reglab/statecodes huggingface dataset:
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-44 - Nursing Facility-Based Level of Care Home and Community-Based Services Programs › Section 5160-44-26 - Nursing facility-based level of care home and community-based services programs: community transition

Current through all regulations passed and filed through July 1, 2024
(A) "Community transition
			 " pays for non-recurring start-up living expenses for
			 individuals transitioning from an institutional setting to a home and
			 community-based services (HCBS) setting that is compliant with rule
			 5160-44-01 of the Administrative
			 Code. Community transition :
(1)
									Community transition includes
			 the following:
(a)
										Expenses necessary to enable an individual to establish
			 a basic household. Examples include:
(i)
											Security deposits
			 and rental fees needed to obtain a lease on an apartment or home and rental
			 expenses required to obtain a residential lease;
(ii)
											Essential
			 household items such as furnishings and moving expenses required to occupy and
			 use a community home, including furniture needed to occupy and maintain
			 housing, including window coverings, food preparation items, and
			 linens;
(iii)
											Set-up fees and deposits for utility and service
			 access, including telephone/cellphone, electricity, gas, garbage, and
			 water;
(iv)
											Services necessary for the individual's health and
			 safety such as pest eradication and one-time cleaning prior to
			 occupancy;
(v)
											Pre-transition transportation necessary to secure
			 housing and benefits, etc.;
(vi)
											Initial cleaning
			 and household supplies;
(vii)
											Activities to arrange for and to procure other
			 non-recurring set-up expenses; and
(viii)
											Essential
			 personal hygiene and clothing items needed to transition
			 safely.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-44 - Nursing Facility-Based Level of Care Home and Community-Based Services Programs › Section 5160-44-32 - Home and community based medicaid waiver program provider and direct care worker relationships

Current through all regulations passed and filed through July 1, 2024
(A)
								This rule is
			 applicable to the following waiver programs and services:
(1)
									Individual
			 options services, as described in Chapter 5123-9 of the Administrative
			 Code:
(a)
										Homemaker/personal care, participant-directed and provided
			 through an agency; and
(b)
										Waiver nursing, provided through an
			 agency.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-45 - Administered Waiver Service Providers › Section 5160-45-06 - Ohio department of medicaid (ODM) -administered waiver program: structural reviews of providers and investigation of provider occurrences

Current through all regulations passed and filed through July 1, 2024
(A) The Ohio
			 department of medicaid (ODM) or its designee shall continuously monitor every
			 ODM-administered waiver provider. Monitoring activities shall include, but not
			 be limited to:
(1) A structural review of
			 compliance with all ODM-administered waiver provider requirements in accordance
			 with paragraph (B) of this rule.
(2) Investigation of provider occurrences in
			 accordance with paragraph (C) of this rule.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-45 - Administered Waiver Service Providers › Section 5160-45-07 - ODM-administered waiver programs: criminal records checks involving agency providers

Current through all regulations passed and filed through July 1, 2024
(A) Unless otherwise stated in paragraphs
			 (A)(1) and (A)(2) of this rule, this rule sets forth the process and
			 requirements for the criminal records checks of persons under final
			 consideration for employment with a waiver agency, and existing employees with
			 a waiver agency in a full-time, part-time or temporary position, and who are
			 providing home and community-based services (HCBS) in an Ohio
			 department of medicaid
			 (ODM) -administered waiver. This rule does not apply to:
(1) Any individual who is subject to a
			 database review or a criminal records check under section
			 3701.881 of the Revised Code and
			 rules adopted thereunder.
(2)
			 Applicants and employees of a waiver agency that is also a community-based long
			 term care provider who are subject to database reviews and
			 criminal records checks in accordance with section 
										173.38
									 of the Revised
			 Code and rules adopted thereunder.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-45 - Administered Waiver Service Providers › Section 5160-45-09 - ODM-administered waiver program: program compliance, monitoring and oversight of ODM-administered waiver service providers and ODM-administered waiver program contractors

Current through all regulations passed and filed through July 1, 2024
(A) The Ohio department of medicaid (ODM) is
			 responsible for the ongoing monitoring and oversight of all ODM-administered
			 waiver service providers and all ODM-administered waiver contractors in order
			 to assure providers' and contractors' compliance with ODM-administered waiver
			 program requirements.
(B)
			 Monitoring and oversight of ODM-administered waiver service providers.
(1) ODM and its designee shall conduct
			 ongoing monitoring and oversight of ODM-administered waiver service providers
			 to verify that each provider is:
(a)
			 Complying with the terms and conditions of its medicaid provider agreement, the
			 ODM-administered waiver program and all applicable federal, state and local
			 laws and regulations.
(b) Ensuring
			 the health and welfare of individuals to whom they are providing
			 services.
(c) Ensuring the
			 provision of quality services as part of the ODM-administered waiver
			 program.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-46 - Ohio home care waiver › Section 5160-46-04 - Ohio home care waiver: definitions of the covered services and provider requirements and specifications

Current through all regulations passed and filed through July 1, 2024
This rule sets forth definitions of some services covered by
				the Ohio home care waiver. This rule also sets forth the provider requirements
				and specifications for the delivery of those Ohio home care waiver services.
				Providers are also subject to the conditions of participation set forth in rule
				5160-44-31 of the Administrative
				Code. Services are reimbursed in accordance with rule
				5160-46-06 of the Administrative
				Code.
(A) Personal care aide services.
(1) "Personal care aide services" are defined
			 as services provided pursuant to the person-centered services plan
			 (PCSP) that assist the individual with activities
			 of daily living (ADL) and instrumental activities of daily living (IADL) needs.
			  If the provider
			 cannot perform IADLs, the provider 
									will notify ODM or its designee, in writing, of
			 the service limitations before inclusion on the individual's
			 PCSP. Personal care aide services include:
(a) Bathing, dressing, grooming, nail care,
			 hair care, oral hygiene, shaving, deodorant application, skin care, foot care,
			 feeding, toileting, assisting with ambulation, positioning in bed,
			 transferring, range of motion exercises, and monitoring intake and
			 output;
(b) General homemaking
			 activities, including but not limited to: meal preparation and cleanup,
			 laundry, bed-making, dusting, vacuuming, washing floors and waste
			 disposal;
(c) Paying bills and
			 assisting with personal correspondence as directed by the individual;
			 and
(d) Accompanying or
			 transporting the individual to Ohio home care waiver services, medical
			 appointments, other community services, or running errands on behalf of that
			 individual.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-46 - Ohio home care waiver › Section 5160-46-06.1 - Ohio home care waiver program: home care attendant services reimbursement rates and billing procedures

Current through all regulations passed and filed through July 1, 2024
(A) Definitions of terms used for billing and
			 calculating home care attendant services (HCAS) rates.
(1) "Base rate," as set forth in column 3 of
			 tables A and B of this rule, means the amount reimbursed by Ohio medicaid for
			 the first thirty-five to sixty minutes of assistance with self-administration
			 of medications and the performance of nursing tasks provided during a single
			 visit.
(2) "Continuous nursing"
			 means nursing services (waiver nursing and/or private duty nursing) that are
			 more than four hours in length and during which personal care aide service
			 tasks as described in paragraph (A)(1) of rule
			 5160-46-04 of the Administrative
			 Code may be provided incidental to nursing services.
(3) "Group rate" means the amount that HCAS
			 providers 
									will be reimbursed when the service is provided in a
			 group setting.
(4) "Group setting"
			 means a situation in which an HCAS provider furnishes HCAS in accordance with
			 rule 5160-44-27 of the Administrative
			 Code, and as authorized by the Ohio department of medicaid (ODM), to two or
			 three individuals who reside at the same address.
(5) "HCAS visit" is a visit during which HCAS
			 is provided in accordance with rule
			 5160-44-27 of the Administrative
			 Code. An HCAS visit 
									will not exceed twelve hours or forty-eight units
			 in duration.
(6) "Intermittent
			 nursing" means nursing services (waiver nursing and/or home health nursing)
			 that are four hours or less in length.
(7) "Medicaid maximum rate" means the maximum
			 amount that 
									will be paid by the Ohio medicaid program for the
			 service rendered. The base rate in column 3 and the unit rate in column 4 of
			 table A of this rule, and the base rate in column 3 and the unit rates in
			 column 5 of table B of this rule represent the medicaid maximum rates for
			 HCAS.
(8) "Modifier", as set forth
			 in column 4 of table A of this rule and column 4 of table B of this rule, means
			 the additional two-alpha-numeric-digit billing code as set forth in paragraph
			 (G) of this rule that HCAS providers 
									will use to provide additional information
			 regarding service delivery.
(9)
			 "Unit rate," as set forth in column 5 of table A of this rule and column 5 of
			 table B of this rule, means the amount reimbursed by Ohio medicaid for each
			 fifteen minutes of HCAS delivered when the visit is:
(a) Greater than sixty minutes in
			 length.
(b) Less than or equal to
			 thirty-four minutes in length. Ohio medicaid will reimburse a maximum of only
			 one unit if HCAS is equal to or less than fifteen minutes in length, and a
			 maximum of two units if the service is sixteen through thirty-four minutes in
			 length.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-48 - Medicaid Coverage of Targeted Care Management Services Provided to Individuals with MR/DD › Section 5160-48-01 - Medicaid coverage of targeted case management services provided to individuals with developmental disabilities

Current through all regulations passed and filed through July 1, 2024
(A) Purpose.
(1) This rule specifies the conditions for
			 medicaid payment of targeted case management (TCM), which is
			 associated with activities described in section
			 5126.15
			 of the Revised Code and in rule 5123-4-02 of the Administrative Code,
			 but only to the extent that they are listed in paragraph (D) of this rule as
			 reimbursable activities for medicaid eligible individuals with developmental
			 disabilities.
(2) The department of
			 developmental disabilities (DODD), through an interagency agreement with the
			 department of medicaid (ODM), administers the TCM program on a daily basis in
			 accordance with section
			 5162.35
			 of the Revised Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-48 - Medicaid Coverage of Targeted Care Management Services Provided to Individuals with MR/DD › Section 5160-48-01 - Targeted case management services provided to individuals with intellectual and developmental disabilities

All regulations passed and filed through
  January 1, 2024
(A)
  Purpose.
(1) This rule specifies the
  conditions for medicaid payment of targeted case management (TCM), which is
  associated with activities described in section
  5126.15 of the Revised Code and
  in rule 5123-4-02 of the Administrative
  Code, but only to the extent that they are listed in paragraph (D) of this rule
  as reimbursable activities for medicaid eligible individuals with
  intellectual and developmental
  disabilities.
(2) The department of
  developmental disabilities (DODD), through an interagency agreement with the
  department of medicaid (ODM), administers the TCM program on a daily basis in
  accordance with section
  5162.35 of the Revised
  Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-49 - Ohio Access Success Project › Section 5160-49-01 - Ohio access success project

Current through all regulations passed and filed through July 1, 2024
(A)
								 This rule sets
			 forth the eligibility requirements and benefit limitations for the
			 non-medicaid-funded Ohio access success project in accordance with section
			 5166.35 of the Revised
			 Code.
(B)
								 Definitions:
(1)
									 "Fiscal year" is
			 defined as the fiscal year of this state, as specified in section
			 9.34 of the Revised
			 Code.
(2)
									 "Helping Ohioans move, expanding choice (HOME choice)"
			 is Ohio's money follows the person demonstration project funded by the centers
			 for medicare and medicaid services as defined in Chapter 5160-51 of the
			 Administrative Code.
(3)
									 "Nursing Facility" is defined as a facility or a
			 distinct part of a facility as defined in division (DD) of section
			 5165.01 of the Revised
			 Code.
(4)
									 "Relocation" is defined as transition from a nursing
			 facility into the community.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-51 - HOME choice ("Helping Ohioans Move, Expanding Choice") demonstration program › Section 5160-51-06 - Helping Ohioans move, expanding choice (HOME choice) program definitions of billing terms, reimbursement rates and billing procedures for providers of covered services

Current through all regulations passed and filed through July 1, 2024
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-51 - HOME choice ("Helping Ohioans Move, Expanding Choice") demonstration program › Section 5160-51-10 - Helping Ohioans move, expanding choice (HOME choice)

Current through all regulations passed and filed through July 1, 2024
(A) Helping Ohioans
			 move, expanding choice (HOME choice) assists individuals to transition from an
			 institutional setting into a community setting.
(B) Definitions
(1)
									"Assessment"
			 means an in-person meeting with the HOME choice applicant to determine
			 eligibility for the program, conducted by the Ohio department of medicaid (ODM)
			 or its designee.
(2) "Community setting"
			 means a location that meets the home and communitybased setting requirements
			 set forth in rule
			 5160-44-01
			 of the Administrative Code or for those moving from an intermediate care
			 facility for individuals with intellectual disabilities the requirements set
			 forth in rule
			 5123:2-9-02
			 of the Administrative Code.
(3) "HOME choice
			 participant" or "participant" means a person who is enrolled in HOME
			 choice.
(4) "Institutional
			 setting" means a hospital as described in Chapter 5160-2 of the Administrative
			 Code, a nursing facility as described in Chapter 5160-3 of the Administrative
			 Code, or an intermediate care facility for individuals with intellectual
			 disabilities as described in Chapter 5123:2-7 of the Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-56 - Medicaid Hospice Program › Section 5160-56-01 - Hospice services: definitions

Current through all regulations passed and filed through July 1, 2024
This rule set forth terms used throughout Chapter 5160-56 of
				the Administrative Code.
(A) "Advance
			 directive" refers to written instructions recognized under state law that are
			 related to the provisions of health care when the individual is incapacitated.
			 Samples of advance directive documents include a living will, a declaration as
			 defined in Chapter 2133. of the Revised Code, and a durable power of attorney
			 for health care as defined in Chapter 1337. of the Revised Code.
(B) "Advanced practice registered nurse
			 (APRN)" refers to a registered nurse (RN) authorized to practice as a clinical
			 nurse specialist, certified registered nurse anesthetist, certified nurse
			 midwife or certified nurse practitioner in accordance with section
			 4723.43 of the Revised Code.
(C) "Attending physician" refers
			 to a health professional identified by the individual at the time of the
			 election of hospice, as having primary responsibility in the determination and
			 delivery of the individual's medical care while under hospice, and one who is:
(1) A doctor of medicine or osteopathy
			 licensed and legally authorized under Chapter 4731. of the Revised Code to
			 practice medicine and surgery or osteopathic medicine and surgery; or
(2) A "nurse practitioner" who meets the
			 training, education, and experience requirements of a certified, advanced
			 practice nurse in accordance with section
			 4723.43 of the Revised Code.
			 APRNs are prohibited from certifying or recertifying a terminal
			 diagnosis.
(3)
									A "physician assistant" (PA) who meets the training,
			 education, and other specifications of a licensed physician assistant in
			 accordance with Chapter 4730 of the Revised Code. PAs are prohibited from
			 certifying or recertifying a terminal diagnosis.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-56 - Medicaid Hospice Program › Section 5160-56-02 - Hospice services: eligibility and election requirements

Current through all regulations passed and filed through July 1, 2024
This rule sets forth the criteria that
				must be met for an individual eligible for medicaid to receive the Ohio
				medicaid hospice benefit.
(A)
								To be covered under Ohio medicaid, the designated
			 hospice must ensure the following criteria are met prior to furnishing hospice
			 care:
(1)
									The
			 designated hospice has a certification of the terminal illness on behalf of the
			 individual, obtained in accordance with
			 42 C.F.R.
			 418.22 (October 1, 2017);
(2)
									A hospice
			 election statement, completed by the individual, has been obtained by the
			 designated hospice pursuant to paragraphs (B) and (C) of this
			 rule;
(3)
									The individual has a hospice plan of care initiated,
			 pursuant to paragraph (F) of this rule;
(4)
									Other applicable
			 criteria are met which pertain to the individual and the election of
			 hospice:
(a)
										
			 The designated hospice shall ensure an individual eligible for both medicare
			 and medicaid hospice elects the hospice benefit under both programs. Hospice
			 services furnished to individuals who are dual eligible shall be billed to
			 medicare first.
(b)
										If the individual has or later obtains third-party
			 coverage of hospice, the individual must elect the third-party coverage of
			 hospice to cover the same days the medicaid hospice benefit covers in order to
			 ensure medicaid is the secondary payor. If the individual revokes his or her
			 third-party coverage of hospice, the medicaid hospice benefit must be revoked
			 at the same time.
(c)
										If the individual is a participant in the program of
			 all-inclusive care for the elderly (PACE), the individual must access hospice
			 services through the PACE site's network of providers.
(d)
										If the individual
			 is enrolled in a medicaid managed care plan (MCP), the individual must access
			 hospice services through the MCP's network of providers.
(e)
										If the individual
			 is enrolled in a home and community based services (HCBS) waiver, the
			 designated hospice shall assist the individual in coordinating concurrent care
			 and waiver services in accordance with rule
			 5160-56-04
			 of the Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-56 - Medicaid Hospice Program › Section 5160-56-03 - Hospice services: discharge requirements

Current through all regulations passed and filed through July 1, 2024
This rule sets forth the requirements
				for discharging an individual from the designated hospice's care and/or the
				hospice benefit.
(A)
								Discharge refers to the end the hospice benefit and/or
			 the designated hospice's care:
(1)
									Discharge from the designated hospice's care shall
			 occur when the individual:
(a)
										Dies/expires;
(b)
										No longer meets
			 the hospice enrollment or eligibility criteria;
(c)
										No longer is
			 terminally ill, e.g., physician discharges or does not recertify the
			 individual;
(d)
										Moves out of the service area;
(e)
										Enters a facility
			 where the designated hospice has no access and/or cannot enter to provide
			 care;
(f)
										Revokes the hospice benefit in accordance with
			 paragraph (B) of this rule;
(g)
										Transfers to
			 another hospice in accordance with paragraph (D) of this rule;
			 or
(h)
										Is discharged for cause, such as compromising the
			 safety of self or the safety of the hospice staff.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-56 - Medicaid Hospice Program › Section 5160-56-03.3 - Hospice services: reporting requirements

Current through all regulations passed and filed through July 1, 2024
This rule sets forth the requirement
				for recording the hospice provider span for individuals receiving medicaid
				hospice care in accordance with Chapter 5160-56 of the Administrative Code,
				including individuals who may be covered by third-party insurance, such as
				medicare, for which the hospice seeks reimbursement.
(A)
								The designated
			 hospice shall report the required enrollment information to the Ohio department
			 of medicaid using the medicaid information technology system (MITS) for the
			 following:
(1)
									Individuals in fee-for-service (FFS) medicaid hospice under
			 the designated hospice's care on the effective date of this rule;
			 and
(2)
									Individuals in which the hospice seeks to file an
			 original or adjusted claim to ODM for medicaid hospice services rendered under
			 codes T2042 and T2046, including:
(a)
										All individuals with FFS claims for routine home care,
			 code T2042, for the dates of service on or after January 1, 2016, whether or
			 not the claim has previously been submitted and paid.
(b)
										Individuals in
			 the care of hospice prior to the effective date of this rule, if the provider
			 is submitting an original FFS claim for hospice services other than the
			 services specified in paragraph (A)(2)(a) of this rule.
(c)
										Individuals in
			 the care of hospice prior to the effective date of this rule, if the provider
			 is submitting an adjusted FFS claim or if ODM must adjust a FFS claim for
			 hospice services other than the services specified in paragraph (A)(2)(a) of
			 this rule.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-56 - Medicaid Hospice Program › Section 5160-56-05 - Hospice services: covered services

Current through all regulations passed and filed through July 1, 2024
This rule sets forth medicaid covered services that hospice
				providers may or must furnish to individuals to the extent specified by the
				individual's plan of care.
(A) The
			 designated hospice shall ensure the hospice services furnished to an individual
			 in accordance with this rule are reasonable and necessary for the palliation
			 and management of the terminal illness and related conditions.
(B) Unless otherwise specified, covered
			 services shall be furnished to the individual in his or her residence,
			 including the individual's home, a relative's home or any other type of living
			 arrangement, a skilled nursing facility (SNF), a nursing facility (NF), an
			 intermediate care facility for individuals with intellectual disabilities
			 (ICF-IID), or a hospice inpatient unit.
(C) The designated hospice shall ensure
			 covered services provided to the individual are furnished by qualified
			 personnel pursuant to
			 42 C.F.R.
			 418.114 (October 1, 2017), who are employed
			 by the hospice, under an individual contract, or under arrangement with another
			 provider.
(D) The following
			 services are covered by medicaid when furnished or arranged by the designated
			 hospice based on the individual's needs, appropriate level of care, and plan of
			 care:
(1) Core hospice services
			 may be provided through a combination of contracting
			 services and telehealth services as necessary:
(a) Nursing care;
(b) Medical social services, provided by a
			 social worker under the direction of a physician or attending
			 provider;
(c) Physicians' services,
			 including attending physician services, and services rendered by advance nurse
			 practitioners or physician assistants acting as
			 attending physicians; and
(d)
			 Counseling services, including but not limited to dietary counseling,
			 bereavement counseling and spiritual counseling.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-56 - Medicaid Hospice Program › Section 5160-56-06 - Hospice services: reimbursement

Current through all regulations passed and filed through July 1, 2024
This rule sets forth the Ohio department of medicaid (ODM)
				payment for hospice services and care.
(A) ODM will directly pay the designated
			 hospice to care for an individual enrolled in medicaid hospice. Payment to the
			 designated hospice shall cover the array of services listed in rule
			 5160-56-05 of the Administrative
			 Code, except for:
(1) Services pursuant to
			 paragraph (E) of this rule which are paid directly to the physician;
			 and
(2) Services furnished by a
			 non-hospice provider pursuant to paragraph (I) of this rule for the concurrent
			 care of an individual under the age of twenty-one.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-57 - Medicaid Provider Incentive Program › Section 5160-57-01 - Medicaid provider incentive program (MPIP): program eligibility requirements and payment

Current through all regulations passed and filed through July 1, 2024
(A)
								The medicaid
			 provider incentive program (MPIP) is Ohio's program implementing section 4201
			 of the American Recovery and Reinvestment Act of 2009 (ARRA),
			 Pub.
			 L. No. 111-5, and the published regulations in 42
			 C.F.R. Part 495. Certain medicaid eligible professionals and hospitals are
			 eligible to participate in MPIP. Funding for this program ends in
			 2021.
(B)
								An eligible professional participating in Ohio's MPIP
			 program is a provider that meets eligibility requirements in
			 42 C.F.R.
			 495.304 (as in effect on October 1, 2018) and
			 practices within his or her scope of practice as recognized under Ohio law for
			 each type of professional. In addition, an advanced practice registered nurse
			 (APRN) defined in rule
			 5160-4-04
			 of the Administrative Code with an appropriate scope of practice will be
			 considered as an eligible provider for Ohio's MPIP program.
(C)
								Medicaid eligible
			 hospitals participating in Ohio's MPIP program are subject to the program
			 eligibility rules and regulations published in 42 C.F.R. Part 495 (as in effect
			 on October 1, 2018).
(D)
								To be eligible for a year of participation in MPIP,
			 each eligible professional and hospital must:
(1)
									Be an enrolled
			 Ohio medicaid provider with an active Ohio medicaid provider
			 agreement;
(2)
									Except for eligible hospitals, not have received an
			 electronic health record (EHR) incentive payment within the current payment
			 year from another state, MPIP, or the medicare EHR incentive payment
			 program;
(3)
									Not have a current sanction or exclusion identified at
			 the United States department of health and human services, office of inspector
			 general, list of excluded individuals and entities, or the Ohio medicaid list
			 of excluded providers.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-57 - Medicaid Provider Incentive Program › Section 5160-57-04 - Medicaid provider incentive program (MPIP): program integrity and provider appeals

Current through all regulations passed and filed through July 1, 2024
(A) Program integrity.
(1) MPIP legal notice.
(a) All eligible professionals and eligible
			 hospitals submitting an application to receive an MPIP payment are required to
			 sign the MPIP legal notice before confirming and submitting their
			 application.
(b) All program
			 applicants are bound by the requirements of the MPIP legal notice.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-58 - MyCare Ohio › Section 5160-58-01.1 - MyCare Ohio plans: application of general managed care rules

Current through all regulations passed and filed through July 1, 2024
(A) MyCare Ohio
			 plans must comply with all of the requirements applicable to managed care
			 
								organizations (MCOs) and managed care entities (MCEs)
			 in the following rules:
(1) Rule
			 5160-26-05
			 of the Administrative Code;
(2)
			 Rule 5160-26-05.1 of the Administrative Code;
(3) Rule
			 5160-26-06
			 of the Administrative Code;
(4)
			 Rule 5160-26-08.3 of the Administrative Code;
(5) Rule 5160-26-09.1
			 of the Administrative Code;
(6) Rule
			 5160-26-10
			 of the Administrative Code; and
(7) Rule
			 5160-26-11
			 of the Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-58 - MyCare Ohio › Section 5160-58-02 - MyCare Ohio plans: eligibility and enrollment

Current through all regulations passed and filed through July 1, 2024
(A) Eligibility.
(1) Except as specified in paragraph (A)(2)
			 of this rule, in mandatory service areas as permitted by
			 42 C.F.R.
			 438.52 (October 1, 2021), an
			 individual must be enrolled in a MyCare Ohio plan (MCOP) if he or she meets all of the following
			 criteria:
(a) Age eighteen or older at the
			 time of enrollment in the 
										MCOP;
(b) Eligible for medicare parts A, B and D,
			 and full benefits under the medicaid program; and
(c) Reside in a plan demonstration county in
			 Ohio. A list of demonstration counties, and the 
										MCOPs available
			 in those counties, is available at
http://medicaid.ohio.gov
.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-58 - MyCare Ohio › Section 5160-58-02.1 - MyCare Ohio plans: termination of enrollment

Current through all regulations passed and filed through July 1, 2024
(A) A member will be terminated from
			 enrollment in a MyCare Ohio plan (MCOP) for any of the following reasons:
(1) The member becomes ineligible for full
			 medicaid or medicare parts A or B or D. Termination of MCOP enrollment is
			 effective the end of the last day of the month in which the member became
			 ineligible.
(2) The member's
			 permanent place of residence is moved outside the plan's service area.
			 Termination of MCOP enrollment is effective the end of the last day of the
			 month in which the member moved from the service area.
(3) The member dies, in which case plan
			 enrollment ends on the date of death.
(4) The member is found by the Ohio
			 department of medicaid (ODM), or their designee, to meet the criteria for the
			 developmental disabilities (DD) level of care and has a stay in an intermediate
			 care facility for individuals with intellectual disabilities (ICF-IID) or is
			 enrolled in a DD waiver. After the MCOP notifies ODM this has occurred,
			 termination of MCOP enrollment takes effect on the last day of the month
			 preceding the ICF-IID facility stay or enrollment on the DD waiver.
(5) The member has third party coverage,
			 excepting medicare coverage.. Termination of MCOP enrollment is effective the
			 end of the last day of the month in which ODM identified the third party
			 coverage.
(6) The provider
			 agreement between ODM and the MCOP is terminated or not renewed. The effective
			 date of termination shall be the date of provider agreement termination or
			 nonrenewal.
(7) The member is not
			 eligible for enrollment in an MCOP for one of the reasons set forth in rule
			 5160-58-02 of the Administrative
			 Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-58 - MyCare Ohio › Section 5160-58-02.2 - MyCare Ohio waiver: eligibility and enrollment

Current through all regulations passed and filed through July 1, 2024
(A) To be eligible for enrollment in the
			 MyCare Ohio waiver, a member must meet all of the following requirements:
(1) Be enrolled in the MyCare Ohio
			 demonstration at the time of application for the MyCare Ohio waiver;
(2) Be determined to have a nursing
			 facility-based level of care (i.e., intermediate or skilled) in accordance with
			 rule 5160-3-08 or 5160-3-09 of the
			 Administrative Code;
(3) In the
			 absence of the MyCare Ohio waiver, require hospitalization or
			 institutionalization in a nursing facility to meet his or her needs;
(4)
									The member:
(a)
										Has a need for and agrees to receive at least one
			 waiver service monthly that is otherwise unavailable through another source
			 (including, but not limited to: private pay, community resources, and the
			 medicaid state plan) in an amount sufficient to meet the individual's assessed
			 need; or
(b)
										Has a need for:
(i)
											Continuous
			 nursing services more than four hours in length,
(ii)
											At least one
			 waiver service annually, and
(iii)
											Monthly
			 monitoring of the individual's health and welfare through a combination of
			 telephonic and in-person contacts with the waiver service coordinator and
			 agrees to cooperate with the monthly monitoring.
(5) Reside in a setting that
			 possesses the home and community-based setting characteristics set forth in
			 rule 5160-44-01 of the Administrative
			 Code, and is not a hospital, nursing facility, intermediate care facility for
			 individuals with intellectual disabilities (ICF-IID) or another
			 licensed/certified facility, any facility covered by section 1616(e) of the
			 Social Security Act (October 1, 2020), residential care facility (except an
			 assisted living facility as described in rule
			 173-39-02.16 of the
			 Administrative Code), adult foster home or another group living arrangement
			 subject to state licensure or certification.
(6) Sign an agreement prior to waiver
			 enrollment confirming that the member has been informed of service
			 alternatives, choice of qualified providers available in the MyCare Ohio plan's
			 provider panel and the options of institutional and community-based care, and
			 he or she elects to receive MyCare Ohio waiver services. If the individual is
			 unable to sign the agreement prior to waiver enrollment, the individual will
			 submit an electronic signature or standard signature via regular mail, or
			 otherwise provide a signature in no instance any later than at the next
			 face-to-face visit with the case manager; and
(7) Be able to have waiver services that can
			 be identified in a person-centered services plan as described in rule
			 5160-44-02 of the Administrative
			 Code that will safely meet his or her assessed needs.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-58 - MyCare Ohio › Section 5160-58-03 - MyCare Ohio plans: covered services

Current through all regulations passed and filed through July 1, 2024
(A) A MyCare Ohio plan (MCOP) must ensure
			 members have access to all medically-necessary medical, drug, behavioral
			 health, nursing facility and home and community-based services (HCBS) covered
			 by Ohio medicaid. After consideration of verified third party liability
			 including medicare coverage pursuant to rule 5160-26-09.1 of the Administrative
			 Code, the MCOP 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 MCOP has placed a pre-identified limitation
			 to ensure the limitation may be exceeded when medically necessary, unless the
			 MCOP's limitation is also a limitation for fee-for-service medicaid
			 coverage;
(4) Medicaid 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 medicaid services from an MCOP 
									network
			 provider, the 
									MCOP must adequately and timely cover the services out
			 of 
									network until the 
									MCOP is able to
			 provide the services from a 
									network provider.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-58 - MyCare Ohio › Section 5160-58-03.1 - MyCare Ohio plans: primary care and utilization management

Current through all regulations passed and filed through July 1, 2024
(A)
								A MyCare Ohio plan (MCOP) will 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 MCOP will
			 ensure PCPs are in compliance with the following triage requirements. Members
			 with:
(a)
										Emergency care needs will be triaged and treated immediately
			 on presentation at the PCP site;
(b)
										Persistent
			 symptoms will be treated no later than the end of the following working day
			 after their initial contact with the PCP site; and
(c)
										Requests for
			 routine care will be seen within six weeks.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-58 - MyCare Ohio › Section 5160-58-05.3 - MyCare Ohio waiver and 1915(i) specialized recovery services program (SRSP): incident management system

Current through all regulations passed and filed through July 1, 2024
(A) For the purposes of this rule,
(1) "Alert" means an incident that must be
			 reported to the Ohio department of medicaid (ODM) due to the severity and/or
			 impact on a member enrolled on the MyCare Ohio waiver or
			 SRSP or the need for ODM involvement in the
			 incident investigation. Alerts include, but are not limited to the events
			 described in paragraph (J) of this rule.
(2) "Incident" means an alleged, suspected or
			 actual event that is not consistent with the routine care of, and/or service
			 delivery to, a member. Incidents include, but are not limited to the events
			 described in paragraph (F) of this rule.
(3) "Provider" means a MyCare Ohio waiver
			 or SRSP service provider, any other service
			 provider that is directed to adhere to this rule, and all of their respective
			 staff who have direct contact with members.
(4)
									"Specialized
			 Recovery Services Program (SRSP)" means Ohio's specialized recovery service
			 program authorized by Section 1915(i) of the Social Security Act,
			 42 U.S.C.
			 1396n(i) (July 1,
			 2016).
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-59 - OhioRISE › Section 5160-59-01 - OhioRISE: definitions

Current through all regulations passed and filed through July 1, 2024
(A)
								The definitions
			 set forth in rule
			 5160-26-01
			 of the Administrative Code, with the exceptions noted in paragraphs (A)(1) and
			 (A)(2) of this rule, apply to the Ohio resilience through integrated systems
			 and excellence (OhioRISE) rules set forth in Chapter 5160-59 of the
			 Administrative Code. Definitions that reference managed care organizations
			 (MCOs) in Chapter 5160-26 of the Administrative Code apply to the OhioRISE
			 plan.
(1)
									Definitions that reference rule
			 5160-26-03
			 of the Administrative Code are replaced by reference to rule 5160-59-03 of the
			 Administrative Code.
(2)
									Definitions that reference rule 5160-26-03.1 of the
			 Administrative Code are replaced by reference to rule 5160-59-03.1 of the
			 Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-59 - OhioRISE › Section 5160-59-01.1 - OhioRISE: application of general managed care rules

Current through all regulations passed and filed through July 1, 2024
(A)
								The Ohio resilience through integrated systems and
			 excellence (OhioRISE) plan has to adhere to all of the requirements applicable
			 to managed care organizations (MCOs) or managed care entities (MCEs) in the
			 following rules:
(1)
									Rule
			 5160-26-05
			 of the Administrative Code with the exception of paragraphs (B)(4), (B)(5),
			 (D)(21), (D)(25), and (D)(26);
(2)
									Rule 5160-26-05.1
			 of the Administrative Code with the exception of paragraph
			 (B)(1);
(3)
									Rule
			 5160-26-06
			 of the Administrative Code;
(4)
									Rule 5160-26-08.3
			 of the Administrative Code with the exception of paragraphs (A)(19) and
			 (A)(25);
(5)
									Rule 5160-26-08.4 of the Administrative
			 Code;
(6)
									Rule 5160-26-09.1 of the Administrative
			 Code;
(7)
									Rule
			 5160-26-10
			 of the Administrative Code with the exceptions of paragraphs (B)(2)(c),
			 (B)(2)(d), and (B)(2)(e); and
(8)
									Rule
			 5160-26-11
			 of the Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-59 - OhioRISE › Section 5160-59-02.1 - OhioRISE: first day eligibility and enrollment

Current through all regulations passed and filed through July 1, 2024
(A)
								Scope. This rule
			 sets forth the provisions for eligibility and enrollment into Ohio resilience
			 through integrated systems and excellence (OhioRISE) on the first day the
			 program is effective. Individuals that do not meet the OhioRISE first day
			 eligibility criteria described in paragraph (B) of this rule will have the
			 opportunity to be enrolled in OhioRISE as set forth in rule 5160-59-02 of the
			 Administrative Code.
(B)
								Eligibility. For individuals who meet criteria in
			 paragraphs (B)(1) to (B)(4) of this rule, enrollment will be mandatory in the
			 OhioRISE program on the first day the program is in effect:
(1)
									Be twenty years
			 of age or younger;
(2)
									Be determined eligible for Ohio medicaid in accordance
			 with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code;
(3)
									Not enrolled in a
			 MyCare Ohio plan as described in Chapter 5160-58 of the Administrative Code on
			 the first day the program is in effect; and
(4)
									Meet one or more
			 of the following criteria:
(a)
										Within six months prior to the effective date of the
			 OhioRISE program had an admission into an out of state psychiatric residential
			 treatment facility (PRTF) as defined in
			 42 C.F.R.
			 441.150 (October 1, 2021) to
			 42 C.F.R.
			 441.184 (October 1, 2021), or had an
			 inpatient admission to a hospital, as defined in Chapter 5160-2 of the
			 Administrative Code, with a primary diagnosis of mental illness or substance
			 use disorder; or
(b)
										Within three months prior to the effective date of the
			 OhioRISE program:
(i)
											Received intensive home-based treatment (IHBT) as
			 described in rule
			 5160-27-05
			 of the Administrative Code; or
(ii)
											Met the criteria
			 described in either paragraph (A)(4) or (A)(5) in rule 5160-59-02 of the
			 Administrative Code; or
(iii)
											Received the intensive behavioral support rate add-on
			 at an intermediate care facility for individuals with intellectual disabilities
			 as described in rule
			 5123-7-28
			 of the Administrative Code; or
(iv)
											Be seventeen
			 years of age or younger and receive services in a developmental center as
			 defined in section
			 5124.01 of the
			 Revised Code; or
(c)
										 Within two
			 months prior to the effective date of the OhioRISE program:
(i)
											Received
			 substance use disorder residential treatment services as described in rule
			 5122-29-09
			 of the Administrative Code; or
(ii)
											While in the
			 custody of a Title IV-E agency as defined in rule
			 5101:2-1-01
			 of the Administrative Code, was placed in a children's residential center or
			 was a parent in a residential parenting facility as described in rule 5101:2-9
			 of the Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-59 - OhioRISE › Section 5160-59-03 - OhioRISE: covered services

Current through all regulations passed and filed through July 1, 2024
(A)
								The Ohio
			 resilience through integrated systems and excellence (OhioRISE) plan has to
			 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 medically
			 necessary 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 OhioRISE plan has placed a
			 preidentified limitation to ensure the limitation may be exceeded when
			 medically necessary;
(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 described in this rule through an OhioRISE plan network provider, the
			 OhioRISE plan has to adequately and timely cover the services out of network,
			 until the OhioRISE plan is able to provide the services from a network
			 provider.
(6)
									Providers delivering services in the OhioRISE program
			 will adhere to the incident management criteria set forth in rule
			 5160-44-05
			 of the Administrative Code.