Ohio Administrative Code

(A) An individual may choose how waiver services are delivered pursuant to the person-centered planning process outlined in rule 5160-44-02 of the Administrative Code.(B) For purposes of this rule and rule 5160-45-03.5 of the Administrative Code:(1) Home and community-based servi…

(A) Scope. This rule sets forth provisions governing coverage for self-directed goods and services provided as part of an Ohio department of medicaid-(ODM) administered waiver program.(B) "Self-directed goods and services" are services, equipment, or supplies that:(1) Are not ava…

(A) Ohio department of medicaid (ODM) -administered waiver provider applicants must successfully complete the provider enrollment process set forth in this rule and receive approval from ODM before furnishing services to an individual enrolled on an ODM-administered waiver. Servi…

(A) The Ohio department of medicaid (ODM) or its designee shall continuously monitor every ODM-administered waiver provider. Monitoring activities shall include, but not be limited to:(1) A structural review of compliance with all ODM-administered waiver provider requirements in …

(A) Unless otherwise stated in paragraphs (A)(1) and (A)(2) of this rule, this rule sets forth the process and requirements for the criminal records checks of persons under final consideration for subcontract or employment with a waiver agency, and existing subcontractors or empl…

(A) This rule sets forth the process and requirements for the criminal records checks of independent providers of home and community-based services (HCBS) in Ohio department of medicaid (ODM) -administered waiver programs.(B) For the purposes of this rule:(1) "Applicant" means a …

(A) The Ohio department of medicaid (ODM) is responsible for the ongoing monitoring and oversight of all ODM-administered waiver service providers and all ODM-administered waiver contractors in order to ensure providers' and contractors' compliance with ODM-administered waiver pr…

(A) Except as set forth in paragraph (H) of this rule, a waiver agency may only employ an applicant, or continue to employ an employee, or continue to contract with a subcontractor who has been convicted of or pleaded guilty to an offense listed in divisions (A)(3)(a) to (A)(3)(e…

(A) An individual is eligible for enrollment in the Ohio home care waiver program only if the individual meets all of the following criteria: (1) The individual is between the ages of birth through age fifty-nine years.(2) The individual is determined eligible for Ohio medicaid i…

This rule sets forth the definition of personal care aide services and as well as the provider requirements and specifications for the delivery of the service. Providers are also subject to the conditions of participation set forth in rule 5160-44-31 of the Administrative Code. S…

(A) The following waiver services are covered by the Ohio home care waiver:(1) Home delivered meals as described in rule 5160-44-11 of the Administrative Code (2) Home maintenance and chores as described in rule 5160-44-12 of the Administrative Code (3) Home modification as descr…

(A) Definitions of terms used for billing and calculating home care attendant services (HCAS) rates.(1) "Base rate," as set forth in column 3 of tables A and B of this rule, means the amount reimbursed by Ohio medicaid for the first thirty-five to sixty minutes of assistance with…

This rule sets forth the definition of the vehicle modification service as well as the provider requirements and specifications for the delivery of the service. Providers are also subject to the conditions of participation set forth in rule 5160-44-31 of the Administrative Code. …

This rule sets forth the definition of the supplemental transportation service as well as the provider requirements and specifications for the delivery of the service. Providers are also subject to the conditions of participation set forth in rule 5160-44-31 of the Administrative…

This rule sets forth the definition of the supplemental assistive and adaptive devices service and provider requirements and specifications for the delivery of the service. Providers are also subject to the conditions of participation set forth in rule 5160-44-31 of the Administr…

This rule sets forth the definition of the adult day health center service as well as the provider requirements and specifications for the delivery of the service. Providers are also subject to the conditions of participation set forth in rule 5160-44-31 of the Administrative Cod…

(A) Purpose.(1) This rule specifies the conditions for medicaid payment of targeted case management (TCM), which is associated with activities described in section 5126.15 of the Revised Code and in rule 5123-4-02 of the Administrative Code, but only to the extent that they are l…

(A) This rule sets forth provisions governing payment for professional, non-institutional dental services. Provisions governing payment for dental services performed as the following service types are set forth in the indicated part of the Administrative Code:(1) Hospital service…

(A) Helping Ohioans move, expanding choice (HOME choice) assists individuals to transition from an institutional setting into a community setting. (B) Definitions(1) "Assessment" means an in-person meeting with the HOME choice applicant to determine eligibility for the program, c…

This rule set forth terms used throughout Chapter 5160-56 of the Administrative Code.(A) "Advance directive" refers to written instructions recognized under state law that are related to the provisions of health care when the individual is incapacitated. Samples of advance direct…

(A) To be covered under Ohio medicaid, the designated hospice will ensure the following criteria are met prior to furnishing hospice care:(1) The designated hospice has a certification of the terminal illness on behalf of the individual, obtained in accordance with 42 C.F.R. 418.…

This rule sets forth the requirements for discharging an individual from the designated hospice's care and/or the hospice benefit.(A) Discharge refers to the end the hospice benefit or the designated hospice's care:(1) Discharge from the designated hospice's care should occur whe…

This rule sets forth the requirement for recording the hospice provider span for individuals receiving medicaid hospice care in accordance with Chapter 5160-56 of the Administrative Code, including individuals who may be covered by third-party insurance, such as medicare, for whi…

This rule sets forth the responsibilities, including the conditions of participation for a hospice engaged in the provision of medicaid hospice services. To be eligible to provide and to request reimbursement for hospice services, a designated hospice should:(A) Meet the medicare…

This rule sets forth medicaid covered services that hospice providers should furnish to individuals to the extent specified by the individual's plan of care.(A) The designated hospice will ensure the hospice services furnished to an individual in accordance with this rule are rea…

This rule sets forth the Ohio department of medicaid (ODM) payment for hospice services and care.(A) ODM will directly pay the designated hospice to care for an individual enrolled in medicaid hospice. Payment to the designated hospice will cover the array of services listed in r…

(A) The medicaid provider incentive program (MPIP) is Ohio's program implementing section 4201 of the American Recovery and Reinvestment Act of 2009 (ARRA), Pub. L. No. 111-5, and the published regulations in 42 C.F.R. Part 495. Certain medicaid eligible professionals and hospita…

(A) Program integrity.(1) MPIP legal notice.(a) All eligible professionals and eligible hospitals submitting an application to receive an MPIP payment are required to sign the MPIP legal notice before confirming and submitting their application.(b) All program applicants are boun…

(A) The general definitions set forth in rule 5160-26-01 of the Administrative Code regarding managed care entities (MCEs) apply to the MyCare Ohio rules set forth in Chapter 5160-58 of the Administrative Code.(B) In addition to the definitions set forth in rule 5160-26-01 of the…

(A) MyCare Ohio plans must comply with all of the requirements applicable to managed care organizations (MCOs) and managed care entities (MCEs), as applicable, in the following rules:(1) Rule 5160-26-05 of the Administrative Code;(2) Rule 5160-26-05.1 of the Administrative Code;(…

(A) Eligibility.(1) An individual is enrolled in a MyCare Ohio plan (MCOP) if he or she meets all of the following criteria:(a) Age twenty-one or older at the time of enrollment in the MCOP;(b) Eligible for medicare parts A, B, and D, and full benefits under the medicaid program.…

(A) Disenrollment from the MyCare Ohio program occurs for the following reasons:(1) The member becomes ineligible for full benefits under the medicaid program or medicare parts A or B or D. Termination of MyCare Ohio plan (MCOP) enrollment is effective the end of the last day of …

(A) To be eligible for enrollment in the MyCare Ohio waiver, a member meets all of the following requirements:(1) Is enrolled in the MyCare Ohio program at the time of application for the MyCare Ohio waiver;(2) Is determined to have a nursing facility-based level of care (i.e., i…

(A) A MyCare Ohio plan (MCOP) ensures members have access to all medically-necessary medical, medicaid-covered over the counter drugs, behavioral health, nursing facility and home and community-based services (HCBS) covered by Ohio medicaid. Prescription drug coverage for members…

(A) A MyCare Ohio plan (MCOP) ensures each member has a primary care provider (PCP) who serves as an ongoing source of primary care and assists with care coordination appropriate to the member's needs.(1) The MCOP ensures PCPs are in compliance with the following triage requireme…

(A) A member may choose to receive MyCare Ohio waiver services from any combination of providers on the provider panel of the MyCare Ohio plan selected by the member pursuant to paragraph (B) of rule 5160-58-04 of the Administrative Code.(B) A member receiving waiver services fro…

(A) The purpose of this rule is to establish both the services covered by the MyCare Ohio home and community based services (HCBS) waiver program and the providers eligible to furnish those services to members enrolled in the MyCare Ohio waiver.(B) Providers seeking to furnish se…

(A) Member care coordination.(1) All MyCare Ohio members are assigned a care coordinator to assist with management of their care and navigation of services in accordance with 42 CFR 422.101, as applicable. MyCare Ohio members who are not receiving long-term care services through …

(A) Grievances and appeals vary depending on the MyCare Ohio enrollment of the member.(1) If the member is enrolled as a dual-benefits member, as defined in rule 5160-58-01 of the Administrative Code, then all grievances and appeals are conducted by the MyCare Ohio plan (MCOP).(2…

(A) The definitions set forth in rule 5160-26-01 of the Administrative Code, with the exceptions noted in paragraphs (A)(1) and (A)(2) of this rule, apply to the Ohio resilience through integrated systems and excellence (OhioRISE) rules set forth in Chapter 5160-59 of the Adminis…

(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan has to adhere to all of the requirements applicable to managed care organizations (MCOs) or managed care entities (MCEs) in the following rules:(1) Rule 5160-26-05 of the Administrative Code with th…

(A) To be eligible for enrollment in the Ohio resilience through integrated systems and excellence (OhioRISE) program, an individual has to meet the criteria in paragraphs (A)(1) to (A)(3) along with either paragraph (A)(4), (A)(5), (A)(6) or (B) of this rule.(1) Be twenty years …

(A) Scope. This rule sets forth the provisions for eligibility and enrollment into Ohio resilience through integrated systems and excellence (OhioRISE) on the first day the program is effective. Individuals that do not meet the OhioRISE first day eligibility criteria described in…

(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan has to ensure:(1) Services are sufficient in amount, duration, and scope to reasonably be expected to achieve the purpose for which the services are provided;(2) The amount, duration, and scope of a…

(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan will have a utilization management (UM) program with clearly defined structures and processes designed to maximize the effectiveness of the care provided to the member. (1) The OhioRISE plan has to …

(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan will assign a care coordination tier for all youth eligible for enrollment in the OhioRISE plan. Tier assignment of limited, moderate, or intensive is based on assessed or indicated needs and may be…

(A) Scope. This rule sets forth provisions governing medicaid coverage of intensive home-based treatment (IHBT) services.(B) Definition. IHBT is the service and activities as set forth by the Ohio department of mental health and addiction services (OhioMHAS) in rule 5122-29-28 of…