reglab/statecodes huggingface dataset:
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-59 - OhioRISE › Section 5160-59-03.1 - OhioRISE: utilization management

Current through all regulations passed and filed through July 1, 2024
(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, 2021).
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-59 - OhioRISE › Section 5160-59-03.2 - OhioRISE: care coordination

Current through all regulations passed and filed through July 1, 2024
(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 http://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);
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-59 - OhioRISE › Section 5160-59-03.3 - Ohio RISE: intensive home-based treatment service

Current through all regulations passed and filed through July 1, 2024
(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.
(C) Eligible providers of
			 IHBT services.
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-59 - OhioRISE › Section 5160-59-03.4 - OhioRISE: behavioral health respite service

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-59 - OhioRISE › Section 5160-59-03.5 - OhioRISE: primary flex funds

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-59 - OhioRISE › Section 5160-59-03.6 - Psychiatric residential treatment facility (PRTF) service

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-59 - OhioRISE › Section 5160-59-05 - OhioRISE home and community-based services waiver: covered services and providers

Current through all regulations passed and filed through July 1, 2024
(A)
								This rule
			 establishes the services available under the Ohio resilience through integrated
			 systems and excellence (OhioRISE) home and community-based services (HCBS)
			 1915(c) waiver program (waiver) established in accordance with 1915(c) of the
			 Social Security Act
			 42 U.S.C.
			 1396n (January 1, 2022), 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 set forth in rules
			 5160-44-02
			 and
			 5160-44-31
			 of the Administrative Code, as appropriate. Providers that have responsibility
			 for developing the child and family-centered care plan cannot provide other
			 direct 1915(c) waiver services to the 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 personcentered 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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-59 - OhioRISE › Section 5160-59-05.1 - OhioRISE home and community-based services waiver: out-of-home respite

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-59 - OhioRISE › Section 5160-59-05.2 - OhioRISE home and community-based services waiver: transitional services and supports

Current through all regulations passed and filed through July 1, 2024
(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)
			 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) "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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-59 - OhioRISE › Section 5160-59-05.3 - OhioRISE home and community-based services waiver: secondary flex funds

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-59 - OhioRISE › Section 5160-59-07 - Psychiatric residential treatment facility (PRTF): cost reports

Current through all regulations passed and filed through July 1, 2024
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:
(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
			 PRTF's reporting period.
(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
(c)
										On the last day before a change of operator for an
			 existing provider.
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-70 - Hearing or Review for Providers › Section 5160-70-02 - Procedures for providers seeking review of department actions or proposed department actions

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-70 - Hearing or Review for Providers › Section 5160-70-03 - Chapter 119. hearings: department notice, making a hearing request, and failure to make a hearing request

Current through all regulations passed and filed through July 1, 2024
(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;
(c)
										 The statutes or
			 rules directly involved;
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-70 - Hearing or Review for Providers › Section 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

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-70 - Hearing or Review for Providers › Section 5160-70-05 - Chapter 119. hearings: pre-hearing discovery and subpoenas

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-70 - Hearing or Review for Providers › Section 5160-70-06 - Chapter 119. hearings: conducting the hearing, report and recommendation, filing objections, adjudication order, appealing the adjudication order

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-71 - Hearings for recovery of overpayments › Section 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

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-71 - Hearings for recovery of overpayments › Section 5160-71-03 - Chapter 119. hearings conducted under authority of section 5111.914 of the Revised Code: interest for findings pursued for recovery

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-71 - Hearings for recovery of overpayments › Section 5160-71-04 - Chapter 119. hearings conducted under authority of section 5111.914 of the Revised Code: notice and requesting a hearing

Current through all regulations passed and filed through July 1, 2024
(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;
(c) Statute or
			 rule directly involved;
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-71 - Hearings for recovery of overpayments › Section 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

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-71 - Hearings for recovery of overpayments › Section 5160-71-06 - Chapter 119. hearings conducted under authority of section 5111.914 of the Revised Code: discovery

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-71 - Hearings for recovery of overpayments › Section 5160-71-07 - Chapter 119. hearings conducted under authority of section 5111.914 of the Revised Code: conduct of the hearing and adjudication order

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-80 - Rights and Procedures Applicable to Medical Assistance Recipients › Section 5160-80-03 - Postponement of the hearing

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-80 - Rights and Procedures Applicable to Medical Assistance Recipients › Section 5160-80-04 - Denial and dismissal of hearing requests

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-80 - Rights and Procedures Applicable to Medical Assistance Recipients › Section 5160-80-05 - Scheduling and attendance

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-80 - Rights and Procedures Applicable to Medical Assistance Recipients › Section 5160-80-06 - Rights and responsibility of the parties and hearing examiner

Current through all regulations passed and filed through July 1, 2024
(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.