reglab/statecodes huggingface dataset:
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-5 - Dental Services › Section 5160-5-01 - Dental services

Current through all regulations passed and
  filed through July 1, 2024
(A) This rule sets forth provisions governing
  payment for professional, non-institutional dental services. Provisions
  governing payment for dental services performed as the following service types
  are set forth in the indicated part of the Administrative Code:
(1) Hospital services, Chapter
  5160-2;
(2) Nursing facility
  services, Chapter 5160-3;
(3)
  Intermediate care facility services, Chapter 5123:2-7;
(4) Federally qualified health center
  services, Chapter 5160-28;
(5)
  Ambulatory surgery center services, Chapter 5160-22; and
(6) Telehealth services, rule
  5160-1-18.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-6 - Vision Care Services › Section 5160-6-01 - Eye care services

Current through all regulations passed and filed through July 1, 2024
(A)
								Scope. This rule
			 sets forth general coverage and payment policy for eye care services.
			 Additional provisions for eye care services provided through a medicaid managed
			 care organization are described in Chapter 5160-26 of the Administrative
			 Code.
(B)
								Definitions.
(1)
									"Eligible provider" has the same meaning as in rule
			 5160-1-17 of the Administrative
			 Code.
(2)
									"Eye care services" is a collective term for the
			 following services and materials involving the health of the eyes:
(a)
										Vision care
			 services, which include the following procedures:
(i)
											Diagnostic and
			 comprehensive examination;
(ii)
											Testing;
(iii)
											Therapeutic
			 treatment;
(iv)
											Lens fitting; and
(v)
											Vision
			 therapy;
(b)
										Vision care materials, which include the following
			 items:
(i)
											Spectacle lenses and frames; and
(ii)
											Contact
			 lenses;
(c)
										Low-vision aids; and
(d)
										Ocular prostheses
			 and prosthesis services.
(3)
									"Participating
			 optical laboratory" is an optical laboratory that is a party to the volume
			 purchasing contract.
(4)
									"Prior authorization" has the same meaning as in rule
			 5160-1-31 of the Administrative
			 Code.
(5)
									"Volume purchase contract," for purposes of this rule,
			 is the current contract designated "medicaid vision volume purchase program:
			 ophthalmic laboratory services and delivery" that is maintained by the Ohio
			 department of administrative services. The contract can be accessed at
https://ohiobuys.ohio.gov/page.aspx/en/ctr/contract_browse_public
.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-7 - Podiatric Services › Section 5160-7-01 - Podiatry services

Current through all regulations passed and filed through July 1, 2024
(A)
								For the purpose
			 of this rule the following definitions apply.
(1)
									"Doctor of
			 podiatric medicine" (or "podiatric physician" or "podiatrist") is as described
			 in section 4731.51 of the Revised
			 Code.
(a)
										Doctors of podiatric medicine are deemed to be physicians
			 only in respect to functions they are legally authorized to perform in
			 accordance with section
			 4731.51 of the Revised Code and
			 rule
			 4731-20-02
			 of the Administrative Code.
(b)
										For purposes of
			 medicaid coverage and payment, an intern or resident of podiatric medicine is
			 not a podiatric physician. This exclusion applies even if an intern or resident
			 is authorized to practice as a podiatric physician under the laws of the state
			 in which services are performed or a resident holds a staff or faculty
			 appointment or is designated as a fellow. For purposes of medicaid coverage and
			 payment, an intern or resident of podiatric medicine is not a podiatric
			 physician.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-8 - Therapeutic and Diagnostic Services › Section 5160-8-05 - Behavioral health services - other licensed professionals

Current through all regulations passed and filed through July 1, 2024
(A) Scope. This
			 rule sets forth provisions governing payment for behavioral health services
			 provided by certain licensed professionals in non-institutional settings.
(1) Provisions governing payment for
			 behavioral health services as the following service types are set forth in the
			 indicated part of the Administrative Code:
(a) Cost-based clinic services, Chapter
			 5160-28; and
(b) Medicaid school
			 program services, Chapter 5160-35.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-8 - Therapeutic and Diagnostic Services › Section 5160-8-11 - Chiropractic services

Current through all regulations passed and filed through July 1, 2024
(A) Scope. This rule sets forth provisions
			 governing payment for professional, non-institutional spinal manipulation and
			 related diagnostic imaging services.
(B) Providers.
(1) Rendering providers. The following
			 eligible providers may render a service described in this rule:
(a) A chiropractor,
										 defined in
			 Chapter 4734. of the Revised Code.
(b) A mechanotherapist,
										 defined in
			 Chapter 4731. of the Revised Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-8 - Therapeutic and Diagnostic Services › Section 5160-8-30 - Skilled therapy: scope and definitions

Current through all regulations passed and filed through July 1, 2024
(A)
								 Rules
			 5160-8-31
			 to
			 5160-8-34
			 of the Administrative Code set forth provisions governing payment for skilled
			 therapies as non-institutional professional services. Provisions governing
			 payment for skilled therapies as the following service types are set forth in
			 the indicated part of the Administrative Code:
(1)
									 Hospital
			 services, Chapter 5160-2;
(2)
									 Nursing facility services, Chapter
			 5160-3;
(3)
									 Home health services, Chapter 5160-12;
(4)
									 Clinic services
			 rendered by the following providers:
(a)
										 Fee-for-service ambulatory health care clinics,
			 Chapter 5160-13;
(b)
										 Rural health clinics, Chapter 5160-16;
(c)
										 Federally
			 qualified health centers, Chapter 5160-28; or
(d)
										 Outpatient
			 health facilities, Chapter 5160-29;
(5)
									 Medicaid school
			 program services, Chapter 5160-35; and
(6)
									 Intermediate
			 care facility services, Chapter 5123:2-7.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-8 - Therapeutic and Diagnostic Services › Section 5160-8-32 - Skilled therapy: coverage

Current through all regulations passed and filed through July 1, 2024
(A)
								 Payment may be
			 made for a skilled therapy service if the following conditions are met:
(1)
									 The service is
			 medically necessary, in accordance with rule
			 5160-1-01
			 of the Administrative Code.
(2)
									 The service is
			 rendered on the basis of a clinical evaluation and assessment and in accordance
			 with a treatment plan. (Audiology must meet this condition in order to be
			 considered skilled therapy for purposes of this chapter.) The performance of a
			 clinical evaluation and assessment and the development of a treatment plan are
			 discrete services; payment for them is made separately from payment for skilled
			 therapy. The clinical evaluation and assessment and the treatment plan are
			 described in rule
			 5160-8-33
			 of the Administrative Code; copies must be kept on file by the
			 provider.
(3)
									 The amount, frequency, and duration of treatment is
			 reasonable. For rehabilitative services, the maximum treatment period without
			 reevaluation is sixty days; for developmental services, the maximum treatment
			 period without reevaluation is six months.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-8 - Therapeutic and Diagnostic Services › Section 5160-8-33 - Skilled therapy: documentation of services

Current through all regulations passed and filed through July 1, 2024
(A)
								 A clinical
			 evaluation and assessment of the need for skilled therapy services includes the
			 following elements:
(1)
									 A diagnosis of the type and severity of the disorder
			 or a description of the deficit in physical or sensory
			 functionality;
(2)
									 A review of the individual's current physical,
			 auditory, visual, motor, and cognitive status;
(3)
									 A case history,
			 including, when appropriate, family perspectives on the individual's
			 development and capacity to participate in therapy;
(4)
									 The outcomes of
			 standardized tests and any non-standardized tests that use age-appropriate
			 developmental criteria;
(5)
									 Other test results and interpretation;
(6)
									 An evaluation
			 justifying the provision of skilled therapy services, which may be expressed as
			 one of two prognoses of the patient's rehabilitative or developmental
			 potential:
(a)
										
			 The patient's functionality is expected to improve within sixty days after the
			 evaluation because of the delivery of rehabilitative skilled therapy services
			 or within six months after the evaluation because of the delivery of
			 developmental skilled therapy services, and the patient is expected to attain
			 full functionality or make significant progress toward expected developmental
			 milestones within twelve months; or
(b)
										 The patient is
			 not expected to attain full functionality or make significant progress toward
			 expected developmental milestones within twelve months, but a safe and
			 effective maintenance program may be established; and
(7)
									 Any
			 recommendations for further appraisal, follow-up, or referral.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-8 - Therapeutic and Diagnostic Services › Section 5160-8-34 - Skilled therapy: payment

Current through all regulations passed and filed through July 1, 2024
(A) If more than one skilled therapy service
			 
								of
			 the same discipline (e.g., physical therapy) is rendered by
			 the same
								
			 non-institutional provider or provider group to
			 
								a recipient on the same date, then the service
			 with the highest payment amount specified in
			 appendix DD to rule
			 5160-1-60 of the
			 Administrative Code is considered  the
			 primary procedure. The maximum payment amount for a skilled therapy service is the
			 lesser of the provider's submitted charge or a percentage of the amount
			 specified in appendix DD to rule
			 5160-1-60 of the
			 Administrative Code, determined in the following manner:
(1) For 
									the first unit
			 of a primary procedure,  one
			 hundred per cent.
(2) For each
			 additional unit or procedure
			 within the same therapy discipline,
			 
									eighty per cent.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-8 - Therapeutic and Diagnostic Services › Section 5160-8-35 - Skilled therapy services

Current through all regulations passed and filed through July 1, 2024
(A) Scope. This rule sets forth provisions
			 governing payment for skilled therapies as non-institutional professional
			 services furnished by skilled therapists and skilled therapist assistants or
			 aides. Provisions governing payment for skilled therapies as the following
			 service types are set forth in the indicated part of the Administrative Code:
(1) Hospital services, Chapter
			 5160-2;
(2) Nursing facility
			 services, Chapter 5160-3;
(3)
			 Physical medicine services furnished by or under the supervision of a
			 physician, advanced practice registered nurse, or physician assistant, Chapter
			 5160-4;
(4) Physical medicine
			 services furnished by or under the supervision of a podiatrist, Chapter
			 5160-7;
(5) Home health services,
			 Chapter 5160-12;
(6)
									
									Services rendered by the following providers:
(a)
										
										Ambulatory health care
			 clinics, Chapter 5160-13; or
(b)
										
										Federally qualified health centers (FQHCs) or rural health
			 clinics (RHCs), Chapter 5160-28;
(7) Medicaid school program services, Chapter
			 5160-35; and
(8) Intermediate care
			 facility services, Chapter 5123:2-7.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-8 - Therapeutic and Diagnostic Services › Section 5160-8-41 - Services provided by a dietitian

Current through all regulations passed and filed through July 1, 2024
(A)
								Providers.
(1)
									Rendering
			 providers. The following practitioners, defined in Chapter 4759. of the Revised
			 Code, may enroll in medicaid as eligible providers of dietitian services:
(a)
										A licensed
			 dietitian; and
(b)
										A registered dietitian.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-8 - Therapeutic and Diagnostic Services › Section 5160-8-42 - Lactation consultation services

Current through all regulations passed and filed through July 1, 2024
(A)
								Scope and
			 definitions.
(1)
									This rule sets forth provisions governing payment for
			 professional, non-institutional lactation consulting services.
(2)
									"Lactation
			 consultation" is the development and implementation of management strategies
			 for complex problems related to breastfeeding and human
			 lactation.
(3)
									"International Board Certified Lactation Consultant"
			 (IBCLC) is a professional member of the healthcare team who has earned and
			 maintains the credential which identifies knowledge and expertise in
			 breastfeeding management and care. This includes insight, skills, and knowledge
			 to identify complex breastfeeding problems and to educate, promote, and
			 facilitate an optimal breastfeeding experience and environment.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-8 - Therapeutic and Diagnostic Services › Section 5160-8-52 - Services provided by a pharmacist

Current through all regulations passed and filed through July 1, 2024
(A) Definition. "Pharmacist" has the same
			 meaning as in Chapter 4729:1-1 of the Administrative Code.
(B) Providers. An individual pharmacist may
			 enroll in medicaid as a pharmacist provider.
(C) Coverage.
(1) Payment may be made only for a pharmacist
			 service for which the following criteria are met:
(a) The service is within a pharmacist's
			 scope of practice;
(b) The service
			 is medically necessary in accordance with rule
			 5160-1-01
			 of the Administrative Code;
(c) For
			 a service rendered by prescription, the pharmacist provider obtains an order
			 issued by a practitioner having appropriate prescriptive authority and
			 maintains supporting documentation; and
(d) The service is rendered for one of the
			 following purposes:
(i) Managing medication
			 therapy under a consulting agreement with a prescribing practitioner pursuant
			 to section
			 4729.39
			 of the Revised Code;
(ii)
			 Administering immunizations in accordance with section
			 4729.41 of
			 the Revised Code; or
(iii)
			 Administering medications in accordance with section
			 4729.45
			 of the Revised Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-8 - Therapeutic and Diagnostic Services › Section 5160-8-51 - Acupuncture services

Current through all regulations passed and filed through July 1, 2024
(A)
								Definitions.
(1)
									"Acupuncture" has the same meaning as in Chapter 4762.
			 of the Revised Code.
(2)
									"Eligible provider" has the same meaning as in rule
			 5160-1-17 of
			 the Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-8 - Therapeutic and Diagnostic Services › Section 5160-8-53 - Diabetes prevention and self-management training

Current through all regulations passed and filed through July 1, 2024
(A)
								Definitions. For the purposes of this rule, the
			 following definitions apply:
(1)
									"Diabetes self-management training" (DSMT) is the
			 education and instruction of an individual with diabetes by a qualified
			 provider for the purpose of providing the individual with necessary skills and
			 knowledge to participate in the management of the individual's diabetes,
			 including the self-administration of injectable drugs.
(2)
									"National
			 Diabetes Prevention Program" (NDPP) is an evidence-based, educational and
			 support program administered by the centers for disease control and prevention
			 (CDC) designed to assist at-risk individuals from developing type 2
			 diabetes.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-9 - Pharmacy Services › Section 5160-9-01 - Pharmacy services: definitions

Current through all regulations passed and filed through July 1, 2024
(A)
								Covered
			 drugs.
(1)
									"Compounded prescriptions" are prescription drugs made by
			 combining two or more drugs. Active pharmaceutical ingredients (API) and
			 excipients are listed on the ODM pharmacy program website at
https://pharmacy.medicaid.ohio.gov
.
(2)
									"Covered prescribed drug" means a drug covered by the
			 Ohio department of medicaid (ODM) pharmacy program, or a managed care plan
			 entity as defined in rule
			 5160-26-01 of the Administrative
			 Code. Covered prescribed drugs are prescribed drugs that are dispensed to an
			 eligible recipient for use in the recipient's residence, including a nursing
			 facility (NF), as defined in section
			 5165.01 of the Revised Code, or
			 intermediate care facility for individuals with intellectual disabilities
			 (ICF/IID), as defined in section
			 5124.01 of the Revised Code, and
			 fall into one of the following categories:
(a)
										"Dangerous drugs"
			 as defined in section
			 4729.01 of the Revised Code that
			 meet the definition of a "covered outpatient drug (COD)" as defined in
			 42 C.F.R.
			 447.502 (November 19, 2021) that are not
			 non-covered drugs.
(b)
										Over-the-counter (OTC) drugs listed on the "OH PBM OTC
			 List" located on the ODM pharmacy website at
https://pharmacy.medicaid.ohio.gov
. The list is updated regularly and is recorded with the
			 effective date included in each new version.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-9 - Pharmacy Services › Section 5160-9-02 - Pharmacy services: medical supplies and durable medical equipment

Current through all regulations passed and filed through July 1, 2024
(A)
								Eligible pharmacies in the Ohio medicaid program may
			 bill for medical supplies and durable medical equipment in accordance with
			 Chapter 5160-10 of the Administrative Code, with the following
			 stipulations:
(1)
									The provider must:
(a)
										Apply to, and be
			 approved by, the Ohio department of medicaid (ODM) to be eligible to dispense
			 medical supplies/durable medical equipment; and
(b)
										Use the same
			 medicaid provider number as when billing for pharmaceuticals;
			 and
(c)
										Be licensed, registered, or exempt from licensure or
			 registration under Chapter 4761. of the Revised Code to bill for home medical
			 equipment that is subject to regulation under Chapter 4752. of the Revised
			 Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-9 - Pharmacy Services › Section 5160-9-03 - Pharmacy services: covered drugs and associated limitations

Current through all regulations passed and filed through July 1, 2024
(A) Covered
			 prescribed drugs
Drugs covered by the Ohio department of medicaid (ODM) pharmacy
				program, or a managed care 
									entity as defined in rule
				5160-26-01 of the Administrative
				Code, are prescribed drugs as defined in rule
				5160-9-05 of the Administrative
				Code that are dispensed to an eligible 
									recipient for
				use in the 
									recipient's residence, including a nursing facility
				(NF), as defined in section
				5165.01 of the Revised Code, or
				intermediate care facility for individuals with intellectual disabilities
				(ICF/IID), as defined in section
				5124.01 of the Revised Code, and
				fall into one of the following categories:
(1) "Dangerous drugs" as defined in section
			 4729.01 of the Revised Code that
			 meet the definition of a "covered outpatient drug (COD)" as defined in
			 42 C.F.R.
			 447.502
									
									(November 19, 2021) that are
			 not non-covered drugs as described in paragraph (B) of this rule.
(2) Over-the-counter (OTC) drugs listed 
									on
			 the "OH PBM OTC List" located on the ODM pharmacy website at
https://pharmacy.medicaid.ohio.gov
. The list is updated regularly and is recorded with the
			 effective date included in each new version.
(3) Compounded prescriptions in accordance
			 with paragraph (E) of this rule, when compounded with ingredients described in
			 paragraphs (A)(1) to (A)(2) of this rule or with active pharmaceutical
			 ingredients (API) and excipients listed on the ODM pharmacy program
			 
									website at
https://pharmacy.medicaid.ohio.gov
.
(4)
									 Vaccines, inoculations, and
			 immunizations, other than  influenza and coronavirus
			 vaccines, are covered under fee-for-service by the ODM pharmacy program only
			 for residents of a NF or ICF/IID; otherwise these services
			 
									should
			 be billed as physician services in accordance with Chapter 5160-4 of the
			 Administrative Code. 
									Influenza and coronavirus
			 vaccines may be billed by the pharmacy for
			 
									a
			 recipient who is not a resident of a NF or ICF/IID if the vaccine will be
			 administered at the pharmacy, or for 
									a recipient who is a resident
			 of a NF or ICF/IID to be administered by facility staff.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-9 - Pharmacy Services › Section 5160-9-04 - Pharmacy services: drug utilization review

Current through all regulations passed and filed through July 1, 2024
(A)
								
								Recipient
			 profiles, prospective drug utilization review (DUR), and
			 
								recipient counseling
(1)
									
									Recipient
			 profiles, prospective DUR and 
									recipient counseling must be performed for
			 medicaid 
									recipients by medicaid pharmacy providers in
			 accordance with 
									agency 4729 of the Administrative Code.
(2) Documentation and records required by
			 
									agency 4729 of the Administrative Code must be
			 maintained in accordance with rule
			 5160-1-17.2 of the
			 Administrative Code.
(3) In
			 addition to the prospective DUR required in paragraphs (A)(1) and (A)(2) of
			 this rule, the Ohio department of medicaid (ODM) or its designee will also
			 perform prospective DUR at the time of claim adjudication and may deny claims
			 that exceed limitations described in rule
			 5160-9-03 of the Administrative
			 Code or that, on their own or in combination with other claims previously
			 adjudicated, have been determined to have a high risk for fraud, waste, abuse,
			 or clinically significant adverse medical results. Denials may be overridden by
			 ODM or its designee through the prior authorization process in cases where
			 medical necessity has been determined.
(4) Prospective DUR
			 
									is
			 performed for the purpose of identifying prescriptions that may not be
			 therapeutically appropriate, as described in paragraphs (B)(1)(b) to (B)(1)(j)
			 of this rule.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-9 - Pharmacy Services › Section 5160-9-05 - Pharmacy services: payment for prescribed drugs

Current through all regulations passed and filed through July 1, 2024
(A)
								Payment for
			 prescribed drugs is the lesser of the provider's billed charges or the
			 calculated allowable, after any coordination of benefits is applied as
			 described in paragraph (E) of this rule. For prescribed drugs that are subject
			 to a co-payment, the amount paid by the Ohio department of medicaid (ODM) is
			 decreased by the amount equal to the co-payment billed to the recipient in
			 accordance with rules
			 5160-1-09 and
			 5160-9-09 of the Administrative
			 Code.
(B)
								The ingredient cost portion of the calculated allowable
			 is determined in accordance with the following criteria:
(1)
									No ingredient
			 cost is allowed for a pandemic vaccine or any other medication, provided by the
			 Ohio department of health or other government entity at no cost to the
			 provider.
(2)
									For any drug purchased under the 340B program, the
			 ingredient cost is the lesser of submitted ingredient cost or the 340B ceiling
			 price. If the 340B ceiling price is not available, the ingredient cost is the
			 lesser of the submitted ingredient cost or fifty per cent of wholesale
			 acquisition cost (WAC) If WAC is not available, the ingredient cost is the
			 lesser of submitted ingredient cost or Ohio average acquisition cost
			 (OAAC).
(3)
									For a clotting factor, the ingredient cost is the
			 lesser of submitted ingredient cost or the payment limit shown in the current
			 medicare part B drug pricing file, minus the furnishing fee assigned by
			 medicare part B. The medicare part B pricing file is available at
https://www.cms.gov
.
(4)
									For all other ingredients not captured in paragraphs
			 (B)(1) to (B)(3) of this rule the ingredient cost is the lesser of submitted
			 ingredient cost or national average drug acquisition cost (NADAC). If the
			 centers for medicare and medicaid services (CMS) has not published a NADAC for
			 the ingredient for the date of service, the ingredient cost is the lesser of
			 submitted ingredient cost, OAAC, or WAC.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-9 - Pharmacy Services › Section 5160-9-06 - Pharmacy services: billing requirements, record keeping requirements, and cost of dispensing survey.

Current through all regulations passed and filed through July 1, 2024
(A) The pharmacy claims submitted to the Ohio department of medicaid (ODM)
			 or its designee, the pharmacy point-of-sale vendor, must reflect the actual
			 national drug code (NDC) on the container from which the product was
			 dispensed.
(B) All records of
			 prescriptions must comply with federal and state regulations and
			  be retained by the provider for a
			 period of six years from the date of payment of the claim and if an audit is
			 initiated during this time, records must be retained until the audit is
			 resolved.
(C) For a pharmacy claim
			 to be eligible for payment by ODM, any prescription executed in written (and
			 non-electronic) format must be executed on a tamper-resistant form.
(1) To be considered tamper resistant, a
			 prescription form must contain all of the following three characteristics:
(a) One or more features designed to prevent
			 unauthorized copying of a completed or blank prescription form;
(b) One or more features designed to prevent
			 the erasure or modification of information written on the prescription by the
			 prescriber; and
(c) One or more
			 features designed to prevent the use of counterfeit prescription
			 forms.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-9 - Pharmacy Services › Section 5160-9-07 - Pharmacy services: drug coverage review process

Current through all regulations passed and filed through July 1, 2024
(A) For a drug to be considered for
			 coverage without prior authorization in accordance
			 with rule 5160-9-03 of the Administrative Code, the following
			 information may be requested from the manufacturer or labeler:
(1) Trade name of the drug.
(2) Generic name of the drug.
(3) National drug code number
			 (NDC).
(4) Package sizes
			 available.
(5) Strengths.
(6) Therapeutic use(s).
(7) List of therapeutic
			 ingredients.
(8) Direct, average
			 wholesale price, wholesale acquisition cost and average manufacturer
			 price.
(9) Bioavailability and
			 bioequivalency data.
(10) Letter(s)
			 of approval of new drug application (NDA), or abbreviated new drug application
			 (ANDA).
(11) Product labeling as
			 approved by the food and drug administration.
(12) A statement of justification for
			 
									coverage without
			 prior authorization including cost effectiveness and relative
			 merits.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-9 - Pharmacy Services › Section 5160-9-09 - Pharmacy services: co-payments

Current through all regulations passed and filed through July 1, 2024
(A) Adults eligible for the medicaid program
			 will pay a three dollar co-payment for prescribed drugs that require prior
			 authorization and a two dollar co-payment for selected trade name prescribed
			 drugs as indicated in the list specified in paragraph (C) of rule
			 5160-9-03 of the Administrative
			 Code.
(B) Rules
			 5160-1-09 and
			 5160-1-60 of the Administrative
			 Code establish additional requirements regarding co-payments.
(C) Rule
			 5160-1-09 of the Administrative
			 Code establishes exceptions to the requirement that an individual pay a
			 co-payment.
(D) The exception
			 established in paragraph (C)(4) of rule
			 5160-1-09 of the Administrative
			 Code regarding emergency services does not extend to drugs prescribed to an
			 individual during a visit to a hospital, clinic, office, emergency department,
			 or other provider setting, that are intended to be used by the individual
			 outside of the provider setting.
(E) No provider of pharmacy services may deny
			 a prescribed drug to an individual eligible for medicaid coverage because the
			 individual is unable to pay the co-payment. The provisions of paragraph (B) of
			 rule 5160-1-09 of the Administrative
			 Code apply to co-payments for prescribed drugs dispensed by a provider eligible
			 to be paid for pharmacy services.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-9 - Pharmacy Services › Section 5160-9-10 - Ohio average acquisition cost (OAAC) appeal and managed care pharmacy dispensing fee modification request

Current through all regulations passed and filed through July 1, 2024
(A)
								Ohio average
			 acquisition cost (OAAC) appeal.
(1)
									OAAC is the average acquisition cost of a product
			 calculated based on surveys submitted by pharmacy providers enrolled with the
			 Ohio department of medicaid (ODM).
(a)
										The OAAC rate does not account for off-invoice
			 adjustments between pharmacy providers and wholesalers or manufacturers and is
			 reflective of the market conditions specific to enrolled Ohio pharmacy
			 providers.
(b)
										The OAAC rate is recalculated utilizing surveys issued
			 to pharmacy providers semiannually, in April and October.
(c)
										Rates are updated
			 weekly based on published pricing and market fluctuations.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-01 - Durable medical equipment, prostheses, orthoses, and supplies (DMEPOS): general provisions

Current through all regulations passed and filed through July 1, 2024
(A)
								Scope.
(1)
									This rule sets
			 forth general coverage and payment policies for durable medical equipment
			 (DME), prostheses, orthotic devices, medical supplies, and supplier services
			 dispensed or rendered by an enrolled DMEPOS provider.
(2)
									Additional
			 conditions specific to a particular DMEPOS item or service may be set forth in
			 other rules in this chapter of the Administrative Code.
(3)
									Policies set
			 forth in other rules in this chapter supersede any provisions in this rule with
			 which they conflict.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-02 - DMEPOS: repair

Current through all regulations passed and filed through July 1, 2024
(A) Definitions.
(1) "Major repair" is a repair for which the
			 combined medicaid allowed amounts for materials and labor exceed one hundred
			 twenty dollars for an orthotic or prosthetic device or one hundred dollars for
			 any other item.
(2) "Minor repair"
			 is a repair for which the combined medicaid allowed amounts for materials and
			 labor do not exceed one hundred twenty dollars for an orthotic or prosthetic
			 device or one hundred dollars for any other item. Reporting a major repair on a
			 claim as a series of minor repairs is not permitted.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-07 - DMEPOS: bathing seats

Current through all regulations passed and filed through July 1, 2024
(A) Definitions and explanations.
(1) "Assistance," for purposes of this rule,
			 is help with bathing-related tasks that individuals cannot accomplish by
			 themselves, such as getting into and out of a bathing chair, moving in and out
			 of the bathing area, or fastening and unfastening securements and positioners.
			 The term does not include actual bathing (soaping, shampooing, scrubbing,
			 rinsing).
(2) "Bathing seat" is a
			 collective term for an item or device that enables an individual to sit
			 securely and comfortably while taking a bath or shower.
(3) The primary healthcare purpose of a
			 bathing seat is to promote cleanliness. Certain bathing seats can also function
			 as commodes, and many commodes can be used as bathing seats. An item that
			 functions equally well as a bathing seat and as a commode is deemed to be a
			 commode for medicaid payment purposes.
(4)
									Prior
			 authorization (PA) may be given only if a face-to-face evaluation of need has
			 been performed not earlier than one hundred eighty days before the submission
			 of the PA request.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-08 - DMEPOS: high-frequency chest wall oscillation (HFCWO) devices

Current through all regulations passed and filed through July 1, 2024
(A) Coverage.
(1) Payment may be made for a high-frequency
			 chest wall oscillation (HFCWO) device on a rental/purchase basis.
(2)
									Purchase of a
			 HFCWO device will not be considered without an initial trial period lasting at
			 least two months, excluding any portion that coincides with an inpatient
			 hospital stay. Payment may be made for rental during this trial period.
(3)
									The default
			 certificate of medical necessity (CMN) is form ODM 10229, "Certificate of
			 Medical Necessity: High-Frequency Chest Wall Oscillation Devices"
			 (7/2018).
									A CMN 
									includes the following elements:
(a) Evidence of a respiratory condition for
			 which a HFCWO device is an appropriate treatment, including but not limited to
			 the following examples:
(i) A diagnosis of
			 cystic fibrosis that has not been ameliorated by any other treatment;
(ii) A diagnosis of another respiratory
			 condition that produces chronic, excessive, retained bronchopulmonary
			 secretions; or
(iii) A medical
			 history of chronic or recurrent respiratory infections that
			 
											necessitate antibiotic treatment and multiple
			 hospitalizations and are unresolved by other bronchial hygiene
			 therapy;
(b) If
			 applicable, documentation that other airway-clearance treatments are
			 ineffective or contraindicated;
(c)
			 Specification of the duration and frequency of therapy; and
(d) If applicable, specification of other
			 individuals (e.g., siblings) with whom equipment is to be shared.
(4) If use of the HFCWO device is
			 to be continued in a residential setting after the initial trial period, the
			 CMN 
									is revised to include the following information:
(a) An attestation to the effectiveness of
			 the device during the trial period and every previous rental period;
(b) If applicable, specification of a change
			 in the duration or frequency of therapy; and
(c) A recommendation either for additional
			 rental or for purchase.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-11 - DMEPOS: hearing aids

Current through all regulations passed and filed through July 1, 2024
(A) Definition. "Basic hearing test" is an
			 evaluation of an individual's ability to hear that includes the following
			 components:
(1) Testing of air-conducted
			 stimuli at thresholds of five hundred hertz (Hz), one thousand Hz, two thousand
			 Hz, and four thousand Hz;
(2)
			 Assessment of air-conducted speech awareness or speech reception
			 threshold;
(3) Establishment of
			 most comfortable and most uncomfortable listening levels;
(4) Pure-tone bone conduction audiometry
			 (unless the individual's age or capability precludes such testing);
			 and
(5) For an individual younger
			 than twenty-one years of age, the following components:
(a) Tympanometry;
(b) Acoustic reflex battery; and
(c) Otoacoustic emissions testing.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-13 - DMEPOS: oxygen

Current through all regulations passed and filed through July 1, 2024
(A) Definitions.
(1) "Blood gas study" is the measurement of
			 such characteristics of blood as the partial pressure of oxygen (PO2) or oxygen
			 saturation. The term applies either to pulse oximetry or to an arterial blood
			 gas (ABG) study.
(2) "Group I" and
			 "group II" criteria are sets of clinical indicators used to determine the
			 coverage of oxygen without prior authorization.
(a) Group I criteria.
(i) If the individual is tested while awake
			 and at rest, either of the following measures applies:
(a)
												Arterial PO2 of fifty-five millimeters of mercury (mm
			 Hg) or less; or
(b)
												Arterial oxygen saturation at or below eighty-eight per
			 cent.
(ii) If the
			 individual is tested while ambulating, either of the following measures
			 applies:
(a) Arterial PO2 of fifty-five mm Hg
			 or less during ambulation without oxygen, with documented improvement during
			 ambulation with oxygen; or
(b)
			 Arterial oxygen saturation at or below eighty-eight per cent during ambulation
			 without oxygen, with documented improvement during ambulation with
			 oxygen.
(iii) If the
			 individual is tested while asleep, any of the following measures applies:
(a) Arterial PO2 of fifty-five mm Hg or
			 less;
(b) Arterial oxygen
			 saturation at or below eighty-eight per cent;
(c) A decrease in arterial PO2 of more than
			 ten mm Hg, associated with symptoms of or signs reasonably attributable to
			 hypoxemia; or
(d) A decrease in
			 arterial oxygen saturation of more than five per cent, associated with symptoms
			 of or signs reasonably attributable to hypoxemia.
(b) Group II criteria.
(i) Either of the following measures applies:
(a) Arterial PO2 of at least fifty-six mm Hg
			 and not more than fifty-nine mm Hg; or
(b) Arterial oxygen saturation at or above
			 eighty-nine per cent.
(ii) In addition, at least one of the
			 following conditions applies:
(a) Dependent
			 edema suggestive of congestive heart failure;
(b) Pulmonary hypertension or cor pulmonale,
			 determined by measurement of pulmonary artery pressure, gated blood pool scan,
			 echocardiogram, or the presence of P pulmonale on an EKG; or
(c) Erythrocythemia with a hematocrit greater
			 than fifty-six per cent.
(3) "Transfill unit" is a device that
			 transfers oxygen from a source such as an oxygen concentrator to portable
			 tanks.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-14 - DMEPOS: compression garments

Current through all regulations passed and filed through July 1, 2024
(A)
			 The default certificate of medical necessity (CMN) form is the ODM 01905,
			 "Certificate of Medical Necessity: Compression Garments" (rev.
			 
								7/2024).
(B) Payment may be made
			 only for compression garments generating a pressure of at least eighteen
			 millimeters of mercury (mm Hg).
(C) For a gradient
			 compression garment, the provider 
								specifies at least one clinical
			 indication such as but not limited to the conditions 
								identified
			 in the following list:
(1)
			 Elephantiasis;
(2)
			 Lymphedema;
(3) Milroy's
			 disease;
(4) Orthostatic
			 hypotension;
(5) Post-thrombotic
			 syndrome;
(6) Stasis
			 dermatitis;
(7) Stasis
			 ulcers;
(8) Symptomatic chronic
			 venous insufficiency (characterized by, for example, pain, swelling, ulcers, or
			 severe varicose veins);
(9) Symptomatic venous
			 insufficiency associated with pregnancy; or
(10)
			 Thrombophlebitis.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-15 - DMEPOS: transcutaneous electrical nerve stimulation (TENS) units

Current through all regulations passed and filed through July 1, 2024
(A) Definitions.
(1) "Accessories" is a collective term that
			 encompasses but is not necessarily limited to the following items:
(a) Adapters;
(b) Clips;
(c) Additional connecting cable for lead
			 wires;
(d) Carrying pouches;
			 and
(e) Covers.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-16 - DMEPOS: wheelchairs

Current through all regulations passed and filed through July 1, 2024
(A) Definitions and explanations.
(1) "Basic equipment package" is the
			 following standard set of parts and accessories that come with a wheelchair at
			 the time of purchase:
(a) A sling or solid
			 seat with back, a captain's chair, or a stadium-style seat;
(b) Standard casters or wheels with
			 tires;
(c) Standard
			 armrests;
(d) Standard front
			 rigging 
										,
			 such as non-elevating legrests with footrestsor a footplate;
(e)
			 Wheel locks or brakes;
(f) With a
			 power mobility device, motors;
(g)
			 With a power mobility device, a non-expandable controller;
(h) With a power mobility device, a battery
			 charger;
(i) With a power
			 wheelchair, a standard proportional joystick; and
(j) With a power-operated vehicle,
			 batteries.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-17 - DMEPOS: pneumatic compression devices

Current through all regulations passed and filed through July 1, 2024
(A)
								Payment may be
			 made directly to a provider for a pneumatic compressor or a related appliance
			 or accessory only if the following conditions are satisfied:
(1)
									The equipment is
			 used to treat either lymphedema in the extremities or chronic venous
			 insufficiency (CVI) with venous stasis ulcers; and
(2)
									
									The prescribing practitioner has determined
			 either that there was no significant improvement or that significant symptoms
			 persisted when one of the following treatments was applied:
(a) For lymphedema in
			 the extremities, four weeks of therapy involving the use of an appropriate
			 compression bandage system or compression garment (either prefabricated or
			 custom-fabricated), exercise, and elevation of the limb; or
(b)
			 For CVI, six months of therapy involving the use of an appropriate compression
			 bandage system or compression garment, appropriate wound dressings, exercise,
			 and elevation of the limb.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-18 - DMEPOS: hospital beds, bed accessories, and pressure-reducing support surfaces

Current through all regulations passed and filed through July 1, 2024
(A) Definitions and explanations.
(1) "Group 1," "group 2," and "group 3" are
			 classes of pressure-reducing support surface.
(a) Group 1 surfaces are generally
			 non-powered pads or overlays that are designed to be placed on top of a
			 hospital bed or standard mattress. They achieve their effect through the
			 application of, for example, a gel layer, air pressure, natural lamb's wool, or
			 synthetic sheepskin. Group 1 may also include some powered systems (alternating
			 pressure or low air loss) that are not classified as group 2.
(b) Group 2 surfaces generally encompass
			 powered air flotation beds, powered air mattresses, and non-powered advanced
			 overlays that are designed to be placed on top of a hospital bed frame or
			 standard bed frame.
(c) Group 3
			 surfaces are generally air-fluidized beds, which simulate the characteristics
			 of fluid by circulating air through a medium such as silicone-coated ceramic
			 beads. They are used for the treatment of stage III or stage IV pressure
			 sores.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-19 - DMEPOS: positive airway pressure devices

Current through all regulations passed and filed through July 1, 2024
(A) Definition. "Apnea-hypopnea index (AHI)"
			 is the mean number of episodes of apnea or hypopnea per hour recorded over a
			 period of at least two hours without the use of a positive airway pressure
			 device, reported by polysomnogram. 
								Extrapolation or
			 projection of the AHI is not permitted.
(B) Coverage.
(1) The default certificate of medical
			 necessity (CMN) form is the ODM 01903, "Certificate of Medical Necessity:
			 Positive Airway Pressure Devices" (rev. 
									7/2021). The
			 CMN 
									includes the following information:
(a) A diagnosis of obstructive sleep apnea
			 or other condition for which positive airway pressure
			 is an appropriate treatment;
(b) The results of a
			 
										respiratory study ;
			 and
(c) An estimated length of
			 need.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-21 - DMEPOS: incontinence garments and incontinence supplies

Current through all regulations passed and filed through July 1, 2024
(A) Coverage.
(1)
									Payment for
			 quantities of incontinence garments or incontinence supplies that exceed the
			 indicated limit is subject to prior authorization (PA). The default
			 certificate of medical necessity (CMN) form is
			 the ODM 02912, "Certificate of Medical Necessity: Incontinence Items" (rev.
			 
									7/2024). The CMN 
									includes the following elements:
(a) An indication that the individual is at
			 least thirty-six months of age;
(b)
			 The applicable diagnosis of the specific disease, injury, developmental delay,
			 or developmental disability causing the incontinence;
(c) The type of incontinence; and
(d) The type and quantity of incontinence
			 garments or incontinence supplies being prescribed.