Ohio Administrative Code

(A) PACE is a full-risk program in which the PACE organization assumes all financial risk for the cost of the medical care and services provided to participants.(B) PACE organizations shall receive a monthly capitated payment from the Ohio department of medicaid (ODM) for each PA…

(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 long-term care facility (i.e., a "facility-based" physician) only if the following conditions are met:(1) The services co…

(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 su…

(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…

(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) "Ser…

(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 nurse-midwife (CNM), and certified n…

(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 …

(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, …

(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 pr…

(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…

(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 treat…

(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 serv…

(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 …

(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…

(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., …

(A) Rendering providers. The following non-dentist practitioners may render topical fluoride treatments such as the application of fluoride varnish or silver diamine fluoride: (1) A physician;(2) A physician assistant; or(3) An advanced practice registered nurse.(B) Payment for t…

(A) Purpose(1) The Ohio department of developmental disabilities (DODD) is responsible for the daily operations of the individual options (IO) waiver which will be administered pursuant to sections 5166.02 and 5166.20 of the Revised Code. (2) DODD operates the IO waiver program p…

(A) PurposeThis rule sets forth the requirements of a county board of developmental disabilities to establish and maintain a waiting list for home and community-based services.(B) Definitions(1) "County board" means a county board of developmental disabilities established under C…

(A) The purpose of this rule is to set forth the requirements the Ohio department of developmental disabilities (DODD) must meet to assure free choice of provider.(B) The DODD through an interagency agreement with the Ohio department of medicaid (ODM), acts as the administrative …

(A) Purpose.This rule authorizes the provisions set forth in rule 5123-4-05 of the Administrative Code which sets forth the process a county board of developmental disabilities follows to request assistance from the department of developmental disabilities (DODD) for home and com…

(A) Purpose.(1) The Ohio department of developmental disabilities (DODD) is responsible for the daily operation of the self-empowered life funding (SELF) waiver which will be administered pursuant to sections 5166.02 and 5166.20 of the Revised Code.(2) DODD operates the SELF waiv…

(A) Purpose. The purpose of this rule is to establish the payment standards for the individual options home and community-based services (HCBS) waiver for services provided to individuals enrolled in a HCBS program, as a component of the medicaid program and as administered by th…

(A) Purpose. The purpose of this rule is to establish the payment standards for the level one home and community-based services (HCBS) waiver for services provided to individuals enrolled in a HCBS program, as a component of the medicaid program and as administered by the departm…

(A) Purpose.The purpose of this rule is to establish the payment standards for the self-empowered life funding (SELF) home and community-based services (HCBS) waiver for services provided to individuals enrolled in a HCBS program, as a component of the medicaid program and as adm…

(A) Purpose(1) The Ohio department of developmental disabilities (DODD) is responsible for the daily operation of the level one (L1) waiver which will be administered pursuant to sections 5166.20 and 5166.02 of the Revised Code.(2) DODD operates the L1 waiver program pursuant to …

(A) The following definitions apply to Chapter 5160-43 of the Administrative Code:(1) "Adult Needs and Strengths Assessment (ANSA)" (8/2021) is an integration information assessment tool for use in the development of individualized person-centered care plans, to monitor outcomes,…

(A) An individual may be eligible for enrollment in the specialized recovery services program if they meet all of the following:(1) Be at least twenty-one years of age;(2) Be determined eligible for Ohio medicaid in accordance with Chapters 5160:1-1 to 5160:1-5 of the Administrat…

(A) Enrollment in the specialized recovery services program is voluntary. Individuals enrolled in the program in accordance with rule 5160-43-02 of the Administrative Code shall be informed of their rights and responsibilities. Individuals also have choice and control over the ar…

(A) This rule sets forth the covered services available to an individual enrolled in the specialized recovery services program (SRSP) and the requirements for providers of those services.(B) Individualized placement and support - supported employment (IPS-SE) is the implementatio…

(A) Specialized recovery service program providers shall maintain professional relationships with the individuals they serve. Providers shall furnish services in a person-centered manner that is in accordance with the individual's approved person-centered service plan, is attenti…

(A) The Ohio department of medicaid (ODM) is responsible for the ongoing monitoring and oversight of all providers of specialized recovery services (hereafter referred to as providers) and contractors to ensure compliance with program requirements.(B) Monitoring and oversight of …

(A) Definitions of terms used for billing and calculating rates.(1) "Billing unit" as used in column 4 of paragraph (C) of this rule, means a single fixed item, amount of time or measurement.(2) "Unit rate" as used in column 3 of paragraph (C) of this rule, means the amount reimb…

(A) This rule sets forth the process and requirements for the criminal records checks of providers of home and community-based services (HCBS) to individuals enrolled in the specialized recovery services program. HCBS include recovery management and individualized placement and s…

(A) Individuals receiving home and community-based services (HCBS) through either an Ohio department of medicaid (ODM) or Ohio department of aging (ODA) -administered waiver program authorized under section 1915(c) of the Social Security Act (as in effect on January 1, 2023) or t…

(A) Person-centered planning process.Individuals receiving home and community-based services (HCBS) through either an Ohio department of medicaid (ODM) or Ohio department of aging (ODA) -administered waiver program authorized under section 1915(c) of the Social Security Act (as i…

This rule sets the standards and procedures for managing incidents that may have a negative impact on individuals. The purpose is to establish the procedures for reporting and addressing critical incidents and reportable incidents and to prevent and reduce the risk of harm to ind…

(A) The following definitions are applicable to this rule:(1) "Dietitian" and "licensed dietitian" mean a person with a current, valid license to practice dietetics under section 4759.06 of the Revised Code.(2) "Home delivered meals" is a meal delivery service based on an individ…

(A) "Home maintenance and chore" means a service that maintains a clean and safe living environment through the performance of tasks in the individual's home that are beyond the individual's capability. Home maintenance and chore services shall not exceed a total of ten thousand …

(A) "Home modifications" are environmental adaptations to the private home(s) of the individual authorized by the individual's person-centered services plan, that are necessary to ensure the health, welfare and safety of the individual or that enable the individual to function wi…

(A) "Community integration" means independent living assistance and community support coaching activities that are necessary to enable an individual to live independently and have access to, choice of, and an opportunity to participate in, a full range of community activities.(B)…

(A) "Personal emergency response systems" (PERS) is a service with a monitoring, reminder and/or reporting component available to support individuals' independence in the community. PERS include telecommunications equipment, a central monitoring station (station), and a medium fo…

(A) "Out-of-home respite" are services delivered to an individual in an out-of-home setting to allow a period of rest or relief for caregivers normally providing care. The service will include an overnight stay.(1) An out-of-home respite provider will make available the following…

(A) "Waiver nursing services" are defined as nursing tasks and activities provided to individuals who require the skills of a registered nurse (RN) or licensed practical nurse (LPN) at the direction of an RN.(1) All nurses providing waiver nursing services to individuals will: (a…

(A) "Community transition" pays for non-recurring start-up living expenses for individuals transitioning from an institutional setting to a home and community-based services (HCBS) setting that is compliant with rule 5160-44-01 of the Administrative Code. Community transition:(1)…

(A) The following definitions are applicable to this rule:(1) "Adult" means an individual at least eighteen years of age.(2) "Authorizing health care professional" means a health care professional who, pursuant to section 5166.307 of the Revised Code, authorizes a home care atten…

(A) An ODM-administered waiver service provider will maintain a professional relationship with the individuals to whom they provide services. Providers will furnish services in a manner that is in accordance with the individual's approved person-centered services plan, is attenti…

(A) This rule is applicable to the following waiver programs and services:(1) Individual options services, as described in Chapter 5123-9 of the Administrative Code:(a) Homemaker/personal care, participant-directed and provided through an agency; and(b) Waiver nursing, provided t…