reglab/statecodes huggingface dataset:
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.74 | Reimbursement of Graduate Medical Education Costs.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The medicaid director shall adopt rules under section 5164.02 of the Revised Code governing the calculation and payment of, and the allocation of payments for, graduate medical education costs associated with medicaid services rendered to medicaid recipients. Subject to section 5164.741 of the Revised Code, the rules shall provide for payment of graduate medical education costs associated with medicaid services rendered to medicaid recipients, including recipients enrolled in a medicaid managed care organization, that the department of medicaid determines are allowable and reasonable.
Last updated October 6, 2021 at 11:01 AM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.741 | Payment for Graduate Medical Education Costs to Noncontracting Hospitals.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) Except as provided in division (B) of this section, the department of medicaid may deny medicaid payment to a hospital for direct graduate medical education costs associated with the delivery of medicaid services to any medicaid recipient if the hospital refuses without good cause to contract with a medicaid managed care organization that serves the area in which the hospital is located.
(B) A hospital is not subject to division (A) of this section if all of the following are the case:
(1) The hospital is located in a county in which participants in the care management system are required before January 1, 2006, to be enrolled in a medicaid managed care organization that is a health insuring corporation.
(2) The hospital has entered into a contract before January 1, 2006, with at least one health insuring corporation serving the participants specified in division (B)(1) of this section.
(3) The hospital remains under contract with at least one health insuring corporation serving participants in the care management system who are required to be enrolled in a health insuring corporation.
(C) The medicaid director shall specify in the rules adopted under section 5164.02 of the Revised Code what constitutes good cause for a hospital to refuse to contract with a medicaid managed care organization.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.75 | Medicaid Payment for a Drug Subject to a Federal Upper Reimbursement Limit.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
As used in this section, "federal upper reimbursement limit" means the limit established pursuant to the "Social Security Act," section 1927(e), 42 U.S.C. 1396r-8(e).
The medicaid payment for a drug that is subject to a federal upper reimbursement limit shall not exceed, in the aggregate, the federal upper reimbursement limit for the drug.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.751 | State Maximum Allowable Cost Program.

Effective:
April 12, 2021
Latest Legislation:
Senate Bill 263 - 133rd General Assembly
(A) As used in this section, "state maximum allowable cost" means the per unit amount the medicaid program pays a terminal distributor of dangerous drugs for a prescribed drug included in the state maximum allowable cost program established under division (B) of this section. "State maximum allowable cost" excludes dispensing fees and copayments, coinsurance, or other cost-sharing charges, if any.
(B) Subject to section 5167.123 of the Revised Code, the medicaid director shall establish a state maximum allowable cost program for purposes of managing medicaid payments to terminal distributors of dangerous drugs for prescribed drugs identified by the director pursuant to this division. The director shall do all of the following with respect to the program:
(1) Identify and create a list of prescribed drugs to be included in the program.
(2) Update the list of prescribed drugs described in division (B)(1) of this section on a weekly basis.
(3) Review the state maximum allowable cost for each prescribed drug included on the list described in division (B)(1) of this section on a weekly basis.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.752 | Determining Maximum Dispensing Fee.

Effective:
September 29, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
In July of every even-numbered year, the department of medicaid shall initiate a confidential survey of the cost of dispensing drugs incurred by terminal distributors of dangerous drugs in this state. The survey shall be used as the basis for establishing the medicaid program's dispensing fees for terminal distributors in accordance with section 5164.753 of the Revised Code. The survey shall be completed and its results published not later than the last day of November of the year in which it is conducted.
Each terminal distributor that is a provider of drugs under the medicaid program shall participate in the survey. Except as necessary to publish the survey's results, a terminal distributor's responses to the survey are confidential and not a public record under section 149.43 of the Revised Code.
The survey shall be conducted in conformance with the requirements set forth in 42 C.F.R. 447.500 to 447.518. The survey shall include operational data and direct prescription expenses, professional services and personnel costs, and usual and customary overhead expenses of the terminal distributors surveyed. The survey shall compute and report the cost of dispensing by terminal distributors.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.753 | Dispensing Fee.

Effective:
September 29, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
In December of every even-numbered year, the medicaid director shall establish dispensing fees, effective the following July, for terminal distributors of dangerous drugs that are providers of drugs under the medicaid program. In establishing dispensing fees, the director shall take into consideration the results of the survey conducted under section 5164.752 of the Revised Code. The director may establish dispensing fees that vary by terminal distributor, taking into consideration the volume of drugs a terminal distributor dispenses under the medicaid program or any other criteria the director considers relevant.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.754 | Agreement for Multiple-State Drug Purchasing Program.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) As used in this section, "dangerous drug" and "manufacturer of dangerous drugs" have the same meaning as in section 4729.01 of the Revised Code.
(B) The medicaid director may enter into or administer an agreement or cooperative arrangement with other states to create or join a multiple-state prescription drug purchasing program for the purpose of negotiating with manufacturers of dangerous drugs to receive discounts or rebates for dangerous drugs covered by the medicaid program.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.755 | Supplemental Drug Rebate Program.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The medicaid director, in rules adopted under section 5164.02 of the Revised Code, may establish and implement a supplemental drug rebate program under which drug manufacturers may be required to provide the department of medicaid a supplemental rebate as a condition of having the drug manufacturers' drug products covered by the medicaid program without prior approval. The department may receive a supplemental rebate negotiated under the program for a drug dispensed to a medicaid recipient pursuant to a prescription or a drug purchased by a medicaid provider for administration to a medicaid recipient in the provider's primary place of business.
If the director establishes a supplemental drug rebate program, the director shall consult with drug manufacturers regarding the establishment and implementation of the program.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.756 | Drug Rebate Agreement or Supplemental Drug Rebate Agreement for Medicaid Program Not Subject to Public Records Law.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
Any record, data, pricing information, or other information regarding a drug rebate agreement or a supplemental drug rebate agreement for the medicaid program that the department of medicaid receives from a pharmaceutical manufacturer or creates pursuant to negotiation of the agreement is not a public record under section 149.43 of the Revised Code and shall be treated by the department as confidential information.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.757 | E-Prescribing Applications.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) As used in this section, "licensed health professional authorized to prescribe drugs" has the same meaning as in section 4729.01 of the Revised Code.
(B) The medicaid director may acquire or specify technologies to provide information regarding medicaid recipient eligibility, claims history, and drug coverage to medicaid providers through electronic health record and e-prescribing applications.
If such technologies are acquired or specified, the e-prescribing applications shall enable a medicaid provider who is a licensed health professional authorized to prescribe drugs to use an electronic system to prescribe a drug for a medicaid recipient. The purpose of the electronic system is to eliminate the need for such medicaid providers to issue prescriptions for medicaid recipients by handwriting or telephone. The technologies acquired or specified by the director also shall provide such medicaid providers with an up-to-date, clinically relevant drug information database and a system of electronically monitoring medicaid recipients' medical history, drug regimen compliance, and fraud and abuse.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.758 | Adoption of Rules for Implementation of Coordinated Services Program for Medicaid Users Who Abuse Prescription Drugs.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The medicaid director shall adopt rules under section 5164.02 of the Revised Code to implement a coordinated services program for medicaid recipients who are found to have obtained prescribed drugs under the medicaid program at a frequency or in an amount that is not medically necessary. The program shall be implemented in a manner that is consistent with the "Social Security Act," section 1915(a)(2), 42 U.S.C. 1396n(a)(2), and 42 C.F.R. 431.54(e).
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.759 | Outpatient Drug Use Review Program.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
In accordance with the "Social Security Act," section 1927(g), 42 U.S.C. 1396r-8(g), the department of medicaid shall establish an outpatient drug use review program to assure that prescriptions obtained by medicaid recipients are appropriate, medically necessary, and unlikely to cause adverse medical results.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.76 | Manner of Payment for Community Mental Health Service Providers or Facilities and Alcohol and Drug Addiction Services.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) In rules adopted under section 5164.02 of the Revised Code, the medicaid director shall modify the manner or establish a new manner in which the following are paid under medicaid:
(1) Community mental health service providers or facilities for providing community mental health services covered by the medicaid program pursuant to section 5164.15 of the Revised Code;
(2) Providers of alcohol and drug addiction services for providing alcohol and drug addiction services covered by the medicaid program.
(B) The director's authority to modify the manner, or to establish a new manner, for medicaid to pay for the services specified in division (A) of this section is not limited by any rules adopted under section 5119.22 or 5164.02 of the Revised Code that are in effect on June 26, 2003, and govern the way medicaid pays for those services. This is the case regardless of what state agency adopted the rules.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.761 | Beta Testing of Updates to Billing Codes or Payment Rates.

Effective:
September 29, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
Before the department of medicaid or department of mental health and addiction services updates medicaid billing codes or medicaid payment rates for community behavioral health services as part of the behavioral health redesign, the departments shall conduct a beta test of the updates. Any medicaid provider of community behavioral health services may volunteer to participate in the beta test. An update may not begin to be implemented outside of the beta test until at least half of the medicaid providers participating in the beta test are able to submit under the beta test a clean claim for community behavioral health services that is properly adjudicated not later than thirty days after the date the clean claim is submitted.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.78 | Medicaid Payment Rates for Certain Neonatal and Newborn Services.

Effective:
October 3, 2023
Latest Legislation:
House Bill 33 - 135th General Assembly
(A) The medicaid payment rates for the following neonatal and newborn services shall equal not less than seventy-five per cent of the medicare payment rates for the services in effect on the date the services are provided to medicaid recipients eligible for the services:
(1) Initial care for normal newborns;
(2) Subsequent day, hospital care for normal newborns;
(3) Same day, initial history and physical examination and discharge for normal newborns;
(4) Initial neonatal critical care for children not more than twenty-eight days old;
(5) Subsequent day, neonatal critical care for children not more than twenty-eight days old;
(6) Subsequent day, pediatric critical care for children at least twenty-nine days but less than two years old;
(7) Initial neonatal intensive care;
(8) Subsequent day, neonatal intensive noncritical care for children weighing less than one thousand five hundred grams;
(9) Subsequent day, neonatal intensive noncritical care for children weighing at least one thousand five hundred grams but not more than two thousand five hundred grams;
(10) Subsequent day, neonatal noncritical care for children weighing more than two thousand five hundred grams but not more than five thousand grams.
(B) The medicaid payment rates for other medicaid services selected by the medicaid director shall be less than the amount of the rates in effect on November 22, 2017, so that the cost of the rates set pursuant to division (A) of this section do not increase medicaid expenditures. The director may not select any medicaid service for which the medicaid payment rate is determined in accordance with state statutes.
Last updated October 5, 2023 at 3:24 PM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.80 | Public Notice for Changes to Payment Rates for Medicaid Assistance.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
As necessary to comply with the "Social Security Act," section 1902(a)(13)(A), 42 U.S.C. 1396a(a)(13)(A), and any other federal law that requires public notice of proposed changes to payment rates for medicaid services, the medicaid director shall give public notice in the register of Ohio of any change to a method or standard used to determine the medicaid payment rate for a medicaid service.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.82 | Payment for Provider-Preventable Condition.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The department of medicaid shall not knowingly make a medicaid payment for a provider-preventable condition for which federal financial participation is prohibited by regulations adopted under the "Patient Protection and Affordable Care Act," section 2702, 42 U.S.C. 1396b-1.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.85 | Enrolling in Group Health Plan.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) As used in this section, "cost-effective" and "group health plan" have the same meanings as in the "Social Security Act," section 1906, 42 U.S.C. 1396e, and any regulations adopted under that section.
(B) The department of medicaid may implement a program pursuant to the "Social Security Act," section 1906, 42 U.S.C. 1396e, for the enrollment of medicaid-eligible individuals in group health plans when the department determines that enrollment is cost-effective.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.86 | Qualified State Long-Term Care Insurance Partnership Program.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The medicaid director shall establish a qualified state long-term care insurance partnership program consistent with the definition of that term in the "Social Security Act," section 1917(b)(1)(C)(iii), 42 U.S.C. 1396p(b)(1)(C)(iii). An individual participating in the program who is subject to the medicaid estate recovery program instituted under section 5162.21 of the Revised Code shall be eligible for the reduced adjustment or recovery under division (D) of that section.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.88 | Coordinated Care Through Health Homes.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The medicaid director may implement within the medicaid program a system under which medicaid recipients with chronic conditions are provided with coordinated care through health homes, as authorized by the "Social Security Act," section 1945, 42 U.S.C. 1396w-4.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.881 | Health Home Services.

Effective:
October 12, 2016
Latest Legislation:
House Bill 158 - 131st General Assembly
The medicaid director, in consultation with the director of developmental disabilities, may develop and implement within the medicaid program a system under which eligible individuals with chronic conditions, as defined in the "Social Security Act," section 1945 (h)(1), 42 U.S.C. 1396w-4(h)(1), who also have developmental disabilities may receive health home services, as defined in the "Social Security Act," section 1945 (h)(4), 42 U.S.C. 1396w-4(h)(4). Any such system shall focus on the needs of individuals and have as its goal improving services and outcomes under the medicaid program by improving integration of long-term care services and supportive services with primary and acute health care services.
In developing any system under this section, the directors shall consult with representatives of county boards of developmental disabilities, the Ohio provider resource association, and the arc of Ohio. The directors may consult with any other individuals or entities that have an interest in the well being of individuals with developmental disabilities.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.89 | Case Management of Nonemergency Transportation Services.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The department of medicaid may require county departments of job and family services to provide case management of nonemergency transportation services provided under the medicaid program. County departments shall provide the case management if required by the department in accordance with rules adopted under section 5164.02 of the Revised Code.
The department shall determine, for the purposes of claiming federal financial participation, whether it will claim expenditures for nonemergency transportation services as administrative or program expenditures.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.90 | Transition of Medicaid Recipients to Community Settings.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) As used in this section, "MFP demonstration project" means a money follows the person demonstration project that the United States secretary of health and human services is authorized to award under section 6071 of the "Deficit Reduction Act of 2005" (Pub. L. No. 109-171, as amended).
(B) To the extent funds are available under an MFP demonstration project awarded to the department of medicaid, the director of medicaid may operate the helping Ohioans move, expanding (HOME) choice demonstration component of the medicaid program to transition medicaid recipients who qualify for the demonstration component to community settings.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.91 | Integrated Care Delivery System.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The medicaid director may implement a demonstration project called the integrated care delivery system to test and evaluate the integration of the care that dual eligible individuals receive under medicare and medicaid. No provision of Title LI of the Revised Code applies to the integrated care delivery system if that provision implements or incorporates a provision of federal law governing medicaid and that provision of federal law does not apply to the system.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.911 | Integrated Care Delivery System Evaluation.

Effective:
March 20, 2014
Latest Legislation:
Senate Bill 206 - 130th General Assembly
(A) If the medicaid director implements the integrated care delivery system and except as provided in division (C) of this section, the director shall annually evaluate all of the following:
(1) The health outcomes of ICDS participants;
(2) How changes to the administration of the ICDS affect all of the following:
(a) Claims processing;
(b) The appeals process;
(c) The number of reassessments requested;
(d) Prior authorization requests for services.
(3) The provider panel selection process used by medicaid managed care organizations participating in the ICDS.
(B) When conducting an evaluation under division (A) of this section, the director shall do all of the following:
(1) For the purpose of division (A)(1) of this section, do both of the following:
(a) Compare the health outcomes of ICDS participants to the health outcomes of individuals who are not ICDS participants;
(b) Use both of the following:
(i) A control group consisting of ICDS participants who receive health care services from providers not participating in ICDS;
(ii) A control group consisting of ICDS participants who receive health care services from alternative providers that are not part of a participating medicaid managed care organization's provider panel but provide health care services in the geographic service area in which ICDS participants receive health care services.
(2) For the purpose of division (A)(2) of this section, do all of the following:
(a) To the extent the data is available, use data from all of the following:
(i) The fee-for-service component of the medicaid program;
(ii) Medicaid managed care organizations;
(iii) Managed care organizations participating in the medicare advantage program established under Part C of Title XVIII of the "Social Security Act," 42 U.S.C. 1395w-21 et seq.
(b) Identify all of the following:
(i) Changes in the amount of time it takes to process claims and the number of claims denied and the reasons for the changes;
(ii) The impact that changes to the administration of the ICDS had on the appeals process and number of reassessments requested;
(iii) The number of prior authorization denials that were overturned and the reasons for the overturned denials.
(3) Require medicaid managed care organizations participating in the ICDS to submit to the director any data the director needs for the evaluation.
(C) The director is not required to conduct an evaluation under this section for a year if the same evaluation is conducted for that year by an organization under contract with the United States department of health and human services.
Last updated May 6, 2021 at 5:21 PM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.912 | Integrated Care Delivery System Standardized Claim Form.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
The medicaid director shall select from among universally accepted claim forms used in the United States a standardized claim form for each type of medicaid provider that provides medicaid services under the integrated care delivery system. The director shall create standardized claim codes to be used on the standardized claim forms. Each medicaid provider and medicaid provider's designee that bills for medicaid services provided under the integrated care delivery system shall use the appropriate standardized claim form and standardized claim codes.
Last updated May 6, 2021 at 5:22 PM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.913 | Home Health Aide and Personal Care Aide Training.

Effective:
October 3, 2023
Latest Legislation:
House Bill 33 - 135th General Assembly
(A)(1) In addition to any other eligibility requirement of this chapter, to be eligible to serve as a personal care aide under the integrated care delivery system, an individual must successfully complete thirty hours of pre-service training acceptable to the department of medicaid.
To maintain eligibility, each personal care aide must successfully complete six hours of in-service training acceptable to the department. Such training must be completed every twelve months.
(2) In administering the integrated care delivery system, the department shall not require a personal care aide to do either of the following:
(a) Complete more than thirty hours of pre-service training;
(b) Complete more than six hours of in-service training in a twelve-month period.
(B) The department of medicaid shall not require an individual serving as a home health aide under the integrated care delivery system to complete more hours of pre-service training or annual in-service training than required by federal law.
(C) Only the following may supervise a home health aide or personal care aide under the integrated care delivery system:
(1) A registered nurse;
(2) A licensed practical nurse under the direction of a registered nurse.
Last updated October 6, 2023 at 5:07 PM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.92 | Advanced Diagnostic Imaging Services Coverage Under Medicaid Program.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
As used in this section, "advanced diagnostic imaging services" means magnetic resonance imaging services, computed tomography services, positron emission tomography services, cardiac nuclear medicine services, and similar imaging services.
The department of medicaid shall implement evidence-based, best practice guidelines or protocols and decision support tools for advanced diagnostic imaging services covered by the fee-for-service component of the medicaid program.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.93 | Incentive Payments for Adoption and Use of Electronic Health Record Technology.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) The department of medicaid may establish a program under which it provides incentive payments, as authorized by the "Social Security Act," section 1903(a)(3)(F) and (t), 42 U.S.C. 1396b(a)(3)(F) and (t), to encourage the adoption and use of electronic health record technology by medicaid providers who are identified under that federal law as eligible professionals.
(B) After the department has made a determination regarding the amount of a medicaid provider's electronic health record incentive payment or the denial of an incentive payment, the department shall notify the provider. The provider may request that the department reconsider its determination.
A request for reconsideration shall be submitted in writing to the department not later than fifteen days after the provider receives notification of the determination. The request shall be accompanied by written materials setting forth the basis for, and supporting, the reconsideration request.
On receipt of a timely request, the department shall reconsider the determination. On the basis of the written materials accompanying the request, the department may uphold, reverse, or modify its original determination. The department shall mail to the provider by certified mail a written notice of the reconsideration decision.
In accordance with Chapter 2505. of the Revised Code, the medicaid provider 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.
(C) The medicaid director may adopt rules under section 5162.02 of the Revised Code as necessary to implement this section. The rules, if any, shall be adopted in accordance with Chapter 119. of the Revised Code.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.94 | Delivery of Services in Culturally and Linguistically Appropriate Manners.

Effective:
March 20, 2014
Latest Legislation:
Senate Bill 206 - 130th General Assembly
The medicaid director shall implement within the medicaid program a system that encourages medicaid providers to provide medicaid services to medicaid recipients in culturally and linguistically appropriate manners.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.951 | Standards for Medicaid Payments for Services Provided Through Teledentistry.

Effective:
March 20, 2019
Latest Legislation:
Senate Bill 259 - 132nd General Assembly
As used in this section, "teledentistry" has the same meaning as in section 4715.43 of the Revised Code.
The department of medicaid shall establish standards for medicaid payments for services provided through teledentistry. The standards shall provide coverage for services to the same extent that those services would be covered by the medicaid program if the services were provided without the use of teledentistry.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.96 | Ground Emergency Medical Transportation Supplemental Payment Program.

Effective:
October 3, 2023
Latest Legislation:
House Bill 33 - 135th General Assembly
(A) As used in this section, "ground emergency medical transportation service provider" means a public emergency medical service organization as defined in section 4765.01 of the Revised Code.
(B)(1) The medicaid director shall submit a medicaid state plan amendment to the United States centers for medicare and medicaid services seeking authorization to establish and administer a supplemental payment program to provide supplemental medicaid payments to eligible ground emergency medical transportation service providers. If approved, the medicaid director shall establish and administer the program.
(2) To be eligible to receive payments under the supplemental payment program, a ground emergency medical transportation service provider must hold a valid medicaid provider agreement and provide emergency medical transportation services to medicaid recipients.
(C) The medicaid director shall adopt rules in accordance with Chapter 119. of the Revised Code to implement this section.
Last updated October 6, 2023 at 5:09 PM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.011 | Nursing Facility References.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) Except as provided in division (B) of this section, whenever "skilled nursing facility," "intermediate care facility," or "dual skilled nursing and intermediate care facility" is referred to or designated in any statute, rule, contract, provider agreement, or other document pertaining to the medicaid program, the reference or designation is deemed to refer to a nursing facility.
(B) A reference to or designation of an "intermediate care facility for individuals with intellectual disabilities" or "ICF/IID" is not deemed to refer to a nursing facility.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.02 | Rules.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The medicaid director shall adopt rules as necessary to implement this chapter. The rules shall be adopted in accordance with Chapter 119. of the Revised Code.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.031 | Hearing.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
An individual who applies for admission to or resides in a nursing facility may appeal if adversely affected by a determination made by the department of mental health and addiction services under section 5119.40 of the Revised Code or by the department of developmental disabilities under section 5123.021 of the Revised Code. If the individual is an applicant for or recipient of medicaid, the individual may appeal pursuant to section 5160.31 of the Revised Code. If the individual is not an applicant for or recipient of medicaid, the individual may appeal pursuant to a process the department of medicaid shall establish, which shall be similar to the appeals process established by section 5101.35 of the Revised Code. The department of medicaid shall provide notice of the right to appeal to individuals adversely affected by determinations made under sections 5119.40 and 5123.021 of the Revised Code. Any decision made on the basis of such an appeal is binding on the department of mental health and addiction services and the department of developmental disabilities.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.06 | Nursing Facility Eligibility.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
Subject to section 5165.072 of the Revised Code, an operator is eligible to enter into a provider agreement for a nursing facility if all of the following apply:
(A) The nursing facility is certified by the director of health for participation in medicaid;
(B) The nursing facility is licensed by the director of health as a nursing home if so required by law;
(C) The operator and nursing facility comply with all applicable state and federal laws and rules.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.07 | Provider Agreement Requirements.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) Except as provided in section 5165.072 of the Revised Code, the department of medicaid shall enter into a provider agreement with a nursing facility operator who applies, and is eligible, for the provider agreement.
(B) A provider agreement shall require the department to make medicaid payments to the provider in accordance with this chapter for nursing facility services the nursing facility provides to its residents who are medicaid recipients eligible for nursing facility services.
(C) A provider agreement shall require the provider to do all of the following:
(1) Maintain eligibility for the provider agreement as provided in section 5165.06 of the Revised Code;
(2) Keep records relating to a cost reporting period for the greater of seven years after the cost report is filed or, if the department issues an audit report in accordance with section 5165.109 of the Revised Code, six years after all appeal rights relating to the audit report are exhausted;
(3) File reports as required by the department;
(4) Open all records relating to the costs of the nursing facility's services for inspection and audit by the department;
(5) Open its premises for inspection by the department, the department of health, and any other state or local authority having authority to inspect;
(6) Supply to the department such information as it requires concerning the nursing facility's services to residents who are, or are eligible to be, medicaid recipients;
(7) Comply with section 5165.08 of the Revised Code.
(D) A provider agreement may contain other provisions that are consistent with law and considered necessary by the department.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.072 | Revalidation.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The department of medicaid shall not revalidate a nursing facility provider agreement if the provider fails to maintain eligibility for the provider agreement as provided in section 5165.06 of the Revised Code.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.073 | Termination for Non-Compliance With Installation of Fire Extinguishing and Fire Alarm Systems.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The department of medicaid shall terminate the provider agreement with a nursing facility provider that does not comply with the requirements of section 3721.071 of the Revised Code for the installation of fire extinguishing and fire alarm systems.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.081 | Action Against Facility for Breach of Provider Agreement or Other Duties.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
A nursing facility resident has a cause of action against a nursing facility provider for breach of the provider agreement obligations or other duties imposed by section 5165.08 of the Revised Code. The action may be commenced by the resident, or on the resident's behalf by the resident's sponsor or a residents' rights advocate, by the filing of a civil action in the court of common pleas of the county in which the nursing facility is located, or in the court of common pleas of Franklin county.
If a court of common pleas finds that a provider has breached a provider agreement obligation or other duty imposed by section 5165.08 of the Revised Code, the court may do one or more of the following:
(A) Enjoin the provider from engaging in the practice;
(B) Order such affirmative relief as may be necessary;
(C) Award to a resident and a sponsor or government entity that brings the action on behalf of a resident actual damages, costs, and reasonable attorney's fees.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.082 | Qualification of Beds.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) Except as provided in division (B) of this section, the operator of a nursing facility that elects to have the nursing facility participate in the medicaid program shall qualify all of the nursing facility's medicaid-certified beds in the medicare program. The medicaid director may adopt rules under section 5165.02 of the Revised Code to establish the time frame in which a nursing facility must comply with this requirement.
(B) The department of veterans services is not required to qualify all of the medicaid-certified beds in a nursing facility the department maintains and operates under section 5907.01 of the Revised Code in the medicare program.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.10 | Annual Cost Report.

Effective:
September 15, 2014
Latest Legislation:
House Bill 483 - 130th General Assembly
(A) Except as provided in division (C) of this section, each nursing facility provider shall file with the department of medicaid an annual cost report for each of the provider's nursing facilities that participate in the medicaid program. The cost report for a year shall cover the calendar year or the portion of the calendar year during which the nursing facility participated in the medicaid program. Except as provided in division (D) of this section, the cost report is due not later than ninety days after the end of the calendar year, or portion of the calendar year, that the cost report covers.
(B) If a nursing facility undergoes a change of provider that the department determines, in accordance with rules adopted under section 5165.02 of the Revised Code, is not an arm's length transaction, the new provider shall file the nursing facility's cost report in accordance with division (A) of this section and the cost report shall cover the portion of the calendar year during which the new provider operated the nursing facility and the portion of the calendar year during which the previous provider operated the nursing facility.
(C) The provider of a new nursing facility is not required to file a cost report in accordance with division (A) of this section for the first calendar year that the provider has a provider agreement for the nursing facility if the initial provider agreement goes into effect after the first day of October of that calendar year. The provider shall file a cost report for the nursing facility in accordance with division (A) of this section for the immediately following calendar year.
(D) The department may grant to a provider a fourteen-day extension to file a cost report under this section if the provider provides the department a written request for the extension and the department determines that there is good cause for the extension.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.101 | Cost of Franchise Permit Fee Not Reimbursable Expense.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
A nursing facility provider filing the nursing facility's cost report with the department of medicaid under section 5165.10 or 5165.522 of the Revised Code shall report as a nonreimbursable expense the cost of the nursing facility's franchise permit fee.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.102 | Fines Excluded From Cost Report.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
No nursing facility provider shall report fines paid under sections 5165.60 to 5165.89 or section 5165.99 of the Revised Code in a cost report filed under section 5165.10 or 5165.522 of the Revised Code.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.103 | Completion of Cost Reports.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
Cost reports shall be completed using the form prescribed under section 5165.104 of the Revised Code and in accordance with the guidelines established under that section.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.104 | Form of Cost Reports; Guidelines.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The department of medicaid shall do all of the following:
(A) Prescribe the form to be used for completing a cost report and a uniform chart of accounts for the purpose of reporting costs on the form;
(B) Distribute a paper copy of the form, or computer software for electronic submission of the form, to each provider at least sixty days before the date the cost report is due;
(C) Establish guidelines for completing the form.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.105 | Addendum for Disputed Costs.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The department of medicaid shall develop an addendum to the cost report form that a nursing facility provider may use to set forth costs that the provider believes the department may dispute. The department may consider such costs in determining a nursing facility's medicaid payment rate. If the department does not consider such costs in determining a nursing facility's medicaid payment rate, the provider may seek reconsideration of the determination in accordance with section 5165.38 of the Revised Code. If the department subsequently includes such costs in a nursing facility's medicaid payment rate, the department shall pay the provider interest at a reasonable rate established in rules adopted under section 5165.02 of the Revised Code for the period that the rate excluded the costs.