reglab/statecodes huggingface dataset:
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-27 - Community Mental Health Agency Services › Section 5160-27-09 - Substance use disorder treatment services

Current through all regulations passed and filed through July 1, 2024
(A)
								For the purpose
			 of medicaid reimbursement, substance use disorder treatment services shall be
			 defined by and shall be provided according to the American society of addiction
			 medicine also known as the ASAM treatment criteria for addictive, substance
			 related and co-occurring conditions for admission, continued stay, discharge,
			 or referral to each level of care (LOC).
(B)
								Medicaid will
			 reimburse for the services provided under the following ASAM levels of
			 care:
(1)
									LOC
			 1: outpatient services. LOC 1 services are designed to treat the recipient's
			 level of clinical severity and function. These services may be delivered in a
			 variety of settings. Addiction, mental health, or general health care treatment
			 personnel provide professionally directed screening, evaluation, treatment, and
			 ongoing recovery and disease management services. Such services are provided in
			 regularly scheduled sessions and follow a defined set of policies and
			 procedures or medical protocols. Service provision is limited to less than nine
			 hours per week for adults and less than six hours per week for
			 adolescents.
(2)
									LOC 2: intensive outpatient/partial hospitalization
			 including LOC 2 withdrawal management (WM). LOC 2 services are capable of
			 meeting the complex needs of people with addiction and co-occurring conditions.
			 They can be rendered during the day, before or after work or school, in the
			 evening, and/or on weekends.
(3)
									LOC 3:
			 residential services/inpatient services including LOC 3 WM. These services are
			 co-occurring capable, co-occurring enhanced, and complexity capable in nature
			 and provided by addiction treatment, mental health and general medical
			 personnel in a twenty four hour treatment setting. Services are provided in
			 Ohio department of mental health and addiction services certified permanent
			 facilities which are staffed twenty four hours a day. The following services
			 are included in the residential treatment service and will not be reimbursed
			 separately:
(a)
										Ongoing assessments and diagnostic
			 evaluations.
(b)
										Crisis intervention.
(c)
										Individual,
			 group, family psychotherapy and counseling.
(d)
										Case
			 management.
(e)
										Substance use disorder peer recovery
			 services.
(f)
										Urine drug screens.
(g)
										Medical
			 services.
(4)
									The following services are considered non-covered for
			 individuals in residential treatment:
(a)
										Therapeutic
			 behavioral services.
(b)
										Psychosocial rehabilitation.
(c)
										Community
			 psychiatric supportive treatment.
(d)
										Mental health day
			 treatment.
(e)
										Assertive community treatment.
(f)
										Intensive home
			 based treatment.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-27 - Community Mental Health Agency Services › Section 5160-27-10 - Substance use disorder targeted case management

Current through all regulations passed and filed through July 1, 2024
(A)
								Targeted case
			 management assists an individual within the eligible target population to gain
			 access to needed medical, social, educational and other services.
(1)
									Targeted case
			 management services shall include, at a minimum, the following
			 activities:
(a)
										Comprehensive assessment and periodic reassessment of
			 individual needs to determine the need for any medical, educational, social or
			 other services. Assessment activities include taking client history;
			 identifying the individual's needs and completing related documentation and
			 gathering information from other sources such as family members, medical
			 providers, social workers and educators to form a complete assessment of the
			 eligible individual.
(b)
										Development and periodic revision of a specific care
			 plan that is based on the information gathered through the assessment. The care
			 plan must include the following requirements:
(i)
											Goals and actions
			 to address the medical, social, educational and other services needed by the
			 individual; and
(ii)
											A plan to ensure the active participation of the
			 eligible individual and or their authorized health care decision maker;
			 and
(iii)
											A course of action to respond to the assessed needs of
			 the eligible individual.
(c)
										Referral and
			 related activities to help the eligible individual obtain needed
			 services
(d) 
										Monitoring and follow-up activities or contacts that
			 are necessary to ensure that the care plan is implemented and adequately
			 addresses the eligible individual's needs. Changes in needs or status must be
			 reflected in the care plan. Monitoring shall be performed no less frequently
			 than annually. Monitoring may be performed in person or by electronic
			 communication.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-27 - Community Mental Health Agency Services › Section 5160-27-11 - Behavioral health nursing services

Current through all regulations passed and filed through July 1, 2024
(A)
								Behavioral health
			 nursing services are mental health and substance use disorder (SUD) nursing
			 services performed by registered nurses or licensed practical nurses. They
			 include those activities that are performed within professional scope of
			 practice and in authorized settings by staff that are licensed by the Ohio
			 board of nursing and are intended to address the behavioral and other physical
			 health needs of individuals receiving treatment for psychiatric symptoms or
			 substance use disorders.
(B)
								Activities may include but are not limited to
			 performance of the following:
(1)
									Health care screenings
(2)
									Nursing
			 assessments
(3)
									Nursing exams
(4)
									Checking vital
			 signs
(5)
									Monitoring the effects of medication
(6)
									Monitoring
			 symptoms
(7)
									Behavioral health education
(8)
									Collaboration
			 with the individual and/or family as clinically indicated
(9)
									Group nursing
			 services
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-27 - Community Mental Health Agency Services › Section 5160-27-12 - Behavioral health crisis intervention provided by unlicensed practitioners

Current through all regulations passed and filed through July 1, 2024
(A) For the purpose
			 of medicaid reimbursement, behavioral health crisis intervention is a timely
			  intervention with medicaid
			 recipients who are experiencing a life threatening or complex emergent
			 situation related to mental illness or a substance use disorder.
(1) The goals of crisis intervention are to
			 ease the crisis, re-establish safety and institute interventions to minimize
			 psychological trauma.
(2)
			 Activities may include but are not limited to: emergent care, assessment,
			 immediate stabilization, de-escalation, counseling, care planning and
			 resolution.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-27 - Community Mental Health Agency Services › Section 5160-27-13 - Mobile response and stabilization service

Current through all regulations passed and filed through July 1, 2024
(A)
								For the purposes
			 of this rule, mobile response and stabilization service (MRSS), is the service
			 as set forth by the Ohio department of mental health and addiction services
			 (OhioMHAS) in rule
			 5122-29-14 of the
			 Administrative Code.
(B)
								Eligible providers.
(1)
									 Providers
			 certified by OhioMHAS in accordance with rule
			 5122-29-14 of the
			 Administrative Code are eligible for MRSS reimbursement.
(2)
									Services rendered
			 by MRSS team staff described in rule
			 5122-29-14 of the
			 Administrative Code that are eligible providers of behavioral health services
			 in accordance with rule
			 5160-27-01
			 of the Administrative Code are reimbursable.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-28 - Cost-Based Clinic (FQHC, OHF, RHC) Services › Section 5160-28-01 - Federally qualified health center (FQHC) and rural health clinic (RHC) services: definitions and explanations

Current through all regulations passed and filed through July 1, 2024
(A)
								"Change in scope
			 of service" is an alteration in aspects of a prospective payment system (PPS)
			 service such as the procedures or items that are furnished, the frequency with
			 which they are furnished, and the type of personnel who furnish them.
(1)
									A change in scope
			 of service is characterized by such factors as are specified in the following
			 non-exhaustive list:
(a)
										The addition or discontinuation of a PPS
			 service;
(b)
										The addition or discontinuation of a procedure or class
			 of procedures within a PPS service that involves the skills and training of a
			 higher-level practitioner, such as the expansion of PPS medical service to
			 include obstetrical-gynecological care provided by a physician or advanced
			 practice registered nurse or the provision of a full range of dental procedures
			 performed by a licensed dentist where previously only the services of a dental
			 hygienist had been available; or
(c)
										A change in the
			 distribution of procedures within a PPS service that materially affects the
			 allocation of resources to that PPS service, such as a change in a medical
			 service "case mix" from eighty per cent family practice and twenty per cent
			 obstetrical-gynecological care to forty per cent family practice and sixty per
			 cent obstetrical-gynecological care.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-28 - Cost-Based Clinic (FQHC, OHF, RHC) Services › Section 5160-28-02 - FQHC and RHC services: conditions affecting medicaid provider participation

Current through all regulations passed and filed through July 1, 2024
(A)
								Unless otherwise noted, any stipulations or limitations
			 specified in the Revised Code or in agency 5160 of the Administrative Code
			 apply to services rendered by a federally qualified health center (FQHC) or
			 rural health clinic (RHC). Provisions of other rules in agency 5160 of the
			 Administrative Code that concern coordination of benefits apply to payment for
			 FQHC and RHC services.
(B)
								Responsibilities of an FQHC.
(1)
									 When it enrolls
			 or changes its enrollment (e.g., adds a service), an FQHC submits to the Ohio
			 department of medicaid (ODM) a copy of a notice of authorization or notice of
			 look-alike designation it has received from the federal health resources and
			 services administration (HRSA). In particular, two pieces of documentation are
			 needed:
(a)
										Confirmation that the FQHC satisfies HRSA criteria for
			 providing the PPS services it plans to render (either new services or services
			 added through a change in scope); and
(b)
										A list of the
			 services approved by HRSA for the FQHC to perform at any of its
			 sites.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-28 - Cost-Based Clinic (FQHC, OHF, RHC) Services › Section 5160-28-03 - FQHC and RHC services: covered services, limitations, and copayments

Current through all regulations passed and filed through July 1, 2024
(A)
								A federally qualified health center (FQHC) may receive
			 prospective payment system (PPS) payment for providing any of the following
			 FQHC PPS services:
(1)
									In accordance with section 330 of the Public Health
			 Services Act, 42 U.S.C. chapter 6A (October 1, 2021), medical services, which
			 comprise any of four types of services:
(a)
										Services
			 referenced at
			 42
			 U.S.C. 1395x(aa)(3) (October
			 1, 2021), including but not limited to an evaluation and management (E&M)
			 service, another medical or surgical procedure, or the administration of a
			 vaccine or other provider-administered pharmaceutical;
(b)
										Professional
			 services (including the administration of a vaccine) furnished by a qualified
			 healthcare practitioner (physician, physician assistant, advanced practice
			 registered nurse, dietitian, pharmacist, registered nurse working under
			 supervision), along with any services or supplies furnished incident to the
			 professional services on the same date;
(c)
										Professional
			 services and related supplies provided at a later date as necessary follow-up
			 to a medical services visit, even if the same services and supplies were also
			 provided as part of (or incident to) the original medical services visit;
			 or
(d)
										Visiting nurse services if the following three
			 conditions are satisfied:
(i)
											The services are furnished by either a registered nurse
			 or a licensed practical nurse employed by or under contract with the
			 FQHC;
(ii)
											The FQHC is located in an area determined by the
			 centers for medicare and medicaid services (CMS) to have a shortage of home
			 health agencies; and
(iii)
											The services are furnished under a written plan of
			 treatment that is established by a physician, physician assistant, or advanced
			 practice registered nurse or by a supervising physician of the FQHC; is signed
			 by a physician, physician assistant, or advanced practice registered nurse or
			 by a supervising physician of the FQHC; and is reviewed at least every sixty
			 days by a supervising physician of the FQHC.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-28 - Cost-Based Clinic (FQHC, OHF, RHC) Services › Section 5160-28-04 - FQHC and RHC services: submission of a cost report

Current through all regulations passed and filed through July 1, 2024
(A)
								Data entered into
			 a cost report should represent "reasonable and allowable costs," which are
			 defined in "Principles of reasonable cost reimbursement," 42 C.F.R. part 413
			 (October 1, 2021).
(B)
								For purposes of payment determination, an FQHC or RHC
			 submits a cost report in any of the following circumstances:
(1)
									An FQHC or RHC
			 that is newly enrolled as a medicaid provider submits a cost report covering
			 the twelve-month period beginning either on the first day of the first calendar
			 month or on the first day of the first full fiscal year after
			 enrollment.
(2)
									An FQHC or RHC that requests an adjustment of a
			 per-visit payment amount (PVPA) based on a change in scope of an existing FQHC
			 or RHC PPS service submits a cost report for that service covering the
			 twelve-month period beginning either on the first day of the first calendar
			 month or on the first day of the first full fiscal year after the change in
			 scope. If the adjustment is granted, the PVPA derived from the cost report
			 becomes the new PVPA.
(3)
									An FQHC or RHC that has chosen to provide an additional
			 PPS service (other than transportation) submits a cost report for that service
			 covering the twelvemonth period beginning either on the first day of the first
			 calendar month or on the first day of the first full fiscal year after addition
			 of the service.
(4)
									A government-operated FQHC that requests the alternate
			 payment method (APM) described in rule 5160-28-07.1 of the Administrative Code
			 submits cost reports in accordance with that rule.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-28 - Cost-Based Clinic (FQHC, OHF, RHC) Services › Section 5160-28-06.1 - Federally qualified health center (FQHC) and rural health clinic (RHC) services: constraints on a per-visit payment amount (PVPA) for an FQHC perspective payment system (PPS) service

Current through all regulations passed and filed through July 1, 2024
(A) Allowable costs are calculated in
			 accordance with the instructions for the  FQHC
			 cost report. Certain restrictions apply:
(1)
			 Costs related to direct inpatient care are not allowable.
(2) Procedures or items that are not PPS
			 services are not allowable.
(3) The
			 straight-line method of computing depreciation is used for all depreciable
			 assets.
(4) The cost claimed for
			 services, facilities, and supplies furnished by a related organization cannot
			 exceed the lesser of two figures:
(a) The cost
			 to the related organization; or
(b)
			 The price of comparable services, facilities, or supplies that are generally
			 available in the competitive marketplace.
(5) Total allowable administrative and
			 general overhead costs cannot exceed thirty-five per cent of the costs of the
			 services to which they are applied. Of these costs, not more than thirty
			 thousand dollars are allowable annually as recruitment cost incurred by a
			 provider of FQHC medical service.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-28 - Cost-Based Clinic (FQHC, OHF, RHC) Services › Section 5160-28-06.2 - Cost-based clinics: determination of a PVPA for an OHF service on the basis of a medicaid cost report

Current through all regulations passed and filed through July 1, 2024
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-28 - Cost-Based Clinic (FQHC, OHF, RHC) Services › Section 5160-28-07.1 - Federally qualified health center (FQHC) and rural health clinic (RHC) services: alternate payment method (APM) for determining additional payment for government-operated FQHCs

Current through all regulations passed and filed through July 1, 2024
(A) This rule describes an
			  APM that may be selected, with approval from the Ohio
			 department of medicaid (ODM), by a government-operated
			 
			 FQHC such as a public health department.
			 Under this APM, a government-operated FQHC may receive payment in addition to
			 amounts established under the prospective payment system (PPS) method described
			 in rule 5160-28-05 of the Administrative
			 Code. To qualify for additional payment under this APM, a government-operated
			 FQHC site submits  a fully audited cost report for 
								each
			 cost-reporting period. The government-operated FQHC may
			 also submit an optional preliminary cost report for a cost-reporting
			 period. For purposes of this rule, a cost-reporting period is the fiscal
			 year used by the government-operated FQHC. For a government-operated FQHC that
			 has newly selected the APM, ODM may agree to an initial cost-reporting period
			 covering not less than six months nor more than seventeen months.
(B) The APM involves
			 
								the
			 following steps:
(1) Submission of
			 
									at least
			 one cost report each cost-reporting period.
(a)
										Within one
			 hundred twenty days after the close of a cost-reporting period, the
			 government-operated FQHC site may submit an optional preliminary cost report of
			 all PPS services rendered during that cost-reporting period.
(b)
										Within
			 five-hundred days after the close of a cost-reporting period, the
			 government-operated FQHC site submits a fully audited cost report.
			 Government-operated FQHC sites of the same parent organization compile and
			 submit separate cost reports. When it submits a cost report, a
			 government-operated FQHC site certifies that its costs were an expenditure of
			 public funds not derived from a federal funding source and not otherwise used
			 as a state or local match for federal funds.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-28 - Cost-Based Clinic (FQHC, OHF, RHC) Services › Section 5160-28-09 - Federally qualified health centers (FQHCs): prospective payment system (PPS) rate review for change in scope of service

Current through all regulations passed and filed through July 1, 2024
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-28 - Cost-Based Clinic (FQHC, OHF, RHC) Services › Section 5160-28-12 - Establishment of a per-visit payment amount (PVPA) derived from a cost report submitted by a federally qualified health center (FQHC) or rural health clinic (RHC) site affected by a public health emergency (PHE) declaration

Current through all regulations passed and filed through July 1, 2024
(A)
								The purpose of this rule is to allow a change to the
			 time period of a cost report from which per-visit payment amounts (PVPAs) are
			 derived. This rule applies to cost report time periods affected by a nationwide
			 federal or Ohio public health emergency (PHE) declaration.
(B)
								This rule applies
			 to a cost report prepared by an individual federally qualified health center
			 (FQHC) or rural health clinic (RHC) site in accordance with this chapter of the
			 Administrative Code for one of the following reasons:
(1)
									The FQHC or RHC
			 is newly enrolled as a medicaid provider; or
(2)
									The FQHC or RHC
			 plans to request the establishment or adjustment of a PVPA based on a change in
			 scope of a prospective payment system (PPS) service.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-31 - Medicaid Home and Community Based Services Waiver Portion of the PASSPORT Program › Section 5160-31-04 - Enrollment process for PASSPORT HCBS waiver program

Current through all regulations passed and filed through July 1, 2024
(A)
								The Ohio department of aging (ODA) is responsible for
			 the daily operation of the pre-admission screening system providing options and
			 resources today (PASSPORT) home and community- based services (HCBS) waiver.
			 ODA will operate this waiver pursuant to an interagency agreement with the Ohio
			 department of medicaid (ODM) in accordance with sections
			 5162.35 and
			 5166.21 of the Revised Code. ODA
			 will establish processes and procedures to enroll individuals on this
			 waiver.
(B)
								Individuals who wish to enroll in PASSPORT must have
			 his/her medicaid eligibility determination made by ODM's administrative agency
			 and an assessment of his/her PASSPORT eligibility made by ODA's
			 designee.
(C)
								If the individual has been determined eligible and a
			 waiver slot is available, the individual shall be enrolled in accordance with
			 the PASSPORT HCBS waiver program's home first component, if applicable, and
			 rule
			 173-42-03
			 of the Administrative Code.
(D)
								ODA's designee
			 shall make the determination of PASSPORT eligibility using the requirements set
			 forth in rule
			 5160-31-03
			 of the Administrative Code. .
(E)
								Any applicant for
			 PASSPORT HCBS waiver program services is entitled to notice and hearing rights
			 as set forth in section
			 5101.35 of the Revised Code and
			 division 5101:6 of the Administrative Code.
Replaces: 5160-31-04
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-31 - Medicaid Home and Community Based Services Waiver Portion of the PASSPORT Program › Section 5160-31-05 - PASSPORT HCBS waiver program covered services

Current through all regulations passed and filed through July 1, 2024
(A) The purpose of this rule is to establish
			 the services covered by the pre-admission screening system providing options
			 and resources today (PASSPORT) home and community based services (HCBS)
			 program.
(B) The PASSPORT program
			 benefit package is limited to the following services:
(1) Adult day as set forth in rule
			 173-39-02.1 of the Administrative
			 Code;
(2) Alternative meals as set
			 forth in rule
			 173-39-02.2 of the Administrative
			 Code;
(3) Choices home care
			 attendant as set forth in rule
			 173-39-02.4 of the Administrative
			 Code;
(4) Community integration as
			 set forth in rule
			 173-39-02.15 of the
			 Administrative Code;
(5) Community
			 transition as set forth in rule
			 173-39-02.17 of the
			 Administrative Code;
(6) Enhanced
			 community living as set forth in rule
			 173-39-02.20 of the
			 Administrative Code;
(7) Homemaker
			 as set forth in rule
			 173-39-02.8 of the Administrative
			 Code;
(8) Home care attendant as
			 set forth in rule
			 173-39-02.24 of the
			 Administrative Code;
(9) Home
			 delivered meals as set forth in rule
			 173-39-02.14 of the
			 Administrative Code;
(10) Home
			 maintenance and chore as set forth in rule
			 173-39-02.5 of the
			 
									Administrative Code;
(11) Home medical equipment and supplies as
			 set forth in rule
			 173-39-02.7 of the Administrative
			 Code;
(12)
									 Home modification as set forth in rule
			 173-39-02.9 of the Administrative
			 Code;
(13) Non-medical
			 transportation as set forth in rule
			 173-39-02.18 of the
			 Administrative Code;
(14) Nutrition
			 consultation as set forth in rule
			 173-39-02.10 of the
			 Administrative Code;
(15) Out-of-home
			 respite as set forth in rule
			 173-39-02.23 of the
			 Administrative Code;
(16) Personal care as
			 set forth in rule
			 173-39-02.11 of the
			 Administrative Code;
(17) Personal
			 emergency response system as set forth in rule
			 173-39-02.6 of the Administrative
			 Code;
(18) Social work
			 or counseling as set forth in rule
			 173-39-02.12 of the
			 Administrative Code; and
(19) Waiver nursing as
			 set forth in rule
			 173-39-02.22 of the
			 Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-31 - Medicaid Home and Community Based Services Waiver Portion of the PASSPORT Program › Section 5160-31-06 - Provider conditions of participation for the PASSPORT HCBS waiver program

Current through all regulations passed and filed through July 1, 2024
(A) The purpose of this rule is to establish
			 the conditions under which providers are able to participate in the
			 preadmission screening system providing options and resources today (PASSPORT)
			 home and community based services (HCBS) waiver program.
(B) In order to obtain a medicaid provider
			 agreement to be a PASSPORT provider furnishing services in rule
			 5160-31-05
			 of the Administrative Code the provider shall be certified by the Ohio
			 department of aging (ODA) in accordance with the provisions of Chapter 173-39
			 of the Administrative Code.
(C)
			 Individuals enrolled in the PASSPORT HCBS waiver shall be given a free choice
			 of qualified providers in accordance with rule
			 173-42-06
			 of the Administrative Code.
(D)
								ODA is authorized to deem any provider approved by the
			 Ohio department of medicaid (ODM) or certified by the Ohio department of
			 developmental disabilities (DODD) to provide waiver services as having
			 satisfied the requirements for certification by ODA for the same or similar
			 services.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-31 - Medicaid Home and Community Based Services Waiver Portion of the PASSPORT Program › Section 5160-31-07 - PASSPORT HCBS waiver program rate setting

Current through all regulations passed and filed through July 1, 2024
The purpose of this rule is to describe the methods used to
				determine provider rates for the pre-admission
				screening system providing options and resources today ( PASSPORT) program.
(A) Rates determined under this rule shall
			 not exceed the maximum allowable rates for PASSPORT services in appendix A to
			 rule 5160-1-06.1 of the
			 Administrative Code. Payment for PASSPORT waiver services constitutes payment
			 in full and shall not be construed as a partial payment when the payment amount
			 is less than the provider's usual and customary rate. The provider shall not
			 bill the individual for any difference between the medicaid payment and the
			 provider's rate or request the individual to share in the cost through a
			 co-payment or other similar charge.
(B) PASSPORT rates are established for the
			 services in rule
			 5160-31-05 of the Administrative
			 Code under the following categories:
(1)
			 Per-job bid rate;
(2) Per-item
			 rate; and
(3) Unit rate.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-32 - Choices Program › Section 5160-32-01 - Electronic visit verification (EVV) program

Current through all regulations passed and filed through July 1, 2024
(A)
								This rule
			 establishes Ohio medicaid programs and program services subject to
			 participation in the EVV program, required under Section 1903 of the Social
			 Security Act (42 U.S.C.
			 1396b) as in effect on the effective date of
			 this rule.
(B)
								For purposes of this chapter, EVV is the use of
			 technology to verify certain data elements related to the delivery of
			 medicaid-covered services.
(C)
								Ohio medicaid
			 services subject to the EVV program include any medicaid state plan or 1915 (c)
			 home and community-based services (HCBS) waiver program meeting the following
			 criteria:
(1)
									
			 Service definition includes one of the following:
(a)
										Assistance with
			 activities of daily living, as described in rule
			 5160-3-05 of the Administrative
			 Code; or
(b)
										Includes activities provided by a licensed healthcare
			 professional; and
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-32 - Choices Program › Section 5160-32-02 - Electronic visit verification (EVV) data collection

Current through all regulations passed and filed through July 1, 2024
(A)
								The Ohio department of medicaid (ODM) EVV system
			 collects and maintains data for medicaid programs and services subject to
			 participation in the EVV program.
(B)
								Data collection
			 method option:
(1)
									Application installed on one of the following
			 devices:
(a)
										An
			 electronic device provided by ODM that is available at no cost to the service
			 provider. ODM's contracted entity is responsible for electronic device
			 distribution, collection, and ongoing maintenance activities.
(b)
										A mobile
			 electronic device owned by the service provider or direct care worker.
(i)
											ODM is not
			 responsible for any costs incurred.
(ii)
											Data services
			 connected to the service provider or direct care worker owned device will be
			 used to transmit visit data from the application to the data aggregator in near
			 real time.
(iii)
											The device used with the application will comply with
			 device qualifications found at
https://medicaid.ohio.gov/resources-for-providers/special-programs-and-initiatives/electronic-visit-verification
.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-32 - Choices Program › Section 5160-32-03 - Alternate electronic visit verification (EVV) vendor

Current through all regulations passed and filed through July 1, 2024
(A)
								An alternate EVV vendor may be used for EVV data
			 collection.
(B)
								The state is not responsible for any costs related to
			 the development, approval, testing, and utilization of a qualifying alternate
			 EVV vendor.
(C)
								To use an alternate EVV vendor, agency providers
			 should:
(1)
									Notify the Ohio department of medicaid (ODM) or its
			 contracted entity of the intent to seek ODM approval to utilize the selected
			 alternate EVV vendor; and
(2)
									Complete alternate system aggregator
			 training.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-32 - Choices Program › Section 5160-32-04 - Electronic visit verification (EVV) program providers

Current through all regulations passed and filed through July 1, 2024
(A)
								This rule establishes Ohio medicaid service provider
			 requirements for services subject to EVV as described in rule 5160-32-01 of the
			 Administrative Code.
(B)
								All providers and financial management service vendors
			 will:
(1)
									Complete initial and ongoing training per Ohio department of
			 medicaid (ODM) instructions published on the ODM website
https://medicaid.ohio.gov/resources-for-providers/special-programs-and-initiatives
.
(2)
									Create and maintain updated and accurate records of
			 individuals receiving EVV subject services. Needed data elements in the EVV
			 system include:
(a)
										First and last name.
(b)
										A minimum of one
			 known address at which the individual may routinely receive services. For
			 individuals participating in the address confidentiality program, in accordance
			 with section 111.42 of the Revised Code, the
			 address documented will be according to program policy and may include a post
			 office box.
(c)
										Telephone number.
(d)
										Program billing
			 identifier of the individual receiving the service:
(i)
											Medicaid
			 identification number, otherwise known as medicaid ID: the unique billing
			 number assigned by ODM. The individual's medicaid ID is necessary for claims
			 validation;
(ii)
											PASSPORT information management system ID assigned by
			 the Ohio department of aging for individuals temporarily enrolled in the state
			 funded preadmission screening system providing options and resources today
			 (PASSPORT) waiver program. When the individual receiving the service has been
			 assigned a medicaid ID, the provider should update the EVV system with the
			 individual's medicaid ID. Billed claims will not be validated unless the
			 individual receiving the service has an active and valid medicaid ID entered
			 into the system; or
(iii)
											An indicator that the individual receiving the service
			 is a newborn, not yet assigned a medicaid ID. When the newborn receiving the
			 service has been assigned a medicaid ID, the provider should update the EVV
			 system with the individual's medicaid ID. Billed claims will not be validated
			 unless the newborn receiving the service has an active and valid medicaid ID
			 entered into the system.
(e)
										Payer, program,
			 and service provided. Valid values accepted are found on ODM's website
https://medicaid.ohio.gov/INITIATIVES/Electronic-Visit-Verification/
.
(3)
									Utilize EVV for
			 all services described in rule 5160-32-01 of the Administrative
			 Code.
(4)
									Report known or suspected tampering of devices to ODM
			 upon discovery.
(5)
									Report any known or suspected falsification of EVV data
			 to ODM upon discovery.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-33 - Assisted living HCBS waiver program › Section 5160-33-03 - Eligibility for the medicaid funded component of the assisted living program

Current through all regulations passed and filed through July 1, 2024
(A) The purpose of this rule is to outline
			 the requirements that must be met for an individual to be eligible to enroll in
			 the medicaid funded component of the assisted living program.
(B) To be eligible for the medicaid funded
			 component of the assisted living program, an individual must meet all of the
			 following:
(1) Be eligible for medicaid in
			 accordance with Chapters 5160:1-3 to 5160:1-6 of the Administrative
			 Code.
(2) Have an intermediate or
			 skilled level of care in accordance with rule
			 5160-3-08 of the Administrative
			 Code. If the individual requires skilled nursing care beyond supervision of
			 special diets, application of dressings, or administration of medication, it
			 must be provided in accordance with rule
			 3701-16-09.1 of the
			 Administrative Code.
(3) Be age
			 twenty-one years old or older at the time of enrollment.
(4) Participate in the development of a
			 person-centered services plan in accordance with the process and requirements
			 set forth in rule
			 5160-44-02 of the Administrative
			 Code.
(5) Have the ability to make
			 room and board payments calculated at the current supplemental security income
			 (SSI) federal benefit level minus fifty dollars. Providers shall not charge or
			 collect room and board payments from individuals in excess of the room and
			 board payment calculated in accordance with this paragraph. In the event an
			 individual does not have sufficient personal income:
(a) An individual may arrange for informal
			 supports to provide a supplemental payment to the provider in order to meet
			 room and board requirements;
(i) The
			 supplemental payment shall represent no more than the difference between the
			 individual's personal income and the maximum room and board payment established
			 in paragraph (B)(5) of this rule.
(ii) The amount of the supplemental payment
			 shall not be considered when calculating the individual's patient liability as
			 described in rule
			 5160:1-6-07.1 of the
			 Administrative Code.
(b)
			 A provider may elect to accept a reduced room and board rate.
(6) Have health and safety related
			 needs met, as determined by the Ohio department of aging's (ODA)
			 designee.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-33 - Assisted living HCBS waiver program › Section 5160-33-04 - Enrollment process for medicaid-funded component of the assisted living waiver program

Current through all regulations passed and filed through July 1, 2024
(A) The purpose of this rule is to outline
			 the requirement that must be met for an individual to enroll in the
			 medicaid-funded component of the assisted living waiver program.
(B) To be eligible for enrollment, an
			 individual must:
(1) Have been determined to
			 meet the eligibility requirements set forth in rule
			 5160-33-03
			 of the Administrative Code; and
(2)
			 Upon initial and continued enrollment, reside in an approved living unit
			 in accordance with paragraph (C) of rule
			 173-38-03
			 of the Administrative Code, located in a licensed residential care
			 facility (RCF) certified by the Ohio department of aging (ODA) that possesses
			 the home and community-based setting characteristics set forth in rule
			 5160-44-01
			 of the Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-33 - Assisted living HCBS waiver program › Section 5160-33-05 - Provider conditions for the assisted living home and community based services (HCBS) waiver program

Current through all regulations passed and filed through July 1, 2024
(A) The purpose of this rule is to establish
			 the conditions under which providers are able to participate in the assisted
			 living HCBS waiver program.
(B) In
			 order to obtain a medicaid provider agreement to be an assisted living services
			 provider, the provider 
								will be certified by the Ohio department of aging
			 (ODA) 
								as an assisted living provider in accordance with
			 
								Chapter 173-39 of the Administrative
			 Code.
(C) Individuals enrolled in
			 the assisted living HCBS waiver 
								are given a free choice of qualified providers in
			 accordance with rule
			 173-42-06
			 of the Administrative Code and
			 42 C.F.R.
			 431.51 (as in effect on October 1,
			 2021).
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-33 - Assisted living HCBS waiver program › Section 5160-33-06 - Covered services for the assisted living services home and community based services (HCBS) waiver program

Current through all regulations passed and filed through July 1, 2024
(A) The purpose of this rule is to establish
			 the services covered by the assisted living HCBS waiver program.
(B) The assisted living HCBS waiver
			 
								program is limited to the following services:
(1) Assisted living service
									
			 as defined
									 in rule 173-39-02.16 of the Administrative Code, and
(2) Community transition
			 service
									 as defined
									 in rule 173-39-02.17 of the
			 Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-33 - Assisted living HCBS waiver program › Section 5160-33-07 - Assisted living home and community based services (HCBS) waiver rate setting

Current through all regulations passed and filed through July 1, 2024
(A) The purpose of this rule is to describe
			 the methods used to determine provider rates for the assisted living HCBS
			 waiver as set forth in appendix A to rule 5160-1-06.5 of the Administrative
			 Code.
(B) Provider rates
			 are
			 determined for the following categories:
(1)
									Per-job bid rate or deposit made.
(2) Unit rate.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-35 - Medicaid School Program › Section 5160-35-02 - Qualifications to be a medicaid school program (MSP) provider

Current through all regulations passed and filed through July 1, 2024
(A) The purpose of
			 this rule is to set forth the qualifications to become a medicaid school
			 program provider (MSP) and requirements 
								to be followed by an MSP
			 provider.
(B) An MSP provider
			 :
(1)
									Is one of the
			 following:
(a)
										A local
			 education agency (LEA) city school district, local school district, exempted
			 village school district ,or any other school
			 district as defined in sections
			 3311.01 to
			 
										
											3111.05
										 of the Revised
			 Code;
(b)
										
										A state
			 school for the deaf as defined by section
			 3325.01 of the Revised Code;
(c)
										
										A state school
			 for the blind as defined by section
			 3325.01 of the Revised
			 Code;
(d)
										A
			 community school as defined by Chapter 3314. of the Revised
			 Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-35 - Medicaid School Program › Section 5160-35-04 - Reimbursement for services provided by medicaid school program (MSP) providers

Current through all regulations passed and filed through July 1, 2024
(A) The purpose of this rule is to set forth
			 the provisions for claiming to receive medicaid reimbursement for the provision
			 of services by medicaid school program (MSP) providers as defined in Chapter
			 5160-35 of the Administrative Code.
(B) The CPT (common procedural terminology)
			 and HCPCS (healthcare common procedure coding system) covered services provided
			 through MSP providers that are allowable for medicaid reimbursement are listed
			 
								on the department's website,
http://medicaid.ohio.gov
and are
			 provided in accordance with Chapter 5160-35 and rule
			 5160-8-35
			 of the Administrative Code. The following limits apply:
(1) Assessment/evaluation services cannot be
			 billed more than once per continuous twelve month period.
(2) Re-assessment/re-evaluation services
			 
									may be performed not more
			 frequently than every thirty days nor less frequently than every sixty days;
			 for developmental services, reevaluation may be performed not more frequently
			 than every thirty days nor less frequently than every six
			 months.
(3) Skilled services
			 cannot be billed for dates of service beyond twelve months of the initial
			 assessment/evaluation or re-assessment/re-evaluation.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-35 - Medicaid School Program › Section 5160-35-05 - Services authorized for medicaid coverage that can be provided by medicaid school program (MSP) providers

Current through all regulations passed and filed through July 1, 2024
(A) The purpose of this rule is to set forth
			 the services authorized for medicaid coverage that a MSP provider can provide,
			 and to set forth the conditions for providing the services.
(B) A MSP provider may provide skilled
			 services. Following are the skilled services an MSP provider may provide:
(1) Occupational therapy services:
(a) Description: services that evaluate and
			 treat, as well as services to analyze, select, and adapt activities for an
			 eligible child whose functioning is impaired by developmental deficiencies,
			 physical injury or illness. The occupational therapy service
			 will be
			 recommended by a licensed occupational therapist acting within the scope of his
			 or her practice under Ohio law who holds a current, valid license to practice
			 occupational therapy issued under Chapter 4755. of the Revised Code. Services
			 provided by an individual holding a limited permit, as described in section
			 4755.08 of the Revised Code, are
			 not allowable.
(b) Qualified
			 practitioners who can deliver the services:
(i) Licensed occupational therapist who holds
			 a current, valid license to practice occupational therapy issued under Chapter
			 4755. of the Revised Code, who is employed or contracted with the MSP provider,
			 and who is acting within the scope of his or her practice under Ohio
			 law.
(ii) Licensed occupational
			 therapy assistant who holds a current, valid license issued under Chapter 4755.
			 of the Revised Code, who is employed or contracted with the MSP provider, and
			 who is acting within the scope of his or her practice under Ohio law. Further,
			 the licensed occupational therapy assistant will be
			 practicing under the supervision of a licensed occupational therapist who is
			 employed or contracted by the MSP provider.
(iii)
											An occupational
			 therapy student who is completing an internship or externship in accordance
			 with the clinical requirements as established by the credentialing
			 board.
(c)
			 Allowable activities include:
(i) Evaluation
			 and re-evaluation to determine the current sensory and motor functional level
			 of the eligible child and identifying appropriate therapeutic interventions to
			 address the findings of the evaluation/re-evaluation.
(ii) Therapy to improve the sensory and motor
			 functioning of the eligible child, to teach skills and behaviors crucial to the
			 eligible child's independent and productive level of functioning.
(iii) Application and instruction in the use
			 of orthotic and prosthetic devices, and other equipment to accomplish the goal
			 of therapy in accordance with paragraph (B)(1)(c)(ii) of this rule.
(iv) May make referrals for occupational
			 therapy services under the MSP component of the medicaid program as authorized
			 in section 5162.366 of the Revised
			 Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-35 - Medicaid School Program › Section 5160-35-06 - Other services, medical supplies and equipment authorized for medicaid coverage that can be provided by medicaid school program (MSP) providers

Current through all regulations passed and filed through July 1, 2024
(A) The purpose of
			 this rule is to set forth the services authorized for medicaid coverage, beyond
			 those indicated in rule
			 5160-35-05
			 of the Administrative Code, that a MSP provider can provide, and to set forth
			 the conditions for providing the services.
(B) In addition to the services indicated in
			 rule
			 5160-35-05
			 of the Administrative Code, a MSP provider may render and receive payment for
			 the following services:
(1) Transportation:
(a) For purposes of Chapter 5160-35 of the
			 Administrative Code, "transportation" is specialized conveyance that
			 accommodates the specific needs of an eligible child (for example,
			 transportation by wheelchair-accessible vehicle or adapted school bus) for the
			 purpose of traveling to or from the MSP provider to receive medically necessary
			 services allowable under rule
			 5160-35-05
			 of the Administrative Code.
(b)
			 Claims for transportation mileage are paid in accordance with
			 rates as found in the "Healthcare Common Procedure Coding
			 System (HCPS)," with the 'Current Procedural Terminology (CPT)" codes, and in
			 rule
			 5160-1-60 of the
			 Administrative Code.
(c)
			 Unallowable services include transportation that is otherwise available to all
			 students, transportation that is provided in a vehicle that is not used
			 specifically to accommodate an eligible child, transportation accommodations
			 that are not indicated in an eligible child's individualized education program
			 (IEP), and transportation provided from home to school or from school to home
			 if no medicaid-covered service allowable under rule
			 5160-35-05
			 of the Administrative Code was received at school on that
			 day.