Ohio Administrative Code

(A) Purpose. This rule implements section 5164.96 of the Revised Code regarding supplemental medicaid payments to eligible emergency medical services organizations operated by a government entity.(B) Definitions applicable to this rule.(1) "Eligible provider" has the same meaning…

(A) Reimbursement for abortion services, other than those identified in paragraph (D) of this rule, is restricted to the following circumstances when the appropriate certification in paragraph (B) of this rule is made:(1) Instances in which the woman suffers from a physical disor…

(A) Definitions.(1) "Freestanding birth center (FBC)" is an entity defined in 42 U.S.C. 1396d(l)(3)(B) (in effect as of January 1, 2023) that is operated in conformity with rules 3701-83-33 to 3701-83-42 of the Administrative Code.(2) "Independent practitioner" and "non-independe…

(A) This rule defines coverage and payment for providers who meet the provisions in sections 5103.60, 5103.602, 5103.603, 5103.6010, 5103.6011, 5103.6017 and 5103.6018 of the Revised Code and the provisions described in this rule.(B) Definitions. For the purpose of this rule the …

(A) For the purpose of rules 5160-19-01 and 5160-19-02 of the Administrative Code, the following definitions apply:(1) "Attribution" is the process through which medicaid recipients are assigned to specific primary care practitioners (PCPs) who are able to participate in the medi…

(A) A comprehensive primary care (CPC) entity has to be enrolled and meet the provisions set forth in rule 5160-19-01 of the Administrative Code to be eligible for patient centered medical home (PCMH) payments.(B) A CPC entity participating in the CPC for kids program has to be e…

The "comprehensive maternal care (CMC) program" is a maternal and infant support program that utilizes a comprehensive care coordination and service model incorporating supportive services for expectant and postpartum women to reduce adverse birth and infant outcomes.(A) For purp…

(A) All hospitals, except those excluded in paragraph (A)(2) of this rule, that meet medicare (Title XVIII) conditions of participation as described in 42 C.F.R. 482 effective as of October 1, 2025, are eligible to participate in the Ohio medicaid (Title XIX) program upon executi…

For purposes of Chapter 5160-2 of the Administrative Code, the following definitions apply, unless the context clearly indicates otherwise:(A) "Diagnosis related groups (DRGs)" is a patient classification system that reflects clinically cohesive groupings of services that consume…

(A) Conditions and limitations applicable to both inpatient and outpatient hospital services.(1) Coverage of provider-based physician services reimbursable as an inpatient or outpatient hospital service is limited to those services reimbursable under medicare, part A, except as p…

(A) Drugs.(1) Drugs are classified as: administered inpatient (drugs administered to a patient while an inpatient); administered outpatient (drugs administered to a patient at the hospital in connection with outpatient services); take-home (drugs dispensed on an outpatient basis …

(A) Definitions in Chapter 5160-2 of the Administrative Code.(1) "Cancer hospitals" are hospitals recognized by medicare that primarily treat neoplastic disease in accordance with 42 C.F.R. 412.23(f), effective October 1, 2025.(2) "Children's hospitals" are hospitals that primari…

This rule sets forth the data used to determine assessments and adjustments, and the data policies that are applicable for each program year for all providers of hospital services included in the definition of "hospital" as described under section 5168.01 of the Revised Code.(A) …

(A) Applicability.The requirements of this rule apply as long as the United States centers for medicare and medicaid services (CMS) determines that the assessment imposed under section 5168.06 of the Revised Code is a permissible health care related tax. Whenever the department o…

This rule is applicable for each program year for all medicaid-participating providers of hospital services included in the definition of "hospital" as described under section 5168.01 of the Revised Code.(A) Definitions.(1) "Total fee for service (FFS) medicaid costs" for each ho…

This rule is applicable for each program year for all medicaid-participating psychiatric hospitals as described in paragraphs (B) to (D) of rule 5160-2-01 of the Administrative Code.(A) Definitions for each psychiatric hospital.(1) "Cash subsidies for inpatient services received …

(A) Appeals. Pursuant to Chapter 5160-70 of the Administrative Code, final settlements that are based upon final audits by the department may be appealed by hospitals under Chapter 119. of the Revised Code. Rule 5160-2-24 of the Administrative Code describes final fiscal audits a…

(A) The Ohio department of medicaid (ODM) will perform or contract with a medical review entity to perform utilization review for medicaid inpatient services regardless of the payment methodology used for reimbursement of those services. For the purposes of this rule, "ODM" means…

(A) In accordance with section 5168.14 of the Revised Code, each hospital that receives payment under the provisions of Chapter 5168. of the Revised Code, will provide, without charge to the individual, basic, medically necessary hospital-level services to the individual who is a…

This rule applies to all hospital services excluded from the inpatient hospital and outpatient hospital prospective payment systems.(A) Applicability.(1) Cost-related reimbursement, where payments are made for services to approximate cost based on a historical cost-to-charge rati…

(A) For cost-reporting purposes, each eligible provider, as defined in rule 5160-2-01 of the Administrative Code, is to submit periodic reports that generally cover a consecutive twelve-month period of the provider's operations. Failure to submit all necessary items and schedules…

(A) General provisions.(1) Audits will be conducted by the Ohio department of medicaid for services rendered by the hospital under the medicaid program. The examination of hospital costs and charges will be made in consideration with generally accepted auditing standards necessar…

Rule 5160-1-08 of the Administrative Code sets forth general provisions that the department make payment for covered services only after any available third-party benefits are exhausted. In addition, this rule identifies other provisions applicable to services provided by hospita…

This rule sets forth the assessment rate for the hospital franchise fee program implemented under sections 5168.20 to 5168.28 of the Revised Code.(A) DefinitionsFor purposes of this rule, ''total facility costs'' are as defined in section 5168.20 of the Revised Code, and excludes…

(A) Definitions.For purposes of this rule, the following definitions apply:(1) A "hospital" is a provider eligible under rule 5160-2-01 of the Administrative Code.(2) "Medical necessity" is as defined in rule 5160-1-01 of the Administrative Code.(3) "Pre-certification" is a proce…

Effective for services or discharges on or after the effective date of this rule, payments made to Ohio hospitals under the prospective payment systems or non-diagnostic related groups (DRG) and non-ambulatory patient grouping (EAPG) prospective payment systems will receive a cos…

This rule sets forth the payment policies for inpatient hospital services for discharges on or after the effective date of this rule.(A) Hospitals defined as eligible providers of hospital services in rule 5160-2-01 of the Administrative Code and grouped in paragraph (B)(1) of ru…

This rule outlines the calculation of capital payments for hospitals that are subject to the all patient refined diagnosis related groups (APR-DRG) prospective payment methodology, effective for dates of discharges occurring on or after January 1, 2024.(A) For purposes of this ru…

Effective for dates of discharge on or after the effective date of this rule, to qualify for a medical education payment as described in this rule, Ohio hospitals must have an approved medical education program as defined in 42 C.F.R. 415.152 (October 1, 2016) and the costs of th…

For the purposes of this rule, eligible providers of hospital services, as defined in rule 5160-2-01 of the Administrative Code, and assigned to prospective payment peer groups as defined in rule 5160-2-05 of the Administrative Code, are subject to the enhanced ambulatory patient…

(A) This rule establishes a consumer co-payment for non-emergency emergency department services as authorized by section 5162.20 of the Revised Code.(B) For purposes of this rule, the following definitions apply.(1) "Emergency medical condition" means a medical condition manifest…

(A) Notwithstanding the provisions of rules 5160-2-65 and 5160-2-75 of the Administrative Code, long-acting reversible contraceptive (LARC) devices may be billed separately when provided during an inpatient hospitalization.(B) LARC devices may include intrauterine devices (IUD) a…

The following definitions apply to rule 5160-20-04 of the Administrative Code(A) "Abuse" means recipient practices that result in unnecessary cost to the medicaid program as defined in rule 5160-26-01 of the Administrative Code.(B) "Abuse potential drug" means any drug that conta…

(A) The coordinated services program (CSP) provides continuity of care, helps reduce inappropriate or unnecessary utilization of pharmacy services, fraud, and excessive use, waste, or abuse of prescribed abuse potential drugs. A recipient enrolled in CSP remains eligible for all …

(A) Principles.(1) Medicaid-eligible individuals have access to medicaid-covered pregnancy prevention services. This access is not restricted by factors including but not limited to religion, race, color, national origin, disability, age, sex, sexual orientation, gender identity,…

(A) Definitions.(1) For the purposes of this rule, "hysterectomy" means, in accordance with 42 C.F.R. 441.251 (October 1, 2010 edition), a medical procedure or operation for the purpose of removing the uterus.(2) For the purposes of this rule, "institutionalized individual" means…

(A) Coverage.(1) Unless a different time period is specified, services described in this rule are covered through the pregnancy and the delivery.(2) Basic pregnancy-related services include but are not limited to antepartum care, delivery, outpatient postpartum care, and family p…

(A) Unless otherwise noted, any limitations or conditions specified in the Revised Code or in agency 5160 of the Administrative Code apply to services addressed in this rule.(B) Definitions.(1) "Advanced practice registered nurse (APRN)" has the same meaning as in Chapter 4723-08…

(A) Unless otherwise noted, any limitations or conditions specified in the Revised Code or in agency 5160 of the Administrative Code apply to services addressed in this rule.(B) Definitions applied to this rule. (1) "Eligible provider" has the same meaning as defined in rule 5160…

Effective for dates of service on or after the effective date of this rule, eligible ambulatory surgery centers, as defined in paragraphs (A)(1) and (B) of this rule, are subject to the enhanced ambulatory patient grouping system (EAPG) and prospective payment methodology utilize…

As used in Chapter 5160-26 of the Administrative Code:(A) "Abuse" means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the medicaid program, or in reimbursement for services that are not medically n…

(A) This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code.(B) Eligibility for managed care or…

(A) This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code.(B) The Ohio department of medicaid…

(A) This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code.(B) Except as otherwise provided in…

(A) This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code.(B) A managed care organization (MC…

(A) This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code.(B) The managed care organization (…

(A) Provider contracts.(1) A managed care entity (MCE) must provide or arrange for the delivery of covered health care services described in rule 5160-26-03 of the Administrative Code either through the use of employees or through contracts with network providers of health care s…