Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-1 - General Medicaid Eligibility Policy › Section 5160:1-1-03 - Medicaid: restrictions on payment for services

Current through all regulations passed and filed through July 1, 2024
(A) Medicaid will not pay for services
			 provided under the conditions set out in paragraph (C) of this rule, even
			 when an
			 individual has been found eligible for a medical assistance category and is
			 enrolled in medicaid.
(B)
			 Definitions.
(1) "Inmate" means an individual
			 who is serving time for a criminal offense or who is confined in a state or
			 federal prison, jail, detention facility, or other penal facility.
(2) "Inmate of a public institution" means
			 an
			 individual who is living in a public institution as defined in rule
			 5160:1-1-01 of the
			 Administrative Code.
(a) An individual who is
			 residing in a public institution awaiting criminal proceedings, penal
			 dispositions, or other detainment determinations is considered an inmate. The
			 duration of time that an individual is residing in the public institution
			 awaiting these arrangements does not determine inmate status.
(b) An individual is not considered an inmate
			 when:
(i)
											Residing in a public educational
			 or vocational training institution for purposes of securing education or
			 vocational training; or
(ii)
											Residing in a public institution for a temporary
			 period pending other living arrangements appropriate to his or her needs;
			 or
(iii)
											Residing in a detention center, jail, or county penal
			 facility after his or her case has been adjudicated and other living
			 arrangements are being decided; or
(iv)
											On parole or probation and living in
			 the community;
			 or
(v)
											Serving the remainder of the criminal sentence in a
			 halfway house licensed as such by the Ohio department of rehabilitation and
			 correction (DRC), in accordance with section
			 2967.14 of the Revised Code,
			 which allows for freedom of movement and association as determined by the Ohio
			 department of medicaid (ODM) or its designee.
(3) "Inpatient" means a patient
			 who has been admitted to a medical institution as an inpatient on
			 recommendation of a physician or dentist and who:
(a) Receives room, board, and medical
			 services in the institution for a twenty-four hour period or longer;
			 or
(b) Is expected by the
			 institution to receive room, board, and medical services in the institution for
			 a twenty-four-hour period or longer even though it later develops that the
			 patient dies, is discharged, or is transferred to another facility and does not
			 actually stay in the institution for twenty-four hours.
(4) "Intermediate care facility for
			 individuals with intellectual disabilities" (ICF-IID) is defined in Chapter
			 5160-3 of the Administrative Code.
(5) "Medical institution" means an
			 institution that:
(a) Is organized to provide
			 medical care, including nursing and convalescent care; and
(b) Has the necessary professional personnel,
			 equipment, and facilities to manage the medical, nursing, and other health
			 needs of patients on a continuing basis in accordance with accepted standards;
			 and
(c) Is authorized under state
			 law to provide medical care; and
(d) Is staffed by professional personnel who
			 are responsible to the institution for professional medical and nursing
			 services. The services must include:
(i)
			 Adequate and continual medical care and supervision by a physician;
			 and
(ii) Registered nurse or
			 licensed practical nurse supervision and services and nurses' aid services,
			 sufficient to meet nursing care needs; and
(iii) A physician's guidance regarding the
			 professional aspects of operating the institution.
(6) "Outpatient" means a patient
			 of an organized medical facility or distinct part of that facility who is
			 expected by the facility to receive, and who does receive, professional
			 services for less than a twenty-four-hour period regardless of the hour of
			 admission, whether or not a bed is used, and whether or not the patient remains
			 in the facility past midnight.
(7)
			 "Patient" means an individual who is receiving needed professional services
			 that are directed by a licensed practitioner of the healing arts toward
			 maintenance, improvement, or protection of health, or lessening of illness,
			 disability, or pain.