Ohio Administrative Code

In addition to the provisions contained in sections 5165.10 to 5165.109 of the Revised Code, the following provisions apply.(A) For reporting purposes NFs shall use the chart of accounts for NFs as set forth in rule 5160-3-42 of the Administrative Code, or relate its chart of acc…

(A) A nursing facility provider, or a group or association of nursing facility providers, may request a reconsideration of a prospective NF rate on the basis of a possible error in the calculation of the rate as follows:(1) A request for reconsideration shall be filed with the Oh…

(A) Definitions."Effective FPF termination date" (EFTD) means the date on which the centers for medicare and medicaid services (CMS) determines that the FPF does not qualify for federal financial participation.(B) Determination of the FPF as an impermissible health care related t…

(A) The Ohio department of medicaid (ODM) uses the debt estimation methodology set forth in this rule to estimate the exiting operator's actual and potential debts to ODM and the United States centers for medicare and medicaid services (CMS) under the medicaid program in cases of…

(A) Debt summary reports issued in accordance with section 5165.525 of the Revised Code are served in the same manner as notices issued under rule 5160-70-03 of the Administrative Code.(B) Notice to the Ohio department of medicaid (ODM) of facility closure, voluntary withdrawal o…

(A) Successor liability agreements entered into pursuant to section 5165.521 of the Revised Code are subject to approval by the Ohio department of medicaid (ODM).(B) Successor liability agreements must be signed by the exiting operator, ODM, and the entity assuming liability purs…

(A) For purposes of Section 220.60 of Amended Substitute House Bill 169 of the 134th General Assembly and this rule, a "sale" occurs when a purchase agreement or similar document that outlines the terms of the purchase and results in the payment of money for the business or bed l…

(A) Forms.For dates of services preceding July 1, 2005, NFs shall submit the form "Nursing Facility Payment and Adjustment Authorization" (JFS 09400, rev. 10/2012) directly to the Ohio department of job and family services (ODJFS) for the reimbursement of services.The county depa…

(A) Nursing facilities shall submit claims in accordance with rule 5160-1-19 of the Administrative Code. Additional requirements specific to the submission of long-term care per diem claims are in paragraphs (B) to (E) of this rule.(B) Additional requirements to be met prior to s…

(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…

(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…

(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…

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, a…

(A) As used in this rule:(1) "Annual facility average case mix score" is the score used to calculate the facility's cost per case-mix unit.(2) "Assessment reference date (ARD)" is the last day of the observation (or "look back") period that the MDS 3.0 assessment covers for the r…

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 …

(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 submitt…

(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 …

(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 …

(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 da…

(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 (…

(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 medic…

(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 certificatio…

(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 followin…

(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…

(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 intell…

This rule describes the methodology for calculating payment rates for state-operated intermediate care facilities for individuals with intellectual disabilities (ICFs/IID) operated by the Ohio department of developmental disabilities (DODD) and is effective for periods on or afte…

(A) The purpose of this rule is to define the terms used in Chapter 5160-31 of the Administrative Code governing the preadmission screening system providing options and resources today (PASSPORT) home and community-based services (HCBS) waiver program.(B) "Assessment" means an ev…

(A) The "Ohio department of aging (ODA)" is the agency responsible for daily operations for the pre-admission screening system providing options and resources today (PASSPORT) home and community-based services (HCBS) waiver. ODA will operate this waiver pursuant to an interagency…

(A) The purpose of this rule is to establish the services covered by the pre-admission screening system providing options and resources today (PASSPORT) home and community based services (HCBS) program. (B) The PASSPORT program benefit package is limited to the following services…

The purpose of this rule is to describe the methods used to determine provider rates for the pre-admission screening system providing options and resources today (PASSPORT) program. (A) Rates determined under this rule will not exceed the maximum allowable rates for PASSPORT serv…

(A) This rule establishes Ohio medicaid programs and program services subject to participation in the EVV program, required under Section 1903 of the Social Security Act (42 U.S.C. 1396b) as in effect on the effective date of this rule. (B) For purposes of this chapter, EVV is th…

(A) The Ohio department of medicaid (ODM) EVV system collects and maintains data for medicaid programs and services subject to participation in the EVV program.(B) Data collection method option: (1) Application installed on one of the following devices: (a) An electronic device p…

(A) An alternate EVV vendor may be used for EVV data collection.(B) The state is not responsible for any costs related to the development, approval, testing, and utilization of a qualifying alternate EVV vendor.(C) To use an alternate EVV vendor, providers should: (1) Notify the …

(A) This rule establishes Ohio medicaid service provider requirements for services subject to EVV as described in rule 5160-32-01 of the Administrative Code. (B) All providers and financial management service vendors will:(1) Complete initial and ongoing training per Ohio departm…

(A) The purpose of this rule is to define the terms used in Chapter 5160-33 of the Administrative Code governing the medicaid assisted living HCBS waiver program.As used in this chapter:(B) "Assessment" means a face-to-face evaluation used to obtain information about an individua…

(A) The purpose of this rule is to outline the requirements that must be met for an individual to be eligible to enroll in the medicaid funded component of the assisted living program.(B) To be eligible for the medicaid funded component of the assisted living program, an individu…

(A) The purpose of this rule is to outline the requirement that must be met for an individual to enroll in the medicaid-funded component of the assisted living waiver program.(B) To be eligible for enrollment, an individual must:(1) Have been determined to meet the eligibility re…

(A) The purpose of this rule is to establish the conditions under which providers are able to participate in the assisted living HCBS waiver program.(B) In order to obtain a medicaid provider agreement to be an assisted living services provider, the provider will be certified by …

(A) The purpose of this rule is to establish the services covered by the assisted living HCBS waiver program.(B) The assisted living HCBS waiver program is limited to the following services:(1) Assisted living service as defined in rule 173-39-02.16 of the Administrative Code, an…

(A) The purpose of this rule is to describe the methods used to determine provider rates for the assisted living HCBS waiver as set forth in appendix A to rule 5160-1-06.5 of the Administrative Code.(B) Provider rates are determined for the following categories:(1) Per-job bid ra…

(A) For the purposes of Chapter 5160-35 of the Administrative Code, the following terms are defined.(1) At the direction of: the communication of a practitioner plan of care to a licensed practical nurse as defined in Chapter 4723. of the Revised Code by a physician as defined in…

(A) The purpose of this rule is to set forth the qualifications to become a medicaid school program provider (MSP) and processes to be followed by an MSP provider.(B) An MSP provider:(1) Is one of the following:(a) A local education agency (LEA) city school district, local school…

(A) The purpose of this rule is to set forth the provisions for claiming to receive medicaid reimbursement for the provision of services by medicaid school program (MSP) providers as defined in Chapter 5160-35 of the Administrative Code.(B) The CPT (common procedural terminology)…

(A) The purpose of this rule is to set forth the services authorized for medicaid coverage that an MSP provider can provide, and to set forth the conditions for providing the services.(B) The MSP provider will only submit claims for services which it has statutory authority to pr…

(A) The purpose of this rule is to set forth the services authorized for medicaid coverage, beyond those indicated in rule 5160-35-05 of the Administrative Code, that a MSP provider can provide, and to set forth the conditions for providing the services.(B) In addition to the ser…

(A) The purpose of this rule is to set forth the services authorized for medicaid coverage, beyond those indicated in rules 5160-35-05 and 5160-35-06 of the Administrative Code, that an MSP provider can provide, and to set forth the conditions for providing the services.(B) MSP p…

(A) "Authorized representative" has the same meaning as in rule 5160:1-1-01 of the Administrative Code.(B) "Capitated payment" means the monthly payment paid to the program of all inclusive care for the elderly PACE organization by the Ohio department of medicaid (ODM) for medica…