reglab/statecodes huggingface dataset:
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-60.1 - Special provisions for reimbursement for physician groups acting as outpatient hospital clinics

Current through all regulations passed and filed through July 1, 2024
(A) For physician services rendered on and
			 after the effective date of this rule by physician group practices that meet
			 the criteria described in paragraphs (B) and (C) of this rule, the
			 reimbursement amounts in appendix DD to rule 5101:3-1-60 of the Administrative
			 Code, except for CPT codes 80002 to 89399, will be multiplied by 1.4. Pregnancy
			 related services will be reimbursed according to appendix A to rule
			 5101:3-4-081 of the Administrative Code from March 3, 1992 through March 31,
			 1992. Pregnancy services will be reimbursed in accordance with appendix DD to
			 rule 5101:3-1-60 of the Administrative Code from April 1, 1992. For dates of
			 service May 1, 1994 and thereafter, the following evaluation and management
			 codes will be reimbursed in accordance with appendix DD to rule 5101:3-1-60 of
			 the Administrative Code: 99211, 99212, 99213, 99214, and 99215."CPT" as used in
			 this rule is defined in rule 5101:3-1-19.3 of the Administrative Code.
(B) The physician group practice
			 is physically attached to a hospital that does not provide physician clinic
			 outpatient services and the hospital and physician group practice have signed a
			 letter of agreement indicating that the physician group practice provides the
			 outpatient hospital clinic service for that hospital.
(C) The Ohio department of job and family
			 services provider utilization summary for calendar year 1990 establishes that
			 the physician group practice provides at least forty per cent of the total
			 number of medicaid physician visits provided in the county in which the
			 physician group practice is located and an aggregate total of at least ten per
			 cent of the physician visits provided in the contiguous counties.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-60.2 - Direct reimbursement for out-of-pocket expenses incurred for medicaid covered services during approved eligibility periods

Current through all regulations passed and filed through July 1, 2024
(A)
								For purposes of
			 this rule:
(1)
									
			 "Applicant for reimbursement" is:
(a)
										An individual who has been determined eligible for a
			 retroactive eligibility period in accordance with rule
			 5160:1-2-01
			 of the Administrative Code, and who is seeking reimbursement for medical
			 expenses for which the individual paid for during this approved time period;
			 or
(b)
										An individual who, as a result of an eligibility
			 determination or state hearing decision, now has effective dates of eligibility
			 and is seeking reimbursement for medical expenses for which the individual paid
			 during this approved time period; or
(c)
										An individual who
			 has been erroneously charged a medicaid co-pay for services eligible for a
			 co-pay in accordance with rule
			 5160-1-09 of the
			 Administrative Code, and who is seeking reimbursement of the co-pay amount
			 incurred during the time period when the individual should not have been
			 subject to a co-pay and for which the individual paid; or
(d)
										A person not
			 legally obligated to pay for an individual's medical bills, but who does, in
			 fact, contribute payment toward the individual's medical bills incurred during
			 the approved eligibility period.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-60.4 - By-report procedures, services, and supplies

Current through all regulations passed and filed through July 1, 2024
(A)
								The term
			 "by-report" identifies a covered procedure, service, or supply for which no
			 single maximum payment amount has been established and for which payment is not
			 determined by prior authorization. Claims for by-report procedures, services,
			 and supplies are reviewed manually by the department or its designee. The
			 purpose of the review is to determine whether the procedure code for the
			 by-report procedure, service, or supply reported on the claim is the most
			 appropriate and, if so, to establish a maximum payment amount for the
			 procedure, service, or supply on a case-by-case basis. Information must be
			 submitted on or with the claim (e.g., supporting documents such as operative
			 reports, clinical assessments, or other medical records) to identify the
			 particular by-report procedure, service, or supply.
(B)
								By-report
			 procedures, services, and supplies are so indicated in the relevant rule in
			 agency 5160 of the Administrative Code or in its associated payment
			 schedule.
(C)
								A non-covered procedure, service, or supply that is
			 reported on a claim with a by-report procedure code is
			 non-covered.
(D)
								A claim for a by-report procedure, service, or supply
			 will not be reviewed further and may be denied under either of the following
			 conditions:
(1)
									Information submitted on or with the claim does not
			 sufficiently identify the by-report procedure, service, or supply, and
			 additional documentation requested by the reviewer is not supplied; or
(2)
									The
			 procedure, service, or supply can be reported appropriately with a different
			 procedure code for which a specific maximum payment amount has been
			 established.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-61 - Non-covered services

Current through all regulations passed and filed through July 1, 2024
(A)
								
								The following services
			 are entirely excluded from coverage:
(1) A service that is
			 experimental in nature and is not performed in accordance with
			  standards of medical practice;
(2) A
			 service that is related to forensic studies;
(3) An autopsy
			 service;
(4)
									A service for the
			 treatment of infertility;
(5) An abortion that
			 does not meet the criteria for coverage set forth in rule
			 5160-17-01 of the
			 Administrative Code;
(6) A service that does
			 not meet the criteria for coverage set forth in any other rule in agency 5160
			 of the Administrative Code;
(7) A service
			 pertaining to a pregnancy that is a result of a contract for surrogacy
			 services, under which a woman agrees to become pregnant for the purpose of
			 carrying and giving birth to a child she will not raise but instead will
			 relinquish to the other contracting party; and
(8) Assisted suicide
			 and other measures taken actively with the specific intent of causing or
			 hastening death.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-70 - Relocated provisions concerning episode based payments

Current through all regulations passed and filed through July 1, 2024
Provisions concerning episode based
				payments are set forth in rule 5160-19-04 of the Administrative
				Code.
Replaces: 5160-1-70
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-71 - Relocated provisions concerning patient centered medical homes (PCMH) and eligible providers

Current through all regulations passed and filed through July 1, 2024
Provisions concerning patient centered
				medical homes (PCMH) and eligible providers are set forth in rule 5160-19-01 of
				the Administrative Code. The PCMH rules implement the Ohio department of
				medicaid's comprehensive primary care (CPC) program and CPC for Kids
				programs.
Replaces: 5160-1-71
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-72 - Relocated provisions concerning patient centered medical homes (PCMH) and payments

Current through all regulations passed and filed through July 1, 2024
Provisions concerning patient centered
				medical homes (PCMH) and payments are set forth in rule 5160-19-02 of the
				Administrative Code. The PCMH rules implement the Ohio department of medicaid's
				comprehensive primary care (CPC) program and CPC for Kids
				programs.
Replaces: 5160-1-72
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-80 - Substitute practitioners (locum tenens)

Current through all regulations passed and filed through July 1, 2024
(A) Definitions.
(1) "Practitioner," for purposes of this
			 rule, is a collective term for the following professionals:
(a) Doctor of medicine or
			 osteopathy;
(b) Advanced practice
			 registered nurse;
(c)
			 Dentist;
(d) Optometrist;
(e) Podiatrist; or
(f) Chiropractor.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-97 - One-time medicaid provider relief payments

Current through all regulations passed and filed through July 1, 2024
The department of medicaid (ODM) will
				make relief payments available to Ohio medicaid hospitals defined in paragraph
				(A) of this rule, as authorized under Section
				270.15 of Amended Substitute
				House Bill 45 of the 134th General Assembly:
(A)
								ODM will make
			 available a one-time lump sum payment to the following hospital types:
(1)
									"Critical access
			 hospitals," as defined in rule
			 5160-2-05 of the Administrative
			 Code.
(2)
									"Rural hospitals," as defined in rule
			 5160-2-05 of the Administrative
			 Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-98 - Deposits to the health care/medicaid support and recoveries fund for program support

Current through all regulations passed and filed through July 1, 2024
(A)
								The Ohio
			 department of medicaid (ODM) will deposit a portion of the intergovernmental
			 transfers (IGT) that are paid under any state directed payment (SDP) program as
			 authorized under 42 CFR
			 438.6(c) effective as of
			 October 1, 2022 and are subject to Section 333.360 of Amended Substitute House
			 Bill 33 of the 135th General Assembly, to the health care/medicaid support and
			 recoveries fund created under section
			 5162.52 of the Revised
			 Code.
(B)
								On or after the effective date of this rule and for
			 each year thereafter:
(1)
									Pursuant to paragraph (A) of this rule, each provider
			 eligible to receive a directed SDP program payment will submit to ODM an
			 additional IGT which is to be four per cent of the hospital's computed IGT
			 amount.
(2)
									In subsequent SDP program years, ODM may establish a
			 rate higher or lower than the rate described in paragraph (B)(1) of this rule
			 as approved by the medicaid director.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-01 - Eligible providers

Current through all regulations passed and filed through July 1, 2024
(A) All hospitals, except those excluded in
			 paragraphs (A)(1) and (A)(2) of this rule, that meet medicare (Title XVIII)
			 conditions of participation as described in
			 42 C.F.R
			 482 effective as of October 1,
			 
								2022,
			 are eligible to participate in the Ohio medicaid (Title XIX) program upon
			 execution of a provider agreement. Also considered to be eligible is a hospital
			 that is currently determined to meet the 
								established
			 criteria for Title XVIII participation and has in effect a hospital
			 utilization review plan applicable to all patients who receive medical
			 assistance under Title XIX. The following hospitals are excluded from
			 participation:
(1) Tuberculosis hospitals,
			 and
(2) Hospitals that have fifty
			 per cent or more of their beds registered pursuant to Chapter 3701-59 of the
			 Administrative Code as alcohol and/or drug abuse rehabilitation beds, and have
			 no beds licensed as psychiatric beds pursuant to Chapter 5122-14 of the
			 Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-02 - General provisions: hospital services

Current through all regulations passed and filed through July 1, 2024
For purposes of Chapter 5160-2 of the Administrative Code, the
				following definitions apply, unless the context clearly indicates
				otherwise:
(A) "Diagnosis related
			 groups (DRGs)" is a patient classification system that reflects
			 clinically cohesive groupings of services that consume similar amounts of
			 hospital resources in an inpatient setting. The groupings used to assign cases
			 to a DRG for claim payment and the grouping logic used to develop
			 relative weights for DRG's are described in rule
			 5160-2-65 of the Administrative
			 Code.
(B) "Discharged"
			 means a
			 patient who:
(1) Is formally released from a
			 hospital;
(2) Dies while
			 hospitalized;
(3) Is discharged
			 within the same hospital from an acute care bed and admitted to a bed in an
			 inpatient psychiatric facility, or is discharged
			 within the same hospital from a bed in an inpatient psychiatric facility to an
			 acute care bed. Rule
			 5160-2-65 of the Administrative
			 Code explains the payment methodology for these types of
			  discharges; or
(4) Signs himself or herself out against
			 medical advice .
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-03 - Conditions and limitations

Current through all regulations passed and filed through July 1, 2024
(A) Conditions and limitations applicable to
			 both inpatient and outpatient hospital services.
(1) Coverage of provider-based physician
			 services reimbursable as an inpatient or outpatient hospital service is limited
			 to those services reimbursable under medicare, part A, except as provided in
			 rule
			 5160-4-01 of
			 the Administrative Code.
(2)
									The
			 following inpatient or outpatient services related to the provision of
			 the services described in this rule are not covered:
(a) Abortions other than those that meet the
			 criteria for coverage set forth in rule
			 5160-17-01 of the
			 Administrative Code.
(b)
			 Sterilizations and hysterectomies other than those that meet the criteria for
			 coverage set forth in Chapter 5160-21 of the Administrative Code.
(c) Artificial insemination, treatment of
			 infertility, including procedures for reversal of voluntary
			 sterilization.
(d) Plastic or
			 cosmetic surgery when the surgery is performed for aesthetic purposes; for
			 example, rhinoplasty, ear piercing, mammary augmentation or reduction, tattoo
			 removal, excision of keloids, facioplasty, osteoplasty (prognathism and
			 micrognathism), dermabrasion, skin grafts, and lipectomy.
(e) Gender transformation.
(f) Acupuncture, with
			 the exception of conditions described in rule
			 5160-8-51 of
			 the Administrative Code.
(g)
			 Services of a research nature or services that are experimental and not in
			 accordance with customary standards of medical practice or are not commonly
			 used.
(h) Dental procedures unless:
(i) The nature of the surgery or the
			 condition of the patient precludes performing the procedure in the dentist's
			 office or other non hospital outpatient setting and the inpatient or outpatient
			 service is a medicaid covered service.
(ii) The service was an emergency dental
			 procedure performed in the emergency room.
(i) Patient convenience items.
(j) Pregnancy related services pertaining to
			 a pregnancy that is a result of a contract for surrogacy services. For the
			 purposes of this rule, "surrogacy services" means a woman agrees to become
			 pregnant for the purpose of gestating and giving birth to a child she will not
			 raise, but hand over to a contracted party.
(3) Blood and blood components--The
			 department encourages the use of replacement blood donated on behalf of the
			 recipient. However, the medicaid program will cover the cost of all blood
			 administered, equivalent quantities of packed red blood cells or plasma when
			 not available to the recipient from other sources, and the administering of
			 replacement blood.
(4) Services
			 related to covered organ donations are reimbursable when the recipient of a
			 transplant is medicaid eligible.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-04 - Coverage of hospital-provided pharmaceutical, dental, vision care, medical supply and equipment, and medically-related transportation services

Current through all regulations passed and filed through July 1, 2024
(A) Drugs.
(1) Drugs are classified as: administered
			 inpatient (drugs administered to a patient while an inpatient); administered
			 outpatient (drugs administered to a patient at the hospital in connection with
			 outpatient services); take-home (drugs dispensed on an outpatient basis for use
			 away from the hospital).
(2)
			 Administered inpatient drugs are considered inpatient services and are
			 reimbursed as an inpatient service. Administered outpatient drugs are
			 considered outpatient services and are reimbursed as an outpatient hospital
			 service in accordance with rule 5160-2-75 of
			 the Administrative Code. Take-home drugs will be billed
			 and reimbursed in accordance with provisions in
			 Chapter 5160-9 of the Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-08.1 - Assessment rates

Current through all regulations passed and filed through July 1, 2024
(A) Applicability.
The requirements of this rule apply as long as the United
				States centers for medicare and medicaid services (CMS) determines that the
				assessment imposed under section
				5168.06 of the Revised Code is a
				permissible health care related tax. Whenever the department of medicaid is
				informed that the assessment is an impermissible health care-related tax, the
				department shall promptly refund to each hospital the amount of money currently
				in the hospital care assurance match fund that has been paid by the hospital,
				plus any investment earnings on that amount.
(B)
								Definitions
(1)
									"Program year" -
			 The period beginning the first day of October of a calendar year and ending on
			 the thirtieth day of September of the following calendar year.
(2)
									"Current program
			 year" - The program year beginning the first day of October of the most recent
			 calendar year and ending on the thirtieth day of September the following
			 calendar year.
(3)
									"Past program year" - Any program year beginning the
			 first day of October in a calendar year preceding the current program year and
			 ending the thirtieth day of September the following calendar year.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-12 - Appeals and reconsideration of departmental determinations regarding hospital inpatient and outpatient services

Current through all regulations passed and filed through July 1, 2024
(A)
								Appeals.
Pursuant to Chapter 5160-70 of the
				Administrative Code, final settlements that are based upon final audits by the
				department may be appealed by hospitals under Chapter 119. of the Revised Code.
				Rule
				5160-2-24 of the
				Administrative Code describes final fiscal audits and final settlements
				performed by the department. Rules
				5160-1-27
				and
				5160-1-29
				of the Administrative Code describe the audits performed by the department
				which may be appealable under Chapter 119. of the Revised Code. Since the scope
				and substance of these two types of audits differ, in no instance will the
				conduct and implementation of one type of audit preclude the conduct and
				implementation of the other.
(B)
								Utilization
			 review reconsideration.
Pursuant to rule 5160-2-13 of the
				Administrative Code, the department or a medical review entity under contract
				with the department may make determinations regarding utilization review. These
				determinations are subject to the reconsideration process described in rule
				5160-70-02
				of the Administrative Code as follows:
(1)
									A written request
			 for a reconsideration should be submitted to the department or the medical
			 review entity, whichever made the initial determination as indicated by the
			 denial letter, within sixty calendar days of the date of the determination. The
			 department or the medical review entity has thirty business days from receipt
			 of the request for reconsideration to issue a final and binding decision
			 accepting, modifying, or rejecting its previous determination. The request for
			 reconsideration must include:
(a)
										A copy of the written determination;
(b)
										A copy of the
			 patient's medical record (if not already submitted to the review entity);
			 and
(c)
										Copies of any and all additional information that may
			 support the provider's position.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-14 - Potentially preventable readmissions

Current through all regulations passed and filed through July 1, 2024
(A)
								General
			 provisions.
(1)
									All hospitals that are subject to the all patient refined
			 diagnosis related groups (APR-DRG) prospective payment methodology utilized by
			 the Ohio department of medicaid as defined in rule
			 5160-2-65
			 of the Administrative Code are subject to the potentially preventable
			 readmissions (PPR) provisions set forth in this rule.
(2)
									Hospitals that
			 have twenty or more medicaid discharges in the reporting year as described in
			 paragraph (D) of this rule are subject to a PPR rate adjustment as described in
			 paragraph (E) of this rule.
(3)
									PPR hospital
			 report cards are available on the department's website at medicaid.ohio.gov.
			 Report cards will be updated biannually with the most current claims data as
			 defined in this rule.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-17 - Provision of basic, medically necessary hospital-level services

Current through all regulations passed and filed through July 1, 2024
(A)
								In accordance with section
			 5168.14
			 of the Revised Code, each hospital that receives payment under the provisions
			 of Chapter 5168. of the Revised Code, will provide, without charge to the
			 individual, basic, medically necessary hospital-level services to the
			 individual who is a resident of this state, is not a recipient of the medicaid
			 program, and whose income is at or below the federal poverty line. Residence is
			 established by a person who is living in Ohio voluntarily and who is not
			 receiving public assistance in another state.
(B)
								For purposes of
			 this rule, the following definitions apply:
(1)
									"Basic, medically
			 necessary hospital level services" are all inpatient and outpatient services
			 covered under the medicaid program in Chapter 5160-2 of the Administrative Code
			 with the exception of transplantation services and services associated with
			 transplantation. These covered services are to be ordered by a practitioner of
			 physician services and delivered at a hospital where the provider has clinical
			 privileges, and where such services are permissible to be provided by the
			 hospital under its certificate of authority granted under Chapters 3711.,
			 3727., and 5119. of the Revised Code. Hospitals will be responsible for
			 providing basic, medically necessary hospital-level services to those persons
			 described in paragraph (C) of this rule.
(2)
									"Family" includes
			 the patient, the patient's spouse (regardless of whether they live in the
			 home), and all of the patient's children, natural or adoptive, under the age of
			 eighteen who live in the home. If the patient is under the age of eighteen, the
			 "family" will include the patient, the patient's natural or adoptive parent(s)
			 (regardless of whether they live in the home), and the parent(s)' children,
			 natural or adoptive, under the age of eighteen who live in the home. If the
			 patient is the child of a minor parent who still resides in the home of the
			 patient's grandparents, the "family" includes only the parent(s) and any of the
			 parent(s)' children, natural or adoptive, who reside in the
			 home.
(3)
									"Income" is defined as total salaries, wages, and cash
			 receipts before taxes; cash receipts that reflect reasonable deductions for
			 business expenses will be counted for both farm and non-farm
			 self-employment.
(4)
									"Third-party payer" means any private or public entity
			 or program that may be liable by law or contract to make payment to or on
			 behalf of an individual for health care services. Third-party payer does not
			 include a hospital.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-22 - Non-DRG prospective payment for hospital services

Current through all regulations passed and filed through July 1, 2024
This rule applies to all hospital services excluded from
				the inpatient hospital and outpatient hospital prospective payment systems.
(A)
			 Applicability.
(1)
									Cost-related
									 reimbursement,  where  payments are made for services to approximate cost based on a historical
			 cost-to-charge ratio, and where no 
									subsequent 
									reconciliation
			 occurs
									, applies
			 to:
(a) All outpatient hospital services
			 provided by  hospitals excluded
			 from 
										outpatient prospective payment as set forth in rule
			 5160-2-05 of the Administrative Code
			 .
(b)
										 All
										
										inpatient
			 hospital services provided by hospitals excluded from
			 inpatient prospective payment as set forth in
			 rule 5160-2-05 of the Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-24 - Audits

Current through all regulations passed and filed through July 1, 2024
(A) General
			 provisions.
(1) Audits will be conducted by
			 the Ohio department of medicaid for services rendered by the hospital under the
			 medicaid program. The examination of hospital costs and charges will be made in
			 consideration with generally accepted auditing standards necessary to fulfill
			 the scope of the audit. To facilitate this examination, providers
			 will make available all records and source documents
			 necessary to fully disclose the extent of services provided to program
			 recipients, the corresponding costs and charges made and payments received for
			 such services, for the period corresponding to the cost-reporting period. The
			 principle objective of the audit is to enable the department to determine that
			 payment has been, or will be made, in accordance with
			 federal, state, and department
			 standards. Based on the audit, adjustments in payments
			 to the provider will be made as necessary by
			 provisions of this rule. Records necessary to fully disclose the extent of
			 services provided will be maintained for a period of six years or, if an
			 audit has been initiated, until the audit is completed and every exception is
			 resolved. Said records will be made
			 available, upon request, to the department for audit purposes. No payment for
			 outstanding medical services can be made if a request for audit is
			 refused.
(2) Additionally, audits
			 will be performed to verify hospital costs and charges utilized in the
			 determination of the hospital's contribution to and reimbursement from the
			 hospital care assurance fund and disproportionate share fund as described in
			 rules 5160-2-08,
			 5160-2-08.1, 5160-2-09 and 5160-2-10 of
			 the Administrative Code.
(3) All
			 audit activities described in this rule may be undertaken during any rate year
			 for the purpose of assuring accuracy of data maintained by the
			 department.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-25 - Coordination of benefits: hospital services

Current through all regulations passed and filed through July 1, 2024
Rule 5160 -1-08 of the Administrative Code sets forth general
				provisions  that the
				department make payment for covered services only after any available
				third-party benefits are exhausted. In addition , this rule identifies other
				
								provisions applicable to services provided by
				hospitals.
(A) All hospitals are to
			 
								use
			 third-party resources for all services a consumer receives while in the
			 hospital. If a hospital receives reimbursement from a third-party
			 
								after submitting a claim or 
								after
			 receiving payment from the department, the hospital is to repay the department
			 by submitting a claim adjustment. Patient liabilities associated with persons
			 eligible for medicaid are described in division 5160:1 of the Administrative
			 Code and are considered a third-party resource. Benefits available through
			 Title XVIII of the Social Security Act under medicare part A and part B, including medicare part A lifetime reserve days, or
			 through medicare part C (medicare advantage) are considered third-party resources.
(B) The following
			 payment provisions apply when billing for services provided to medicaid
			 
								eligible consumers with available resources.
(1) For qualified medicare beneficiaries
			 (QMB), including QMB plus and medicaid consumers enrolled in medicare part A,
			 the following payment provisions apply to cost-sharing liability for inpatient
			 services.
(a) For purposes of paragraph (B)(1)
			 of this rule, the "medicaid maximum allowed amount" is the amount that would be
			 payable by medicaid if the hospitalization were billed, in its entirety, to the
			 department as a medicaid-only claim for a medicaid eligible consumer. The
			 medicaid maximum allowed amount is calculated as:
(i) Described in rule
			 5160-2-65 of the Administrative
			 Code in the case that a hospital is paid in accordance with the all patient
			 refined diagnosis related groups (APR-DRG) prospective payment system;
			 or
(ii) Described in rule
			 5160-2-22 of the Administrative
			 Code in the case that a hospital is subject to non-DRG prospective
			 payment.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-30 - Hospital franchise fee program

Current through all regulations passed and filed through July 1, 2024
This rule sets forth the  assessment rate
								 for the
				hospital franchise fee program implemented under sections
				5168.20 to
				5168.28 of the Revised
				Code.
(A) Definitions
For purposes of the hospital franchise fee program only,
				''total facility costs'' are as defined in section
				5168.20 of the Revised Code, and
				also exclude a hospital's costs associated with providing care to recipients of
				the medicare program as shown on the cost-reporting data used for purposes of
				determining the hospital's assessment under section
				5168.21 of the Revised
				Code.
(B) Assessment
(1)
									For the program
			 year that ends in calendar year 2020, the amount of each hospital's franchise
			 fee assessment shall be three and one thousand nine hundred sixty-five
			 ten-thousandths per cent of the hospital's total facility costs as defined in
			 paragraph (A) of this rule.
(2)
									For the program
			 year that ends in calendar year 2021, the amount of each hospital's franchise
			 fee assessment shall be three and thirty-five hundredths per cent of the
			 hospital's total facility costs as defined in paragraph (A) of this
			 rule.
(3)
									For the program year that ends in calendar year 2022,
			 and for each program year thereafter, the amount of each hospital's franchise
			 fee assessment shall be three and thirty-seven hundredths per cent of the
			 hospital's total facility costs as defined in paragraph (A) of this
			 rule.
(4)
									The department may establish a rate higher or lower
			 than the rates described in paragraphs (B)(1) to (B)(3) of this rule based on
			 the franchise fee assessment needed to operate the current program
			 year.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-40 - Psychiatric pre-certification review

Current through all regulations passed and filed through July 1, 2024
(A)
								Definitions.
For purposes of this rule, the
				following definitions apply:
(1)
									A "hospital" is a provider eligible under rule
			 5160-2-01 of
			 the Administrative Code.
(2)
									"Medical necessity" is as defined in rule
			 5160-1-01
			 of the Administrative Code.
(3)
									"Pre-certification" is a process whereby the Ohio department
			 of medicaid (ODM) or its contracted medical review entity assures that covered
			 psychiatric services are medically necessary and are provided in the most
			 appropriate and cost effective setting.
(4)
									A "psychiatric
			 admission" is an admission of an individual to a hospital with a primary
			 diagnosis of mental illness and not a medical or surgical admission. A
			 discharge from a medical unit and an admission to a distinct part psychiatric
			 unit within the same facility is considered a psychiatric admission and is
			 subject to pre-certification.
(5)
									"Standards of
			 medical practice" are nationally recognized protocols for diagnostic and
			 therapeutic care. These protocols are approved by the medicaid program. ODM
			 will notify providers of the standards of medical practice to be used by ODM.
			 If ODM should change the protocols, providers will be notified sixty business
			 days in advance.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-65 - Inpatient hospital reimbursement

Current through all regulations passed and filed through July 1, 2024
This rule sets forth the payment policies for inpatient
				hospital services for discharges on or after the effective date of this
				rule.
(A) Hospitals defined as
			 eligible providers of hospital services in rule
			 5160-2-01 of the Administrative
			 Code and grouped in paragraph (B)(1) of rule
			 5160-2-05 of the Administrative
			 Code are subject to the all patient refined diagnosis related groups (APR-DRG)
			 prospective payment methodology as described in this rule.
(B) Hospital peer groups. For purposes of
			 setting rates and making payments under the APR-DRG prospective payment system,
			 the Ohio department of medicaid (ODM) classifies all hospitals not defined in
			 paragraph (A) of this rule into one of the mutually exclusive peer groups
			 defined in this paragraph.
(1) Children's
			 hospitals as defined in rule
			 5160-2-05 of the Administrative
			 Code that are located in Ohio.
(2)
			 Children's hospitals as defined in rule
			 5160-2-05 of the Administrative
			 Code that are not located in Ohio.
(3) Critical access hospitals as defined in
			 rule 5160-2-05 of the Administrative
			 Code that are located in Ohio.
(4)
			 Rural hospitals as defined in rule
			 5160-2-05 of the Administrative
			 Code that are located in Ohio.
(5)
			 Teaching hospitals as defined in rule
			 5160-2-05 of the Administrative
			 Code that are located in Ohio.
(6)
			 Teaching hospitals as defined in rule
			 5160-2-05 of the Administrative
			 Code that are not located in Ohio.
(7) Urban hospitals as defined in rule
			 5160-2-05 of the Administrative
			 Code that are located in Ohio.
(8)
			 For purposes of this rule, freestanding psychiatric hospitals (FSPs) as defined
			 in rule 5160-2-05 of the Administrative
			 Code are so named for the implementation of special payment policies as
			 described in this rule.
(9) All
			 other hospitals that are not located in Ohio that are not classified in
			 paragraph (B)(2) or (B)(6) of this rule.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-66 - Capital costs

Current through all regulations passed and filed through July 1, 2024
This rule outlines the calculation of capital payments for
				hospitals that are subject to the all patient refined diagnosis related groups
				(APR-DRG) prospective payment methodology, effective for dates of discharges
				occurring on or after 
								January 1, 2024.
(A) For purposes of this rule, capital costs
			 include the categories of costs recognized by medicare on the centers for
			 medicare and medicaid services (CMS) CMS 2552-10 revised
			 
								October 2016 and filed in accordance with CMS
			 instructions, available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals.html
(revised 
								June 2022).
(B) Capital-related costs for services
			 provided by Ohio hospitals paid under prospective payment will be subject to
			 prospective payment without subsequent settlement to actual capital
			 costs.
(C) Annual update of interim
			 capital payments.
(1) The calculation of
			 interim capital payments resulting in the capital allowance identified in rule
			 5160-2-65 of the Administrative
			 Code is based on the hospital's cost-reporting period.
On an annual basis, the interim capital payments will be
				redetermined by identifying eighty-five per cent of the capital-related costs
				reported on the ODM 02930, "Ohio Medicaid Hospital Cost Report"; multiplying
				that cost by the per cent of the sum of the
				medicaid inpatient charges to total charges; and dividing the result by the
				sum of the number of medicaid discharges that
				occurred during the cost-reporting period. The cost report used to complete
				these calculations is the interim settled cost report ending in the state
				fiscal year ending in the calendar year preceding the immediate past calendar
				year prior to January first of the calendar year to which the new capital rate
				will
				apply.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-67 - Medical education

Current through all regulations passed and filed through July 1, 2024
Effective for dates of discharge on or after the effective date
				of this rule, to qualify for a medical education payment as
				described in this rule, Ohio hospitals must have an approved medical education
				program as defined in
				42
				C.F.R. 415.152 (October 1, 2016) and the
				costs of the approved medical education program were reflected in their state
				fiscal year (SFY) 2014 Ohio medicaid hospital cost report (ODM 02930 rev.
				6/2014). This rule describes the methodology used for computing the direct
				graduate medical education and indirect medical education components of each
				hospital's medical education add-on rate.
(A) Computation of direct graduate medical
			 education (DGME) costs, which are the costs that are directly related to the
			 training of interns and residents and allied professionals in an approved
			 medical education program.
(1) Tabulate the
			 costs captured on the ODM 02930 for interns and residents
			 and allied professionals.
(2)
			 Tabulate the total facility charges and total medicaid fee-for-service and
			 managed care charges reported on the ODM 02930. Calculate the medicaid factor
			 by dividing the sum of total medicaid fee-for-service and managed care charges
			 by total charges.
(3) Tabulate the
			 total medicaid fee-for-service and managed care discharges from the ODM
			 02930.
(4) The medicaid portion of
			 DGME costs equal the total DGME costs as described in paragraph (A)(1) of this
			 rule multiplied by the medicaid factor as described in paragraph (A)(2) of this
			 rule.
(5) A cost per discharge is
			 computed using the medicaid portion of DGME costs as described in paragraph
			 (A)(4) of this rule divided by the total number of medicaid discharges as
			 described in paragraph (A)(3) of this rule.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-77 - Consumer co-payments for non-emergency emergency department services

Current through all regulations passed and filed through July 1, 2024
(A)
								This rule establishes a consumer co-payment for
			 non-emergency emergency department services as authorized by section
			 5162.20
			 of the Revised Code.
(B)
								For purposes of this rule, the following definitions
			 apply.
(1)
									"Emergency medical condition" means a medical condition
			 manifesting itself by acute symptoms of sufficient severity (including severe
			 pain) such that a prudent lay person, as defined in paragraph (B)(2) of this
			 rule, could reasonably expect the absence of immediate medical attention to
			 result in any of the following: placing the health of the individual (or, with
			 respect to a pregnant woman, the health of her unborn child) in serious
			 jeopardy; serious impairment to bodily functions; or serious dysfunction of any
			 bodily organ or part.
(2)
									"Prudent lay person" means a person with an average
			 knowledge of health and medicine to determine, within reason, that emergency
			 services are necessary.
(3)
									"Non-emergency emergency department service" means an
			 emergency department service that does not meet the definition of emergency
			 medical condition, as defined in paragraph (B)(1) of this rule.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-79 - Reimbursement for LARC devices

Current through all regulations passed and filed through July 1, 2024
(A)
								Notwithstanding
			 the provisions of rules
			 5160-2-65
			 and
			 5160-2-75
			 of the Administrative Code, long-acting reversible contraceptive (LARC) devices
			 may be billed separately when provided during an inpatient
			 hospitalization.
(B)
								LARC devices may include intrauterine devices (IUD) and
			 subdermal contraceptive implants.
(C)
								Implementation
			 and billing procedures.
(1)
									The provisions of this rule are effective for claims
			 associated with the provision of a LARC device in an inpatient hospital setting
			 on or after the effective date of this rule.
(2)
									Only one
			 outpatient claim for a LARC device may be submitted for a recipient in
			 conjunction with an inpatient obstetrical delivery claim.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-01 - Nursing facilities (NFs): definitions

Current through all regulations passed and filed through July 1, 2024
Except as otherwise provided in Chapter 5160-3 of the
				Administrative Code, and in addition to the definitions in section
				5165.01 of the Revised
				Code:
(A) "Allowable costs" has the
			 same meaning as in section
			 5165.01 of the Revised Code and
			 are determined in accordance with the following reference material, in the
			 following priority:
(1) Title 42 Code of
			 Federal Regulations (C.F.R.) Chapter IV (October 1, 2017).
(2) The centers for medicare and medicaid
			 services (CMS) publication 15-1 entitled "The Provider Reimbursement Manual -
			 Part 1" (rev. 9/21/17).
(3) Generally accepted accounting principles
			 in accordance with standards prescribed by the "American Institute of CPAs"
			 (AICPA) as in effect June 26, 2018.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-02 - Nursing facilities (NFs): provider agreements

Current through all regulations passed and filed through July 1, 2024
In addition to provisions in Chapters
				5164. and 5165. of the Revised Code regarding provider agreements, and
				provisions in rules 5160-3- 02.1 and
				5160-3- 02.2 of the Administrative Code, execution and
				maintenance of a provider agreement between the Ohio department of
				medicaid (ODM) and the operator of a NF
				 also are
				contingent upon compliance with requirements set forth in this rule.
(A) Definitions.
(1) "Closure" means the discontinuance of the
			 use of the building or part of the building that houses the facility as a NF,
			 and that results in the relocation of the facility's residents who continue to
			 require NF services. If the building is converted to a different use and
			 acquires a new type of license, residents who require services offered under
			 the new license type may remain.
(a) A
			 facility's closure occurs regardless of whether there is a replacement of the
			 facility whereby the operator completely or partially replaces the facility's
			 physical plant through the construction of a new physical plant or the transfer
			 of the facility's license from one physical plant location to
			 another.
(b) Facility closure
			 occurs regardless of whether residents of the closing facility elect to be
			 relocated to the operator's replacement facility or to another NF.
(c) A facility closure occurs regardless of
			 action taken by the Ohio department of health (ODH) related to the facility's
			 certification under Title XIX of the Social Security Act,
			 
										42 U.S.C.
			 1396
										(April 16,
			 2015), that may result in the transfer of part of the facility's survey
			 findings to a replacement facility, or related to retention of a license as a
			 NF under Chapter 3721. of the Revised Code.
(d) The last effective date of the provider
			 agreement of a closed facility will be the date of the relocation of the last
			 resident.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-02.1 - Nursing facilities (NFs): length and type of provider agreements

Current through all regulations passed and filed through July 1, 2024
(A) Definitions.
(1) "Reasonable assurance period" means a
			 certain period of time, determined by the centers for medicare and medicaid
			 services (CMS), for which a nursing facility operator whose
			 provider agreement has been involuntarily terminated is required to operate
			 without recurrence of the deficiencies that were the basis for termination.
			 Participation in the medicare and medicaid programs may resume only following
			 that period. If corrections were made before submission of a new request for
			 participation, the period of compliance before the new request is counted as
			 part of the period.
(2) "State
			 survey agency" means the agency that is under contract with the state medicaid
			 agency and that inspects 
									nursing facilities for the purposes of survey and
			 certification. The state survey agency in Ohio is the Ohio department of health
			 (ODH). The state medicaid agency in Ohio is the Ohio department of
			 medicaid (ODM).