrelevant or cumulative evidence, prevent argumentative, repetitious, or irrelevant examination or cross-examination, and to assure that the hearing proceeds in an orderly and expeditious manner;

(6) Nothing in this rule or in any other ODM rule is to be construed as granting a hearing examiner the authority to dismiss any hearing. Nothing in this rule or in any other ODM rule limits the director's authority to withdraw a notice of intended action or limits the authority of the director to define the scope of any hearing;

(7) The authority to require the submission of briefs and memoranda at any time during the proceeding. The hearing examiner may limit these filings to one or more specific issues and may prescribe procedures and time schedules for their submission;

(8) The authority to require that a copy of any unreported court decision cited in any brief or memorandum be attached to the brief or memorandum containing the citation.

(E) Pre-hearing conferences

Reasonable notice of all pre-hearing conferences shall be provided to participants in the hearing in advance of each conference. The pre-hearing conference may be conducted by phone if agreed to by the parties and the hearing examiner. Unless otherwise ordered for good cause shown, failure to attend a pre-hearing conference precludes objections to rulings made at such conference.

(1) The first pre-hearing conference is set by ODM. The participants in the hearing shall each file a pre-hearing questionnaire if directed to do so by ODM in the letter scheduling the conference. The hearing examiner may also require the submission of a pre-hearing questionnaire before the scheduled date of any pre-hearing conference or before any scheduled hearing.

(2) Following the conclusion of any pre-hearing conference, the hearing examiner conducting the conference shall issue an appropriate pre-hearing report and order reciting or summarizing any agreements reached or rulings made. Unless otherwise ordered for good cause shown, any order issued is binding upon all participants in the hearing, and such orders control the subsequent course of the proceeding. Hearing examiner orders shall be in writing, furnished to the participants in the hearing, and be part of the record of the case. However, the hearing examiner may modify such orders if, at or before the hearing, modification assists to preserve the essential fairness and progress of the hearing.

(3) Each party and ODM must file a final pre-hearing questionnaire at least ten business days before the hearing or at an earlier date established by the hearing examiner. The questionnaire shall include, at a minimum, a statement of each specific question of law or fact to be decided at the hearing, a list of expert and non-expert witnesses, a list of all exhibits expected to be introduced at the hearing, stipulations, and the estimated number of days required for hearing. Only the relevant issues of law or fact set forth on the final questionnaires shall be considered or rebutted at the hearing. The party waives its right to contest any other issues of law and fact. The questionnaire shall inform the hearing examiner if discovery is complete and, if discovery is incomplete, provide a statement of an agreed upon discovery cut-off date. The questionnaire shall inform the hearing examiner whether or not any motions are yet to be filed. The questionnaire must be signed by trial counsel. After the filing of the final pre-hearing questionnaire, no further additions to the proposed list of witnesses and exhibits shall be permitted without good cause shown and the approval of the hearing examiner.

(4) ODM, upon its own motion or that of the hearing examiner, may waive any pre-hearing conference or questionnaire and may issue a written notice to the participants in the hearing scheduling the hearing and setting forth the conditions applicable to the conduct of the hearing.

(F) Filing with depository agent

(1) All briefs, memoranda, motions, or other filings shall be filed with the depository agent within three days after service on the other participants in the hearing. A certificate of service shall be attached attesting to the service of a copy of the filing on the other participants in the hearing and the hearing examiner. Service is governed by rule 5 of the Ohio Rules of Civil Procedure (www.supremecourt.ohio.gov/LegalResources/Rules/civil/CivilProcedure.pdf, July 1, 2014) except that any reference to "court" in rule 5 will be interpreted to refer to the "depository agent."

(2) A copy of all written requests or filings that are made to the depository agent, the director, or the hearing examiner shall be served upon the other participants in the hearing and the hearing examiner. A certificate of service shall be attached attesting to the service of a copy on the other participants and the hearing examiner.

(3) Only those pleadings, orders, and other documents filed with the depository agent shall be a part of the official record.

(4) All briefs, memoranda, motions, or other pleadings and documents shall be on eight-and-one-half-inch by eleven-inch paper and double-spaced.

(5) All orders, reports, recommendations, and rulings issued by the hearing examiner shall be signed, dated, and filed with the depository agent.

(6) All exhibits, or other evidence admitted into the record or proffered, shall be filed by the hearing examiner with the depository agent at the conclusion of the hearing.

(G) Withdrawal of notice of intended action

ODM, upon its own motion, at any time before the issuance of an adjudication order, may withdraw its notice of intended action without prejudice to the rights of the parties. A party may withdraw a request for a hearing only with the prior approval of the hearing examiner.

History

Effective: January 1, 2015
Promulgated Under: 119.03

Ohio Adm.Code 5160-70-05 Chapter 119. hearings: pre-hearing discovery and subpoenas.

(A) Pre-hearing discovery

(1) Unless otherwise ordered by the hearing examiner, pre-hearing discovery is allowed. Unless otherwise ordered by the hearing examiner or as set forth in this rule, pre-hearing discovery shall be conducted and used at the hearing in accordance with the Ohio Rules of Civil Procedure (www.supremecourt.ohio.gov/LegalResources/Rules/civil/CivilProcedure.pdf, July 1, 2014) except that any reference to "court" shall be interpreted to refer to the "hearing examiner".

(2) Depositions of ODM employees shall be conducted in the Columbus offices of ODM during normal business hours unless other arrangements are approved by ODM.

(3) In accordance with Civ. R. 45, depositions of persons who are not participants in the hearing shall be taken in the county where the deponent resides or is employed or transacts business in person, or at such other convenient place as agreed to by the participants in the hearing or as fixed by an order of the hearing examiner.

(4) Pre-hearing discovery may begin immediately after a hearing request is timely made and must be completed before the commencement of the hearing, unless the hearing examiner issues an order establishing a different begin date and/or end date for discovery.

(5) At a time required by the hearing examiner, a party shall provide a report prepared by every witness identified as an expert by the party. The report shall be signed by the witness and shall contain a complete statement of all opinions to be expressed and the basis and reasons therefor; the data or other information considered by the witness in forming the opinions; any exhibits to be used as a summary of or support for the opinions; the qualifications of the witness, including a list of all publications authored by the witness within the preceding ten years; the compensation to be paid for the study and testimony; and a listing of any other cases in which the witness has testified as an expert at trial or by deposition within the preceding four years or at any time if the witness testified in any matter in which ODM or its predecessor agencies were a party or participants in a hearing. An expert witness who is an employee of ODM shall not be required to prepare an expert witness report. The participants in a hearing shall bear their own expert witness costs. Any participant in the hearing seeking discovery of an expert shall not be required to pay any portion of the fees and expenses incurred by the other participants in obtaining facts and opinions from an expert or for costs of the expert witness in responding to discovery.

(B) Subpoena issuance and enforcement

(1) ODM shall issue blank subpoena forms to a participant in the hearing requesting a subpoena. The requestor is responsible for completing the subpoena form, including the address where the person is to be served, and returning the completed subpoena form to the depository agent along with a written request for service. The written request for service and the completed subpoena must be received by the depository agent no later than twenty-one business days before the commencement of the hearing or deposition, unless otherwise ordered by the hearing examiner for good cause shown. At its discretion, ODM may make available an electronic version of the subpoena and may authorize electronic submission of a completed subpoena.

(2) For hearings, upon its own initiation or that of any participant in the hearing, ODM shall issue a subpoena to any person within the state requiring the person's attendance as a witness and/or the production of books, records or papers at the hearing. For any person subpoenaed for attendance at a hearing, at the time of service of such a subpoena upon a person outside of Franklin county, the fees for one day's attendance and mileage shall be tendered, without demand by the person being subpoenaed. At the time of service of such a subpoena upon a person inside of Franklin county, the fees for one day's attendance and mileage shall be tendered upon demand by the person being subpoenaed. ODM shall pay the fees and mileage as set forth in section 119.094 of the Revised Code.

(3) For depositions, upon its own initiation or that of any participant in the hearing, ODM shall issue a subpoena to any person within the state who is not a participant in the hearing, requiring his or her attendance and/or the production of books, records or papers.

(a) Participants in the hearing shall participate in depositions upon notice of opposing counsel. A subpoena may not be used to obtain the attendance of a participant or the production of documents by a participant in discovery. Rather, a participant's attendance at a deposition shall be obtained only by notice under Civ.R. 30, and the production of books, records, and papers shall be obtained from a participant in discovery only pursuant to Civ. R. 34.

(b) For any person who is not a participant in the hearing and who is subpoenaed for attendance at a deposition and/or for the production of books, records or papers, at the time of service of a subpoena upon a person outside of Franklin county, the fees for one day's attendance and mileage shall be tendered, without demand by the person being subpoenaed. At the time of service of a subpoena upon a person inside of Franklin county, the fees for one day's attendance and mileage shall be tendered, upon demand by the person being subpoenaed. The amount of the fees and mileage shall be the same as those set forth in section 2335.06 of the Revised Code. Sections 119.09 and 119.094 of the Revised Code require ODM to pay fees and mileage only of persons subpoenaed as witnesses in a hearing. ODM is not required to pay the fees and mileage for a person subpoenaed for a deposition. The participant in the hearing requesting ODM to issue a subpoena for a deposition shall include with the request a check for the fees and mileage made payable to the person subpoenaed.

(4) All subpoenas issued under this rule shall be directed to the sheriff of the county where the person to be served resides or is found, and the sheriff shall serve and return the subpoena in the same manner as a subpoena in a criminal case. The sheriff shall be paid by ODM the same fees for services as are allowed in the court of common pleas in criminal cases as established in section 311.17 of the Revised Code.

(5) In any case of disobedience or neglect of any subpoena served upon any person, or the refusal of any witness to testify to any matter in which there may be lawful interrogation, ODM shall apply to the court of common pleas where such disobedience, neglect, or refusal occurs for an order to compel obedience by attachment proceedings for contempt, as in the case of disobedience of the requirements of a subpoena issued from such court or a refusal to testify therein.

History

Effective: January 1, 2015
Promulgated Under: 119.03

Ohio Adm.Code 5160-70-06 Chapter 119. hearings: conducting the hearing, report and recommendation, filing objections, adjudication order, appealing the adjudication order.

(A) Conducting the hearing

(1) The date, time, and place of any hearing before ODM is set by ODM or the hearing examiner. The hearing examiner shall provide written or electronic notice before the date of the hearing to all participants in the hearing and file a copy of the written notice with the depository agent. Hearings shall be scheduled in accordance with the following requirements.

(a) All hearings shall be conducted in Columbus during normal business hours unless other times are authorized by the director or the hearing examiner.

(b) Upon the written request of a party, the director may designate the site of the hearing to be the county seat of the county wherein a party resides or, alternately, a place within fifty miles of a party's residence. The approval of an alternative location is at the discretion of the director. Requests for an alternative hearing site must be filed with the depository agent at least forty five days before the scheduled date of the hearing and served as provided in rule 5160-70-04 of the Administrative Code.

(c) Once begun, the hearing shall continue day to day until completed, unless continued by the hearing examiner for good cause shown.

(2) Subject to the prior approval of the hearing examiner, the party may choose to present its case entirely in writing provided that a written request is made by the party no later than fourteen business days before the date scheduled for the hearing. Any request by a party to present its case entirely in writing must be filed with the depository agent and served as provided in rule 5160-70-04 of the Administrative Code. Any party who elects to present the case entirely in writing must do so in accordance with procedures ordered by the hearing examiner. The hearing examiner's order shall be in writing and filed with the depository agent. In the event that the party elects to present its case in writing, ODM may elect to present its case entirely in writing. Nothing in this rule is to be construed as preventing ODM from compelling the attendance of the party or other witnesses at the hearing and questioning the party or other witnesses as if on cross-examination. Nothing in this rule is to be construed as preventing the party from examining any witnesses or evidence presented by ODM at the hearing.

(3) During the course of any hearing, the participants in the hearing may enter into oral stipulations of fact, procedure, or the authenticity of documents, which shall be incorporated into the record and shall bind the conduct of the participants. The hearing examiner may require oral stipulations to be reduced to writing and submitted to the hearing examiner. The hearing examiner has the power to rule on the admissibility of evidence or testimony, but a participant may make objections to the rulings. If the hearing examiner refuses to admit evidence or testimony, the participant seeking admission of same must make a proffer thereof and such proffer shall be made a part of the record of the hearing. The hearing examiner may refer to the Ohio Rules of Evidence (www.supremecourt.ohio.gov/LegalResources/Rules/evidence/evidence.pdf, July 1, 2012) as guidance in making decisions on admissibility.

(4) Any notice of intended action or any document that supports the issuance of the notice of intended action issued by ODM, if offered into evidence, constitutes, regardless of consent of any party, prima facie evidence sufficient to establish the facts contained therein and that, if not rebutted by the party, is sufficient to sustain a determination that ODM has met its burden of proof. The party carries the burden of production to rebut the prima facie evidence. Nothing in this rule prevents ODM from presenting additional evidence in reply to the rebuttal evidence presented by the party.

(B) Report and recommendation and filing objections

(1) After the conclusion of the hearing, the hearing examiner shall submit to ODM a written report setting forth the hearing examiner's findings of fact and conclusions of law and a recommendation of the action to be taken by ODM. The report shall be filed with the depository agent. Within five days of the report's filing with the depository agent, as evidenced by the time stamp of the agent, ODM shall send by certified mail, return receipt requested, to the party, the party's attorney, or other authorized representative of record a copy of the hearing examiner's report. The report shall be considered to have been mailed as of the mailing date appearing on United States postal service form 3800 or any future equivalent postal service form. If delivery is not successful by certified mail, the provisions regarding the steps subsequent to the mailing of certified mail in section 119.07 of the Revised Code shall be followed for service of the report.

(2) Any participant in the hearing may file written objections to the hearing examiner's report. Any such objections must be received no later than ten days after the participant in the hearing receives the report. The director may grant an extension of time to file objections if the participant's written request for an extension is received by ODM no later than ten days after the participant's receipt of the report. The date the participant in a hearing receives the hearing examiner's report is the receipt date indicated on the United States postal service form 3800, or any future equivalent postal services form. The director shall consider timely written objections before approving, modifying, or disapproving the recommendation of the hearing examiner.

(3) The director may order additional testimony to be taken by the hearing examiner and permit the introduction of further documentary evidence to the hearing examiner. The hearing examiner shall issue a revised written report and recommendation after consideration of any additional testimony and evidence. If the hearing examiner issues a revised report and recommendation, the provisions of paragraphs (B)(1) and (B)(2) of this rule shall be applied to the revised report and recommendation in the same manner as they were applied to the original report and recommendation.

(1) The recommendation of the hearing examiner may be approved, modified, or disapproved by the director. In those instances where the director modifies or disapproves the recommendation of the hearing examiner, the director shall include the reasons therefor and incorporate said reasons into the adjudication order.

(2) After the director enters an order approving, modifying, or disapproving the hearing examiner's recommendation on the ODM journal of proceedings, the director shall mail to any party by certified mail, return receipt requested, a copy of the order and a statement of the time and method by which an appeal may be perfected. A copy of such order shall be mailed to the attorney or other authorized representative of record.

(D) Appeal of an adjudication order

(1) Any party adversely affected by an adjudication order, pursuant to this rule, may appeal from that order to the Franklin county court of common pleas.

(2) Any party desiring to appeal pursuant to this rule must file a notice of appeal with the depository agent setting forth the order appealed from and stating that the agency's order is not supported by reliable, probative, and substantial evidence and is not in accordance with law. The notice may, but need not, set forth the specific grounds of the party's appeal beyond the statement that the agency's order is not supported by reliable, probative, and substantial evidence and is not in accordance with law. In order to be determined filed with ODM, the notice of appeal must be received by the depository agent, as evidenced by an ODM date and time stamp, no later than fifteen days after the mailing to the party, as evidenced by the mailing date on the United States postal service form 3800 or any future equivalent postal service form, of the adjudication order to be appealed from. The appellant shall also file the notice of appeal with the Franklin county court of common pleas no later than fifteen days after the mailing to the party, as evidenced by United States postal service form 3800 or any future equivalent postal service form, of the adjudication order to be appealed from. In filing a notice of appeal with the agency or the court, the notice that is filed may be the original notice or a copy of the original notice.

(E) Any stenographic record, including depositions, related to a hearing or an appeal pursuant to section 119.12 of the Revised Code shall not be considered a public record for purposes of section 149.43 of the Revised Code.

History

Effective: January 1, 2015
Promulgated Under: 119.03

Chapter 5160-71 Hearings for Recovery of Overpayments

Ohio Adm.Code 5160-71-01 Chapter 119. hearings conducted under authority of section 5111.914 of the Revised Code: definitions and scope of applicability.

(A) The following definitions apply to Chapter 5101:6-51 of the Administrative Code.

(1) "Affected party" means a person whose interests are subject to an adjudication by the Ohio department of job and family services (ODJFS) under authority of section 5111.914 of the Revised Code.

(2) "Appellant" means an affected party who has requested an adjudication hearing pursuant to Chapter 119. of the Revised Code.

(3) "Department" means ODJFS.

(4) "Depository agent" means the official mailing address of the office of legal and acquisition services of ODJFS for the purpose of receiving correspondence or filings for any hearing held under authority of section 5111.914 of the Revised Code.

(5) "Director" means the director of ODJFS or the director's designee.

(6) "Hearing" means a hearing held by an issuing state agency under authority of section 5111.914 of the Revised Code and that is in compliance with sections 119.06 to 119.13 of the Revised Code.

(7) "Issuing state agency" means a state agency that has entered into a contract with ODJFS under section 5111.91 of the Revised Code and that has issued a notice of overpayment under authority of section 5111.914 of the Revised Code. This shall not include a political subdivision directly or by contract.

(8) "ODJFS" means the Ohio department of job and family services.

(9) "Order" means an adjudication issued by ODJFS of the facts and/or sums in controversy in any hearing conducted by an issuing state agency under the authority of section 5111.914 of the Revised Code that is a final disposition of the director as regard to the rights, duties, privileges, benefits, legal relationships, jurisdictional status, or standing of any appellant of a proceeding initiated under authority of section 5111.914 of the Revised Code.

(10) "Person" means a person, firm, corporation, association, or partnership.

(11) "Provider" means any person, institution or entity, governmental or non-governmental, that furnishes medicaid services under a provider agreement with ODJFS pursuant to Title XIX of the Social Security Act, 79 Stat. 286 (1965), 42 U.S.C.A. 1396, as amended.

(12) "Provider agreement" means a contract between ODJFS and a provider of medical services and supplies pursuant to rules contained in Chapter 5101:3-1 of the Administrative Code.

(13) "Repayment due date" means the date that payment is due to the state based upon notification of an identified overpayment. The repayment due date shall be established as follows:

(a) If a settlement is reached in accordance with section 5111.914 of the Revised Code, the repayment shall be due no later than the forty-fifth day after full execution of the settlement. A settlement is fully executed only after all parties to the settlement have signed the settlement and ODJFS has issued written approval of the settlement either by signing the settlement or by separate written approval.

(b) If settlement is not reached in accordance with section 5111.914 of the Revised Code, the repayment shall be due within forty-five days after the effective date of the adjudication order.

(B) Scope of applicability.

(1) Chapter 5101:6-51 of the Administrative Code prescribes the procedures to be followed in all hearings held before an issuing state agency pursuant to section 5111.914 of the Revised Code. The procedures set forth in Chapter 5101:6-51 of the Administrative Code shall be followed in all instances of notices of overpayments issued by the issuing state agency except as follows. The issuing state agency is not required to follow the procedures set forth in Chapter 5101:6-51 of the Administrative Code in cases where a provider requests one or more claims adjustments if all of the following conditions are met:

(a) The provider's request is not a request to negotiate, or to dispute a notice of overpayment, and

(b) The adjustments can be completed in full within forty-five days of the provider's request.

(2) An issuing state agency's proposed findings shall be limited to findings of overpayments for medicaid services where the alleged overpayments were made under the component of the medicaid program that the issuing state agency administers.

(3) Proposed findings issued under authority of section 5111.914 of the Revised Code are not a "final fiscal audit" as defined in rule 5101:6-50-01 of the Administrative Code.

(4) The right to a hearing pursuant to authority provided in section 5111.914 of the Revised Code is limited to an issuing state agency's proposal to recover a medicaid overpayment.

(5) The provisions of Chapter 5101:6-51 of the Administrative Code are to be interpreted and construed to achieve their general purpose of providing orderly and fair procedures for conducting hearings before a state agency.

History

Effective: August 1, 2011
Promulgated Under: 119.03

Ohio Adm.Code 5160-71-02 Chapter 119. hearings conducted under authority of section 5111.914 of the Revised Code: notice of overpayment, negotiation of settlement, terms of settlement, referral to the attorney general for collection, and repayment.

(A) Notice of overpayment.

An issuing state agency that identifies a medicaid overpayment shall send a notification, by certified mail, return receipt requested, of the overpayment amount to the medicaid provider. The issuing state agency shall send a copy of the notification to ODJFS not later than five business days after sending the notification to the provider. The notification of overpayment shall contain a clear statement of all the following:

(1) The amount of the overpayment including interest charges;

(2) A general description of the grounds for the overpayment finding;

(3) A request that the provider voluntarily repay the overpayment;

(4) The address where payment should be made;

(5) The acceptable methods of payment;

(6) A statement that if voluntary repayment is not made in full within thirty days of the provider's receipt of notification that the issuing state agency will proceed with formal notice of hearing rights in accordance with section 5111.914 of the Revised Code; and

(7) A statement that as an alternative to payment the provider may within thirty days of the date of mailing of the notification submit to the issuing state agency a written statement disputing the overpayment amount and requesting an opportunity to negotiate a settlement of the overpayment.

(B) Negotiation of settlement.

The issuing state agency may in its sole discretion attempt to negotiate a settlement in accordance with this rule. If the provider files a written request to negotiate within thirty days of the date of mailing of the notification in accordance with paragraph (A)(7) of this rule, and the issuing state agency exercises its discretion to attempt to negotiate a settlement, the issuing state agency shall notify the provider that the agency is rescinding its notification of overpayment in order to negotiate a settlement of the overpayment.

(1) The issuing state agency must submit a negotiated settlement to ODJFS for review and approval or rejection within thirty days after the provider's written statement filed in accordance with paragraph (A)(7) of this rule. If the issuing state agency does not submit a negotiated settlement to ODJFS within thirty days, the issuing state agency shall issue a notice of opportunity for hearing in accordance with section 5111.914 of the Revised Code and rule 5101:6-51-04 of the Administrative Code.

(2) If ODJFS signs the agreement or issues written approval, the provider shall make repayment under the terms of the settlement.

(3) If ODJFS rejects the settlement, the issuing state agency shall issue a notice of opportunity for hearing in accordance with section 5111.914 of the Revised Code and rule 5101:6-51-04 of the Administrative Code.

(4) If the issuing state agency exercises its discretion to not attempt to negotiate a settlement, the issuing state agency shall issue a notice of opportunity for hearing in accordance with section 5111.914 of the Revised Code and rule 5101:6-51-04 of the Administrative Code.

A negotiated settlement shall comply with the following standards:

(1) The settlement shall expressly require repayment within forty-five days of the date of the later of either full execution of the settlement or final written approval of the settlement by ODJFS.

(2) The negotiated settlement shall cover both the federal share and state share of the amount the parties agree upon and interest charges.

(3) The negotiated settlement shall clearly identify what disputed sums or facts are the subject of final resolution by the settlement and shall identify the grounds upon which any amounts are compromised.

(4) The negotiated settlement may compromise the amount repaid only on the following grounds:

(a) The provider produces evidence showing that specified sums identified are not an overpayment;

(b) A sum was identified as an overpayment based upon an incorrect application of law or fact; or

(5) The settlement may contain any other terms the parties consider necessary for execution of the settlement but such terms shall be invalid if they conflict with laws or rules governing the medicaid program.

(6) A negotiated settlement shall not be valid and enforceable unless ODJFS signs the agreement or issues other written approval of the agreement.

(D) Nothing shall preclude settlement negotiations on the same or different grounds after the issuance of a notice of opportunity for hearing issued under authority of section 5111.914 of the Revised Code.

(E) Referral to the attorney general for collection.

(1) If a settlement is reached in accordance with this rule and the repayment is not received by the forty-fifth day after full execution of the settlement or final written approval of the settlement by ODJFS, the issuing state agency shall refer the matter to the attorney general's office for collection as required by section 131.02 of the Revised Code.

(2) If settlement is not reached in accordance with section 5111.914 of the Revised Code, repayment shall be due within forty-five days after the effective date of the adjudication order that is issued pursuant to a hearing initiated under section 5111.914 of the Revised Code. Except as provided in paragraph (E)(3) of this rule, if repayment is not received by the forty-fifth day after the effective date of the adjudication order, the issuing state agency shall refer the amount to the attorney general for collection as required by section 131.02 of the Revised Code.

(3) If an appeal of the adjudication order is timely filed and a stay is granted by the court within forty-five days of the issuance of the adjudication order, the issuing state agency shall not refer the matter to the attorney general's office for collection until the expiration or lifting of the order granting the stay, or until such other order of the court permits implementation of the adjudication order.

(4) An issuing state agency shall not certify a medicaid overpayment for collection by the attorney general under section 131.02 of the Revised Code without first following the procedures required by section 5111.914 of the Revised Code and Chapter 5101:6-51 of the Administrative Code.

(5) The issuing state agency shall send a report at least quarterly to ODJFS enumerating the status of recovery of any amounts identified in notices issued under authority of this rule. The report shall be in a form and manner specified by ODJFS.

History

Effective: August 1, 2011
Promulgated Under: 119.03

Ohio Adm.Code 5160-71-03 Chapter 119. hearings conducted under authority of section 5111.914 of the Revised Code: interest for findings pursued for recovery.

(A) Pursuant to division (E) of section 5111.03 of the Revised Code, any provider of services or goods contracting with ODJFS pursuant to Title XIX of the Social Security Act that, without intent, obtains payments under Chapter 5111. of the Revised Code in excess of the amount to which the provider is entitled, thereby becomes liable for payment of interest on the amount of the excess payments at the maximum real estate mortgage rate on the date the payment was made to the provider for the period from the date upon which payment was made to the date upon which repayment is made to the state.

(B) Interest payments shall be charged on a daily basis for the period from the date the overpayment was made to the date upon which repayment is received by the state.

(C) The "date upon which payment was made" means the date of the overpayment and shall be determined in accordance with the following:

(1) For any overpayment that is identified as the result of either a reasonable cost based reimbursement settlement, or cost report reconciliation, or rate setting reimbursement settlement, or similar cost settlement reporting, the "date of the overpayment" shall be ten days from the date the issuing state agency's notice of overpayment is received by the provider as shown by the U.S. postal service return receipt slip.

(2) For any other finding of overpayment by the issuing state agency, the "date of the overpayment" shall be the latest date of the warrant issued in payment for any of the paid claims that form the basis for the overpayment finding.

(D) The "date upon which repayment is received by the state" shall mean one of the following:

(1) The date the repayment is time-stamped by the issuing state agency;

(2) The date the repayment is deposited as certified mail with the U.S. postal service; or

(3) In the case of any repayment through offset of future claims for reimbursement, the date the repayment is posted on the books of the issuing state agency.

(E) The maximum real estate mortgage rate shall be calculated pursuant to division (B)(4) of section 1343.01 of the Revised Code, as amended. Namely, the rate shall be three per cent in excess of the discount rate on ninety-day commercial paper in effect at the federal reserve bank in the fourth federal reserve district on the day the repayment was made. (The "discount rate on ninety-day commercial paper in effect at the federal reserve bank in the fourth district" is the rate that the federal reserve bank in the fourth district uses as the interest rate it charges to member banks.)

(F) Interest payments shall be calculated on the basis of simple interest.

(G) Interest shall be charged on medicaid overpayments that have occurred on and after April 24, 1978, and that are identified for repayment after August 1, 1982.

(H) The issuing state agency may waive the interest penalty when repayment is made in full and the amount of interest owed by any single provider is less than fifty dollars. The issuing state agency may waive the interest penalty when voluntary repayment of individual claims is made by a provider before any notification by the issuing agency that an overpayment has occurred.

History

Effective: August 1, 2011
Promulgated Under: 119.03

Ohio Adm.Code 5160-71-04 Chapter 119. hearings conducted under authority of section 5111.914 of the Revised Code: notice and requesting a hearing.

(A) Written notice of intended action.

(1) Whenever an issuing state agency proposes to take an action under authority of section 5111.914 of the Revised Code, the issuing state agency shall send the affected party written notice of the agency's intended action ("notice of intended action"). The issuing state agency shall mail, certified mail, return receipt requested, such notice, which shall at a minimum include all of the following:

(a) Notice of the specific action or actions the agency intends to take;

(b) Charges or reasons for the proposed action or actions;

(d) A statement that the affected party is entitled to a prior hearing if the hearing is requested within thirty days from the date of mailing the notice;

(e) A statement that the affected party may appear at a hearing in person or through an attorney;

(f) A statement that the affected party may present positions entirely in writing, may examine evidence and adverse witnesses at the hearing, and may introduce evidence and bring forth witnesses on behalf of the affected party; and

(g) A statement that rules governing affected party hearings before the issuing state agency are to be found in Chapter 5101:6-51 of the Administrative Code.

(2) The issuing state agency shall also mail a copy of the notice to the affected party's attorney or other representative of record. To qualify as an attorney or representative of record, the party or the attorney or representative must notify the issuing state agency, in writing, that the attorney or representative is to be designated the attorney or representative of record. The notification must include the address where the issuing state agency should mail the notice to the attorney or representative of record. The mailing of notice to the affected party's attorney or representative is not deemed to perfect service of the notice. Failure to mail a copy of the notice to the attorney or representative of record shall not result in failure of otherwise perfected service upon the affected party. In those instances where an affected party is a corporation doing business in Ohio or is incorporated in Ohio, the mailing of notice to the corporation's statutory agent pursuant to sections 1701.07 and 1703.19 of the Revised Code shall perfect service provided there is compliance with all the requirements of paragraph (A) of this rule.

(3) When the notice required by paragraph (A) of this rule is returned because of inability to deliver, the issuing state agency may either have its employee make personal delivery of the notice or cause the notice to be published once a week for three consecutive weeks in a newspaper of general circulation in the county where the last known place of residence or business of the affected party is located. The issuing state agency shall mail, first class mail, a copy of the first publication of the notice in a newspaper to the affected party at the last known place of residence or business. The notice is deemed received as of the date of last publication. Nothing in this rule is to be construed to limit or otherwise prohibit the utilization of sections 1701.07 and 1703.19 of the Revised Code to perfect service of process.

(B) Request for a hearing.

(1) Any request for a hearing made as the result of notice issued pursuant to paragraph (A) of this rule must be made in writing and mailed or delivered to the issuing state agency within thirty calendar days of the mailing or personal delivery of the notice. If a request for a hearing is mailed or delivered to the issuing state agency, the request is deemed to have been made as follows:

(a) If the request is mailed by certified mail, the request is deemed to have been made as of the date stamped by the U.S. postal service on its receipt form (PS form 3800 or any future equivalent postal service form).

(b) If the request is mailed by regular U.S. mail, the request is deemed to have been made as of the date of the postmark appearing upon the envelope containing the request. In those cases where a postmark is illegible or fails to appear on the envelope, the request is deemed to have been made as of the date of its receipt by the issuing state agency as evidenced by the agency's time stamp.

(c) If a request for a hearing is mailed or personally delivered to a party or address other than the issuing state agency, the request is deemed to have been made as of the date of its receipt by the issuing state agency as evidenced by the agency's time stamp.

(d) If a request for a hearing is personally delivered to the issuing state agency, the request is deemed to have been made as of the date of its receipt as evidenced by the agency's time stamp.

(e) If a request for a hearing is made by facsimile transmission or by electronic mail, the request is deemed to have been made as of the date of its receipt as evidenced by the receipt date generated by the facsimile transmission or as shown on the electronic mail received by the issuing state agency.

(2) Any request for a hearing made as the result of notice issued by publication pursuant to paragraph (A)(3) of this rule must be made in writing and delivered to the proper address listed in the notice of the issuing state agency within thirty calendar days of the notice's final date of publication.

(3) All requests for hearings must clearly identify both the affected party involved and the proposed action that is being contested.

(4) A request for a hearing is not valid if it is delivered to ODJFS.

(C) If an affected party fails to request a hearing or if the request is not timely, the issuing state agency shall request ODJFS to issue a final and binding order of adjudication adopting and ratifying the allegations contained in the notice of intended action.

History

Effective: August 1, 2011
Promulgated Under: 119.03

Ohio Adm.Code 5160-71-05 Chapter 119. hearings conducted under authority of section 5111.914 of the Revised Code: appointment and powers of a hearing examiner and rules of practice.

(A) Initial scheduling of the hearing.

(1) When an affected party timely requests a hearing, the issuing state agency shall set the date, time, and place for the hearing and notify the appellant of the scheduling. The issuing state agency shall initially schedule the hearing not earlier than seven calendar days but not later than fifteen days after the hearing was requested. The first notification concerning a scheduled hearing shall be written and sent registered mail, return receipt requested. All subsequent letters and notices shall be sent by regular U.S. mail.

(2) Nothing in this rule shall be construed so as to prevent the issuing state agency from postponing and rescheduling any hearing upon its own motion or upon the motion of any appellant who can show good cause for such a request

(3) Nothing in this rule shall be construed from preventing the issuing state agency and the appellant from entering into a written agreement establishing the time, date, and place of the hearing.

(B) Joinder of individual cases.

On its own motion, or on motion of the appellant, the issuing state agency or the hearing examiner may join any individual cases where there exist incidents of common ownership or interest and where joinder would be appropriate for efficient and economic fairness to the parties.

Section 1.14 of the Revised Code controls the computing of time deadlines imposed by Chapter 119. of the Revised Code.

(D) Rules of practice in hearings conducted under this chapter.

In all hearings conducted under section 5111.914 of the Revised Code, the following rules of practice shall be followed:

(1) The attorney general, or assistants or special counsel designated by the attorney general, will represent the issuing state agency. The director of the issuing state agency may designate staff members of the issuing state agency to assist the attorney general in the preparation and presentation of such hearings and to be present at all times during the hearing and any pre-hearing conferences.

(2) Any individual not appearing pro se and any corporation, partnership, association, or other entity must be represented by an attorney admitted to the practice of law in the state of Ohio. Individuals authorized to practice law in any other jurisdiction may be permitted to represent an appellant in hearings under section 5111.914 only upon order of a court of common pleas of Franklin county. When the appellant is represented by more than one attorney, one attorney must be designated by the appellant as "trial counsel" and that attorney is deemed the appellant's attorney of record and is primarily responsible for the appellant's case at the hearing. No attorney representing an appellant is permitted to withdraw from any hearing without prior notice being served upon the issuing state agency and prior approval by the hearing examiner.

(E) Authority of hearing examiners.

The issuing state agency shall assign a hearing examiner to conduct any hearing held under authority of section 5111.914 of the Revised Code. Any person assigned to be a hearing examiner must be admitted to the practice of law in the state of Ohio. The hearing examiner may be an employee of the issuing state agency or under contract to the issuing state agency. The hearing examiner has the same powers as granted to the issuing state agency in conducting the hearing. These powers include, but are not limited to, the following:

(1) The general authority to regulate the course of the hearing and to issue orders governing the conduct of the hearing.

(2) The authority to administer oaths or affirmations, order the production of documents and the attendance of witnesses, call and examine witnesses in a reasonable and impartial manner, and to determine the order in which the participants to a hearing will present testimony and be examined in a manner consistent with essential fairness and justice.

(3) The authority to pass upon the admissibility of evidence, rule on objections, procedural motions, and other procedural matters.

(4) The authority to issue orders intended to facilitate settlement of the case, including the scheduling of settlement conferences, directing the exchange of offers and demands, and any other actions that may facilitate the prompt resolution of disputed matters.

(5) The authority to hold one or more pre-hearing conferences of the participants for the purpose of resolving issues that can be resolved by the participants including facilitation of a settlement, identifying the witnesses to be presented and the subject of their testimony, discussing possible admissions or stipulations regarding the authenticity of records, identifying and marking exhibits, and ruling on any procedural motions of the participants, resolving outstanding discovery claims, and clarifying the issues to be addressed at the hearing, and discussing any other matters deemed appropriate by the hearing examiner for the thorough and expeditious preparation and disposition of the case.

(6) The authority to take such other actions as might be necessary to avoid unnecessary delay, prevent presentation of irrelevant or cumulative evidence, prevent argumentative, repetitious, or irrelevant examination or cross-examination, and to assure that the hearing proceeds in an orderly and expeditious manner.

(7) Nothing in this rule nor in any other rule of the Administrative Code is to be construed as granting a hearing examiner the authority to dismiss any hearing. Nothing in this rule nor in any other rule of the Administrative Code limits the authority of the issuing state agency to withdraw its written notice of intended action.

(8) The hearing examiner may require the submission of briefs and memoranda at any time during the proceeding. The hearing examiner may limit these filings to one or more specific issues and may prescribe procedures and time schedules for their submission. All briefs, memoranda, motions or other pleadings are subject to the following requirements:

(a) If any unreported court decision is cited in any brief or memorandum, a copy of such decision is to be attached to the brief or memorandum containing the citation.

(b) All briefs, memoranda, motions or other pleadings must be filed with the issuing state agency. A certificate of service is to be attached attesting both to the service of a copy of the pleading on the opposing party and the provision of a copy to the hearing examiner.

(c) Only those pleadings, orders, and other papers filed with the issuing state agency shall be a part of the official record.

(d) All briefs, memoranda, motions, or other pleadings and papers must be on eight-and-one-half-inch by eleven-inch paper and double-spaced.

(e) All orders, reports, recommendations, and rulings issued by the hearing examiner are to be signed, dated, and filed with the issuing state agency.

(f) All exhibits, or other evidence admitted into the record or proffered, shall be filed by the hearing examiner with the issuing state agency at the conclusion of the hearing.

(F) Withdrawal of notice of intended action.

The issuing state agency, upon its own motion, at any time prior to the issuance of an order of adjudication, may withdraw its written notice of intended action. Such withdrawal shall be without prejudice to the rights of the parties. An appellant may withdraw a request for a hearing only with the prior approval of the hearing examiner.

History

Effective: August 1, 2011
Promulgated Under: 119.03

Ohio Adm.Code 5160-71-06 Chapter 119. hearings conducted under authority of section 5111.914 of the Revised Code: discovery.

(A) Hearing examiner may allow pre-hearing discovery.

(1) As a part of the authority to conduct the hearing, and except as provided in paragraph (B) of this rule, the hearing examiner may allow pre-hearing discovery of any matter that is not privileged or confidential and that is relevant to the subject matter of the proceeding, provided that such discovery is necessary to facilitate the thorough and adequate preparation of the hearing. The participants to any hearing governed by this chapter may also conduct pre-hearing discovery by mutually agreeable methods or by stipulations subject to approval by the hearing examiner. When a method of pre-hearing discovery is permitted, it shall be conducted in accordance with the Ohio Rules of Civil Procedure (7/1/2000) unless the hearing examiner orders otherwise, and except as modified by paragraph (B) of this rule. Use of discovered material at any hearing shall also be governed by the Ohio Rules of Civil Procedure (7/1/2000).

(2) When permitted pursuant to this rule, pre-hearing discovery may begin immediately after a hearing request is timely made, and must be completed before the actual commencement of the hearing. The hearing examiner may limit the length of the time allowed for discovery and may shorten or lengthen the time allowed for response to discovery requests. Pre-hearing discovery may be obtained through use of interrogatories, requests for the production of documents, permission to enter upon land or other property, depositions, and requests for admissions.

(3) Nothing in this rule prohibits an appellant or the issuing state agency from gaining access to any information made public by the operation of state law.

(B) Depositions. For the purpose of conducting a hearing, the issuing state agency or any appellant may take depositions of witnesses residing within or without the state in the same manner as is prescribed by law for the taking of depositions in civil actions in the court of common pleas of this state. Depositions of state employees are to be conducted in the Columbus offices of the issuing state agency during normal business hours unless other arrangements are approved by the issuing state agency.

The issuing state agency, upon its own motion or that of any appellant, shall issue a subpoena requiring the attendance of witnesses and the production of books and records as are necessary for the purpose of conducting a hearing.

(1) Upon the request of the appellant, the issuing state agency shall issue a subpoena for any witness or a subpoena duces tecum to compel the production of any books, records, or papers. The issuing state agency shall issue such subpoena in blank to a party requesting it, who is solely responsible for completing the subpoena form, including the address where the person is to be served, and returning it to the issuing state agency along with a written request for service. The written request along with the completed subpoena must be received by the issuing state agency no later than twenty-one business days before commencement of the hearing or deposition, unless otherwise ordered for good cause shown. Upon its own initiative and for its own use, the issuing state agency may issue a subpoena for any purpose set forth in this rule or otherwise authorized by law. At its discretion, the issuing state agency may make available electronically a subpoena in blank and may authorize electronic submission of a completed subpoena.

(2) All subpoenas issued under this rule are to be directed to the sheriff of the county where the person to be served resides or is found. The subpoena is to be served and returned in the same manner as a subpoena in a criminal case. Fees and mileage of the sheriff and the witness will be the same as that allowed in the court of common pleas in criminal cases. The issuing state agency will pay allowable fees and mileage.

(3) In any case of disobedience or neglect of any subpoena served upon any person, or the refusal of any witness to testify to any matter in which there may be lawful interrogation, the issuing state agency will apply to the court of common pleas where such disobedience, neglect, or refusal occurs for an order to compel obedience by attachment proceedings for contempt, as in the case of disobedience of the requirements of a subpoena issued from such court, or a refusal to testify therein.

History

Effective: August 1, 2011
Promulgated Under: 119.03

Ohio Adm.Code 5160-71-07 Chapter 119. hearings conducted under authority of section 5111.914 of the Revised Code: conduct of the hearing and adjudication order.

(A) Conduct of the hearing.

(1) The issuing state agency shall employ or contract with a hearing examiner to conduct all hearings initiated under authority of section 5111.914 of the Revised Code.

(2) The date, time, and place of any hearing under authority of section 5111.914 of the Revised Code is set by the issuing state agency or the hearing examiner. The hearing examiner shall provide written or electronic notice before the date of the hearing to all participants in the hearing and file a copy of the written notice in the record of the hearing.

(3) Subject to the prior approval of the hearing examiner, any appellant may choose to present the case entirely in writing provided that a written request is made by the appellant no later than fourteen business days before the date scheduled for the hearing. Any request to present the case entirely in writing must be filed with the hearing examiner. Any appellant who elects to present the case entirely in writing must do so in accordance with procedures ordered by the hearing examiner. The hearing examiner's order must be in writing and filed in the record of the hearing. In the event that the appellant elects to present its case in writing, the issuing state agency may elect to present its case entirely in writing. Nothing in this rule is to be construed as preventing the issuing state agency from compelling the attendance of the appellant or other witnesses at the hearing and questioning the appellant or other witnesses as if on cross-examination. Nothing in this rule is to be construed as preventing any appellant from examining any witnesses or evidence presented by the issuing state agency at the hearing.

(4) During the course of any hearing, the participants to the proceeding may enter into oral stipulations of fact, procedure, or the authenticity of documents that will be incorporated into the record and will bind the conduct of the participants. The hearing examiner conducting the case may require oral stipulations to be reduced to writing and submitted to the hearing examiner. The hearing examiner assigned to conduct a hearing has the power to rule on the admissibility of evidence or testimony, but a participant may make objections to the rulings thereon. If the hearing examiner refuses to admit evidence or testimony, the participant seeking admission of same must make a proffer thereof and such proffer will be made a part of the record of the hearing. The hearing examiner may refer to the guidelines contained in the Ohio Rules of Evidence (7/1/2007) in making decisions on admissibility.

(B) Findings of fact, conclusions, recommendations, and objections.

(1) Upon the conclusion of any hearing, the hearing examiner shall prepare a written report of findings of fact, conclusions of law, and recommendations of departmental action to be taken in disposition of the case. The hearing examiner shall file the report, together with a complete record of the proceeding, with the issuing state agency within not more than forty-five days after the conclusion of the hearing, unless the parties agree to an extension of the time for the filing of the hearing examiner's report. Within five days of its completion, the issuing state agency shall send by certified mail, return receipt requested, to the appellant or the appellant's attorney, a copy of the hearing examiner's report. The report will be considered to have been mailed as of the date appearing on U.S. postal service form 3800 or any future equivalent postal service form. Also, on completion of the report and recommendation, the issuing state agency shall submit its hearing officer's report and recommendation and the complete record of proceedings, including all transcripts, to ODJFS for final adjudication.

(2) An appellant may file written objections to the hearing examiner's report with ODJFS. Any such objections must be received by ODJFS no later than ten days after the appellant receives the report. Any such objections must be filed with the depository agent of ODJFS. ODJFS may grant an extension of time to file objections if the appellant's written request for an extension is received by ODJFS no later than ten days after the appellant's receipt of the report. The date the appellant receives the hearing examiner's report is the date indicated on the U.S. postal service form 3800 or any future equivalent postal service form. The director will consider timely written objections before approving, modifying, or disapproving the recommendations of the hearing examiner.

(1) Recommendations of the hearing examiner may be approved, modified, or disapproved by the director. The director may remand the matter back to the issuing state agency to allow for additional testimony to be taken and permit the introduction of further documentary evidence. In those instances where the director modifies or disapproves the recommendations of the hearing examiner, the director will include the reasons therefore and incorporate them into the final order of adjudication.

(2) After the director has entered an order approving, modifying, or disapproving the hearing examiner's recommendation on the ODJFS journal of proceedings, the director will mail to the appellant and any attorney of record by certified mail, return receipt requested, a copy of the order and a statement of the time and method by which an appeal may be perfected. The director shall provide a copy of the order to the issuing state agency.

(D) Appeal of final adjudication order.

(1) Any appellant against whom a final order of adjudication is entered, pursuant to this rule, may appeal that order to the Franklin county court of common pleas.

(2) Any appellant desiring an appeal pursuant to this rule must file a notice of appeal with the depository agent of ODJFS and with the issuing state agency, setting forth the order appealed from and stating that the agency's order is not supported by reliable, probative, and substantial evidence and is not in accordance with the law. The notice may, but need not, set forth the specific grounds of the party's appeal beyond the statement that the agency's order is not supported by reliable, probative, and substantial evidence and is not in accordance with the law. In order to be determined filed with ODJFS, the notice of appeal must be received by ODJFS, as evidenced by an ODJFS date and time stamp, no later than fifteen days after the mailing to the affected party, as evidenced by U.S. postal service form 3800, or any future equivalent postal form, of the order to be appealed from. Appellant shall also file the notice of appeal with the court of common pleas no later than fifteen days after the mailing to the affected party, as evidenced by U.S. postal service form 3800, or any future equivalent postal form, of the order to be appealed from. In filing a notice of appeal with ODJFS, the issuing state agency or court, the notice that is filed may be either the original or a copy of the original notice.

History

Effective: August 1, 2011
Promulgated Under: 119.03

Chapter 5160-80 Rights and Procedures Applicable to Medical Assistance Recipients

Ohio Adm.Code 5160-80-01 Hearings conducted under authority of section 5160.37 of the Revised Code: definitions and scope of applicability.

(A) Rules 5160-80-01 to 5160-80-09 of the Administrative Code describe the hearing rights, appeal rights, and procedures applicable to medical assistance recipients under section 5160.37 of the Revised Code for contesting the amount of the department's or county department's claims for reimbursement under section 5160.37 of the Revised Code for medical assistance paid.

(B) Definitions

As used in rules 5160-80-01 to 5160-80-09 of the Administrative Code, the following terms shall have the following meanings unless otherwise specified.

(1) "Appellant" means a medical assistance recipient who is utilizing the hearing process under Chapter 5160-80 of the Administrative Code.

(2) "Authorized representative" means an individual at least eighteen years of age or a legal entity that is appointed by the medical assistance recipient to assist or stand in the place of the medical assistance recipient for the purpose of the hearing process or an appeal to the director. The department may request proper verification from the authorized representative of the appointment.

(3) "County department" means any of the local county department of job and family services.

(4) "Depository agent" means the department's office at its official mailing address for purpose of receiving correspondence or filings for a hearing or administrative appeal conducted under authority of Chapter 5160-80 of the Administrative Code.

(5) "Department" means the Ohio department of medicaid.

(6) "Director" means the director of the Ohio department of medicaid or that person's designee.

(7) "Electronic" has the same meaning as in section 1306.01 of the Revised Code.

(8) "Final lien amount" is the amount the department or county department determines in writing that the medical assistance recipient owes for reimbursement for medical assistance paid on the medical assistance recipient's behalf, subject to the right to collect additional reimbursement as set forth in division (F) of section 5160.37 of the Revised Code.

(9) "Good cause" is defined as death in the immediate family, sudden illness or injury of a participant in the hearing or that person's immediate family, or other circumstances that reasonably prevents or prevented attendance at the hearing.

(10) "Medical assistance recipient" or "recipient" means a recipient or former recipient of a medical assistance program who has had some or all of his or her medical expenses paid by the department or county department.

(11) "Party" includes (a) a medical assistance recipient who requests a hearing or an administrative appeal under Chapter 5160-80 of the Administrative Code, or the executor or administrator of an medical assistance recipient's estate authorized to make or pursue such a request and (b) the department or county department that has claim for medical reimbursement involved in those proceedings.

(12) "Request for hearing" is a clear expression in writing by a medical assistance recipient or the recipient's authorized representative or attorney stating that medical assistance recipient wants to dispute the amount of the department's or county department's claim for reimbursement or to seek recovery of money that the department or county department received pursuant to section 5160.37 or 5160.38 of the Revised Code or former section 5101.58 or 5101.59 of the Revised Code.

(13) "Request for an administrative appeal" is a clear expression by the medical assistance recipient or the medical assistance recipient's authorized representative or attorney to the effect that the appellant wants to have the hearing decision or a decision to deny or dismiss a hearing request reviewed by the director. The request must be in writing and signed by the appellant or the appellant's authorized representative or attorney.

(14) "Third party" means the entity which has provided funds to the medical assistance recipient, or to whom the recipient has initiated informal recovery activity or filed a legal recovery action, that gives rise to the department's or county department's right of recovery.

History

Effective: June 13, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-80-02 Hearing Requests.

(A) Making a request for hearing

(1) A request for hearing must be submitted to the depository agent in writing by the medical assistance recipient or by the medical assistance recipient's authorized representative or attorney and shall be subject to the requirements of this rule.

(2) The request for hearing shall address only the issue of whether the amount determined for reimbursement of medical assistance paid by the department or county department should be different than set forth in section 5160.37 of the Revised Code. The hearing examiner shall freely grant leave to a medical assistance recipient or to a medical assistance recipient's authorized representative or attorney to amend the written hearing request if it fails to comply with this requirement.

(3) For a payment owed to the department or county department on or after September 29, 2015, the following shall apply:

(a) Before a medical assistance recipient can make a hearing request, the medical assistance recipient must receive from the department or county department a letter with a final lien amount.

(b) If the medical assistance recipient is requesting a hearing pursuant to division (L)(1) or (L)(2) of section 5160.37 of the Revised Code, the medical assistance recipient must provide the following information with the hearing request, subject to documentation verification upon demand of the department:

(i) The total amount to be paid to resolve all claims of the medical assistance recipient, including, but not limited to, medical expenses, loss of income, loss of consortium, and pain and suffering.

(ii) The amount that has been collected as a result of the settlement, compromise, judgment, or award giving rise to the department's or county department's claim for reimbursement.

(iii) The amount of attorney fees incurred to obtain the settlement, compromise, judgment, or award.

(iv) The amount of costs and expenses incurred to obtain the settlement, compromise, judgment, or award.

(c) In addition to the information requested pursuant to paragraph (A)(3)(b) of this rule, the medical assistance recipient requesting a hearing pursuant to division (L)(1) or (L)(2) of section 5160.37 of the Revised Code shall provide with the hearing request the following documentation:

(i) A copy of all written settlement agreements, compromises, judgments, or awards referenced in paragraph (A)(3)(b) of this rule.

(ii) If the medical assistance recipient does not pay to the department or county department the final lien amount, documentation from a bank or other financial institution providing the account number and the amount being held in an escrow account or an attestation from an attorney identifying the amount being held in an interest on lawyers' trust account pursuant to division (L)(1) of section 5160.37 of the Revised Code.

(d) If the medical assistance recipient does not include all of the information and documentation required in paragraphs (A)(3)(b) and (A)(3)(c) of this rule, the department shall send written notice to the medical assistance recipient and the medical assistance recipient's attorney or authorized representative listing the information and documentation not provided. If the medical assistance recipient or the medical assistance recipient's attorney or authorized representative fails to provide all the requested information and documentation within thirty calendar days of the date of mailing of the written notification, the department shall dismiss the hearing request without prejudice.

(4) Written documentation of the appointment of an authorization representative by a medical assistance recipient must accompany the hearing request made on the medical assistance recipient's behalf by an authorized representative. Attorneys may make a written hearing request on a medical assistance recipient's behalf without providing written authorization. To obtain medical assistance information or protected health information, an attorney representing the medical assistance recipient must provide a written release meeting the requirements of section 5160.45 of the Revised Code or written documentation that the attorney is acting in the capacity as an authorized representative.

(B) Time limit

(1) For payments owed to the department or county department on or after September 29, 2015, written notification by the department or county department to the medical assistance recipient of the final lien amount shall include a notice of the recipient's right to request a hearing.

(2) If a medical assistance recipient does not elect to escrow or have placed in a lawyers' trust account the final lien amount, a request for hearing must be made not later than ninety calendar days after payment of the final lien amount to the department or county department. When counting the days to determine whether an appeal is timely, the date on which notice was mailed, sent by electronic means, or otherwise provided is not counted. If the last day of the time period falls on a Saturday, Sunday, or state or federal legal holiday, the time period is extended to include the next workday.

(1) If a request for hearing is made to the depository agent, the request is deemed to have been made as follows:

(a) If the request is mailed by certified mail, as of the date stamped by the U.S. postal service on its receipt form (PS form 3800 or any future equivalent postal service form).

(b) If the request is mailed by ordinary U.S. mail, as of the date of the postmark appearing upon the envelope containing the request.

(c) If the request is mailed by ordinary U.S. mail and the postmark is illegible or fails to appear on the envelope, as of the date of its receipt by the depository agent as evidence by the agent's time stamp.

(2) If a request is made through the website designated by the department for making a hearing request, the request is deemed to have been made when the request is electronically recorded by the website.

(3) If a request for a hearing is made by facsimile transmission or by electronic mail to the depository agent, the request is deemed to have been made as of the date of its receipt as evidence by the receipt date generated by the facsimile transmission or the date of receipt shown in the source code of the electronic mail received by the depository agent.

(4) If a request for a hearing is personally delivered to the depository agent, the request is deemed to have been made as of the date of its receipt by the depository agent's time stamp.

(5) If a request for a hearing is mailed, personally delivered, made by facsimile transmission, or made by electronic mail to a person or address other than the depository agent or otherwise not properly sent, the request is deemed to have been made as of the date of its receipt by the depository agent as evidence by the depository agent's time stamp.

(6) The hearing request shall clearly identify the medical recipient making the request by name, address and phone number. If a request is made through a website designated by the department for making a hearing request, the request shall provide the information required by the website to identify the medical assistance recipient.

History

Effective: June 13, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-80-03 Postponement of the hearing.

(A) Postponement is a request prior to the hearing date to reschedule the hearing for a later date.

(1) The hearing may be postponed at the request of a party for good cause.

(2) The hearing examiner shall have final authority to determine whether good cause exists.

(B) When a request for postponement is denied, the party or the party's authorized representative or attorney must attend the scheduled hearing, or submit written arguments and evidence in writing in lieu of attending the hearing if a timely request to do so was made pursuant to rule 5160-80-06 of the Administrative Code, or be subject to dismissal as described in rule 5160-80-04 of the Administrative Code.

History

Effective: June 13, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-80-04 Denial and dismissal of hearing requests.

(A) All hearing requests shall be made in one of the methods set forth in rule 5160-80-02 of the Administrative Code.

(B) A hearing request may be denied prior to the issuance of the department's notice scheduling a hearing for only the following reasons:

(1) The hearing request is untimely, as defined by rule 5160-80-02 of the Administrative Code.

(2) The request was not made by the medical assistance recipient or the medical assistance recipient's authorized representative or attorney, or written authorization specifically designating the person making the request to act on the medical assistance recipient's behalf was not submitted with the request.

(3) The request fails to raise the issue of whether the amount determined for reimbursement of medical assistance paid by the department or county department reimbursement should be different than set forth in section 5160.37 of the Revised Code.

(4) It is clear that the issue has been previously decided through the hearing process.

(C) When a hearing request is denied, the department shall issue to the medical assistance recipient and to the medical assistance recipient's authorized representative or attorney written notice describing the reason for the denial.

(D) Once the hearing examiner has issued a notice scheduling a hearing, a request for a hearing may be dismissed only for the following reasons:

(1) The medical assistance recipient or medical assistance recipient's authorized representative or attorney withdraws the hearing request with prejudice before the hearing decision is issued.

(2) The medical assistance recipient or the medical assistance recipient's authorized representative or attorney fails, without good cause, to appear at the hearing. The hearing examiner shall have final authority to determine if good cause was timely shown. Verification of good cause may be required.

(E) When a hearing request is dismissed pursuant paragraph (D)(2) of this rule, the hearing examiner shall issue to the medical assistance recipient and to the medical assistance recipient's authorized representative or attorney written notice describing the reason for the dismissal, with a copy to counsel for the department or county department.

(F) Dismissal or denial of a hearing request under this rule constitutes a binding decision on the parties. In the event that a dismissal notice or hearing denial is issued in error, it may be reversed by the director on appeal as provided for in rule 5160-80-09 of the Administrative Code.

History

Effective: June 13, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-80-05 Scheduling and attendance.

(A) Time and place of the hearing

(1) All hearings shall be conducted in Columbus, Ohio, during normal business hours unless other times are authorized by the hearing examiner. The appellant and department or county department may elect to participate in the hearing via video conference with the hearing examiner's consent. No telephone hearings shall be allowed.

(2) Upon the written request of an appellant, the director may designate the site of the hearing to be the county seat of the county wherein the appellant resides or, alternately, a place within fifty miles of the appellant's residence. The approval of an alternative location is at the director's discretion. Requests for an alternative hearing site must be filed by the appellant with the depository agent at least forty-five calendar days before the hearing date, with service as required by rule 5160-80-06 of the Administrative Code.

(B) The hearing examiner shall issue a scheduling notice providing the time, date, and place of the hearing to the appellant and to the appellant's authorized representative or attorney and to the department or county department.

(1) A copy of the scheduling notice shall be retained and included in the hearing record.

(2) The scheduling notice shall be issued at least sixty calendar days prior to the date of the hearing, unless the appellant or appellant's attorney or authorized representative requests an expedited hearing. Expedited hearings may be granted at the discretion of the hearing examiner.

(3) The scheduling notice shall:

(a) Provide the name, address and telephone number of the person to notify if a party or party's authorized representative or attorney cannot attend the hearing.

(b) Explain that the hearing request will be dismissed with prejudice if the appellant or the appellant's authorized representative or attorney fails, without good cause, to appear for the hearing.

(c) Contain a general explanation of hearing procedures and provide other information necessary for the appellant's understanding of the proceedings. The explanation of hearing procedures will set forth deadlines, including the deadlines for disclosure of information as identified in paragraph (D) of this rule.

Attendance at the hearing is limited to the following:

(1) The department or county department representative.

(2) The appellant and authorized representative.

(3) Legal representation for the parties. The attorney general, or assistant attorney general or special counsel designated by the attorney general, shall represent the department.

(4) Witnesses called by the appellant and by the department or county department to present relevant testimony, subject to the right of any party to move for separation of witnesses.

(5) Other persons, only if their attendance as determined by the hearing examiner does not interfere with the orderly conduct of the hearing.

(D) Pre-hearing discovery is not allowed. The department or county department shall provide the appellant and the appellant's authorized representative or attorney no later than thirty calendar days following the issuance of the scheduling notice with copies of any relevant, non-privileged records it has concerning the appellant's medical billing, correspondence, and payment history. The appellant or the appellant's authorized representative or attorney shall provide counsel for the department or county department no later than thirty calendar days after issuance of the scheduling notice with the names and addresses of any third party and the attorney for the third party. When the third party is an insurance company, the appellant or the appellant's authorized representative or attorney shall also provide the names and addresses of the beneficiaries of the issuance policy. Upon a showing of good cause, or upon the hearing examiner's own initiative, this thirty day period may be increased or decreased.

(E) Subpoenas

(1) The depository agent shall issue blank subpoena forms to a party requesting a subpoena for the purpose of compelling at the hearing testimony or the production of documents. The party is responsible for completing the subpoena form, including the address where the person is to be served, and returning the completed subpoena form to the depository agent along with a written request for service and a check for witness fees and mileage made payable to the witness. The written request for service and the completed subpoena, along with a check for witness fees and mileage, must be received by the department no later than thirty calendar days before the commencement of the hearing, unless otherwise ordered by the hearing examiner for good cause shown. At its discretion, the department may make available an electronic version of the subpoena and may authorize electronic submission of a completed subpoena. A party requesting issuance of a subpoena shall serve a copy of the subpoena upon the opposing party. A party objecting to the issuance of a subpoena may file a motion to quash setting forth in specific detail the bases for the objection.

(2) For hearings, upon its own initiation or that of any party in the hearing, the department shall issue a subpoena to any person within the state requiring the person's attendance as a witness and/or the production of books, records or papers at the hearing. A subpoena may be served by a sheriff, bailiff, coroner, clerk of court, constable, or a deputy of any of the foregoing, by an attorney at law, or by any other person designated by order of the department who is not a party and is not less than eighteen years of age. Service of a subpoena upon a person named therein shall be made by delivering a copy of the subpoena to the person, by reading it to him or her in person, by leaving it at the person's usual place of residence, or by placing a sealed envelope containing the subpoena in the United States mail as certified or express mail return receipt requested with instructions to the delivering postal authority to show to whom delivered, date of delivery and address where delivered. Witness fees and mileage fees shall be tendered without demand upon residents living outside the county in which the hearing is being held on the day of their testimony, and upon demand on residents living inside the county in which the hearing is being held on the day of their testimony.

(3) In any case of disobedience or neglect of any subpoena served upon any person, or the refusal of any witness to testify to any matter in which there may be lawful interrogation, the department shall apply to the court of common pleas where such disobedience, neglect, or refusal occurs for an order to compel obedience by attachment proceedings for contempt, as in the case of disobedience of the requirements of a subpoena issued from such court or a refusal to testify therein.

History

Effective: June 13, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-80-06 Rights and responsibility of the parties and hearing examiner.

(A) The appellant and the department or county department.

(1) The parties shall comply with the following service requirements:

(a) A certificate of service shall be attached to each filing with the depository agent attesting to service of a copy on the other party and the hearing examiner. Service is governed by rule 5 of the Ohio Rules of Civil Procedure (www.supremecourt.ohio.gov/LegalResources/Rules/civil/CivilProcedure.pdf, March 8, 2016) except that any reference to "court" in rule 5 will be interpreted to refer to the "depository agent."

(b) Only those brief, motions, memoranda, documents, and other filings filed with the depository agent shall be considered part of the hearing record. They must be filed with the depository agent within three days after service on the other party in the hearing.

(c) All briefs, memoranda, motions, and other filings shall be on eight-and-one half inch by eleven-inch paper and double-spaced.

(2) The appellant has the burden of proof by a showing of clear and convincing evidence that the amount determined for reimbursement of medical assistance paid by the department or county department on behalf of the medical assistance recipient should be different than set forth in division (G)(2) of section 5160.37 of the Revised Code.

(3) The parties shall engage in settlement discussions prior to the hearing, as directed by order of the hearing examiner. The settlement discussions shall occur no later than the document exchange required under paragraph (D) of rule 5160-80-05 of the Administrative Code.

(4) The parties may provide to the hearing examiner, at least seven calendar days prior to the hearing, a written statement of their position in the case in lieu of, or supplemental to, an opening statement.

(5) The appellant and the department or county department shall, as ordered by the hearing examiner, prior to hearing exchange all proposed exhibits and other documents to be used at the hearing.

(6) If an appellant's attorney seeks to have access at the hearing to the appellant's medical assistance information or protected health information without the appellant being present and the attorney is not acting in the capacity as an authorized representative, the attorney must present written authorization signed by the appellant meeting the requirements of section 5160.45 of the Revised Code.

(7) The appellant and the department or county department shall have the opportunity to present their case. The hearing shall be conducted informally, and formal rules of evidence shall not apply. The parties shall have an adequate opportunity to:

(a) Present witnesses.

(b) Submit evidence to establish all pertinent facts and circumstances.

(d) Question or refute any testimony or evidence, including the opportunity to confront and cross-examine adverse witnesses.

(B) The hearing examiner

(1) Hearings shall be conducted by an impartial department hearing examiner who has no personal stake or involvement in the case and was not directly involved in the initial determination being appealed. The hearing examiner shall be under the direction and supervision of the department.

(2) All orders, reports, recommendations, and rulings issued by the hearing examiner shall be signed, dated, and filed with the depository agent. The depository agent shall make services of those filings on the parties.

(3) The hearing examiner by order shall direct the parties to engage in settlement discussions and to report back the results of those discussions.

(4) The hearing examiner shall have the general authority to regulate the course of the hearing and to issue orders governing the conduct of the hearing. This includes the authority to:

(a) Administer oaths or affirmations, order the production of documents and the attendance of witnesses, call and examine witnesses in a reasonable and impartial manner, and determine the order in which the participants in the hearing present testimony and are examined in a manner consistent with essential fairness and justice.

(b) To rule on the admissibility of evidence, objections, motions, and to rule on procedural matters.

(c) To take such other actions as might be necessary to avoid unnecessary delay, prevent presentation of irrelevant or cumulative evidence, prevent argumentative, repetitious, or irrelevant examination or cross-examination, and to assure that the hearing proceeds in an orderly and expeditious manner.

(5) The hearing examiner, at his or her discretion, may hold pre-hearing conferences for the purpose of resolving matters that can be resolved by the parties, including facilitation of a settlement, identifying the witnesses to be presented and the subjects of their testimony, discussing possible admissions or stipulations regarding the authenticity of records, identifying and marking exhibits, ruling on any procedural motions of the participants in the hearing, and discussing any other matters deemed appropriate by the hearing examiner for the thorough and expeditious preparation and disposition of the case.

(6) A party may choose to present its case entirely in writing provided that a written notice is served on the other party and hearing examiner no less than fourteen calendar days before the date scheduled for the hearing. Any party who elects to present the case entirely in writing must do so in accordance with procedures ordered by the hearing examiner. In the event that one party elects to present its case entirely in writing, the other party may elect to present its case entirely in writing by providing written notice to the hearing examiner and other party no later than seven calendar days before the date scheduled for the hearing. Nothing in this rule shall be construed as preventing a party from compelling the attendance of another party or other witnesses at the hearing or from questioning the party or other witnesses as if on cross-examination.

(7) The hearing examiner shall begin the hearing by having the recording equipment started and providing the following introductory information:

(a) The name and role of the hearing examiner, the case name, and the appeal number.

(b) How the hearing will be conducted, including the order of presentation and questioning.

(d) Who will issue the decision.

(e) How the parties will be notified of the decision.

(f) Where the complete hearing record will be kept after the decision is issued.

(g) The available appeal rights.

(8) The hearing examiner shall entertain and rule on any procedural matter prior to opening statements or the presentation of evidence.

(9) The hearing examiner shall record the name and role of each person in attendance and shall administer an oath or affirmation to all who intend to offer testimony.

(10) The hearing examiner shall regulate the order of presentation by the parties. Normally, as the party with the burden of proof, the appellant's presentation will be made first, subject to questioning by the department or county department and the hearing examiner, followed by the department's or county department's presentation, subject to questioning by the appellant and the hearing examiner. The parties will then be allowed a brief closing statement.

(11) In regulating the conduct of the hearing, the hearing examiner is responsible for developing the fullest possible record upon which to base all necessary findings of fact. Each party shall be treated fairly and impartially and given adequate opportunity to present its case. The hearing examiner has an affirmative obligation to assist an unrepresented appellant in understanding the nature of the matters at issue and how the hearing is to be conducted. The hearing examiner shall take an active part in questioning the parties and the evidence presented, insofar as that is necessary to develop the fullest possible record.

(12) After all relevant testimony and evidence has been presented, the hearing examiner shall determine whether a sufficient record has been developed upon which to make the decision. If not, the hearing examiner may order that the hearing be continued to a later date, permit the issuance of additional subpoenas (if there is a need for unanticipated, relevant testimony ) or leave the record open for the submission of additional evidence.

(a) If the hearing is to be continued to a later date, the hearing examiner shall schedule the continuance at the earliest possible date and shall formally record the new date and time, as well as the specific purpose of the continuance. Notification of the parties at the hearing shall be followed by the issuance of a hearing scheduling notice to the parties.

(b) If the record is to be left open to allow the submission of additional documentary evidence, the hearing examiner shall formally record the nature and purpose of the additional evidence and shall establish the earliest possible realistic deadline for its submission to the hearing examiner and for response by the parties to that submission.

(c) Additional evidence submitted pursuant to the deadline shall be forwarded by the party to the opposing party. Evidence submitted after the deadline may be returned to the submitting party by the hearing examiner with notice that it will not be used in reaching the decision.

(13) The hearing examiner shall close the hearing by informing the parties when they can expect the written decision, adjourning the hearing, and verifying that the recording equipment is turned off.

(14) All exhibits or other evidence admitted into the record or proffered shall be filed by the hearing examiner with the depository agent at the conclusion of the hearing.

(15) Following the hearing, the hearing examiner shall not discuss the substance of the case with the parties, unless they or their authorized representatives or attorneys participate.

History

Effective: June 13, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-80-07 Recording of hearing.

(A) The hearing examiner shall make an audio recording of the hearing. The recording shall be started at the beginning of the hearing and shall continue until the hearing is concluded. There shall be no testimony or other proceedings off the record. The recording shall not be altered or edited in any manner or for any reason.

(B) The recording of the hearing shall be a part of the hearing record. The recording shall be maintained pursuant to the department's record retention schedule.

(C) The appellant, the appellant's attorney or authorized representative, or department's or county department's legal representative may request a copy of the recording. The department shall respond to such requests within twenty-one business days whenever possible, and shall provide the copy free of any charge. Non-receipt of a copy of a recording within the administrative appeal period shall not result in an extension of the administrative appeal period.

(D) If, during the administrative appeal process, it is found that the recording is lost or unusable (for example, because it has been damaged or because material portions of the recording are inaudible), the director shall remand the case to the hearing examiner for a new hearing if any party takes material issue with the recitation of the testimony set forth in the hearing decision.

History

Effective: June 13, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-80-08 Hearing decisions.

(A) The hearing examiner is responsible for preparing and issuing the hearing decisions under the authority of the department.

(B) Basis

(1) The hearing examiner's findings of fact shall be based exclusively on the evidence introduced at the hearing, and upon the submission of additional evidence after the hearing and subject to examination and rebuttal by the parties as described in rule 5160-80-06 of the Administrative Code.

(a) The hearing examiner may be guided, but shall not be bound, by the Ohio Rules of Evidence in conducting hearings and in making findings of fact. The hearing examiner shall consider all relevant evidence offered at the hearing.

(b) Hearsay evidence may be considered by the hearing examiner in arriving at the findings of fact. However, such evidence must be critically evaluated, since it is not given under oath and cannot be cross-examined to test the declarant's perception, memory, and veracity. Direct evidence shall normally be given more weight than hearsay evidence when the two are in conflict.

The hearing decision shall separately set forth the issue to be decided of whether the amount determined for reimbursement of medical assistance paid by the department or county department should be different than set forth in section 5160.37 of the Revised Code, the hearing examiner's findings of fact, conclusions of law, and the decision and order.

(1) The procedural matters shall be addressed first. These include, but are not limited to, delays due to postponement, resolution of disputes as to standing, and status of subpoena requests.

(2) The findings of fact shall follow procedural matters. The findings of fact shall be a clear and orderly chronological discussion of the facts and events relevant to the reimbursement issue.

(3) Conclusions of law shall follow findings of fact. The decision shall clearly indicate the basis for each conclusion of law, to include discussion of the relative weight given to conflicting evidence in arriving at the decision as well as a discussion of any relevant law.

(D) Notification

The hearing examiner shall file its hearing decision with the depository agent. The decision shall provide notice to the appellant of the right to and the method of obtaining an administrative appeal. Within five business days of the decision's filing with the depository agent, the depository agent shall mail a copy of the hearing decision by regular U.S. mail to the appellant and to the appellant's attorney or authorized agent and to counsel for the county or county department.

(E) Hearing record

The hearing decision, together with the hearing recording, documents admitted into evidence at the hearing and all papers and requests filed in the proceeding, shall constitute the hearing record. The hearing record shall be maintained by the department in accordance with applicable record retention requirements. It will be made available for review by a party upon request.

(F) Binding effect

A hearing held on an appellant's hearing request resulting in a hearing decision is final and binding upon the parties, has res judicata effect, and only subject to review through the appeal process set forth in section 5160.37 of the Revised Code and rule 5160-80-09 of the Administrative Code.

History

Effective: June 13, 2016
Promulgated Under: 119.03

Ohio Adm.Code 5160-80-09 Administrative appeal of the hearing decision.

(A) An appellant who disagrees with a hearing decision has the right to request an administrative appeal from the director.

(B) Notice of the right to and the method of obtaining an administrative appeal shall be included in all hearing denial notices, hearing dismissal notices, and hearing decisions.

(1) A request for an administrative appeal must be in writing and signed by the appellant or the appellant's authorized representative or attorney.

(2) Written documentation of the appointment of an authorization representative must accompany the appeal request made on an appellant's behalf by the appellant's authorized representative, unless the representative was the authorized representative of record at the hearing stage, or the request is made by the appellant's attorney.

(3) The request must be received by the depository agent within fifteen calendar days from the date the hearing decision being appealed was mailed.

(D) Denial of administrative appeal

(1) An administrative appeal request may be denied for any of the following reasons:

(a) It is not made by the appellant's or by the appellant's authorized representative or attorney, as required by paragraph (C)(2) of this rule.

(b) It is not timely, as defined by paragraph (C)(3) of this rule.

(2) The department shall file written notice of the denial with the depository agent. The depository agent within five business days of filing of the denial shall mail copies of the denial by regular U.S. mail to the appellant and to the appellant's authorized representative or attorney and to counsel for the department or county department.

(E) Review by the director of the administrative appeal.

A hearing decision will be reviewed by the director for one or more of the following reasons:

(1) The decision is contrary to the weight of the evidence presented.

(2) A prejudicial error was committed in the course of the proceedings.

(3) The decision relies on an incorrect application of law or rule.

(F) Administrative appeal decisions

(1) The director shall review the appeal request and the hearing record. The director shall issue an administrative appeal decision which addresses the issues of fact and law raised in the appeal request. The director shall adopt the hearing decision when it contains a correct application of law and is supported by the record. The director shall amend the findings of facts or conclusions of law of the hearing decision that contain any errors or do not correctly apply the appropriate laws, rules or burden of proof, and clearly explain the reason and basis for any such amendment. The director may reverse the hearing decision and remand the case to the hearing examiner for additional action if the appellant met the requisite burden of proof or there was a procedural or other type of error that resulted in an unfair or prejudicial process for the appellant. The director also may remand the matter to the hearing examiner for additional testimony or to permit the introduction of further documentary evidence. The director may reverse, decrease, or increase any monetary finding made for the appellant if there is a basis in either law or the record for this action.

(2) The director shall file with the depository agent the director's administrative appeal decision, which shall include notice of right to file an appeal with the court of common pleas of Franklin county in accordance with section 119.12 of the Revised Code. Within five business days of the filing, the depository agent shall mail a copy of the administrative appeal decision to the appellant and to the appellant's attorney or authorized representative and to counsel for the department or county department.

(G) Administrative appeal record

The administrative appeal record shall consist of the hearing record, appeal request, and the administrative appeal decision, together with all requests, documents, and correspondence filed in the administrative appeal proceeding. The administrative appeal record shall be compiled and maintained by the department in accordance with department's record retention schedules and made available for review by the parties or the parties' authorize representative or attorney upon request.

(H) Finality

(1) An administrative appeal decision that affirms, reverses, or modifies the hearing decision being appealed is final and binding upon the parties, has res judicata effect, and is only subject to appeal through the process set forth in section 119.12 of the Revised Code.

(2) An administrative appeal decision that vacates the original decision and remands the case does not constitute a final administrative resolution.

History

Effective: June 13, 2016
Promulgated Under: 119.03