Ohio Administrative Code

(A) To be eligible for the Ohio resilience through integrated systems and excellence (OhioRISE) home and community-based services (HCBS) 1915(c) waiver (waiver), a youth will be determined by the Ohio department of medicaid (ODM) to meet all of the following:(1) Meet eligibility …

(A) This rule establishes the services available under the Ohio resilience through integrated systems and excellence (OhioRISE) home and community-based services (HCBS) waiver program (waiver) established in accordance with 1915(c) of the Social Security Act 42 U.S.C. 1396n (Janu…

(A) Scope. This rule sets forth provisions governing coverage for out-of-home respite services delivered as part of the Ohio resilience through integrated systems and excellence (OhioRISE) 1915(c) waiver program (waiver) established in accordance with 1915(c) of the Social Securi…

(A) Scope. This rule sets forth provisions governing coverage for transitional services and supports provided as part of the Ohio resilience through integrated systems and excellence (OhioRISE) waiver program (waiver) established in accordance with 1915(c) of the Social Security …

(A) Scope. This rule sets forth provisions governing coverage for secondary flex funds delivered as part of the Ohio resilience through integrated systems and excellence (OhioRISE) 1915(c) waiver program (waiver) established in accordance with 1915(c) of the Social Security Act, …

For cost reporting purposes, each eligible psychiatric residential treatment facility (PRTF), as defined in Chapter 5160-59 of the Administrative Code, is to submit cost reports that cover a consecutive twelve-month period of the provider's operations as designated by the departm…

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

(A) Scope. This rule sets forth general coverage and payment policy for eye care services. Additional provisions for eye care services provided through a medicaid managed care organization are described in Chapter 5160-26 of the Administrative Code.(B) Definitions.(1) "Eligible p…

(A) For the purpose of this rule the following definitions apply.(1) "Doctor of podiatric medicine" (or "podiatric physician" or "podiatrist") is as described in section 4731.51 of the Revised Code.(a) Doctors of podiatric medicine are deemed to be physicians only in respect to f…

(A) The following definitions apply to Chapter 5160-70 of the Administrative Code:(1) "Appellant" means the party who requested an adjudication hearing pursuant to Chapter 119. of the Revised Code and is appealing the adjudication order to the Franklin county court of common plea…

(A) Chapter 5160-70 of the Administrative Code prescribes the procedures to be followed when medicaid providers seek review of actions or proposed actions of the department, except for any action taken or decision made by the department with respect to entering into or refusing t…

(A) Notice of intended action (1) Whenever ODM proposes to take an action that the Ohio general assembly has expressly made subject to the administrative adjudication procedure outlined in Chapter 119. of the Revised Code, ODM shall give notice of the intended action to the party…

(A) Initial scheduling of the hearing(1) When a party timely requests a hearing, ODM shall set the date, time, and place for the hearing and notify the party of the scheduling. ODM shall initially schedule the hearing not earlier than seven calendar days but not later than fiftee…

(A) Pre-hearing discovery(1) Unless otherwise ordered by the hearing examiner, pre-hearing discovery is allowed. Unless otherwise ordered by the hearing examiner or as set forth in this rule, pre-hearing discovery shall be conducted and used at the hearing in accordance with the …

(A) Conducting the hearing(1) The date, time, and place of any hearing before ODM is set by ODM or the hearing examiner. The hearing examiner shall provide written or electronic notice before the date of the hearing to all participants in the hearing and file a copy of the writte…

(A) The following definitions apply to Chapter 5101:6-51 of the Administrative Code.(1) "Affected party" means a person whose interests are subject to an adjudication by the Ohio department of job and family services (ODJFS) under authority of section 5111.914 of the Revised Code…

(A) Notice of overpayment.An issuing state agency that identifies a medicaid overpayment shall send a notification, by certified mail, return receipt requested, of the overpayment amount to the medicaid provider. The issuing state agency shall send a copy of the notification to O…

(A) Pursuant to division (E) of section 5111.03 of the Revised Code, any provider of services or goods contracting with ODJFS pursuant to Title XIX of the Social Security Act that, without intent, obtains payments under Chapter 5111. of the Revised Code in excess of the amount to…

(A) Written notice of intended action.(1) Whenever an issuing state agency proposes to take an action under authority of section 5111.914 of the Revised Code, the issuing state agency shall send the affected party written notice of the agency's intended action ("notice of intende…

(A) Initial scheduling of the hearing.(1) When an affected party timely requests a hearing, the issuing state agency shall set the date, time, and place for the hearing and notify the appellant of the scheduling. The issuing state agency shall initially schedule the hearing not e…

(A) Hearing examiner may allow pre-hearing discovery.(1) As a part of the authority to conduct the hearing, and except as provided in paragraph (B) of this rule, the hearing examiner may allow pre-hearing discovery of any matter that is not privileged or confidential and that is …

(A) Conduct of the hearing.(1) The issuing state agency shall employ or contract with a hearing examiner to conduct all hearings initiated under authority of section 5111.914 of the Revised Code.(2) The date, time, and place of any hearing under authority of section 5111.914 of t…

(A) Scope. This rule sets forth provisions governing payment for behavioral health services provided by certain licensed professionals in non-institutional settings.(1) Provisions governing payment for behavioral health services as the following service types are set forth in the…

(A) Scope. This rule sets forth provisions governing coverage and payment for professional, non-institutional spinal manipulation and related diagnostic imaging services.(B) Providers.(1) Rendering providers. The following eligible providers may render a service described in this…

(A) Scope. This rule sets forth provisions governing payment for skilled therapies as non-institutional professional services furnished by skilled therapists and skilled therapist assistants or aides. Provisions governing payment for skilled therapies as the following service typ…

(A) Providers.(1) Rendering providers. The following practitioners, defined in Chapter 4759. of the Revised Code, may enroll in medicaid as eligible providers of dietitian services:(a) A licensed dietitian; and(b) A registered dietitian.(2) Billing ("pay-to") providers. The follo…

(A) Definitions applicable to this rule.(1) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code.(2) "Lactation consultation" is the development and implementation of management strategies for complex problems related to breastfeeding and human…

(A) Definitions applicable to this rule.(1) "Doula" is an individual listed in the registry specified in section 4723.89 of the Revised Code.(2) "Doula service" is any of the support activities specified in section 4723.89 of the Revised Code.(3) "Independent" and "non-independen…

(A) Definitions.(1) "Acupuncture" has the same meaning as in Chapter 4762. of the Revised Code.(2) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code.(B) Providers.(1) Rendering provider. The following eligible providers may render a covered …

(A) Definition. "Pharmacist" has the same meaning as in Chapter 4729:1-1 of the Administrative Code.(B) Providers. An individual pharmacist may enroll in medicaid as a pharmacist provider. (C) Coverage.(1) Payment may be made only for a pharmacist service for which the following …

(A) Definitions. For the purposes of this rule, the following definitions apply:(1) "Diabetes self-management training" (DSMT) is the education and instruction of an individual with diabetes by a qualified provider for the purpose of providing the individual with necessary skills…

(A) Rules 5160-80-01 to 5160-80-09 of the Administrative Code describe the hearing rights, appeal rights, and procedures applicable to medical assistance recipients under section 5160.37 of the Revised Code for contesting the amount of the department's or county department's clai…

(A) Making a request for hearing (1) A request for hearing must be submitted to the depository agent in writing by the medical assistance recipient or by the medical assistance recipient's authorized representative or attorney and shall be subject to the requirements of this rule…

(A) Postponement is a request prior to the hearing date to reschedule the hearing for a later date.(1) The hearing may be postponed at the request of a party for good cause.(2) The hearing examiner shall have final authority to determine whether good cause exists.(B) When a reque…

(A) All hearing requests shall be made in one of the methods set forth in rule 5160-80-02 of the Administrative Code.(B) A hearing request may be denied prior to the issuance of the department's notice scheduling a hearing for only the following reasons:(1) The hearing request is…

(A) Time and place of the hearing(1) All hearings shall be conducted in Columbus, Ohio, during normal business hours unless other times are authorized by the hearing examiner. The appellant and department or county department may elect to participate in the hearing via video conf…

(A) The appellant and the department or county department.(1) The parties shall comply with the following service requirements:(a) A certificate of service shall be attached to each filing with the depository agent attesting to service of a copy on the other party and the hearing…

(A) The hearing examiner shall make an audio recording of the hearing. The recording shall be started at the beginning of the hearing and shall continue until the hearing is concluded. There shall be no testimony or other proceedings off the record. The recording shall not be alt…

(A) The hearing examiner is responsible for preparing and issuing the hearing decisions under the authority of the department.(B) Basis(1) The hearing examiner's findings of fact shall be based exclusively on the evidence introduced at the hearing, and upon the submission of addi…

(A) An appellant who disagrees with a hearing decision has the right to request an administrative appeal from the director.(B) Notice of the right to and the method of obtaining an administrative appeal shall be included in all hearing denial notices, hearing dismissal notices, a…

(A) Covered drugs.(1) "Compounded prescriptions" are prescription drugs made by combining two or more drugs. Active pharmaceutical ingredients (API) and excipients are listed on the ODM pharmacy program website at https://pharmacy.medicaid.ohio.gov.(2) "Covered prescribed drug" m…

(A) Eligible pharmacies in the Ohio medicaid program may bill for medical supplies and durable medical equipment in accordance with Chapter 5160-10 of the Administrative Code, with the following stipulations:(1) The provider must:(a) Apply to, and be approved by, the Ohio departm…

(A) Covered prescribed drugsDrugs covered by the Ohio department of medicaid (ODM) pharmacy program, or a managed care entity as defined in rule 5160-26-01 of the Administrative Code, are prescribed drugs as defined in rule 5160-9-05 of the Administrative Code that are dispensed …

(A) Recipient profiles, prospective drug utilization review (DUR), and recipient counseling(1) Recipient profiles, prospective DUR and recipient counseling must be performed for medicaid recipients by medicaid pharmacy providers in accordance with agency 4729 of the Administrativ…

(A) Payment for prescribed drugs is the lesser of the provider's billed charges or the calculated allowable, after any coordination of benefits is applied as described in paragraph (E) of this rule. For prescribed drugs that are subject to a co-payment, the amount paid by the Ohi…

(A) The pharmacy claims submitted to the Ohio department of medicaid (ODM) or its designee, the pharmacy point-of-sale vendor, must reflect the actual national drug code (NDC) on the container from which the product was dispensed.(B) All records of prescriptions must comply with …

(A) For a drug to be considered for coverage without prior authorization in accordance with rule 5160-9-03 of the Administrative Code, the following information may be requested from the manufacturer or labeler:(1) Trade name of the drug.(2) Generic name of the drug.(3) National …