Ohio Administrative Code

(A) This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code.(B) Notice of action (NOA) by a managed care organization (MCO) or the single pharmacy benefit manager (SPBM).(1) When an adverse benefit determination has occurred or will …

(A) Tort.(1) Pursuant to sections 5160.37 and 5160.38 of the Revised Code, the Ohio department of medicaid (ODM) maintains all rights of recovery (tort) against the liability of any third party payer (TPP) for the cost of medical services.(2) A managed care entity (MCE) is prohib…

(A) This rule does not apply to the single pharmacy benefit manager as defined in rule 5160-26-01 of the Administrative Code.(B) If the MCO fails to fulfill its duties and obligations under 42 C.F.R. Part 438 (October 1, 2021), 42 U.S.C. 1396b(m) (as in effect July 1, 2022), 42 U…

(A) Non-contracting providers of emergency services must accept as payment in full from a managed care organization (MCO) the lesser of billed charges or one hundred per cent of the Ohio medicaid program reimbursement rate (less any payments for indirect costs of medical educatio…

(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 (…

Upon implementation of the Ohio department of medicaid's (ODM) single pharmacy benefit manager (SPBM), ODM or its designees will accept provider claim submissions for pharmaceuticals through ODM's managed care entities (MCEs) in the following manner: (A) Claims for pharmaceutical…

This rule does not apply to the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code. This rule sets the standards and procedures for managing incidents that may have a negative impact on medicaid manag…

(A) For the purposes of this chapter, an "eligible billing provider" is an entity that meets the conditions in paragraph (A)(1) or (A)(2) of this rule. An "eligible rendering provider" is an individual who meets one or more of the conditions stated in paragraphs (A)(3) to (A)(8) …

(A) This rule sets forth coverage and limitations for behavioral health services rendered to medicaid recipients by behavioral health provider agencies who meet all requirements found in agency 5160 of the Administrative Code unless otherwise specified.(1) All claims for behavior…

(A) This rule sets forth the reimbursement requirements and rates for behavioral health services as described in Chapter 5160-27 of the Administrative Code and applies to providers as described in rule 5160-27-01 of the Administrative Code.(B) With the exception of pharmacists as…

(A) For the purposes of medicaid reimbursement, assertive community treatment (ACT) refers to the evidence based model of delivering comprehensive community based behavioral health services to adults with certain serious and persistent mental illnesses who have not benefited from…

(A) For the purpose of medicaid reimbursement, therapeutic behavioral (day treatment), group service-hourly and per diem, is defined as an intensive, structured, goal-oriented, distinct and identifiable group treatment service that addresses the individualized mental health needs…

(A) For the purposes of medicaid reimbursement, therapeutic behavioral services (TBS) are goal-directed supports and solution-focused interventions.(1) Activities included must be intended to achieve the identified goals or objectives as set forth in the individual's treatment pl…

(A) For the purpose of medicaid reimbursement, substance use disorder treatment services shall be defined by and shall be provided according to the American society of addiction medicine also known as the ASAM treatment criteria for addictive, substance related and co-occurring c…

(A) Targeted case management assists an individual receiving alcohol or substance use disorder treatment services from an Ohio department of mental health and addiction services (OhioMHAS) certified substance use disorder treatment program to gain access to needed medical, social…

(A) Behavioral health nursing services are mental health and substance use disorder (SUD) nursing services performed by registered nurses or licensed practical nurses. They include those activities that are performed within professional scope of practice and in authorized setting…

(A) For the purpose of medicaid reimbursement, behavioral health crisis intervention is a timely intervention with medicaid recipients who are experiencing a life threatening or complex emergent situation related to mental illness or a substance use disorder.(1) The goals of cris…

(A) For the purposes of this rule, mobile response and stabilization service (MRSS), is the service as set forth by the Ohio department of mental health and addiction services (OhioMHAS) in rule 5122-29-14 of the Administrative Code.(B) Eligible providers.(1) Providers eligible t…

(A) For the purposes of this rule, behavioral health peer support service is the service as set forth by the Ohio department of mental health and addiction services (OhioMHAS) in rule 5122-29-15 of the Administrative Code.(B) Eligible providers.(1) An eligible rendering provider …

(A) "Change in scope of service" is an alteration in aspects of a prospective payment system (PPS) service such as the procedures or items that are furnished, the frequency with which they are furnished, and the type of personnel who furnish them.(1) A change in scope of service …

(A) Unless otherwise noted, any stipulations or limitations specified in the Revised Code or in agency 5160 of the Administrative Code apply to services rendered by a federally qualified health center (FQHC) or rural health clinic (RHC). Provisions of other rules in agency 5160 o…

(A) A federally qualified health center (FQHC) may receive prospective payment system (PPS) payment for providing any of the following FQHC PPS services:(1) In accordance with section 330 of the Public Health Services Act, 42 U.S.C. chapter 6A (October 1, 2021), medical services,…

(A) Data entered into a cost report should represent "reasonable and allowable costs," which are defined in "Principles of reasonable cost reimbursement," 42 C.F.R. part 413 (October 1, 2021).(B) For purposes of payment determination, an FQHC or RHC submits a cost report in any o…

(A) A discrete, all-inclusive per-visit payment amount (PVPA) is established for each FQHC PPS service provided at an FQHC or related off-site location and for an RHC PPS service provided at an RHC or related off-site location.(1) For all FQHC or RHC sites that are already enroll…

(A) Allowable costs are calculated in accordance with the instructions for the FQHC cost report. Certain restrictions apply:(1) Costs related to direct inpatient care are not allowable.(2) Procedures or items that are not PPS services are not allowable.(3) The straight-line metho…

(A) This rule describes an APM that may be selected, with approval from the Ohio department of medicaid (ODM), by a government-operated FQHC such as a public health department. Under this APM, a government-operated FQHC may receive payment in addition to amounts established under…

(A) The purpose of this rule is to allow a change to the time period of a cost report from which per-visit payment amounts (PVPAs) are derived. This rule applies to cost report time periods affected by a nationwide federal or Ohio public health emergency (PHE) declaration.(B) Thi…

Except as otherwise provided in Chapter 5160-3 of the Administrative Code, and in addition to the definitions in section 5165.01 of the Revised Code:(A) "Allowable costs" has the same meaning as in section 5165.01 of the Revised Code and are determined in accordance with the foll…

In addition to provisions in Chapters 5164. and 5165. of the Revised Code regarding provider agreements, and provisions in rules 5160-3-02.1 and 5160-3-02.2 of the Administrative Code, execution and maintenance of a provider agreement between the Ohio department of medicaid (ODM)…

(A) Definitions.(1) "Reasonable assurance period" means a certain period of time, determined by the centers for medicare and medicaid services (CMS), for which a nursing facility operator whose provider agreement has been involuntarily terminated is required to operate without re…

(A) Written notice.(1) The Ohio department of medicaid (ODM) may terminate, deny, or not revalidate a NF provider agreement upon thirty days written notice to the NF.(2) Notices and termination orders must comply with provisions set forth in sections 5164.38 and 5165.77 of the Re…

(A) Definitions.(1) "Certification" means the process by which the state survey agency certifies its findings to the federal centers for medicare and medicaid services (CMS) or the Ohio department of medicaid (ODM) with respect to a facility's compliance with health, safety, and …

(A) Definitions.(1) For purposes of this rule, the terms "certified beds," "dually participating," "facility," and "religious non-medical health care institution" (RNHCI) are defined in rule 5160-3-02.3 of the Administrative Code.(2) For purposes of this rule, the term "reasonabl…

(A) Purpose.The purpose of this rule is to set forth provisions for the preparation for, response to, and recovery from an emergency or disaster at a NF. The provisions of this rule are in addition to the requirements set forth in sections 5165.77, 5165.80, and 5165.81 of the Rev…

(A) Definitions.(1) "Fines" means civil money penalties (CMPs) and other assessments imposed against a NF as a remedy for deficiencies or a cluster of deficiencies that were not substantially corrected before a survey.(2) "Interest" means the interest rate determined by the tax c…

(A) When ODM is required to provide an adjudicatory hearing pursuant to Chapter 119. of the Revised Code, payment shall continue for medicaid-covered services provided to eligible residents during the appeal of, and the proposed termination or non-revalidation of, a nursing facil…

(A) For the purposes of this rule, the following definitions shall apply:(1) "State survey agency" means for the purpose of medicaid certification, the Ohio department of health (ODH).(2) "Effective date of termination" means the date set by the state survey agency or the United …

(A) For purposes of determining an individual's nursing-facility (NF) based level of care, the following definitions apply unless a term is otherwise defined in a specific rule:(1) "Activity of daily living (ADL)" means a personal or self-care task that enables an individual to m…

(A) The criteria for the protective level of care is met when:(1) The individual's needs for long-term services and supports (LTSS) are less than the criteria for the intermediate or skilled levels of care, as described in paragraphs (A)(4), (B), and (C) of rule 5160-3-08 of the …

(A) The purpose of this rule is to set forth the process by which the Ohio department of medicaid (ODM) shall identify nursing facilities (NFs) that are at risk of becoming IMDs, the preventive measures to be taken by ODM when such facilities have been identified, and the course …

(A) The criteria for the intermediate level of care is met when:(1) The individual's needs for long-term services and supports (LTSS) exceed the criteria for the protective level of care, as described in paragraph (A)(3) of rule 5160-3-06 of the Administrative Code; (2) The indiv…

(A) Level of care determination process, generally:(1) A level of care determination may occur in-person, by a desk review, or by telephone and is one component of medicaid eligibility to receive medicaid payment for services provided in a nursing facility (NF) or through a NF-ba…

(A) The purpose of this rule is to set forth the definitions for terms contained in rules 5160-3-15.1, 5160-3-15.2, 5122-21-03 and 5123-14-01 of the Administrative Code.(B) Definitions:(1) "Adverse determination" means a determination made in accordance with rules 5160-3-15.1, 51…

(A) The purpose of this rule is to set forth the level I and level II preadmission screening requirements pursuant to section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019, to ensure that individuals seeking admission, as defined in rule 5160-3-15 of the Admini…

(A) The purpose of this rule is to set forth resident review requirements in compliance with section 1919(e)(7) of the Social Security Act, as in effect on July 1, 2019, which prohibits nursing facilities (NF) from retaining individuals with serious mental illness (SMI) as define…

(A) A NF may provide private room accommodations, if available, as follows:(1) For a medicaid eligible resident if the resident requires a private room due to medical necessity such as the need for infection control or for therapeutic purposes; or(2) Semi-private or ward accommod…

(A) Definitions.(1) "Home and community-based services" (HCBS) means services that enable individuals to live in a community setting rather than in an institutional setting such as a NF, an intermediate care facility for individuals with intellectual disabilities (ICF-IID), or a …