reglab/statecodes huggingface dataset:
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-41 - Nursing facilities (NFs): placement into peer groups

Current through all regulations passed and filed through July 1, 2024
(A) NF peer groups
			 shall be assigned according to sections
			 5165.16
								, 5165.17, and
			 5165.19 of the Revised Code
			 based on the provider's geographical location and the number of licensed beds
			 reported on the provider's annual cost report for the calendar year preceding
			 the fiscal year for which the rate is established.
(1) For a provider new to the medicaid
			 program, the Ohio department of medicaid (ODM) shall initially determine the
			 number of beds in the facility from the number of licensed beds documented in
			 the 
									provider's licensure application as verified by the
			 Ohio department of health (ODH). ODM shall subsequently determine the number of
			 beds in the facility from the number of licensed
			 beds reported on the provider's annual cost report.
(2) In the case of a change of operator, the
			 entering operator shall be assigned to the peer group that had previously been
			 assigned to the exiting operator on the day immediately preceding the date on
			 which the change of operator occurred. ODM shall subsequently determine the
			 number of beds in the facility from the number of licensed beds reported on the
			 entering provider's annual cost report.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-42 - Nursing facilities (NFs): chart of accounts

Current through all regulations passed and filed through July 1, 2024
(A) The Ohio department of medicaid (ODM)
			 requires that all facilities file cost reports annually to comply with section
			 5165.10 of the Revised Code.
(1) The chart of accounts in table 1 to table
			 8 of appendix A to this rule is to establish the minimum level of detail to
			 allow for cost report preparation.
(2) If the chart of accounts in appendix A to
			 this rule is not used by the provider, it is the responsibility of the provider
			 to relate its chart of accounts directly to the cost report.
(3) Where a chart of accounts number has
			 sub-accounts that relate directly to a cost report line item, the provider
			 shall capture the information requested so that the information will be broken
			 out for cost reporting purposes.
(4) For example, when revenue accounts appear
			 by payer type, it is required that those charges be reported by payer type
			 where applicable; when salary accounts are differentiated between "supervisory"
			 and "other," it is required that this level of detail be reported on the cost
			 report where applicable.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-42.3 - Nursing facilities (NFs): capital asset and depreciation guidelines

Current through all regulations passed and filed through July 1, 2024
(A)
								Depreciation on buildings, components, and equipment
			 used in the provision of patient care that are not reimbursable by medicaid
			 directly to the medical equipment supplier may be paid
			 for through the NF per diem rate.
(B) For purposes of determining if an
			 expenditure should be capitalized, NF providers are to refer to the centers for
			 medicare and medicaid services (CMS) publication 15-1, Chapter 1 entitled
			 "Depreciation," (December 15, 2011), available on the internet at
http://www.cms.gov/
, and shall use the
			 following guidelines:
(1) Any expenditure for
			 an item that costs five thousand dollars or more and has a useful life of two
			 or more years per item must be capitalized and depreciated over the asset's
			 useful life.
(2) A provider may use
			 a capitalization policy less than five thousand dollars per item, but is
			 required to obtain prior approval from the Ohio department of medicaid (ODM) if
			 the provider wishes to change its capitalization policy from its initial
			 capitalization policy.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-42.4 - Nursing facilities (NFs): non-reimbursable costs

Current through all regulations passed and filed through July 1, 2024
The following costs are not reimbursable to NFs through the NF
				per diem, except as specified under Chapter 5160-3 of the
				Administrative Code. Non-reimbursable costs include but are not limited
				to:
(A) Fines or penalties paid under
			 sections 
									5165.1010
								,
			 
									5165.72
								 to
			 
									5165.77
								,
			 
								
									5165.83, and
			 5165.99
								 of the Revised
			 Code.
(B) Disallowances made during
			 the audit of NF cost reports that are sanctioned through
			 adjudication in accordance with Chapter 119. of the Revised Code.
(C) Costs 
								that exceed
			 prudent buyer tests of reasonableness 
								that may be applied pursuant to the provisions of
			 the centers for medicare and medicaid services (CMS)
			 publication 15-1 "Provider Reimbursement Manual" (rev. 9/28/15) during the audit of NF cost
			 reports.
(D)
								Costs of ancillary services
			 rendered to NF residents by providers who bill medicaid directly. Ancillary
			 services include but are not limited to
			 physicians, legend drugs, radiology, and laboratory.
(E)
								
								Costs per case-mix units in excess of the
			 applicable peer group ceiling for direct care costs.
(F) Expenses in excess of the capital costs
			 limitations.
(G) Expenses
			 associated with lawsuits filed against the Ohio department of
			 medicaid (ODM)
								
								that are not
			 upheld by the courts.
(H)
								
								Costs of
			 meals sold to visitors or the public (e.g., meals on
			 wheels).
(I)
								
								Costs of
			 supplies or services sold to nonfacility residents or the public. (J) 
								Costs of
			 operating a gift shop.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-43 - Nursing facilities (NFs): method for establishing the total prospective rate. [Rescinded]

Current through all regulations passed and filed through July 1, 2024
Rescinded eff 2-2-06
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-43.2 - Nursing facilities (NFs): case mix classification system - resource utilization groups (RUG)

Current through all regulations passed and filed through July 1, 2024
The Ohio department of medicaid (ODM)
				shall pay each eligible NF a per resident per day rate for direct care costs
				established prospectively for each facility. The department shall establish
				each facility's rate for direct care costs semiannually. Each facility's rate
				for direct care costs shall be based on a case mix payment system.
(A)
								 The Ohio
			 medicaid case mix payment system for direct care contains the following core
			 components:
(1)
									
			 As set forth in rule 5160-3-43.1 of the Administrative Code, a uniform resident
			 assessment instrument (minimum data set version 3.0 (MDS 3.0 )), that provides
			 the data used to group residents into case mix categories. The MDS 3.0 includes
			 section S. Information regarding section S is available on the ODM website at
http://medicaid.ohio.gov/PROVIDERS/ProviderTypes/LongTermCareFacilities.aspx
.
(2)
									 A methodology for grouping residents into case mix
			 groups in a way that is clinically meaningful and uses criteria that
			 sufficiently differentiates one group from another, as provided in paragraphs
			 (B) to (E) of this rule.
(3)
									 A means of measuring the relative costliness of caring
			 for residents in one group versus another, known as "relative resource
			 weights," as described in paragraph (D) of this rule.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-43.3 - Nursing facilities (NFs): calculation of case mix scores

Current through all regulations passed and filed through July 1, 2024
(A) The definitions
			 of all terms used in this rule are the same as set forth in rules
			 5160-3-01,
			 5160-3-43.1, and 5160-3- 43.4 of the Administrative Code.
(B) To determine resident case mix scores,
			 the Ohio department of medicaid (ODM) shall process resident assessment data
			 submitted by NFs in accordance with rule 5160-3-43.1 of the Administrative
			 Code, and shall classify residents in accordance with rule 5160-3-43.2 of the
			 Administrative Code. These resident case mix scores, based on relative resource
			 weights calculated in accordance with rule 5160-3-43.2 of the Administrative
			 Code, are used to establish two quarterly facility average case mix scores each
			 quarter.
(1) The first quarterly facility
			 average case mix score shall be calculated using all records selected for the
			 quarter and shall be the quarterly facility average total case mix
			 score.
(2) The second quarterly
			 facility average case mix score shall be calculated using only the records
			 selected for the quarter that ODM identifies as medicaid records and shall be
			 the quarterly facility average medicaid case mix score.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-43.4 - Nursing facilities (NFs): exception review process

Current through all regulations passed and filed through July 1, 2024
(A) The definitions
			 of all terms not defined in this rule are the same as set forth in rules
			 5160-3-01 and 5160-3- 43.1 of the Administrative
			 Code.
(1) "Combination review" is a type of
			 exception review where the Ohio department of medicaid
			 (ODM) reviews records selected in one of the following ways:
(a) A combination of records selected
			 pursuant to random and targeted criteria.
(b) Records initially selected for a targeted
			 review, but insufficient records were available to meet the targeted review
			 sample size requirements,  combined with
			 randomly selected records to complete the sample size.
(c) Records initially selected for a random
			 review, combined with records selected for a
			 targeted review as a result of findings of the random review.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-50 - Nursing facilities (NFs): use of additional dollars as a result of rebasing of rates

Current through all regulations passed and filed through July 1, 2024
(A)
								Definitions.
For purposes of this rule:
(1)
									"Ancillary and
			 support costs," "cost center," "direct care costs," "rebasing" and "tax costs"
			 have the same meaning as in section
			 5165.01 of the
			 Revised Code.
(2)
									"Cost center report" means a report submitted to the
			 Ohio department of medicaid (ODM) by a nursing facility provider that
			 identifies the amount spent on each cost center included in
			 rebasing.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-57 - Nursing facilities (NFs): tax costs payment rate

Current through all regulations passed and filed through July 1, 2024
(A)
								The Ohio department of medicaid (ODM) shall pay a
			 provider a per medicaid day payment rate for tax costs determined under section
			 5165.21 of the Revised Code
			 except for the initial rate for new providers. ODM shall determine each new
			 nursing facility's initial per medicaid day payment rate for tax costs in
			 accordance with section
			 5165.151 of the Revised
			 Code.
(B)
								For purposes of calculating the initial rate for tax
			 costs pursuant to division (A)(4)(a) of section
			 5165.151 of the Revised Code, a
			 new nursing facility shall provide ODM with the facility's projected tax costs
			 for the calendar year in which the new nursing facility obtains an initial
			 provider agreement. The projected tax costs may include any of the type of tax
			 costs reportable on schedule "B-1" of the medicaid nursing facility cost
			 report, which is available at
			 http://medicaid.ohio.gov/PROVIDERS/ProviderTypes/LongTermCareFacilities/AutomatedCostReporting.aspx.
			 The projected tax costs must be accompanied by the state and county tax records
			 and assessments supporting the projection. The tax records and assessments
			 provided must be for amounts payable by the new provider. If such state and
			 county tax records and assessments are not available, the new facility may
			 provide any other documentation satisfactory to ODM that verifies the amount
			 and type of tax costs reportable on schedule "B-1" of the medicaid nursing
			 facility cost report,
(1)
									If any documentation required under this rule is not
			 received within thirty days of approval of the initial provider agreement or is
			 determined to be unsatisfactory, the initial tax rate shall be the statewide
			 median tax rate for tax costs for the new facility's peer group in which the
			 facility is placed under division (B) of section
			 5165.16 of the Revised
			 Code.
(2)
									The effective date of the initial tax cost rate for a
			 new nursing facility shall be the same as the effective date of the new
			 facility's medicaid provider agreement.
(3)
									All documentation
			 required under this rule shall be submitted to "Ohio Department of Medicaid,
			 Fiscal Operations - Rate Setting Section, P.O. Box 182709, Columbus, Ohio
			 43215-3414."
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-64 - Nursing facilities (NFs): payment for medicare part A cost sharing

Current through all regulations passed and filed through July 1, 2024
(A) For nursing
			 facility services the nursing facility provides on or after January 1, 2012,
			 "medicaid maximum allowable amount" means one hundred per cent of the nursing
			 facility's medicaid rate on the date that the service was provided.
(B) For qualified medicare beneficiaries
			 (QMB)  as defined in rule
			 5160:1-3- 02.1 of the Administrative Code and medicaid
			 consumers admitted to a nursing facility as a medicare part A benefit, the Ohio
			 department of medicaid (ODM) will pay as cost
			 sharing for nursing facility services the lesser of:
(1) The coinsurance amount as provided by the
			 medicare part A plan; or
(2) The
			 medicaid maximum allowable amount for the identified service or services minus
			 the medicare part A plan's payment to a nursing facility for the same service
			 or services. If the medicare part A plan's payment to a nursing facility for a
			 service or services identified is greater than the medicaid maximum allowable
			 amount, ODM will pay nothing for the same identified service
			 or services.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-64.1 - Nursing facilities (NFs): payment for cost-sharing other than medicare part A

Current through all regulations passed and filed through July 1, 2024
(A) For medicaid eligible NF residents, the
			 NF per diem rate includes medicaid payments for medicare or other third-party
			 insurance cost-sharing, including coinsurance or deductible payments,
			 associated with services that are included in the NF per diem
			 rate.
(B) Neither the medicaid eligible NF resident
			 nor the Ohio department of medicaid (ODM) is responsible for any medicare or
			 other third-party insurance cost-sharing, including coinsurance or deductibles,
			 associated with services that are included in the NF per diem
			 rate.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-65 - Nursing facilities (NFs): rates for providers with an initial date of certification on or after July 1, 2006

Current through all regulations passed and filed through July 1, 2024
(A)
								In accordance
			 with section 5165.151 of the Revised
			 Code,
								the Ohio department of medicaid (ODM) shall determine
			 the initial rate for the fiscal year in which the NF begins participation in
			 the medicaid program for a NF with a first date of licensure and subsequent
			 certification on or after July 1, 2006, including a NF that replaces one or
			 more existing facilities, or a NF with a first date of licensure before
			 July 1,
			 2006 that was initially certified for the medicaid program on or after
			 July 1,
			 2006 under section
			 5165.151 of the Revised Code.
(1) If the number of beds in the replacement
			 facility is greater than the number of beds in the replaced facility, the case
			 mix score shall be equal to the weighted average of the semiannual case mix
			 score used for the replaced beds on the last day of service at the replaced
			 facility and the median annual average case mix score for the NF's peer group
			 for the additional beds.
(2) If a
			 rate for direct care costs is determined under section
			 5165.151 of the Revised Code for
			 a NF using the median annual average case mix score for the NF's peer group,
			 the rate shall be redetermined to reflect the NF's actual semiannual case mix
			 score determined under section
			 5165.192 of the Revised Code
			 after the NF submits its first two quarterly assessment data that qualify for
			 use under paragraph (E) of rule 5160-3-43.3 of the Administrative Code. If the
			 NF's quarterly submissions do not qualify for use in calculating a case mix
			 score, ODM shall continue to use the median annual average case mix score for
			 the NF's peer group in lieu of the NF's semiannual case mix score until the NF
			 submits two consecutive quarterly assessment data that qualify for use in
			 calculating a case mix score.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-65.1 - Nursing facilities (NFs): rates for providers that change provider agreements

Current through all regulations passed and filed through July 1, 2024
(A)
								An entering
			 operator's initial rate shall be the rate the exiting operator would have
			 received had the exiting operator continued to participate in the medicaid
			 program.
(B)
								The rate determined in paragraph (A) of this rule shall
			 not be subject to adjustment until the following state fiscal
			 year.
(C)
								After the end of the state fiscal year in which the
			 entering operator began participation in the medicaid program, the rates for
			 subsequent state fiscal years for other than direct care costs shall be set in
			 accordance with sections
			 5165.01 to
			 5165.49 of the Revised
			 Code.
(D)
								After the end of the state fiscal year in which the
			 entering operator began participation in the medicaid program, the rate for
			 direct care costs for the second state fiscal year shall be redetermined to
			 reflect the entering operator's actual semiannual case mix score determined
			 under section 5165.192 of the Revised Code
			 after the NF submits its first two quarterly assessment data that qualify for
			 use under paragraph (E) of rule 5160-3-43.3 of the Administrative Code. If the
			 entering operator's quarterly submissions do not qualify for use in calculating
			 a case-mix score, the median annual average case-mix score for the entering
			 operator's peer group shall be used to calculate a case-mix score in lieu of
			 the entering operator's actual semiannual case-mix score until the entering
			 operator submits two consecutive quarterly assessment data that qualify for use
			 under paragraph (E) of rule 5160-3-43.3 of the Administrative Code. The rate
			 for direct care costs for subsequent state fiscal years shall be set in
			 accordance with sections
			 5165.01 to
			 5165.49 of the Revised
			 Code.
Replaces: 5160-3- 65.1
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-70 - Nursing facilities (NFs): appeals for special focus facilities (SFFs) proposed for termination from the medicaid program

Current through all regulations passed and filed through July 1, 2024
(A)
								Appeal.
(1)
									A nursing
			 facility may appeal under Chapter 119. of the Revised Code an order pursuant to
			 section
			 5165.771
			 of the Revised Code terminating a nursing facility's participation in the
			 medicaid program as provided in this rule.
(2)
									A nursing
			 facility may only appeal the length of time the facility has been listed in a
			 table as described in division (B) of section
			 5165.771
			 of the Revised Code.
(3)
									The appeal is to be submitted by the nursing facility
			 to the Ohio department of medicaid (ODM) within forty-eight hours of the
			 nursing facility's receipt of the termination order.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-80 - Health care isolation centers

Current through all regulations passed and filed through July 1, 2024
(A)
								Definitions
For purposes of this rule,
(1)
									) "Congregate
			 settings" include nursing facilities, residential care facilities, assisted
			 living facilities, and other designated facilities where individuals reside and
			 receive services.
(2)
									"COVID-19 care needs" are the following levels of
			 clinical care needed by an individual with an active or convalescent COVID-19
			 infection or who has other health care needs and necessitates quarantine
			 following exposure to COVID-19:
(a)
										Individuals at the quarantine level have been exposed
			 to COVID-19 but have no symptoms and do not have a probable or positive
			 COVID-19 diagnosis. They need close monitoring.
(b)
										Individuals with
			 "level one" care needs have minor symptoms and can generally recover safely at
			 home. Individuals with level one care needs should only be admitted to an HCIC
			 if their health care and isolation needs cannot be met due to circumstances
			 related to their living situation.
(c)
										Individuals with
			 "level two" care needs need oxygen or other respiratory treatment and careful
			 monitoring for deterioration.
(d)
										Individuals with
			 "level three" care needs do not need hospitalization but their health care
			 needs may necessitate care beyond a traditional nursing facility's
			 capacity.
(e)
										Individuals with "level four" care needs are at level
			 three and are deteriorating and need hospitalization. They require urgent
			 assessment by medical personnel and may need intensive care.
(3)
									"COVID-19 level of care" is a level of care comparable to
			 that needed for admission to a nursing home, a COVID-19 diagnosis (tested or
			 probable), and a physician order.
(4)
									"Health care
			 facility" is a licensed or certified facility that provides medical
			 care.
(5)
									"Health care isolation center (HCIC)" is a setting that
			 provides a COVID-19 level of care or a quarantine level of care. The HCIC will
			 serve both individuals post hospitalization who are not ready to return to
			 their prior residence due to medical care and isolation or quarantine needs,
			 and individuals who cannot receive needed care in their congregate setting but
			 whose level of need does not rise to the level of hospitalization. HCICs should
			 not be used for clinically stable individuals who can be treated safely where
			 they live, including a nursing facility.
(6)
									"Quarantine level
			 of care" means a level of care comparable to that needed for admission to a
			 nursing home, exposure to COVID-19 which necessitates quarantine, and a
			 physician order.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-90 - Authorization for the Ohio department of developmental disabilities (DODD) to administer the medicaid program for services provided by intermediate care facilities for individuals with intellectual disabilities (ICFs-IID)

Current through all regulations passed and filed through July 1, 2024
(A) The Ohio
			 department of developmental disabilities (DODD), through an interagency
			 agreement with the Ohio department of medicaid (ODM), and with oversight by
			 ODM, administers the medicaid program for services provided by intermediate
			 care facilities for individuals with intellectual disabilities (ICFs-IID)
			  in accordance with section
			 5162.35 of the Revised Code.
			 Pursuant to section 5162.021 of the Revised Code,
			 DODD may develop rules and policies governing the administration of the ICF-IID
			 program, which 
								are filed in 
								Chapter
			 5123-7
								 of the Administrative
			 Code upon review and approval by ODM .
(B) In collaboration with DODD, ODM
			 
								will
			 create and implement oversight measures related to the ICF-IID program in
			 accordance with Chapter 5124. of the Revised Code. Reviews may consist of, but
			 are not limited to, physical inspections of records and sites where services
			 are provided, and interviews of providers and recipients of ICF-IID services.
			 ICF-IID providers 
								will provide any records related to the
			 administration or provision of ICF-IID
			 services to ODM, the centers for medicare and medicaid services (CMS), the
			 medicaid fraud control unit, and any of their designees in accordance with the
			 medicaid provider agreement.
(C)
			 ODM will monitor payment made under authority of this rule as necessary to
			 ensure that funding is used for authorized purposes in compliance with federal
			 and state laws, regulations, and policies governing the medicaid program. ODM
			 and DODD may recover any overpayment identified by requesting voluntary
			 repayment, or through provider payment offsets, or formal adjudicatory or
			 non-adjudicatory recovery proceedings.
(D) Whenever an applicant for or recipient of
			 ICF-IID services is affected by any action proposed or taken by DODD
			 
								or
			 ODM, the entity recommending or taking the action will provide medicaid due
			 process in accordance with section
			 5101.35 of the Revised Code and
			 as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code. Such
			 actions may include, but are not limited to, the approval, denial, or
			 termination of enrollment or a denial of ICF-IID services. If an applicant or
			 enrollee requests a hearing related to an action taken by DODD, the
			 participation of DODD is 
								necessary during the hearing proceedings to
			 justify the decision under appeal.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-4 - Physician Services › Section 5160-4-01 - Specific provisions for services rendered by a physician

Current through all regulations passed and filed through July 1, 2024
(A) Separate payment
			 may be made for covered professional services rendered by a physician employed
			 by or under contract with a facility such as a hospital or longterm care
			 facility (i.e., a "facility-based" physician) only if the following
			  conditions are met:
(1) The services contribute directly to the
			 diagnosis or treatment of an individual patient;
(2) Any applicable requirements set forth in
			 agency 5160 of the Administrative Code are satisfied; and
(3) The expenses associated with the
			 provision of the professional services are excluded from the cost report of the
			 facility.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-4 - Physician Services › Section 5160-4-02 - Healthcare services provided under supervision

Current through all regulations passed and filed through July 1, 2024
(A) Definitions that
			 apply to this rule.
(1) "Independent
			 practitioner" is a practitioner who, under Ohio law, may provide
			 
									healthcare services without
			 supervision.
(2) "Non-independent
			 practitioner" is a practitioner who, under Ohio law, may provide
			 
									healthcare services only with
			 supervision.
(3) "Supervision" is a
			 collective term encompassing two types of professional oversight:
(a) A practitioner providing direct
			 supervision is present in the practice setting, although not necessarily in the
			 same room, and is immediately available to provide assistance and direction
			 throughout the provision of services. Neither availability by telephone nor
			 presence nearby outside the practice setting constitutes direct
			 supervision.
(b) A practitioner
			 providing general supervision is available, although not necessarily present in
			 the practice setting, to provide assistance and direction throughout the
			 provision of services. A practitioner who is not physically present
			 
										has the capability to provide
			 immediate consultation by communications device and can travel to the practice
			 setting quickly in case of emergency.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-4 - Physician Services › Section 5160-4-02.3 - Exception for certain services provided by residents

Current through all regulations passed and filed through July 1, 2024
(A)
								The provisions set forth in paragraph (B) of rule
			 5160-4-02
			 of the Administrative Code do not apply when both of the following criteria are
			 met:
(1)
									A
			 healthcare service is provided by a resident participating in an approved
			 graduate medical education (GME) program; and
(2)
									The conditions
			 specified in
			 42
			 C.F.R. 415.174 (October 1, 2020) are
			 satisfied.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-4 - Physician Services › Section 5160-4-03 - Services provided by a physician assistant

Current through all regulations passed and filed through July 1, 2024
(A)
								Definitions.
(1)
									"Physician assistant" has the same meaning as in
			 Chapter 4730. of the Revised Code.
(2)
									"Physician" has
			 the same meaning as in section
			 4730.01
			 of the Revised Code.
(3)
									"Health care facility" has the same meaning as in
			 section
			 4730.01
			 of the Revised Code.
(4)
									"Service" has the same meaning as in section
			 4730.01
			 of the Revised Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-4 - Physician Services › Section 5160-4-04 - Services provided by an advanced practice registered nurse (APRN)

Current through all regulations passed and filed through July 1, 2024
(A) Definition.
			 "Advanced practice registered nurse (APRN)" has the same meaning as in Chapter
			 4723-08 of the Administrative Code. The term encompasses a certified registered
			 nurse anesthetist (CRNA), clinical nurse specialist (CNS), certified
			 nursemidwife (CNM), and certified nurse practitioner (CNP).
(B) Coverage.
(1) Unless a specific exception is noted, all
			 other rules in agency 5160 of the Administrative Code that pertain to services
			 rendered by a physician apply also to services rendered by an APRN.
(2)
									
									For a covered service rendered
			 by an APRN, payment may be made only if the
			 following conditions are met:
(a) The service is
			 rendered to 
										an
			 Ohio-medicaid-eligible individual in a state in which the APRN
			 is licensed or authorized to practice;
(b) The service is
			 within the scope of practice of the APRN's specialty;
(c)
			 The APRN personally rendered the service to an individual patient;
			 and
(d) The service cannot
			 be performed by someone who lacks the skills and training of an APRN.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-4 - Physician Services › Section 5160-4-06 - Specific provisions for evaluation and management (E&M) services

Current through all regulations passed and filed through July 1, 2024
(A) Site-related provisions. Policies
			 concerning payment for evaluation and management (E&M) services may depend
			 on the site in which the services are provided.
(1) Ambulance. Policies for E&M services
			 provided during ambulance transport by hospital staff members are set forth in
			 rule 5160-2-04 of the Administrative
			 Code. Payment for E&M services provided during ambulance transport by
			 practitioners who are not hospital staff members is subject to the following
			 conditions:
(a) Such services involve direct
			 face-to-face contact between a practitioner and the individual being
			 transported, which begins when the practitioner assumes responsibility for the
			 care of the individual at the point of pickup and ends when the receiving
			 facility assumes this responsibility. Remote direction of emergency care en
			 route (e.g., communication by radio with a physician located in a hospital) is
			 not direct face-to-face contact.
(b) Routine monitoring and maintenance (e.g.,
			 the recording of vital information, pulse oximetry, the initiation of
			 mechanical ventilation) is included; no separate payment is made.
(c) Services provided by other members of the
			 transport team (the ambulance crew) cannot be reported by the practitioner as
			 E&M services.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-4 - Physician Services › Section 5160-4-12 - Immunizations, injections and infusions (including trigger - point injections), skin substitutes, and provider-administered pharmaceuticals

Current through all regulations passed and filed through July 1, 2024
(A) General
			 provisions.
(1) A
			 "not otherwise specified," "unlisted," or "miscellaneous" procedure code should
			 be reported on a claim only if no procedure code is available that identifies
			 the particular service or item provided.
(2)
			 No separate payment is made for an immunization, injection, infusion, vaccine,
			 toxoid, or provider-administered pharmaceutical as a medical service if it is
			 provided in a hospital setting (inpatient hospital, outpatient hospital, or
			 hospital emergency department).
(3) A
			 provider-administered pharmaceutical reported on a claim submitted in
			 accordance with Chapter 5160-9 of the Administrative Code is regarded as a
			 pharmacy service rather than a 
									professional medical service, and payment of the
			 claim is governed by the provisions of that chapter. For example, a vaccine,
			 toxoid, or other provider-administered pharmaceutical prescribed for a resident
			 of a long-term care facility (LTCF) and subsequently administered by a LTCF
			 staff member is a pharmacy service.
(4) Payment for an
			 immunization, injection, or infusion includes  related supplies (e.g., alcohol wipes,
			 needles, syringes, and tubing).
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-4 - Physician Services › Section 5160-4-14 - Professional services associated with dialysis

Current through all regulations passed and filed through July 1, 2024
(A)
								Routine
			 maintenance dialysis.
(1)
									Payment for professional services associated with the
			 medical management of patients receiving maintenance dialysis is made either on
			 a monthly capitation basis or on a daily basis.
(a)
										The monthly
			 capitation payment is available to a single practitioner in the following
			 circumstances:
(i)
											The practitioner alone provides monthly continuity of
			 services to a single patient or to a group of patients; or
(ii)
											The practitioner
			 serves as the primary practitioner in a joint provision (in which one person
			 receives payment on behalf of a team of
			 practitioners).
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-4 - Physician Services › Section 5160-4-19 - Allergy services

Current through all regulations passed and filed through July 1, 2024
(A) Purpose. This rule addresses payment for
			 the professional administration and evaluation of allergy sensitivity test
			 procedures, which can be divided into three categories: allergy testing,
			 ingestion challenge testing, and allergen immunotherapy. Payment for related
			 laboratory tests is addressed in Chapter 5160-11 of the Administrative
			 Code.
(B) Coverage.
(1) Allergy testing.
(a)
										
										Testing is only appropriate if there
			 is a reasonable probability, documented in the individual's medical file,
			 that the individual was exposed to the antigen being used for the
			 test.
(b) The unit of service is
			 the test. Payment may be made only for the fewest number of tests necessary to
			 reach a diagnosis.
(c) Payment
			 includes all associated professional services. No payment is made for
			 evaluation and management unless a separately identifiable service is
			 performed.
(d) A qualitative
			 multiallergen screen for allergen-specific immunoglobulin E (IgE) is not
			 considered to be medically necessary.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-4 - Physician Services › Section 5160-4-20 - Chemotherapy

Current through all regulations passed and filed through July 1, 2024
(A)
								Chemotherapy has two components: administration of a
			 chemotherapeutic agent and the chemotherapeutic agent itself. The
			 administration of chemotherapy includes the preparation of the chemotherapeutic
			 agent and all therapeutic services and medical supplies provided during
			 treatment.
(B)
								Coverage.
(1)
									Chemotherapy provided in a hospital setting (inpatient
			 hospital, outpatient hospital, emergency department) is a hospital service, for
			 which payment is made in accordance with Chapter 5160-2 of the Administrative
			 Code. No separate payment is made to a practitioner for either chemotherapy
			 administration or a chemotherapeutic agent provided in a hospital
			 setting.
(2)
									Separate payment may be made for chemotherapy
			 administration that is provided in a non-hospital setting by a practitioner
			 (such as an oncologist) or by a qualified employee supervised by a
			 practitioner. Any place-of-service restriction on this provision is shown in
			 appendix DD to rule
			 5160-1-60 of the
			 Administrative Code.
(3)
									Separate payment may be made for a chemotherapeutic
			 agent that is furnished by a practitioner, represents a cost to the
			 practitioner, and is administered in a non-hospital setting.
(4)
									The process of
			 supervising and monitoring chemotherapy treatment is included in an evaluation
			 and management service (office visit). The actual administration of
			 chemotherapy, however, is a professional service that is independent of
			 evaluation and management. Separate payment may be made for evaluation and
			 management provided in conjunction with chemotherapy administration in a
			 non-hospital setting.
Replaces: 5160-4-20
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-4 - Physician Services › Section 5160-4-21 - Anesthesia 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 the administration or management of anesthesia as a
			 non-institutional professional service rendered by qualified medical
			 practitioners. Provisions governing payment for anesthesia as a dental service
			 are set forth in Chapter 5160-5 of the Administrative Code.
(2) "Base unit" is an anesthesia-related
			 component representing factors other than an anesthetist's time, such as
			 standard pre-operative and post-operative visits, the administration of fluids
			 or blood incident to anesthesia administration, and monitoring.
(3) "Base unit value" is the
			  value for a base unit assigned by
			 the 
									centers for medicare and medicaid services (CMS).
			 A table of procedure codes and their respective base unit
			 values is available from the CMS web site,
https://www.cms.gov
.
(4)
			 "Time unit" is an anesthesia-related component representing the span, reported
			 in minutes, during which an anesthesiologist or a medically-directed or
			 medically-supervised qualified non-physician anesthetist is continuously
			 present. The measured length of the time unit depends on the type of
			 anesthesia.
(a) For neuraxial labor analgesia,
			 the time unit begins when the analgesic is inserted and ends at delivery. Total
			 duration is limited to two hundred forty minutes (four hours).
(b) For all other anesthesia, the time unit
			 begins when the anesthetist starts to prepare the individual for the induction
			 of anesthesia and ends when the presence of the anesthetist is no longer
			 required and the individual may be safely placed under post-anesthetic
			 care.
(5) "Time unit
			 value" is the number of fifteen-minute increments in a time unit, rounded to
			 the nearest tenth.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-4 - Physician Services › Section 5160-4-22 - Surgical services

Current through all regulations passed and filed through July 1, 2024
(A) Coverage.
(1) In general, payment may be made to an
			 eligible provider for performing a medically necessary surgical procedure on
			 
									a medicaid-eligible individual. The following
			 limitations, however, apply.
(a) No separate
			 payment is made to the provider of a surgical service for local infiltration,
			 the administration of general anesthesia or sedation, normal uncomplicated
			 preoperative and postoperative care, or any procedure that is performed
			 incidental to or as an integral part of the operation. On claims, providers
			 should report comprehensive surgical services; they 
										are not to
			 itemize or "unbundle" individual components.
(b) Certain characteristics of a surgical
			 procedure performed on the same patient by the same provider may affect how it
			 is reported on a claim and how payment for it is made.
(i) The Ohio
			 department of medicaid (ODM) recognizes five
			 groups of surgical procedures defined by a particular characteristic:
(a) Multiple procedures, for which payment is
			 reduced when more than one is performed;
(b) Bilateral procedures, for which payment
			 is adjusted when they are performed on both body parts of a corresponding
			 pair;
(c) Co-surgery procedures,
			 for which payment is split between two surgeons , each in a different specialty,
			 
												who
			 perform parts of the same procedure simultaneously.
(d) Assistant-at-surgery procedures, for
			 which payment is reduced when they are performed by an assistant at surgery;
			 and
(e) Procedures performed on
			 fingers, toes, eyelids, or coronary arteries.
(ii) In assigning covered procedures to these
			 groups, ODM follows the policies of the medicare program
			 except when otherwise noted in this rule.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-4 - Physician Services › Section 5160-4-23 - Covered surgical procedures and professional services at ambulatory surgery centers (ASCs)

Current through all regulations passed and filed through July 1, 2024
(A) Payment may be made to an ambulatory
			 surgery center (ASC) in the form of a facility fee only for covered ASC
			 surgical procedures, which are procedures that meet the standards set forth in
			 42 CFR
			 416.166 (October 1, 2017). Such procedures
			 are listed on the department's website
https://medicaid.ohio.gov/resources-for-providers/billing/fee-schedule-and-rates/fee-schedule-and-rates
.
(B) Payment may be made to a physician for
			 performing a covered surgical procedure in an ASC even if the surgery is not
			 itself a covered ASC surgical procedure.
(C) Payment may be made to a physician for
			 performing the professional component of a covered laboratory, radiologic,
			 diagnostic, or therapeutic service in an ASC only if the physician personally
			 performed the service and was not an employee of the ASC at the time.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-4 - Physician Services › Section 5160-4-25 - Radiology and imaging services performed by a practitioner

Current through all regulations passed and filed through July 1, 2024
(A) Coverage.
(1) Total (global) procedure. Payment may be
			 made to a practitioner for performing both the professional and technical
			 components of a radiology or imaging procedure if two conditions are met:
(a) The technical component was not performed
			 in a hospital setting (i.e., an inpatient hospital, an outpatient hospital, or
			 a hospital emergency department); and
(b) The practitioner who submitted the claim
			 either performed the professional component or has an employment or written
			 contractual arrangement with the practitioner who performed the professional
			 component.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-4 - Physician Services › Section 5160-4-26 - Physical medicine and rehabilitation services

Current through all regulations passed and filed through July 1, 2024
(A)
								 Payment may be
			 made for covered physical medicine and rehabilitation services performed by a
			 physician or by a licensed individual under the direct supervision of a
			 physician in accordance with rule
			 5160-4-02
			 of the Administrative Code.
(B)
								 Physical
			 therapy, occupational therapy, speech-language pathology, and audiology are
			 addressed in Chapter 5160-8 of the Administrative Code.
Replaces: Part of 5160-4-26
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-4 - Physician Services › Section 5160-4-33 - Application of topical fluoride varnish by non-dentist providers

Current through all regulations passed and filed through July 1, 2024
(A) Payment may be
			 made not more frequently than once per one hundred eighty days to
			  for the topical application of fluoride
			 varnish to the teeth of a child younger than six years of age.
			 by any of the following practitioners:
(1)
									A
			 physician;
(2)
									A physician assistant; or
(3)
									An advanced
			 practice registered nurse.