reglab/statecodes huggingface dataset:
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-15 - Medical Transportation Services › Section 5160-15-28 - Transportation: services from an eligible provider: payment

Current through all regulations passed and filed through July 1, 2024
(A) The amount of
			 payment for a transportation service furnished by an eligible provider on a
			 fee-for-service basis is the lesser of either the provider's submitted charge
			 or the medicaid maximum payment amount for the date of transport. The medicaid
			 maximum payment amounts for transportation services are listed in the appendix
			 to this rule.
(B) The amount of
			 payment for a transportation service furnished by an eligible provider under an
			 arrangement with a medicaid managed care organization (MCO) is determined by
			 the provider agreement established in accordance with Chapter 5160-26 of the
			 Administrative Code.
Click to
				view Appendix
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-17 - Abortions › Section 5160-17-01 - Abortions

Current through all regulations passed and filed through July 1, 2024
(A) Reimbursement
			 for abortion services, other than those identified in paragraph (D) of this
			 rule, is restricted to the following circumstances when the appropriate
			 certification in paragraph (B) of this rule is made:
(1) Instances in which the woman suffers from
			 a physical disorder, physical injury, or physical illness, including a
			 life-endangering physical condition caused by or arising from the pregnancy
			 itself, that would, as certified by a physician, place the woman in danger of
			 death unless an abortion is performed; or
(2) Instances in which the pregnancy was the
			 result of an act of rape and the patient, the patient's legal guardian or the
			 person who made the report to the law enforcement agency, certifies in writing
			 that a report was filed, prior to the performance of the abortion, with a law
			 enforcement agency having the requisite jurisdiction, unless the patient was
			 physically unable to comply with the reporting requirement and that fact is
			 certified by the physician performing the abortion; or
(3) Instances in which the pregnancy was the
			 result of an act of incest and the patient, the patient's legal guardian or the
			 person who made the report certifies in writing that a report was filed, prior
			 to the performance of the abortion, with either a law enforcement agency having
			 the requisite jurisdiction, or, in the case of a minor, with a county children
			 services agency established under Chapter 5153. of the Revised Code, unless the
			 patient was physically unable to comply with the reporting requirement and that
			 fact is certified by the physician performing the abortion.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-18 - Freestanding Birth Center › Section 5160-18-01 - Freestanding birth center services

Current through all regulations passed and filed through July 1, 2024
(A)
								Definitions.
(1)
									"Freestanding birth center (FBC)" is an entity defined
			 in 42 U.S.C.
			 1396d(l)(3)(B) (in effect as
			 of January 1, 2023) that is operated in conformity with rules
			 3701-83-33 to
			 3701-83-42 of the Administrative
			 Code.
(2)
									"Independent practitioner" and "non-independent
			 practitioner" have the same meaning as in rule
			 5160-4-02 of the Administrative
			 Code.
(3)
									"Low-risk expectant mother" has the same meaning as in
			 rule 3701-83-33 of the Administrative
			 Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-19 - Patient-Centered Medical Homes › Section 5160-19-01 - Comprehensive primary care (CPC) program: eligible providers

Current through all regulations passed and filed through July 1, 2024
(A) For purposes of
			 rules 5160-19-01 and
			 5160-19-02 of the Administrative
			 Code, the following definitions apply:
(1)
			 "Attribution" is the process through which medicaid recipients are assigned to
			 specific primary care practitioners ( PCPs) who are able to participate in the medicaid program
			 in accordance with rule
			 5160-1-17.2 of the
			 Administrative Code. The Ohio department of medicaid (ODM) is responsible
			 for attributing fee-for-service recipients; medicaid
			 managed care organizations ( MCOs) are
			 responsible for attributing their enrolled recipients.
			  CPC entities who are not
			 able to participate in accordance with rule
			 5160-1-17.2 of the
			 Administrative Code at the time of attribution or during the prospective
			 payment period may not be attributed members or be eligible for payment until
			 the next attribution period following the provider's reinstatement. The
			 following hierarchy will be used in assigning recipients to PCPs under the
			 CPC
			 and CPC for kids program:
(a) The recipient's choice of
			 provider.
(b) Claims data
			 concerning the recipient.
(c) Other
			 data concerning the recipient.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-19 - Patient-Centered Medical Homes › Section 5160-19-02 - Comprehensive primary care (CPC) program: payments

Current through all regulations passed and filed through July 1, 2024
(A) A comprehensive primary care (CPC) entity
			 has to be enrolled and meet the provisions set forth in rule
			 5160-19-01 of the Administrative
			 Code to be eligible for patient centered medical home (PCMH)
			 payments.
(B) A CPC entity
			 participating in the CPC for kids program has to be enrolled as a CPC entity
			 and meet all provisions set forth in rule
			 5160-19-01 of the Administrative
			 Code to be eligible for CPC for kids payments.
(C) An eligible CPC entity may qualify for
			 the following payments:
(1) The "CPC
			 per-member-per-month (PMPM)" is a payment to support the CPC entity.
(a) Payment is in the form of a prospective
			 risk-adjusted PMPM payment that is calculated for each attributed medicaid
			 individual. Further detail regarding risk-adjustment
			 can be found on the Ohio department of medicaid (ODM) website,
www.medicaid.ohio.gov
.
(b) Payment begins following enrollment and
			 in accordance with the payment schedule determined by the Ohio department of
			 medicaid (ODM).
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-19 - Patient-Centered Medical Homes › Section 5160-19-03 - Comprehensive maternal care program

Current through all regulations passed and filed through July 1, 2024
The "comprehensive maternal care (CMC)
				program" is a maternal and infant support program that utilizes a comprehensive
				care coordination and service model incorporating supportive services for
				expectant and postpartum medicaid eligible individuals to reduce adverse birth
				and infant outcomes.
(A)
								For purposes of Chapter 5160-19 of the Administrative
			 Code, the following definitions apply:
(1)
									"Attribution" is
			 the process through which the Ohio department of medicaid (ODM) or its designee
			 assigns eligible individuals to a specific CMC entity.
(2)
									"CMC attributed
			 medicaid individuals" are the eligible pregnant and postpartum Ohio medicaid
			 recipients for whom an entity eligible under this rule has accountability for
			 coordinating and ensuring the delivery of CMC program activities. All eligible
			 individuals will be attributed except for:
(a)
										Individuals who
			 are currently receiving another care coordination service that substantially
			 duplicates those activities provided under this program.
(b)
										Individuals with
			 a limited medicaid benefit plan other than presumptive eligibility for pregnant
			 individuals.
(c)
										Individuals dually enrolled in Ohio medicaid and
			 medicare.
(d)
										Individuals with third party benefits as defined in
			 rule
			 5160-1-08
			 of the Administrative Code except for those with exclusively dental or vision
			 coverage.
(3)
									"Comprehensive maternal care entity" (CMC entity) is
			 the primary entity which meets the criteria described in this rule and is
			 responsible for meeting CMC program activities for attributed medicaid
			 individuals. The following medicaid providers are eligible to participate and
			 receive payment under this rule:
(a)
										Professional medical groups as defined in Chapter
			 5160-1 of the Administrative Code.
(b)
										Federally
			 qualified health centers (FQHC) and rural health clinics (RHC) as defined in
			 Chapter 5160-28 of the Administrative Code.
(c)
										Clinics as
			 defined in Chapter 5160-13 of the Administrative Code.
(d)
										Professional
			 medical groups billing under hospital provider types.
(4)
									"Electronic pregnancy risk assessment form" (e-PRAF) is the
			 electronic version of ODM form 10207 "pregnancy risk assessment form" (PRAF)
			 that is submitted through the web portal designated by ODM.
(5)
									"Electronic
			 report of pregnancy" (e-ROP) is the electronic version of ODM form 10257,
			 "report of pregnancy" (ROP) that is submitted through the web portal designated
			 by ODM.
(6)
									"Eligible provider" is as defined in rule
			 5160-1-17 of
			 the Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-20 - Coordinated Services Program › Section 5160-20-01 - Coordinated services program

Current through all regulations passed and filed through July 1, 2024
(A) Definitions.
(1) "Abuse potential drug" as used in the
			 appendix to this rule, means any drug that contains substances which have a
			 potential for abuse because of depressant or stimulant effects on the central
			 nervous system or hallucinogenic effects. Abuse potential drugs include any
			 drug that is reportable to Ohio automated RX reporting system (OARRS) as
			 described in rules
			 4729:8-2-01
			 and
			 4729:8-2-02
			 of the Administrative Code, in addition to non-controlled drugs including
			 muscle relaxants.
(2) "Assigned
			 provider" means a hospital, health care facility, physician, dentist, pharmacy,
			 or otherwise licensed or certified single provider or provider entity that is
			 authorized to and is not excluded from receiving reimbursement for health care
			 services rendered to an individual. The assigned provider is selected in
			 accordance with paragraph (F) of this rule to serve as the primary provider of
			 non-emergency services for an individual enrolled in the coordinated services
			 program (CSP).
(3) "Fraud" for the
			 purpose of this rule, includes but is not limited to, forged prescriptions,
			 possession and use of multiple medicaid cards, card loaning, and sharing of
			 drugs or other supplies obtained through medicaid.
(4) "Individual" is
			 defined in rule
			 5160:1-1-01
			 of the Administrative Code.
(5) "Managed care
			 organization" (MCO) is defined in rule
			 5160-26-01
			 of the Administrative Code.
(6) "Medication
			 Assisted Treatment" (MAT) is defined in rule
			 5160-1-73
			 of the Administrative Code.
(7)
									"Ohio resilience through integrated systems and
			 excellence (OhioRISE)" is defined in rule 5160-59-01 of the Administrative
			 Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-21 - Preconception Care Services › Section 5160-21-02 - Reproductive health services: pregnancy prevention services

Current through all regulations passed and filed through July 1, 2024
(A) Principles.
(1)
									Medicaid-eligible
			 individuals have access to medicaid-covered
			 pregnancy prevention services. This access is not
			 restricted by factors including but not limited to
									 religion, race, color,
			 national origin, disability, age, sex, sexual
			 orientation, gender identity, gender expression, military status, health
			 status, number of pregnancies, or marital status.
(2)
									
									Medicaid-eligible
			 individuals can obtain medicaid-covered
			 pregnancy prevention services voluntarily, free from coercion or pressure and
			 free to choose the type or method of service to be used.
(3)
									
									The receipt
			 of pregnancy prevention services cannot be made a
			 prerequisite to eligibility for, receipt of, or participation in any other
			 services offered by 
									a provider.
(4)
									
									Medicaid-eligible
			 individuals cannot be denied other medicaid-covered medically necessary
			 services on the basis of fertility or infertility.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-21 - Preconception Care Services › Section 5160-21-02.2 - Medicaid covered reproductive health services: permanent contraception/sterilization services and hysterectomy

Current through all regulations passed and filed through July 1, 2024
(A) Definitions.
(1) For the purposes of this rule,
			 "hysterectomy" means, in accordance with
			 42
			 C.F.R. 441.251
									(October 1, 2010 edition), a medical procedure or
			 operation for the purpose of removing the uterus.
(2) For the purposes of this rule,
			 "institutionalized individual" means, in accordance with
			 42
			 C.F.R. 441.251
									(October 1, 2010 edition), an individual who is:
(a) Involuntarily confined or detained, under
			 a civil or criminal statute, in a correctional or rehabilitative facility,
			 including a mental hospital or other facility for the care and treatment of
			 mental illness; or
(b) Confined,
			 under a voluntary commitment, in a mental hospital or other facility for the
			 care and treatment of mental illness.
(3) For the purposes of this rule, "mentally
			 incompetent individual" means, in accordance with
			 42
			 C.F.R. 441.251
									(October 1, 2010 edition), an individual who has been
			 declared mentally incompetent by a federal, state, or local court of competent
			 jurisdiction for any purpose, unless the individual has been declared competent
			 for purposes which include the ability to consent to sterilization.
(4) For the purposes of this rule,
			 "sterilization" means, in accordance with
			 42
			 C.F.R. 441.251
									(October 1, 2010 edition), any medical procedure,
			 treatment, or operation for the purpose of rendering an individual permanently
			 incapable of reproducing.
(5) For
			 the purposes of this chapter, "permanent pregnancy prevention" has the same
			 meaning as "sterilization."
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-21 - Preconception Care Services › Section 5160-21-05 - Nurse home visiting services

Current through all regulations passed and filed through July 1, 2024
(A) Unless otherwise noted, any limitations
			 or 
								conditions specified in the Revised Code or in agency
			 5160 of the Administrative Code apply to services addressed in this
			 rule.
(B) Definitions.
(1) "Advanced practice registered nurse
			 (APRN)" has the same meaning as in Chapter 4723-08 of the Administrative
			 Code.
(2) "Registered nurse (RN)"
			 has the same meaning as in Chapter 4723. of the Revised Code.
(3) "Eligible provider" has the same meaning
			 as in rule
			 5160-1-17 of the Administrative
			 Code.
(4) "Home visiting" has the
			 same meaning as in Chapter 3701-8 of the Administrative Code.
(5) "Nurse home visiting" is home visiting
			 provided by an APRN or RN. Within the package of home visiting services,
			 emphasis is placed on the following services performed within the scope of the
			 practitioner:
(a) Prenatal visits;
(b) Postpartum visits;
(c) Training in pediatric care;
(d) Nursing examinations, which focus on
			 assessment of social determinants of health, on education, and on emotional
			 support;
(e) Health
			 education;
(f) Maternal depression
			 screening; and
(g) Lactation
			 counseling.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-26 - Managed Care Plan › Section 5160-26-01 - Managed: definitions

Current through all regulations passed and filed through July 1, 2024
As used in Chapter 5160-26 of the Administrative Code:
(A) "Abuse" means provider practices that are
			 inconsistent with sound fiscal, business, or medical practices, and result in
			 an unnecessary cost to the medicaid program, or in reimbursement for services
			 that are not medically necessary or that fail to meet professionally recognized
			 standards for health care. It also includes recipient practices that result in
			 unnecessary cost to the medicaid program.
(B) "Advance directive" means written
			 instructions such as a living will or durable power of attorney for health care
			 relating to the provision of health care when an adult is
			 incapacitated.
(C)
								"Adverse benefit determination" is a managed care
			 entity's (MCE's):
(1)
									Denial or limited authorization of a requested service,
			 including determinations based on the type or level of service, requirements
			 for medical necessity, appropriateness, setting, or effectiveness of a covered
			 benefit;
(2)
									Reduction, suspension, or termination of services prior
			 to the member receiving the services previously authorized by the
			 MCE;
(3)
									Failure to provide services in a timely manner as
			 specified in rule 5160-26-03.1 of the Administrative Code;
(4)
									Failure to act
			 within the resolution time frames specified in rule 5160-26-08.4 of the
			 Administrative Code;
(5)
									Denial of a member's request to dispute a financial
			 liability, including cost sharing, copayments, premiums, deductibles,
			 coinsurance and other member financial liabilities, if applicable;
			 or
(6)
									Denial, in whole or part, of payment for a service. A
			 denial, in whole or in part, of a payment for a service solely because the
			 claim does not meet the definition of a "clean claim" as defined in
			 42 C.F.R.
			 447.45(b) (October 1, 2021)
			 is not an adverse benefit determination.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-26 - Managed Care Plan › Section 5160-26-03 - Managed care: covered services

Current through all regulations passed and filed through July 1, 2024
(A)
								This rule does
			 not apply to MyCare Ohio plans as defined in rule
			 5160-58-01
			 of the Administrative Code or the Ohio resilience through integrated systems
			 and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the
			 Administrative Code.
(B) Except as otherwise
			 provided in this rule, a managed care 
								organization(MCO) and the single pharmacy benefit manager
			 (SPBM) must ensure members have access to all medically necessary
			 services, as applicable, covered by Ohio medicaid
			 under the state plan.  The 
								MCO and SPBM must ensure:
(1) Services are sufficient in amount,
			 duration, 
									and scope to reasonably be expected to achieve the
			 purpose for which the services are provided;
(2) The amount, duration,
			 
									and scope
			 of a required service is not arbitrarily denied or reduced solely because of
			 the diagnosis, type of illness, or condition;
(3) Prior authorization is available for
			 services on which the MCO or the SPBM has placed a pre-identified
			 limitation to ensure the limitation may be exceeded when medically necessary,
			 unless the MCO
			 or SPBM's
									 limitation is also a
			 limitation for fee-for-service medicaid coverage;
(4) Coverage decisions are based on the
			 coverage and medical necessity criteria published in agency 5160 of the
			 Administrative Code and practice guidelines specified in rule 5160-26-05.1 of
			 the Administrative Code; and
(5) If
			 a member is unable to obtain medically necessary services offered by medicaid
			 from 
									an
									MCO or
			 SPBM
									
									network provider, the MCO or SPBM must
			 adequately and timely cover the services out of network, until
			 the MCO or
			 SPBM is able to provide the services from a 
									network
			 provider.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-26 - Managed Care Plan › Section 5160-26-03.1 - Managed care: primary care and utilization management

Current through all regulations passed and filed through July 1, 2024
(A)
								This rule does not apply to MyCare Ohio plans as
			 defined in rule
			 5160-58-01
			 of the Administrative Code or the Ohio resilience through integrated systems
			 and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the
			 Administrative Code.
(B) A managed care
			 
								organization
			 (MCO) must ensure each member
			 has a primary care provider (PCP) who will serve as an ongoing source of
			 primary care and assist with care coordination appropriate to the member's
			 needs.
(1)
									
									The MCO must ensure PCPs are in
			 compliance with the following triage requirements:
(a) Members with emergency care needs must be
			 triaged and treated immediately on presentation at the PCP site;
(b) Members with persistent symptoms must be
			 treated no later than the end of the following working day after their initial
			 contact with the PCP site; and
(c)
			 Members with requests for routine care must be seen within six weeks.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-26 - Managed Care Plan › Section 5160-26-03.2 - Managed care: long-term services and supports respite services for children

Current through all regulations passed and filed through July 1, 2024
(A)
								This rule does
			 not apply to My Care Ohio plans as defined in rule
			 5160-58-01
			 of the Administrative Code or the Ohio resilience through integrated systems
			 and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the
			 Administrative Code.
(B)
								The managed care organization (MCO) is responsible for
			 payment of long-term services and supports (LTSS) respite services as defined
			 in rule
			 5160-26-01
			 of the Administrative Code.
(C)
								To be eligible
			 for respite services, the member has to:
(1)
									Reside with his
			 or her informal, unpaid primary caregiver in a home that is not owned, leased,
			 or controlled by a provider of any health-related treatment or support
			 services;
(2)
									Not be a foster child, as defined in Chapter 5101:2-1
			 of the Administrative Code;
(3)
									Be under
			 twenty-one years of age;
(4)
									Have long-term services and supports (LTSS) needs
			 resulting in the need for respite services as indicated by:
(a)
										Skilled nursing
			 or skilled rehabilitation services at least once per week; or
(b)
										Having a need for
			 at least fourteen hours per week of home health aide services for at least two
			 consecutive months immediately preceding the date respite services are
			 requested; or
(c)
										Being determined eligible for social security income
			 for children with disabilities or supplemental security income;
			 or
(d)
										Having an LTSS needs as determined by the MCO through
			 an institutional level of care determination as set forth in rule
			 5123-8-01
			 or
			 5160-3-08,
			 of the Administrative Code.
(5)
									Be participating
			 in a care management or coordination arrangement.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-26 - Managed Care Plan › Section 5160-26-05 - Managed care: provider network and contracting requirements

Current through all regulations passed and filed through July 1, 2024
(A)
								Provider contracts.
(1) A managed care entity
			 (MCE) must provide or arrange for the delivery of covered health care
			 services described in rule
			 5160-26-03
			 of the Administrative Code either through the use of employees or through
			 
									contracts with network providers of health care
			 services ("providers"). All Provider
			 contracts must be in writing and in accordance with paragraph (D) of this
			 rule and
			 42 C.F.R.
			 434.6 and
			 438.6
			 (October 1, 2021). The 
									MCE's execution of a provider
			 contract
									 does not
			 terminate the 
									MCE's legal responsibility to the Ohio department of
			 medicaid (ODM) to ensure all of the 
									MCE's activities and obligations are performed in
			 accordance with agency 5160 of the Administrative
			 Code, as applicable, the 
									MCE's provider agreement
									or contract with
			 ODM, and all applicable federal, state, and local regulations.
(2)
									
									The MCE shall make all
			 Provider contracts
									available to ODM upon request.
(3)
									Provider
			 contracts may not include language that conflicts with the specifications
			 identified in paragraphs (C) and (D) of this rule.
(4)
									MCE network
			 providers have to maintain an active, valid medicaid provider agreement as set
			 forth in rule 5160-1-17.2 of the Administrative Code.
(5)
			 When utilizing an out of 
									network provider, the 
									MCE must
			 establish a mutually agreed upon compensation amount for the authorized service
			 and notify the provider of the applicable provisions of paragraph (D) of this
			 rule. For medicaid-covered non-emergency hospital services outlined in rule
			 5160-26-03
			 of the Administrative Code, the compensation amount is identified in rule
			 5160-26-11
			 of the Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-26 - Managed Care Plan › Section 5160-26-05.1 - Managed care: provider services

Current through all regulations passed and filed through July 1, 2024
(A)
								A managed care entity
			 (MCE) must provide the following written information to their contracting
			 providers:
(1) The 
									MCE's
			 grievance, appeal and state fair hearing procedures and time frames, including:
(a) The member's right to file grievances and
			 appeals and the requirements and time frames for filing;
(b) The 
										MCE's toll-free
			 telephone number to file oral grievances and appeals;
(c) The member's right to a state fair
			 hearing, the requirements and time frames for requesting a hearing, and
			 representation rules at a hearing;
(d) The availability of assistance from the
			 
										MCE in
			 filing any of these actions;
(e)
			 The member's right to request continuation of benefits during an appeal or a
			 state hearing and specification that at the discretion of ODM the member may be
			 liable for the cost of any such continued benefits; and
(f) The provider's rights to participate in
			 these processes on behalf of the provider's patients and to challenge the
			 failure of the 
										MCE to cover a specific service.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-26 - Managed Care Plan › Section 5160-26-06 - Managed care: program integrity - fraud, waste and abuse, audits, reporting, and record retention

Current through all regulations passed and filed through July 1, 2024
(A)
								A managed care entity
			 (MCE) must have administrative and management arrangements or procedures,
			 including a mandatory compliance plan, to guard against fraud, waste and abuse
			 as required in the MCE provider agreement or
			 contract with the Ohio department of medicaid (ODM) located at
http://medicaid.ohio.gov/
.
(1) These arrangements or procedures must be
			 made available to ODM upon request.
(2) The 
									MCE must annually
			 submit to ODM a report that summarizes the MCE's fraud, waste, and abuse activities for the previous year and
			 identifies any proposed changes to the 
									MCE's fraud,
			 waste, and abuse program for the coming
			 year.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-26 - Managed Care Plan › Section 5160-26-09.1 - Managed care: third party liability and recovery

Current through all regulations passed and filed through July 1, 2024
(A) Tort.
(1) Pursuant to sections
			 5160.37
			 and
			 5160.38
			 of the Revised Code, the Ohio department of medicaid (ODM) maintains all rights
			 of recovery (tort) against the liability of any third party payer (TPP) for the
			 cost of medical services.
(2)
									A
									
									managed care 
									entity (MCE)
									
									is
			 prohibited from accepting any settlement, compromise, judgment, award, or
			 recovery of any action or claim by 
									a member.
(3)
									The MCE must
			 notify ODM and/or its designated entity within fourteen calendar days of all
			 requests for the release of financial and medical records to a member or the
			 member's representative pursuant to the filing of a tort action. Notification
			 must be made via the "Notification of Third Party (tort) Request For Release"
			 form (ODM 03245, rev. 7/2014) or a method determined by the ODM designated
			 entity, provided ODM approved the designated entity's method and notified
			 the
			 MCE.
(4)
									The MCE
			 must submit a summary of financial information to ODM and/ or its designated
			 entity within thirty calendar days of receiving an original authorization to
			 release a financial claim statement letter from ODM pursuant to a tort action.
			 The MCE
			 must use the "Tort Summary Statement" form (ODM 03246, rev. 7/2014) or a method
			 determined by the ODM designated entity, provided ODM has approved the
			 designated entity's method and notified the MCE. Upon
			 request, the MCE must provide ODM and/or its designated entity with
			 true copies of medical claims.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-26 - Managed Care Plan › Section 5160-26-10 - Managed care: sanctions and provider agreement actions

Current through all regulations passed and filed through July 1, 2024
(A)
								This rule does not apply to the single pharmacy benefit
			 manager as defined in rule
			 5160-26-01
			 of the Administrative Code.
(B) If
			 the
			 MCO fails to fulfill its duties and obligations under 42 C.F.R. Part 438
			 (October 1, 2021),
			 42 U.S.C.
			 1396b(m) (as in effect
			 July
			 1, 2022),
			 42 U.S.C.
			 1396u-2 (as in effect
			 July
			 1, 2022), agency 5160 of the Administrative
			 Code, or the MCO provider agreement, ODM will provide timely
			 written notification to the MCO identifying the violations or deficiencies, and
			 may impose corrective actions or any of the following sanctions in addition to
			 or instead of any actions or sanctions specified in the provider agreement:
(1) ODM may require corrective action plans
			 (CAPs) in accordance with the following:
(a)
			 If requested by ODM, the MCO must submit, within the specified time frame, a
			 proposed CAP for each cited violation or deficiency.
(b) The CAP must contain the proposed
			 correction date, describe the manner in which each violation or deficiency will
			 be resolved, and address all items specified in the ODM notification.
(c) The CAP must be reviewed and approved by
			 ODM.
(d) Following the approval of
			 the CAP, ODM will monitor the correction process until all violations or
			 deficiencies are corrected to the satisfaction of ODM.
(e) If the MCO fails to
			 submit an approvable CAP within the ODM-specified time frames, ODM may impose
			 an ODM-developed CAP, sanctions, or both.
(f) If ODM has already determined the
			 specific action that must be implemented by the MCO, ODM may
			 require the MCO to comply with an ODM-developed or directed
			 CAP.
(g) Failure by the
			 MCO to
			 successfully complete the correction process and correct the violations or
			 deficiencies to the satisfaction of ODM may lead to the imposition of any or
			 all of the sanctions listed in paragraph (
									the MCO by ODM include but are not limited to the
			 following:
(a) Suspension of the enrollment of
			 the MCO's
			 members.
(b) Disenrollment of
			 
										the
			 MCO's members.
(c)
			 Prohibition or reduction of 
										the MCO's voluntary assignments.
(d) Prohibition or reduction of
			 
										the
			 MCO's involuntary assignments.
(e) Granting the MCO's members
			 the right to terminate without cause and notifying the affected members of
			 their right to disenroll.
(f)
			 Retention by ODM of 
										the MCO's premium payments or a portion thereof
			 until the violations or deficiencies are corrected.
(g) Imposition of financial
			 sanctions.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-26 - Managed Care Plan › Section 5160-26-11 - Managed care: non-contracting providers

Current through all regulations passed and filed through July 1, 2024
(A)
								Non-contracting providers of emergency services must
			 accept as payment in full from 
								a
								
								managed care organization (MCO) the lesser of
			 billed charges or one hundred per cent of the Ohio medicaid program
			 reimbursement rate (less any payments for indirect costs of medical education
			 and direct costs of graduate medical education that is included in the Ohio
			 medicaid program reimbursement rate) in effect for the date of service.
			 Pursuant to section 
									5167.101
								 of the Revised Code, the 
								MCO shall not compensate a hospital for inpatient
			 capital costs in an amount that exceeds the maximum rate established by
			 ODM.
(B) When ODM has
			 approved 
								the MCO's members to be referred to
			 
								a
			 non-contracting hospital pursuant to rule
			 5160-26-03
			 of the Administrative Code, the 
			 non-contracting hospital must provide the service for which the referral was
			 authorized and must accept as payment in full from the
			 MCO one
			 hundred per cent of the current Ohio medicaid program reimbursement rate in
			 effect for the date of service. Pursuant to section 
									5167.101
								 of the Revised Code, the MCO shall not compensate a hospital for inpatient
			 capital costs in an amount that exceeds the maximum rate established by ODM.
			 Non-contracting hospitals are exempted from this
			 provision when:
(1) The hospital is located in
			 a county in which eligible individuals were required to enroll in an
			 MCO prior
			 to January 1, 2006;
(2) The
			 hospital is contracted with at least one MCO serving the
			 eligible individuals specified in paragraph (B)(1) of this
			 rule prior to January 1, 2006; and
(3) The hospital remains contracted with at
			 least one MCO serving eligible individuals who are required to
			 enroll in an MCO in the service area where the hospital is
			 located.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-26 - Managed Care Plan › Section 5160-26-12 - Managed care: member co-payments

Current through all regulations passed and filed through July 1, 2024
(A) This rule does not apply to MyCare Ohio
			 plans as defined in rule
			 5160-58-01 of the Administrative
			 Code or the Ohio resilience through integrated systems and excellence
			 (OhioRISE) plan as defined in rule
			 5160-59-01 of the Administrative
			 Code.
(B) The managed care
			 organization (MCO) may elect to implement a member co-payment program pursuant
			 to section 5162.20 of the Revised Code for
			 dental services, vision services, or non-emergency emergency department
			 services or until implementation of the single pharmacy benefit manager (SPBM),
			 prescription drugs as provided for in this rule. The MCO must receive prior
			 approval from the Ohio department of medicaid (ODM) before notifying members
			 that a co-payment program will be implemented.
(C) Upon implementation of the SPBM, the SPBM
			 may only elect to implement a member co-payment program pursuant to section
			 5162.20 of the Revised Code for
			 prescription drugs as provided for in this rule if directed to by
			 ODM.
(D) If the MCO or SPBM
			 implements a member co-payment program, the MCO and SPBM must:
(1) Exclude the populations and services set
			 forth in paragraph (E) of this rule;
(2) Not deny services to members as specified
			 in paragraph (F) of this rule;
(3)
			 Not impose co-payment amounts in excess of the maximum amounts specified in
			 42 C.F.R.
			 447.54 (October 1, 2021);
(4) Specify in provider contracts governed by
			 rule 5160-26-05 of the Administrative
			 Code the circumstances under which member co-payment amounts can be requested.
			 If the MCO or SPBM implements a co-payment program, no provider can waive a
			 member's obligation to pay the provider a co-payment except as described in
			 paragraph (I) of this rule;
(5)
			 Ensure that the member is not billed for any difference between the MCO or
			 SPBM's payment and the provider's charge or request that the member share in
			 the cost through co-payment or other similar charge, other than medicaid
			 copayments as defined in this rule;
(6) Ensure that member co-payment amounts are
			 requested by providers in accordance with this rule; and
(7) Ensure that no provider or drug
			 manufacturer, including the manufacturer's representative, employee,
			 independent contractor, or agent shall pay any copayment on behalf of the
			 member.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-26 - Managed Care Plan › Section 5160-26-13 - Managed health care programs: claim billing for pharmaceuticals

Current through all regulations passed and filed through July 1, 2024
Upon implementation of the Ohio
				department of medicaid's (ODM) single pharmacy benefit manager (SPBM), ODM or
				its designees will accept provider claim submissions for pharmaceuticals
				through ODM's managed care entities (MCEs) in the following
				manner:
(A)
								Claims for pharmaceuticals that are dispensed by
			 pharmacy providers are billed through ODM's SPBM.
(B)
								For all other
			 provider types, claims for pharmaceuticals are billed through an MCO, or in
			 accordance with rule 5160-59-03 of the Administrative Code for individuals
			 enrolled in the OhioRISE plan, as applicable.
(C)
								This rule does
			 not apply to "MyCare Ohio" plans as defined in rule
			 5160-58-01
			 of the Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-27 - Community Mental Health Agency Services › Section 5160-27-02 - Coverage and limitations of behavioral health services

Current through all regulations passed and filed through July 1, 2024
(A) This rule sets
			 forth coverage and limitations for behavioral health services rendered to
			 medicaid recipients by behavioral health provider agencies who meet all
			 requirements found in agency 5160 of the Administrative Code unless otherwise
			 specified.
(1) All claims for behavioral
			 health services submitted to the Ohio department of medicaid (ODM) must include
			 an ICD-10 diagnosis of mental illness or substance use disorder. The list of
			 recognized diagnoses can be accessed at
www.medicaid.ohio.gov
.
(2) Medicaid reimbursable behavioral health
			 services are limited to medically necessary services defined in rule
			 5160-8-05
			 of the Administrative Code and Chapter 5160-27 of the Administrative Code.
			 Providers shall follow the requirements in rule
			 5160-8-05
			 of the Administrative Code and Chapter 5160-27 of the Administrative Code
			 regarding services that cannot be billed in combination with other
			 services.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-27 - Community Mental Health Agency Services › Section 5160-27-03 - Reimbursement for community behavioral health services

Current through all regulations passed and filed through July 1, 2024
(A) This rule sets
			 forth the reimbursement requirements and rates for behavioral health services
			 as described in Chapter 5160-27 of the Administrative Code and applies to
			 providers as described in rule
			 5160-27-01 of the Administrative
			 Code.
(B) With the exception
			 of pharmacists as described in paragraph (A)(7) of rule
			 5160-27-01 of the Administrative
			 Code, medicaid reimbursement rates for services and practitioners described in
			 Chapter 5160-27 of the Administrative
			 Code are listed in the appendix to this rule. Ohio medicaid will reimburse the
			 provider the lower of either their usual and customary charges or the
			 reimbursement amount described in the appendix to this rule.
			 Practitioner-specific reimbursement rates that are not otherwise stated in the
			 appendix to this rule are determined by paragraphs (B)(1) to (B)(5) of this
			 rule.
(1) The reimbursement rate for
			 physicians, as described in paragraph (A)(3) of rule
			 5160-27-01 of the Administrative
			 Code, is one hundred per cent of the medicaid maximum rate stated in the
			 appendix to this rule.
(2) The
			 reimbursement rate for clinical nurse specialists, certified nurse
			 practitioners, and physician assistants, as described in paragraph (A)(3) of
			 rule 5160-27-01 of the Administrative
			 Code, is eighty-five per cent of the medicaid maximum rate stated in the
			 appendix to this rule; except for evaluation and management office/outpatient
			 visits, psychiatric diagnostic evaluations, and smoking and tobacco cessation
			 counseling the reimbursement rate is one hundred per cent of the medicaid
			 maximum rate stated in the appendix to this rule.
(3) The reimbursement rate for practitioners
			 described in paragraph (A)(5) of rule
			 5160-27-01 of the Administrative
			 Code is the reimbursement rate percentage described in rule
			 5160-8-05 of the Administrative
			 Code (medicaid maximum rate stated in the appendix to this rule). The
			 reimbursement rates for services not defined in rule
			 5160-8-05 of the Administrative
			 Code are stated in the appendix to this rule.
(4) The reimbursement rates for practitioners
			 described in rule
			 5160-27-01 of the Administrative
			 Code and not otherwise addressed in paragraph 
									(B) of this rule,
			 are stated in the appendix to this rule.
(5) The reimbursement rate for pharmacists as
			 described in paragraph (A)(7) of rule
			 5160-27-01 of the Administrative
			 Code is set forth in rule
			 5160-8-52 of the Administrative
			 Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-27 - Community Mental Health Agency Services › Section 5160-27-04 - Mental health assertive community treatment service

Current through all regulations passed and filed through July 1, 2024
(A) For the purposes of medicaid
			 reimbursement, assertive community treatment (ACT) refers to the evidence based
			 model of delivering comprehensive community based behavioral health services to
			 adults with certain serious and persistent mental illnesses who have not
			 benefited from traditional outpatient treatment. The ACT model utilizes a
			 multidisciplinary team of practitioners to deliver services to eligible
			 individuals.
(B) For the purposes
			 of this rule, collateral contact occurs when the practitioner contacts
			 individuals who play a significant role in a medicaid recipient's life. The
			 information gained from the collateral contact can provide insight into
			 treatment or the basic psychoeducation provided to that collateral contact can
			 assist with the treatment of the medicaid recipient.
(C) The ACT team is the sole provider to ACT
			 recipients of outpatient behavioral health services, including level one
			 outpatient services as defined by the American society of addiction
			 medicine.
(D) ACT services include
			 but are not limited to the following:
(1)
			 Psychiatry and primary care as related to the mental health or substance use
			 disorder diagnoses;
(2) Service
			 coordination;
(3) Crisis assessment
			 and intervention;
(4) Symptom
			 assessment and management;
(5)
			 Community based rehabilitative services;
(6) Education, support, and consultation to
			 families, legal custodians, and significant others who are part of the
			 recipient's support network.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-27 - Community Mental Health Agency Services › Section 5160-27-06 - Therapeutic behavioral group service-hourly and per diem

Current through all regulations passed and filed through July 1, 2024
(A) For the purpose
			 of medicaid reimbursement, therapeutic behavioral (day treatment), group
			 service-hourly and per diem, is defined as an intensive, structured,
			 goal-oriented, distinct and identifiable group treatment service that addresses
			 the individualized mental health needs of the client. The therapeutic
			 behavioral group service-hourly and per diem is clinically indicated by
			 assessment. The environment at this level of treatment is highly structured,
			 and has an appropriate staff-to-client ratio to guarantee sufficient
			 therapeutic services and professional monitoring, control, and protection. The
			 purpose and intent of therapeutic behavioral group service-hourly and per diem
			 is to stabilize, increase or sustain the highest level of functioning.
(1) Therapeutic behavioral group
			 service-hourly and per diem must be a group treatment service that includes but
			 is not limited to the following:
(a) Skills
			 development of interpersonal and social competency, problem solving, conflict
			 resolution, and emotions/behavior management,
(b) Developing of positive coping
			 mechanisms,
(c) Managing mental
			 health and behavioral symptoms to enhance independent living, and
(d) Psychoeducational services including
			 instruction and training of persons served in order to increase their knowledge
			 and understanding of their psychiatric diagnosis(es), prognosis(es), treatment,
			 and rehabilitation in order to enhance their acceptance, increase their
			 cooperation and collaboration with treatment and rehabilitation, and favorably
			 affect their outcomes.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-27 - Community Mental Health Agency Services › Section 5160-27-08 - Mental health therapeutic behavioral services and psychosocial rehabilitation

Current through all regulations passed and filed through July 1, 2024
(A) For the
			 purposes of medicaid reimbursement, therapeutic behavioral services (TBS) are
			 goal-directed supports and solution-focused interventions.
(1) Activities included must be intended to
			 achieve the identified goals or objectives as set forth in the individual's
			 treatment plan. Activities include but are not limited to the following:
(a) Treatment planning. Participating in and
			 utilizing strengths based treatments/planning which may include assisting the
			 individual and family members or other collaterals with identifying strengths
			 and needs.
(b) Identification of
			 strategies or treatment options. Assisting the individual and family members or
			 other collaterals to identify strategies or treatment options associated with
			 the individual's mental illness.
(c) Developing and providing solution focused
			 interventions and emotional and behavioral management drawn from evidence-based
			 psychotherapeutic treatments.
(d)
			 Restoration of social skills. Rehabilitation and support with the restoration
			 of social and interpersonal skills to increase community tenure, enhance
			 personal relationships, establish support networks, increase community
			 awareness, develop coping strategies, and promote effective functioning in the
			 individual's social environment including home, work and school.
(e) Restoration of daily functioning.
			 Assisting the individual to restore daily functioning specific to managing
			 their own home including managing their money, medications, and using community
			 resources and other selfcare requirements; and
(f) Crisis prevention and amelioration.
			 Assisting the individual with effectively responding to or avoiding identified
			 precursors or triggers that would risk their remaining in a community setting
			 or that result in functional impairments.
										Activities may
			 include,
										but not be limited to, assisting the individual
			 and family members or other collaterals with identifying a potential
			 psychiatric or personal crisis, developing a crisis management plan, and/or, as
			 appropriate, seeking other supports to restore stability and
			 functioning.