Chapter 3701-43 Program for Medically Handicapped Children

3701-43-01 Definitions.

As used in this chapter of the Administrative Code:

(A) "Adult with cystic fibrosis" means an Ohio resident who is twenty-one or more years of age, who is diagnosed with cystic fibrosis and who meets the financial eligibility requirements established by rule 3701-43-16 of the Administrative Code.

(B) "Advanced practice nurse" means a certified registered nurse anesthetist, clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner who has met the requirements of section 4723.41 of the Revised Code and who holds a current valid certificate of authority issued by the board of nursing pursuant to section 4723.42 of the Revised Code.

(C) "Applicant" means an individual for whom application has been made for eligibility for payment for diagnostic, service coordination or treatment services or goods by the program for medically handicapped children.

(D) "Diagnostic services" means services necessary to determine whether an Ohio resident under twenty-one years of age has a medically handicapping or potentially medically handicapping condition. Diagnostic services include:

(1) Services needed to establish or rule out a diagnosis that would allow the Ohio resident to meet the medical eligibility requirements for payment for treatment goods and services; and

(2) Services needed to develop a plan of care for an individual.

(E) "Director" means the director of health or an appropriately authorized employee of the Ohio department of health.

(F) "Local health department" or "LHD" means the official public health agency in a health jurisdiction as defined in Chapter 3709. of the Revised Code or other agency which contracts with the Ohio department of health to provide public health nurse services to children with special health care needs and their families who reside in the jurisdiction of the contracted agency.

(G) "Managing physician" means a physician who is a provider and who:

(1) Submits, on behalf of an applicant, a medical application for eligibility for the program, in accordance with rules 3701-43-11 and 3701-43-15 of the Administrative Code, and other medical information necessary for the director to determine whether the applicant is medically eligible for the program under rule 3701-43-17 of the Administrative Code;

(2) Develops, in consultation with other medical specialists or providers as needed, the individualized plan of treatment submitted as part of the medical eligibility application;

(3) Provides direct medical or surgical treatment services or both to a recipient;

(4) Refers the recipient for needed services to other providers; and

(5) Coordinates the provision of all services and goods for diagnostic or treatment services identified in the recipient's individualized plan of treatment.

(H) "Medicaid program" means the Ohio medical assistance program established by Title XIX of the Social Security Act, 98 Stat. 1171 (1984), 42 U.S.C. 1396(1984) and section 5165.01 of the Revised Code.

(I) "Medical advisory council" means the medically handicapped children's medical advisory council established by section 3701.025 of the Revised Code.

(J) "Medically eligible condition" means a condition, congenital or acquired, that renders an applicant or recipient medically eligible for payment for treatment goods and services by the program for medically handicapped children, pursuant to rule 3701-43-17 of the Administrative Code.

(K) "Medically handicapped child" or "child with special health care needs" means an Ohio resident under twenty-one years of age who suffers primarily from an organic disease, defect or a congenital or acquired physically handicapping and associated condition that may hinder the achievement of normal growth and development and who meets the financial and medical eligibility requirements for the program for medically handicapped children established by rules 3701-43-16 and 3701-43-17 of the Administrative Code and the operational manual.

(L) "Medical policies" means guidelines specifying the types and amounts of service coordination, diagnostic and treatment goods and services that may be authorized for the appropriate diagnosis and treatment of medically eligible conditions, as adopted by the director and set forth in the operational manual. In adopting medical policies, the director may consult with the medical advisory council, one or more members of the council or other individuals with expertise in the area.

(M) "Ohio resident" means:

(1) Any person living in the state of Ohio with the intent to remain in Ohio indefinitely. The term "living in the state of Ohio" shall be limited to all persons whose primary domicile is located within Ohio. Intent to remain indefinitely is established through a showing that a person has significant contacts with the state of Ohio as evidenced by indicia thereof, such as maintaining a bank account in Ohio, registering to vote in the state, paying Ohio income taxes, obtaining permanent employment within the state, owning real estate within the state, or possessing an Ohio driver's license or similar permits;

(2) Any person who is present in the state of Ohio for the purpose of performing migrant agricultural labor and who evidenced a pattern of regularly returning to Ohio to perform such work or who expresses an intention to establish a pattern of regularly returning to perform such work. Migrant agricultural labor is defined as agricultural work of a seasonal or temporary nature which requires that the worker be away from their permanent place of residence to perform said work overnight. A pattern of regularly returning to the state to perform such work shall be considered to have been established if a person is present in Ohio to perform migrant agricultural work for two successive growing seasons; or

(3) Any person who is an active duty member of the United States military and on official military assignment within the state of Ohio, whether or not they maintain residence in another state, or any person who is an active duty member of the United States military on official military assignment in another state or country who pays Ohio income taxes.

(N) "Operational manual" means the manual of operational procedures, medical policies and guidelines for the program for medically handicapped children developed pursuant to division (B) of section 3701.021 of the Revised Code.

(O) "Program for medically handicapped children" or "program" means the program established by sections 3701.021 to 3701.028 of the Revised Code for payment of expenses for:

(1) Diagnostic services, as defined in paragraph (D) of this rule, provided to eligible individuals;

(2) Treatment services and goods, as defined in paragraph (V) of this rule, provided to medically handicapped children and to adult cystic fibrosis patients; and

(3) Service coordination services as defined in paragraph (S) of this rule.

(P) "Provider" means a health professional, hospital, medical equipment supplier and any individual, group or agency that is approved by the department of health pursuant to division (C) of section 3701.023 of the Revised Code and rule 3701-43-02 of the Administrative Code and that provides or intends to provide goods or services to an applicant or recipient.

(Q) "Public health nurse services" or "phn services" means activities conducted by registered nurses employed or contracted by local health departments as defined in paragraph (F) of this rule or registered nurses contracted by the Ohio department of health:

(1) That promote the identification of needs and planning for, facilitating, conducting and evaluating interventions for children with special health care needs and their families;

(2) Collaborates with other child serving agencies and advocates for local systems to address the needs of special populations in the community.

(R) "Recipient" means a medically handicapped child or an adult with cystic fibrosis who has been notified of eligibility for payment for diagnostic, service coordination and treatment services or goods under this chapter of the Administrative Code.

(S) "Service coordination services" means case management services provided to medically handicapped children that promote effective and efficient organization and utilization of public and private resources and ensure that care rendered is family-centered, community-based, and coordinated.

(T) "Service coordinator" means a health professional approved by the department of health pursuant to division (C) of section 3701.023 of the Revised Code and rule 3701-43-13 of the Administrative Code and who provides or works to provide service coordination services to an applicant or recipient.

(U) "Standards of care" means criteria for the appropriate treatment or management of a medically eligible condition that have been adopted by the medical advisory council and are contained in the operational manual.

(V) "Third-party benefits" means any and all benefits paid by a third party to or on behalf of a recipient or recipient's parent, guardian or other legal representative for treatment services or goods that are authorized by the director pursuant to division (B) or (D) of section 3701.023 of the Revised Code. Third-party benefits include, but are not limited to, benefits paid by private or governmental entities or pursuant to a plan of insurance.

(W) "Third-party payor" means any insurer or other third party payor licensed by the Ohio superintendent of insurance, any payor under any individual or group contract, and any other governmental payor.

(X) "Treatment services or goods" means medical, surgical or ancillary health care services or related goods that correct a medically eligible condition, improve functioning or prevent potential disabilities in an individual with such a condition or mitigate the effect of the condition. Treatment services do not include:

(1) Experimental or investigational services that are not effective and proven treatments for the conditions for which they are being used or are to be used; or

(2) Cosmetic services.

Whether services or goods meet the definition established by paragraph (X) of this rule shall be determined by the director, who may consult with one or more members of the medical advisory council or other individuals with expertise in the area.

Effective: 04/17/2014
R.C. 119.032 review dates: 01/31/2014 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701022, 3701.023 , 3701.024 , 3701.025 , 3701.026 , 3701.027 , 3701.028
Prior Effective Dates: 1/2/1989, 12/1/01, 1/29/07, 9/1/08

3701-43-02 Standards and procedures for determining eligibility of providers.

(A) The director shall apply the standards and procedures prescribed by this rule and by rules 3701-43-03 to 3701-43-08 and 3701-43-13 of the Administrative Code for the purposes of reviewing the applications of provider applicants and for making determinations as to whether these applicants are eligible providers.

(1) For the purposes of this chapter "provider applicant" means a health care professional, hospital, medical equipment supplier or other individual, group or agency that makes application to become a provider, as defined in paragraph (P) of rule 3701-43-01 of the Administrative Code.

(2) Subject to the termination provisions prescribed by rule 3701-43-10 of the Administrative Code, anyone who is a provider for the program for medically handicapped children or adults with cystic fibrosis on the effective date of this rule is not required to apply for approval under this rule and shall be considered a provider for the purposes of this chapter.

(B) In addition to meeting the standards prescribed by the applicable provisions of this chapter, a provider applicant shall meet the following requirements to be eligible to be a provider:

(1) Participate as a provider in the Ohio medicaid program, if providers of the same type as the provider applicant may be medicaid providers;

(2) Be located in Ohio, except that the director may approve a provider applicant located outside Ohio who meets the standards prescribed in the applicable provisions of this chapter for the purpose of providing diagnostic or treatment services or goods:

(a) Not available in Ohio; or

(b) For recipients for whom travel to obtain comparable services within Ohio would present undue financial or transportation hardship.

The director may consult with one or more members of the medical advisory council or with other individuals with expertise in the area in deciding whether to approve a provider applicant not located in Ohio;

(3) Submit a provider application on a form prescribed by the director, which shall be completed in full and shall include any additional information required by applicable provisions of this chapter;

(4) The provider applicant shall submit any additional information requested by the director for purposes of determining whether the applicant meets the standards for eligibility to be a provider no later than sixty days after the date of the director's request; and

(5) Sign a provider agreement on a form prescribed by the director.

(C) If the director determines that the provider applicant meets all applicable eligibility standards and the other applicable provisions of this chapter, the director shall approve the applicant as a provider. Except as provided in rule 3701-43-22 of the Administrative Code, if the director determines that a provider applicant does not meet the standards for eligibility or has not complied with any of the procedural requirements prescribed by this rule or other applicable rules of this chapter, the director shall not approve the applicant as a provider.

(D) For each provider, the director shall specify the scope of services or goods the provider is approved to provide. The director shall determine the scope of goods or services based upon:

(1) Applicable statutes and rules for licensure of the provider;

(2) The scope of goods or services normally furnished by the provider;

(3) The provider's specialty, skill and experience or other factors specified in applicable provisions of this chapter.

Upon request by a provider and based upon sufficient documentation, the director may revise the approved scope of goods or services.

(E) The director shall notify a provider applicant in writing of approval or disapproval under paragraph (C) of this rule within thirty days after completion of all application procedures. A notice of approval also shall state the scope of goods or services the provider is approved to provide, as determined under paragraph (D) of this rule, and the effective date of approval. The effective date of approval shall be the first day of the month in which the provider applicant complied with all applicable requirements for interviews and submission of additional documentation. A notice of disapproval shall state the reasons for disapproval.

(F) A provider applicant whose application has been disapproved may request reconsideration of the application by the director by submitting a written request for reconsideration and any written materials that the provider applicant wishes to be considered so that they are received by the director no later than forty-five days after the date on the notice of disapproval issued under paragraph (E) of this rule. The director may request additional information, which the provider applicant shall submit so that it is received by the director no later than forty-five days after the date on the request. The director shall issue a written decision on reconsideration within forty-five days after receipt of the request or any requested additional information.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.022 , 3701.023 , 3701.023
Prior Effective Dates: 1/2/1989, 12/1/01, 09/01/08

3701-43-03 Standards and procedures for determining eligibility of physician providers.

(A) The director shall apply the standards and procedures prescribed by this rule in reviewing and making determinations concerning applications by physicians to be providers for the program for medically handicapped children.

(B) To be approved as a provider, a physician shall:

(1) Be licensed to practice allopathic medicine or osteopathic medicine in the state of Ohio or the state in which the physician's practice is located, if the physician will be providing services outside Ohio;

(2) Meet the following certification requirements:

(a) All physicians shall be certified by a certifying board of the "American Board of Medical Specialities" or a certifying board of the "American Osteopathic Association";

(b) To be designated as a subspecialist, a physician shall be certified in the relevant subspecialty by a certifying board of the "American Board of Medical Specialties" or a certifying board of the "American Osteopathic Association." If the applicable board does not certify physicians in the relevant subspecialty, the director may designate a physician as a subspecialist based upon significant advanced postgraduate training in the area. The director may consult with one or more members of the medical advisory council or with other individuals with expertise in the area in determining whether a physician has significant advanced postgraduate training;

(3) Meet the following practice requirements:

(a) Possession of skill and experience in the treatment of children or adolescents with handicapping conditions, as determined by the director. In making this determination, the director may consult with one or more members of the medical advisory council or with other individuals with expertise in the area; and

(b) Actively providing at the time of application, treatment to children with medically eligible conditions or adults with cystic fibrosis; and

(4) Maintain privileges on the staff of a hospital that is approved under rule 3701-43-04 of the Administrative Code; or have arrangements with physicians who are approved under this chapter to admit children needing inpatient care to a hospital that is approved under rule 3701-43-04 of the Administrative Code for inpatient care.

(C) A physician who does not meet the requirements of paragraph (B)(2)(b) of this rule may be designated as a subspecialist on a provisional basis for up to five years if the physician is certified in pediatrics by a certifying board of the "American Board of Medical Specialties" or a certifying board of the "American Osteopathic Association."

(D) In accordance with paragraph (D) of rule 3701-43-02 of the Administrative Code, the director shall determine the scope of services that each physician provider is approved to provide. The director may consult with one or more members of the medical advisory council or with other individuals with expertise in the area in determining the appropriate scope of services. The scope of services that a physician is approved to provide may be limited by:

(1) The physician's specialty and, if applicable, subspecialty designation;

(2) The scope of services that a hospital of whose staff the physician is a member is approved to provide; and

(3) The director's determination as to the skill and experience of the physician in treating particular handicapping conditions.

(E) The director may approve a physician who does not meet the standards prescribed by paragraph (B)(3) or (B)(4) of this rule as a limited provider. The director may consult with one or more members of the medical advisory council or with other individuals with expertise in the area concerning approval of physicians under this paragraph. Limitations on service provision may include, but are not limited to, the age of the recipients to be treated, specific handicapping conditions to be treated and types of services to be provided.

(F) Physician provider applicants shall:

(1) Complete and sign a physician application on a form prescribed by the director;

(2) Comply with the procedures prescribed by rule 3701-43-02 of the Administrative Code; and

(3) Submit two letters of reference that attest to the physician's skill in caring for children with special health care needs. One letter must be from a pediatrician and one letter must be from a member of the physician's specialty.

Effective: 01/16/2014
R.C. 119.032 review dates: 11/01/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.022 , 3701.023
Prior Effective Dates: 1/1/1975, 6/12/82, 1/2/89, 5/20/91, 10/9/93, 12/1/01, 10/13/03, 9/1/08

3701-43-04 Health care facilities.

(A) Hospitals:

(1) Must be approved by joint commission, American osteopathic association, or healthcare facilities accreditation program (HFAP);

(2) Must be licensed or registered in the state in which they are located;

(3) For inpatient services and outpatient surgery, must have:

(a) Physical facilities appropriate for the care of pediatric patients;

(b) Trained and qualified staff to care for pediatric patients; and

(c) Anesthesia providers approved under rule 3701-43-03 of the Administrative Code.

(4) Must meet national standards of care for children with special health care needs including, but not limited to the American academy of pediatrics. The department may establish approval criteria and policies for specialized services with no national standards of care.

(B) Ambulatory surgery centers must be accredited by the joint commission, the accreditation association for ambulatory healthcare or the American association for accreditation of ambulatory surgery facilities.

(C) Rehabilitation clinics and outpatient therapy centers must be accredited by the commission on accreditation of rehabilitation facilities (CARF), or American association for accreditation of ambulatory surgery facilities as appropriate.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.21
Rule Amplifies: 3701.021 , 3701.23
Prior Effective Dates: 1/1/1975, 11/28/86, 12/1/01, 9/1/08, 2/13/12

3701-43-05 Medical equipment suppliers.

(A) To be approved as a medical equipment supplier of orthotics, prosthetics, or wheelchairs, a provider shall meet the requirements of rule 3701-43-02 of the Administrative Code and the following.

(B) If the provider is:

(1) A prosthetist or orthotist, he or she shall:

(a) Hold a current, valid license issued in accordance with Chapter 4779. of the Revised Code; and

(b) Be capable of maintaining and repairing the wheelchairs on the provider's premises if he or she is providing wheelchairs; or

(2) Neither a prosthetist nor an orthotist but supplies wheelchairs, the provider shall possess a certificate of attendance at a seating seminar presented by a major wheelchair manufacturer and be capable of providing maintenance and repair of wheelchairs on the provider's premises.

(C) All orthotic, prosthetic, or wheelchair services provided shall be requested by a physician approved under rule 3701-43-03 of the Administrative Code who is:

(1) An orthopedic surgeon, physiatrist, neurologist or rheumatologist;

(2) A pediatrician certified by the "American Board of Medical Specialties" or a certifying board of the "American Osteopathic Association."

Effective: 01/16/2014
R.C. 119.032 review dates: 11/01/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.022 , 3701.023 , 3701.024 , 3701.025 , 3701.026 , 3701.027 , 3701.028
Prior Effective Dates: 12/1/2001, 11/30/03

3701-43-06 Dentists.

(A) To be approved for general dental services, a dentist must be a graduate of an approved dental school and licensed as such by the state of Ohio or in the state in which the dentist's practice is located;

(B) A dental specialist shall:

(1) Meet the requirement in paragraph (A) of this rule;

(2) Submit verification of having had a minimum of two years of graduate training in the specialty; and

(3) Document his or her primary area of practice.

(C) Requests for dental services may be made by a physician approved under rule 3701-43-03 of the Administrative Codeor an advanced practice nurse approved under rule 3701-43-07 of the Administrative Code.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.21
Rule Amplifies: 3701.021 , 3701.23
Prior Effective Dates: 1/1/1975, 12/1/01, 2/13/12

3701-43-07 Health professionals and other providers.

(A) To be eligible for consideration as a provider, the following applicants must be licensed, registered, or certified in accordance with the following:

(1) Advanced practice nurses in accordance with Chapter 4723. of the Revised Code;

(2) Ambulances in accordance with Chapter 4766. of the Revised Code;

(3) Audiologists in accordance with Chapter 4753. of the Revised Code;

(4) Dietitians in accordance with Chapter 4759. of the Revised Code;

(5) Hearing aid dealers in accordance with Chapter 4747. of the Revised Code;

(6) Occupational therapists in accordance with Chapter 4755. of the Revised Code;

(7) Optometrists in accordance with Chapter 4725. of the Revised Code;

(8) Pedorthists in accordance with Chapter 4779. of the Revised Code;

(9) Pharmacies in accordance with Chapter 4729. of the Revised Code;

(10) Pharmacists in accordance with Chapter 4729. of the Revised Code;

(11) Physical therapists in accordance with Chapter 4755. of the Revised Code;

(12) Podiatrists in accordance with Chapter 4731. of the Revised Code;

(13) Psychologists in accordance with Chapter 4732. of the Revised Code; and

(14) Speech language pathologists in accordance with Chapter 4753. of the Revised Code.

(B) In addition to the requirements of paragraph (A) of this rule, services provided by eligible providers shall be requested by the child's physician and shall meet the following requirements:

(1) Advanced practice nurses shall provide services permitted under section 4723.43 of the Revised Code;

(2) Dietetic services shall be prescribed by a physician approved under rule 3701-43-03 of the Administrative Code;

(3) Hearing aid dealer and fitter services shall be prescribed by an otolaryngologist approved under rule 3701-43-03 of the Administrative Code;

(4) Optometry services shall be prescribed by an ophthalmologist approved under rule 3701-43-03 of the Administrative Code;

(5) Pedorthist services shall be prescribed by a physician approved under rule 3701-43-03 of the Administrative Code;

(6) Pharmacist services shall be prescribed by a physician approved under rule 3701-43-03 of the Administrative Code;

(7) Physical therapy, occupational therapy, speech language and audiology services shall be prescribed by a physician approved under rule 3701-43-03 of the Administrative Code;

(8) Podiatric services shall be prescribed by a physician approved under rule 3701-43-03 of the Administrative Code; and

(9) Psychological services shall be prescribed by a physician approved under rule 3701-43-03 of the Administrative Code.

Replaces: 3701-43-07

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.022 , 3701.023
Prior Effective Dates: 1/1/1975, 3/20/97, 12/1/01, 2/13/12

3701-43-08 Local health departments.

(A) Local health department applicants:

(1) Must meet the definition of a "local health department" as defined under paragraph (F) of rule 3701-43-01 of the Administrative Code; and

(2) Must meet provider requirements of rule 3701-43-02 of the Administrative Code.

(B) A local health department providing public health nursing services for individuals on the program:

(1) Must meet the requirements of paragraph (A) of this rule;

(2) Must employ, or contract with, licensed registered nurses as defined in division (A) of section 4723.01 of the Revised Code for the purpose of providing public health nursing services as defined under paragraph (Q) of rule 3701-43-01 of the Administrative Code for individuals on the program;

(3) Must comply with the medical policies for public health nurses serving children with special health care needs as established in the operation manual; and

(4) Must notify the program in writing no less than thirty days of ceasing to provide public health nursing services to individuals within its jurisdiction on the program. A local health department may enter into an agreement with another local health department provider to provide public health nursing services within its jurisdiction. The local health departments involved must notify the program in writing no less than thirty days in advance of this arrangement.

(C) When a local health department does not make arrangements for the provision of public health nursing services to children on the program within its jurisdiction, the program may enter into provider agreements with other agencies, including, but not limited to, home health agencies, private nursing agencies, or hospitals for the purpose of assuring that public health nursing services are available to individuals on the program.

(D) A local health department providing therapy or nutrition services for individuals on the program:

(1) Must meet the requirements of paragraph (A) of this rule;

(2) Must be a medicaid provider; and

(3) Must be a home health agency certified under the medicare program pursuant to 42 U.S.C. 1302(1987) , 42 U.S.C. 1395(hh) , and 42 C.F.R. part 484(2000); or may contract with providers who are physical therapists, occupational therapists, speech pathologists, or dieticians who meet provider requirements in rule 3701-43-07 of the Administrative Code.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.022 , 3701.023
Prior Effective Dates: 12/1/2001, 1/29/07, 9/1/08

3701-43-09 Criteria and procedures for payment of providers.

(A) The director shall pay providers for diagnostic services and for treatment services and goods furnished to recipients in accordance with this rule.

(B) The director shall pay only for services or goods that have been authorized to be provided under the applicable provisions of this chapter.

(C) A provider shall submit a request for payment on a form prescribed by the director and containing at least the name and identification number of the applicant or recipient to whom the services or goods were provided, the provider's identification number, a description of the goods or services provided and the amount of the charges for the goods or services. The request for payment shall be submitted so that it is received by the director no later than twelve months after the last date on which goods or services included in the request were furnished.

(D) If the request for payment does not contain sufficient information for the director to determine whether payment may be made, the director shall deny the request. The director shall notify the provider within thirty days after receipt of a request for payment that the request has been denied and of any additional or corrected information necessary to process the request. Additional information may include, but is not limited to, reports, descriptions of the types or amounts of goods or services provided, the amount of charges for the goods or services and information concerning submission of claims for third-party benefits. The provider may resubmit the request for payment but shall not resubmit the request so that it is received by the director more than twenty-four months after the last date on which goods or services included in the request were furnished.

(E) A provider shall submit claims for medicaid benefits and for all other third-party benefits which may provide payment for the services rendered or goods supplied and shall make all reasonable efforts to assist the recipient to whom the goods or services were provided and the recipient's parent, guardian or other legal representative to submit claims for third-party benefits and any information necessary for processing the claims. The claims for third-party benefits shall have been submitted no less than sixty days before a request for payment is submitted to the director under this rule.

(1) If any payment is made for the goods or services by the medicaid program, the director shall not make payment under this rule. If the recipient of the goods or services giving rise to the request for payment is a medicaid recipient at the time that the services or goods were furnished, the director shall not make payment under this rule until after the medicaid program has denied payment for the goods or services.

(2) If payment is received by the provider through third-party benefits, other than medicaid program benefits, for the goods or services, the director shall subtract the amount of the third-party benefits from the amount determined under paragraph (F) of this rule and shall pay the difference to the provider.

(3) If a provider receives payment from the medicaid program or through other third-party benefits of at least the amount determined under paragraph (F) of this rule from the program for goods or services authorized to be provided by the director under the applicable provisions of this chapter, the provider shall not seek payment of any additional amount from the recipient, recipient's parent, guardian or other legal representative.

(F) If the director determines that a request for payment meets the criteria prescribed by this rule, the director shall pay the provider within sixty days after receipt of all necessary information. Subject to paragraph (E)(2) of this rule, the director shall pay:

(1) For inpatient hospital care, outpatient care and for all other medical assistance furnished by hospitals to recipients in accordance with reasonable cost principles for reimbursement under the medicare program established under Title XVIII of the Social Security Act, 79 Stat. 291 (1965), 42 U.S.C. 1395(1965) .

(2) Providers of good or services other than inpatient or outpatient hospital care in accordance with the fee schedules set forth in the operational manual.

The director shall notify the provider in writing of the amount paid and, if the amount paid is less than the charges, of the reconsideration procedure established by paragraph (B) of rule 3701-43-23 of the Administrative Code.

(3) For pharmaceuticals, the pharmaceutical shall be approved by the medicaid program and be necessary to treat an eligible condition as specified in rule 3701-43-17 of the Administrative Code. The director may deny approval for certain pharmaceuticals when the director determines that there are other therapeutic equivalents available within the drug class and on the basis of costs, medical efficacy, operational guidelines and other factors, the denial is determined to be in the best interest of the program.

(G) The director shall deny payment if the provider fails to meet any of the deadlines established by this rule or if the request for payment does not meet the criteria for payment prescribed by this rule. The director shall notify the provider in writing of the denial of a request for payment and the reasons for denial of the request for payment within thirty days of:

(1) Receipt of information verifying that the request for payment does not meet the criteria prescribed by this rule; or

(2) The provider's failure to comply with a deadline established by this rule.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.023
Prior Effective Dates: 1/2/1989, 10/19/98, 2/14/00, 12/1/01, 1/29/07, 9/1/08, 10/8/10

3701-43-10 Termination of provider services.

A provider of services approved under rules 3701-43-02 to 3701-43-08 and 3701-43-13 of the Administrative Code may have his or her approval terminated if he or she:

(A) Voluntarily terminates his or her medicaid provider agreement or the provider's medicaid provider agreement is terminated by the Ohio department of job and family services;

(B) Is deceitful or fraudulent in connection with obtaining approval or in providing services;

(C) Violates any provision of sections 3701.021 to 3701.028 of the Revised Code or Chapter 3701-43 of the Administrative Code;

(D) Reports in writing that he or she no longer wishes to participate in the program;

(E) Is deceased;

(F) Is unable to be located by the program;

(G) Is required to have a license or certification and the license or certification have been revoked or suspended due to legal action; or

(H) Is not providing services:

(1) In accordance with applicable federal or state standards relevant to care of children with handicapping conditions;

(2) Which are in the best interest of a child; or

(3) In accordance with standards prescribed by the program or a national professional organization for the care of children with handicapping conditions such as the American academy of pediatrics.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.022 , 3701.023
Prior Effective Dates: 1/1/1975, 12/1/01, 2/13/12

3701-43-11 Application and eligibility for provision of diagnostic services.

(A) Application for provision of diagnostic services as defined in paragraph (D) rule 3701-43-01 of the Administrative Code requires the following:

(1) The applicant, parent, guardian or other legal representative of the child for whom services are being requested shall submit to the director a signed consent form allowing the program to release information to persons or agencies who may participate in or facilitate the delivery of authorized services to the child; and

(2) The managing physician shall sign and submit to the director a medical application on a form prescribed by the director. The form shall be completed in full and shall include an individual plan for diagnostic services describing the medical and nonmedical procedures needed for diagnosing or confirming a medical condition of the applicant. The completed medical application inclusive of signed consent forms shall be received by the director within sixty days of the initial examination.

(B) Subject to paragraph (C) of this rule, an applicant is eligible for diagnostic services if based on information submitted pursuant to paragraph (A) of this rule the director determines that the applicant is in need of diagnostic services to determine whether or not the applicant has a medically handicapping or potentially medically handicapping condition.

(C) Notwithstanding paragraph (B) of this rule, the director may determine that the applicant is not in need of diagnostic services necessary to determine whether or not he has a medically handicapping or potentially medically handicapping condition if either of the following apply:

(1) Diagnostic services for the same medically handicapping or potentially medically handicapping condition have previously been authorized for the applicant and there has been no change in managing physician or no substantial change in the suspected handicapping condition that was previously approved for diagnostic services; or

(2) Diagnostic services are being requested for school or adoptive placement.

(D) If the completed medical application is received by the director within sixty days of the date of initial examination by the managing physician, eligibility for diagnostic services shall be effective no earlier than the initial date of examination by the managing physician.

(E) Based on the type and number of services requested on the managing physician's individual plan for diagnostic services, the director shall establish for each eligible recipient a period of eligibility for payment of diagnostic services which shall not exceed one hundred eighty days from the effective date of eligibility.

(F) The director shall notify the applicant or his or her parent, guardian or other legal representative, selected providers of major services, the local health department and the managing physician of the approval or proposed denial of eligibility and the effective date of eligibility, if approved. The director shall issue this notification within sixty days of the date of receipt of the last document necessary to make the eligibility determination or of the failure to submit timely an application or requested additional information. A notice of proposed denial of eligibility shall contain a statement of the reasons for denial and a description of the reconsideration procedure established by paragraph (B) of rule 3701-43-23 of the Administrative Code.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.022 , 3701.023
Prior Effective Dates: 10/3/1992, 12/1/01, 9/1/08

3701-43-12 Authorization for payment of diagnostic services.

(A) Subject to paragraphs (B) and (C) of this rule, diagnostic services shall be authorized for applicants determined to be eligible for diagnostic services pursuant to paragraph (B) of rule 3701-43-11 of the Administrative Code if all of the following apply:

(1) The services are included in the applicant's medical application submitted by the managing physician in accordance with paragraph (A)(2) of rule 3701-43-11 of the Administrative Code, or additional services have been requested by the applicant's managing physician or other BCMH provider on forms prescribed by the director;

(2) The services are furnished by providers, as defined in paragraph (P) of rule 3701-43-01 of the Administrative Code, who are approved under applicable provisions of this chapter to provide the specific services requested and the services are furnished within the period of eligibility for diagnostic services;

(3) The services are deemed necessary by the director for an assessment of the eligible applicant's condition in accordance with medical policies and the applicable standards of care as defined in paragraph (U) of rule 3701-43-01 of the Administrative Code;

(4) The managing physician and any provider shall furnish to the director upon request medical reports and progress records verifying completion of the diagnostic services and indicating whether the child has a handicapping condition;

(5) The services are rendered in Ohio. The director may waive this requirement if comparable services are not available in Ohio or if the director determines that travel to obtain comparable services in Ohio would present an undue hardship for the applicant; and

(6) Request for authorization of services must be received within eleven months from date of service to enable payment for those services to occur in accordance with this chapter.

(B) Notwithstanding paragraph (A) of this rule and pursuant to division (G) of section 3701.023 of the Revised Code, the director may deny payment of diagnostic services for an eligible recipient if payment for the services will be made by a third party payor.

(C) Notwithstanding paragraph (A) of this rule, in authorizing provision of major services such as surgery or inpatient hospital stays, the director may limit the authorization for payment of diagnostic services to a specified type and number of services or to specific providers based upon the applicant's condition.

(D) The department shall notify the applicant or his or her parent, guardian or other legal representative, selected providers of major services, the local health department and the managing physician of the approval or proposed denial of eligibility and the effective date of eligibility, if approved. The director shall issue this notification within sixty days of the date of receipt of the last document necessary to make the eligibility determination or of the failure to submit timely an application or requested additional information. A notice of proposed denial of eligibility shall contain a statement of the reasons for denial and a description of the reconsideration procedure established by paragraph (B) of rule 3701-43-23 of the Administrative Code.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.022 , 3701.023
Prior Effective Dates: 10/3/1992, 12/1/01, 9/1/08

3701-43-13 Application and eligibility for provision of service coordination.

(A) An applicant who wishes to be approved as a service coordinator shall:

(1) Have a bachelor's degree or higher in nursing or social work and is licensed, registered, or certified in the profession, as applicable, by the state of Ohio;

(2) Be employed through a hospital-based interdisciplinary specialty team or physician provider office team approved by the program for the delivery of service coordination services; and

(3) Submit a service coordinator provider application as required in rule 3701-43-02 of the Administrative Code, and include a copy of applicant's resume and current position description that describes how the service coordinator will function within the team.

(B) To be eligible for service coordination services the following applications shall be submitted to the director within sixty days of an initial meeting between the service coordinator and the applicant:

(1) An applicant, parent, guardian or other legal representative of applicant shall submit to the director a signed application on a form prescribed by the director. The application form shall include consent and authorization for the program to release information to persons or agencies who may participate in or facilitate the delivery of authorized services to the applicant; and,

(2) The service coordinator, approved as a provider in accordance with rule 3701-43-02 of the Administrative code, shall sign and submit to the director a completed application on a form prescribed by the director, documenting that the applicant has a medically handicapping condition that is eligible for service coordination and that the child's medical care is managed by an approved hospital-based interdisciplinary specialty team or physician provider office team.

(C) An applicant shall be approved for service coordination services if, based on the applications submitted pursuant to paragraph (B) of this rule, the program determines the applicant is in need of service coordination based on the applicant's medically handicapping condition, as set forth in the operations manual, and documentation that service coordination is provided by an approved hospital-based interdisciplinary specialty team or physician provider office team.

(1) If the application is received by the director within sixty days of the initial meeting between the applicant and the service coordinator eligibility for service coordination shall be effective no earlier than that date.

(2) If the application is received more than sixty days after the date of the initial meeting between the applicant and the service coordinator, the date of the eligibility for service coordination shall be sixty days prior to the receipt of the application by the director.

(D) The director shall establish for each eligible recipient a period of eligibility for payment of service coordination, which shall not exceed twelve months after the effective date of eligibility specified under paragraph (C) of this rule, except that the director may establish:

(1) A shorter period, based upon a reasonable expectation that the recipient may become medically ineligible during the period; or

(2) A longer period, not to exceed thirty-six months, based upon a reasonable expectation that the recipient will remain medically eligible during the period.

(E) The service coordinator must submit a comprehensive service plan annually on behalf of each recipient of service coordination.

(F) The recipient of service coordination, the recipient's parent, guardian or other legal representative, or the service coordinator shall notify the director in writing of any changes in information included in the application form including: name, address, phone number, change of service coordinator or managing physician within thirty days of such a change.

(G) Applications for renewal of eligibility shall be submitted and reviewed in the same manner as initial applications for eligibility under this rule.

Replaces: 3701-43-13

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701-21
Rule Amplifies: 3701-21, 3701.022 , 3701.023
Prior Effective Dates: 12/1/2001, 9/1/2008

3701-43-14 Authorization for payment of service coordination services.

(A) Service coordination services shall be authorized for eligible applicants pursuant to rule 3701-43-13 of the Administrative Code if all of the following apply:

(1) Application for service coordination has been received in accordance with rule 3701-43-13 of the Administrative Code;

(2) Service coordination services are furnished by providers, who are approved under applicable provisions of this chapter to provide the specific services requested and the services are furnished within the period of eligibility for service coordination;

(3) The service coordination services are deemed necessary by the director for the applicant's medically handicapping condition in accordance with medical policies and the applicable standards of care as defined in paragraph (U) of rule 3701-43-01 of the Administrative Code;

(4) The service coordinator shall furnish to the director a comprehensive service plan in accordance with medical policies verifying progress in the coordination of services for the child.

(B) The department shall notify the service coordinator, the local health department jurisdiction and the applicant, parent, guardian or other legal representative of the child in writing of approval or denial of authorization for provision of services under this rule. The director shall issue this notification within sixty days of the date of receipt of the completed application for service coordination filed pursuant to rule 3701-43-13 of the Administrative Code. A notice of proposed denial of authorization for service coordination shall contain a statement of the reasons for the denial and a description of the reconsideration procedure established by paragraph (B) of rule 3701-43-23 of the Administrative Code.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.022 , 3701.023
Prior Effective Dates: 12/1/2001, 9/1/08

3701-43-15 Application and review procedures for eligibility for payment for treatment.

(A) This rule prescribes the procedures for applying for a determination by the director as to whether the applicant is eligible for payment for treatment services and goods by the program because the applicant:

(1) Meets the definition of medically handicapped child established by paragraph (K) of rule 3701-43-01 of the Administrative Code; or

(2) Meets the definition of adult with cystic fibrosis established by paragraph (A) of rule 3701-43-01 of the Administrative Code.

(B) The application shall consist of:

(1) A completed medical application as described in paragraph (C) of this rule, signed by the managing physician;

(2) A completed financial application as described in paragraph (D) of this rule, signed by the applicant or applicant's parent, guardian, or other legal representative, unless the applicant is a recipient of benefits from the Ohio medicaid program; and

(3) A completed release and consent on a form prescribed by the director, signed by the applicant or applicant's parent, guardian or other legal representative.

(C) A medical application shall be submitted to the director in the following manner:

(1) The medical application shall be submitted by the applicant's managing physician on a form prescribed by the director;

(2) The medical application form shall be completed in full, shall include an individualized plan of treatment describing the medical and nonmedical interventions needed for treatment of the applicant and shall be signed by the managing physician. The managing physician also shall submit any medical reports necessary to determine medical eligibility under rule 3701-43-17 of the Administrative Code;

(3) The managing physician shall submit the medical application form so that it is received by the director no later than sixty days after the requested effective date of program eligibility. The requested effective date of program eligibility shall not be earlier than the date of the initial examination of the applicant by the managing physician; and

(4) The managing physician shall submit medical reports or additional information requested by the director for the purposes of determining medical eligibility so that it is received by the director no later than thirty days after the date appearing on the letter requesting the information.

(D) A financial application shall be submitted to the director in the following manner:

(1) The financial application shall be on a form prescribed by the director;

(2) The financial application shall be completed in full and shall include:

(a) Verification of income and medical and other expenses;

(b) Information concerning eligibility for third-party benefits; and

(c) Other documentation as specified on the application form or as necessary to determine financial eligibility under rule 3701-43-16 of the Administrative Code.

(3) The financial application and the signed consent and release form shall be submitted so that it is received by the director no later than sixty days after the forms were mailed by the program to the applicant; and

(4) Upon request by the director, the applicant or his or her parent, guardian or other legal representative shall submit the following information so that it is received by the director no later than sixty days after the date appearing on the letter requesting the information:

(a) Income verification such as federal income tax forms and schedules, pay stubs, employer statements or benefit notices;

(b) Verification of paid, unreimbursed medical or dental expenses or other expenses, such as receipts, cancelled checks, physician statements; and

(c) Any other information necessary to determine financial eligibility under this rule.

(E) If the director, upon review of the medical and financial applications and any necessary additional information, determines that the applicant is eligible for payment for treatment by the program, the director shall establish an effective date of eligibility. Except as provided in paragraph (F) of this rule, the effective date of eligibility shall be the date requested by the managing physician.

(F) If the director, upon review of the medical or financial application or any other relevant information, determines that the applicant is not eligible for the program, the director shall deny the application. In the event an application or any requested additional information is not submitted in compliance with the deadlines specified in paragraph (C) or (D) of this rule, the director either shall deny the application or shall establish, as the effective date of eligibility, the date thirty days before the date on which the application or the last item of requested additional information was received by the director.

(G) The director shall notify the applicant or his or her parent, guardian or other legal representative, selected providers of major services, the local health department and the managing physician of the approval or proposed denial of eligibility and the effective date of eligibility determination. The director shall issue this notification within thirty days of the date of receipt of the last document necessary to make the eligibility determination or of the failure to submit timely an application or requested additional information. A notice of proposed denial of eligibility shall contain a statement of the reasons for denial and a description of the reconsideration procedure established by paragraph (B) of rule 3701-43-23 of the Administrative Code.

(H) The director shall establish a period of eligibility for payment for treatment for each recipient. A recipient, other than an adult with cystic fibrosis, who becomes twenty-one years of age during the period, shall be medically and financially eligible for a period of twelve months after the effective date of eligibility specified under paragraph (E) or (F) of this rule except that the director may establish:

(1) A shorter period, based upon a reasonable expectation that the recipient may become medically or financially ineligible during the period; or

(2) A longer period, not to exceed thirty-six months, based upon a reasonable expectation that the recipient will remain medically or financially eligible during the period.

(I) The applicant or his or her parent, guardian or other legal representative shall notify the director in writing of any changes in information including name, address, phone number, medical care provider, insurance coverage, medicaid status, or change in any other available third party coverage within thirty days of such change. Failure to notify the director of a change may result in denial of coverage.

(J) Applications for renewal of eligibility shall be submitted and reviewed in the same manner as initial applications for eligibility under this rule. In the event that different time periods have been established for a recipient's medical and financial eligibility under paragraph (H) of this rule, the director may waive submission, for renewal purposes, of either the financial or medical application, as applicable.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.022 , 3701.023
Prior Effective Dates: 1/1/1975, 1/2/1989, 6/3/1996, 12/1/01, 9/1/08

3701-43-16 Financial eligibility requirements for payment for treatment for children with medical handicaps.

(A) As used in this rule:

(1) "Income guidelines" means the guidelines, as established by the director on April first of each year, for use in determining financial eligibility for payment for treatment. The income guidelines shall be equal to one hundred eighty-five per cent of the poverty income for each size family, as reported in the "Federal Register" by the United States department of health and human services, rounded up to the nearest five hundred dollars.

(2) A "family unit" means the group consisting of the following persons:

(a) The applicant or recipient;

(b) The applicant's or recipient's spouse;

(c) The applicant's or recipient's parent(s) or custodian(s); and

(d) Other persons who, for federal income tax purposes, are considered dependents of the individual who claims the applicant or recipient as a dependent or who are considered dependents of the applicant or recipient, except for a spouse who is not the biological parent.

A family unit consists only of the applicant or recipient if the applicant or recipient is self-supporting and has no spouse or dependents, or if the applicant or recipient is in the custody of a government or private agency.

(3) "Family income" means the current year's projected adjusted gross earnings based on current gross earnings as reported on pay stubs and/or the sum of the annual adjusted gross incomes, as reported to the United States internal revenue service for federal income tax purposes for the previous year, of each member of the family unit, except for the incomes of a custodian who is not the applicant's or recipient's natural or adoptive parent and the custodian's dependents. In the case of an applicant or recipient who is eighteen or more years of age and self-supporting or twenty-one or more years of age, the family income shall include only the adjusted gross income of the applicant or recipient.

For the purposes of this rule, family income shall not include educational scholarships, loans, and grants; amounts spent by the family unit for child care expenses; amounts spent by the family unit for respite care (with appropriate verification from a qualified respite care provider); and lump-sum death benefits.

(4) "Maximum ability to pay for medical care" means the difference between the amount a family unit spends, including payroll deductions, for health-related insurance coverage and the sum of the following amounts:

(a) Ten per cent of the first fifteen thousand dollars by which the family income exceeds the applicable income guideline, as defined in paragraph (A)(1) of this rule;

(b) Twenty-five per cent of the next twenty-five thousand dollars by which the family income exceeds the applicable income guideline, as defined in paragraph (A)(1) of this rule; and

(c) Thirty-seven and one half per cent of the remaining amount by which the family income exceeds the applicable income guideline, as defined in paragraph (A)(1) of this rule.

(5) "Service level credit" means a credit against the maximum ability to pay for medical care as determined by the director based upon the applicant's or recipient's need for treatment services. The need for treatment services is determined by reference to the services requested by the managing physician on the medical application, to the extent that those services are eligible for authorization under paragraph (E) of rule 3701-43-18 of the Administrative Code. Service levels and service level credits are the following:

(a) Service level one is based on the applicant's or recipient's need for routine physician visits or routine outpatient hospital care. The service level credit for this service level is five hundred dollars.

(b) Service level two is based on the applicant's or recipient's anticipated need for brief hospitalizations, minor surgical procedures, medications, durable equipment, or medical supplies. The service level credit for this service level is one thousand dollars.

(c) Service level three is based on the applicant's or recipient's documented need for multiple hospitalizations, major surgical procedures, medications or supplies costing more than five hundred dollars per month, or medical services for more than one child with special health care needs. The service level credit for this service level is two thousand dollars.

(B) The director shall determine the applicant or recipient to be financially eligible for payment for treatment services either of the following apply:

(1) Family income of the applicant's or recipient's family unit, as defined in paragraph (A)(3) of this rule, is less than or equal to the applicable income guideline, as defined in paragraph (A)(1) of this rule; or

(2) The service level credit for the applicant or recipient, as defined in paragraph(A)(5) of this rule, equals or exceeds his or her family unit's maximum ability to pay for medical care, as defined in paragraph (A)(4) of this rule.

(C) Notwithstanding paragraph (B) of this rule, in order to assure that services to a medically eligible applicant will not be interrupted, the director may determine that such an applicant is financially eligible for payment for treatment services if the applicant's family unit provides satisfactory evidence of both of the following:

(1) During the twelve-month period before the date of application, the family unit paid for unreimbursed medical, vision, therapy services and dental services that were provided to any member of the family unit, or the family unit has contracted in writing to pay for any such services during the twelve months after the date of application; and

(2) The total dollar amount that the family unit spent or is contracted to pay equals or exceeds the difference between the maximum ability to pay for medical care, as defined in paragraph (A)(4) of this rule, and the applicable service level credit, as defined in paragraph (A)(5) of this rule.

(D) Applicants or recipients who are receiving services from the special supplemental food program for women, infants, and children (WIC), supplemental security income (SSI) benefits, or medicaid benefits, except for delayed medicaid spend-down cases as defined in rule 5101:1-39-10 of the Administrative Code, are financially eligible for payment for treatment by the program.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.023
Prior Effective Dates: 1/1/1975, 12/29/80, 7/14/86, 1/2/89, 4/1/92, 4/1/94, 12/1/01, 10/13/03, 10/1/05

3701-43-16.1 Adult hemophilia insurance premium payment program.

(A) As used in this rule:

(1) "Adjusted family income" means a balance after credits for child care expenses or educational expenses not reimbursed by a third party, estimated annual expenditures for health insurance not reimbursed by a third party, and service level are subtracted from family income.

(2) "Assistance" means reimbursement to the eligible participant or legal representative for premiums paid by the eligible participant or legal representative for health insurance coverage for the eligible participant. Assistance may include payments for premiums for an eligible participant's single coverage under a health insurance plan or payments for premiums for the dependent portion of an insurance plan when the eligible participant is one of a group of dependents who is covered under a health insurance plan.

(3) "Eligible participant" means a person twenty-one years of age or older with hemophilia or a related bleeding disorder, who is under the care of a BCMH approved hemophilia treatment center, and who also meets the conditions for eligibility for insurance premium payment assistance set forth in paragraph (B) or (C) of this rule.

(4) "Estimated annual expenditure for health insurance" means the estimated amount for which a family unit spends on insurance premiums.

(5) "Family income" means the current year's projected adjusted gross earnings based on current gross earnings as reported on pay stubs and/or the sum of the annual adjusted gross incomes, as reported to the United States internal revenue service for federal income tax purposes for the previous year, of the eligible participant.

Family income shall not include educational scholarships, loans, and grants; amounts spent by the family unit for child care expenses; amounts spent by the family unit for respite care (with appropriate verification from a qualified respite care provider); and lump-sum death benefits.

(6) "Family unit" means the group consisting of the following persons:

(a) The eligible participant;

(b) The eligible participant's spouse, if married;

(c) The eligible participant's parents, if participant is considered a dependent by parents for federal income tax purposes;

(d) Other persons who, for federal income tax purposes are considered dependents of the eligible participant.

(7) "Service level" means a credit against the family income as determined by the director based upon the eligible participant's need for treatment services. Service level credits are the following:

(a) Service level one is based on the eligible participant's need for routine physician visits or routine outpatient hospital care. The service level credit for this service level is five hundred dollars.

(b) Service level two is based on the eligible participant's need for brief hospitalizations, minor surgical procedures, medications, durable equipment, or medical supplies. The service level credit for this service level is one thousand dollars.

(c) Service level three is based on the eligible participant's documented need for medication and supplies costing more than five hundred dollars per month. The service level credit for this service is two thousand dollars.

(B) The director may authorize assistance to an applicant who meets the definition of an eligible participant under paragraph (A) of this rule, has health insurance coverage and meets all the following criteria:

(1) The applicant's adjusted family income is less than or equal to the income guidelines as defined in paragraph (A)(1) of rule 3701-43-16 of the Administrative Code.

(2) The cost of the applicant's or family unit's annual health insurance premiums exceed seven and one half per cent of the family unit's gross annual earnings and assistance with the premiums is cost-effective as determined by the director; and (3) There are funds available in the hemophilia insurance premium program encumbrance to cover the eligible participant.

(C) If an applicant is found ineligible for assistance under paragraph (B) of this rule, the director may deem the applicant eligible if the applicant meets the definition of an eligible participant under paragraph (A) of this rule, has health insurance coverage and meets all the following criteria:

(1) The applicant's annual health insurance premiums exceed fifteen per cent of the family unit's gross annual earnings and assistance with the premiums is cost-effective as determined by the director;

(2) The applicant's adjusted family income does not exceed 300% of the federal poverty level;

(3) The director determines that the cost of the annual premiums constitutes a hardship to the applicant; and

(4) There are funds available in the hemophilia insurance premium program encumbrance to cover the eligible participant.

(D) The director shall require that the following written documentation be submitted to determine the applicant's eligibility for assistance:

(1) The BCMH medical application form signed by the applicant or legal representative, and the treating physician or authorized representative of the BCMH approved hemophilia treatment center.

(2) Combined program application and supporting documentation to determine financial eligibility;

(3) Documentation showing the annual insurance premium amount;

(4) Documentation of annual health care costs of the applicant that has been covered by the insurance; and

(5) Any other documentation requested by the director.

(E) The director shall notify the applicant in writing of his decision to provide assistance within thirty days of the receipt of all the required documentation. Assistance with health insurance premium payments will not begin prior to the first day of the month in which all the required documentation is received.

(F) The director shall establish an initial period of eligibility for assistance not to exceed twelve months. The director may renew the eligibility on an annual basis as long as the requirements of paragraph (B) or (C) is met and funds are available.

(G) The eligible participant or legal representative shall submit, within thirty days of the date of the change, documentation of any changes to income that result in an increase in annual gross earnings, changes to the eligible participant's medical condition or treatment thereof, changes to the eligible participant's health insurance coverage, or documentation of any other changes that would affect the eligible participant's eligibility for assistance.

(H) The director may discontinue assistance or change the terms of assistance if:

(1) The eligible participant or legal representative fails to meet the requirements set forth in paragraphs (B) and (C) of this rule: or

(2) The eligible participant or legal representative fails to pay the health insurance premiums; or

(3) The funding for the hemophilia insurance premium payment program has been expended.

(I) The director shall provide the eligible participant or legal representative written notice of the decision to discontinue or change the terms of assistance. Any such discontinuation or change will become effective no sooner than thirty calendar days from the date of the written notice.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.022 , 3701.023 , 3701.024 , 3701.025 , 3701.026 , 3701.027 , 3701.028
Prior Effective Dates: 1/30/2004

3701-43-16.2 Financial eligibility requirements for payment for treatment for adults with cystic fibrosis.

(A) As used in this rule:

(1) "Income guidelines" means the guidelines, as established by the director on April first of each year, for use in determining financial eligibility for payment for treatment. The income guidelines shall be equal to one hundred eighty-five per cent of the poverty income for each size family, as reported in the "Federal Register" by the United States department of health an human services, rounded up to the nearest five hundred dollars.

(2) A "family unit" means the group consisting of the following persons:

(a) The applicant or recipient;

(b) The applicant's or recipient's spouse;

(c) Other persons who, for federal income tax purposes, are considered dependents of the individual who claims the applicant or recipient as a dependent or who are considered dependents of the applicant or recipient, except for a spouse who is not the biological parent. A family unit consists only of the applicant or recipient if the applicant or recipient is self-supporting and has no spouse or dependents.

(3) "Family income" means the current year's projected adjusted gross earnings based on current gross earnings as reported on pay stubs and/or the sum of the annual adjusted gross incomes, as reported to the United States internal revenue service for federal income tax purposes for the previous year, of each member of the family unit. For the purposes of this rule, family income shall not include educational scholarships, loans, and grants; amounts spent by the family unit for child care expenses; amounts spent by the family unit for respite care (with appropriate verification from a qualified respite care provider); and lump-sum death benefits.

(4) "Maximum ability to pay for medical care" means the difference between the amount a family unit spends, including payroll deductions, for health-related insurance coverage and the sum of the following amounts:

(a) Ten per cent of the first fifteen thousand dollars by which the family income exceeds the applicable income guidelines, as defined in paragraph (A)(1) of this rule;

(b) Twenty-five per cent of the next twenty-five thousand dollars by which the family income exceeds the applicable income guideline, as defined in paragraph (A)(1) of this rule; and

(c) Thirty-seven and one half per cent of the remaining amount by which the family income exceeds the applicable income guideline, as defined in paragraph (A)(1) of this rule.

(5) "Service level credit" means a credit of two thousand dollars.

(B) The director shall determine the applicant or recipient to be financially eligible for payment for treatment services if either of the following apply:

(1) Family income of the applicant's or recipient's family unit, as defined in paragraph (A)(3) of this rule, is less than or equal to the applicable income guideline, as defined in paragraph (A)(1) of this rule; or

(2) The service level credit for the applicant or recipient, as defined in paragraph (A)(5) of this rule, equals or exceeds his or her family unit's maximum ability to pay for medical care, as defined in paragraph (A)(4) of this rule.

(C) Notwithstanding paragraph (B) of this rule, in order to assure that services to a medically eligible applicant will not be interrupted, the director may determine that such an applicant is financially eligible for payment for treatment services if the applicant's family unit provides satisfactory evidence of both of the following:

(1) During the twelve-month period before the date of application, the family unit paid for unreimbursed medical, vision, therapy services and dental services that were provided to any member of the family unit, or the family unit has contracted in writing to pay for any such services during the twelve months after the date of application; and

(2) The total dollar amount that the family unit spent or is contracted to pay equals or exceeds the difference the maximum ability to pay for medical care, as defined in paragraph (A)(4) of this rule, and the applicable service level credit, as defined in paragraph (A)(5) of this rule.

(D) Applicants or recipients who are receiving services from the special supplemental food program for women, infants, and children (WIC), supplemental security income (SSI) benefits, or medicaid benefits, except for delayed medical spend-down cases as defined in rule 5101:1-39-10 of the Administrative Code, are financially eligible for payment for treatment by the program.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.023
Prior Effective Dates: 10/1/2005

3701-43-17 Medical eligibility requirements for payment for treatment.

(A) The director shall apply the requirements prescribed by this rule in determining whether an applicant or recipient is medically eligible for payment for treatment services and goods by the program for medically handicapped children. An applicant or recipient is medically eligible if he or she has been diagnosed as having a medically eligible condition. In determining whether an applicant's or recipient's condition is a medically eligible condition under paragraphs (B) and (C) of this rule, the director may consult with one or more members of the medical advisory council or with other individuals with expertise in the area.

(B) A condition is a medically eligible condition if:

(1) The condition is a "chronic, physically handicapping condition," defined, for purposes of this chapter as a condition which has a degree of severity that restricts physical development and is expected to impair health functioning for a period of one year or more or at frequently recurring intervals;

(2) The condition is amenable to treatment through treatment services or goods, as defined in paragraph (X) of rule 3701-43-01 of the Administrative Code;

(3) The condition either is a neoplasm or a congenital anomaly or affects one or more of the following:

(a) Endocrine system;

(b) Immune system;

(c) Nervous system;

(d) Integumentary system;

(e) Cardiovascular system;

(f) Respiratory system;

(g) Digestive system;

(h) Genitourinary system;

(i) Musculoskeletal system;

(j) Sensory organs;

(k) Metabolic diseases;

(l) Diseases of the blood.

(C) Notwithstanding paragraph (B) of this rule, conditions that are classified in one or more of the following categories are not medically eligible conditions:

(1) Mental retardation and related diagnoses;

(2) Psychological and emotional disorders;

(3) Learning disabilities;

(4) Acute, infectious or common childhood conditions unless treatment of the condition is necessary to prevent the occurrence or exacerbation of a chronic, physically handicapping condition, as defined in paragraph (B)(1) of this rule;

(5) Common refractive errors;

(6) Parasitic diseases;

(7) Pregnancy and pregnancy-related diagnoses;

(8) Conditions that are self-correcting through maturation;

(9) Developmental delays;

(10) Routine dental problems and common malocclusions;

(11) Conditions listed in the operational manual as not medically eligible because the director has determined that the program does not have sufficient funding to permit payment for treatment of the conditions. In deciding whether specific conditions should be added to or deleted from the list of conditions not eligible under this paragraph, the director may consult with the medical advisory council, one or more members of the council or other individuals with expertise in the area.

(D) None of the conditions listed in paragraph (C) of this rule precludes treatment of a medically eligible condition as defined in paragraph (B) of this rule.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.022 , 3701.023
Prior Effective Dates: 1/2/1989, 4/1/94, 12/1/01, 9/1/08

3701-43-18 Authorization for provision of treatment services and goods.

(A) The director shall apply the criteria prescribed by this rule in determining whether or not to authorize the provision of treatment services and goods to recipients, pursuant to division (E) of section 3701.023 of the Revised Code. An applicant's managing physician shall request authorization for provision of goods or services by submitting an individualized plan of treatment as part of the medical application for program eligibility under rule 3701-43-15 of the Administrative Code.

(B) Requests for authorization for provision of services or goods to recipients that are not included in the current individualized plan of treatment may be submitted by the recipient's managing physician or other BCMH provider to the director within eleven months of the date of service on forms prescribed by the director.

(C) The managing physician and any provider must furnish any information requested by the director, including but not limited to medical or operative reports, hospital discharge summaries, evaluation reports, and other descriptions of services, that is necessary to determine whether the goods or services may be authorized. The information must be submitted so that it is received by the director within eleven months of the date of service. The managing physician and any provider also shall submit any information requested by the director to evaluate the results achieved by the provision of the goods or services.

(D) Subject to paragraph (E) of this rule, the director shall authorize treatment services or goods if:

(1) The services or goods are included in the recipient's individualized plan of treatment, submitted by the recipient's managing physician, in accordance with paragraph (C)(2) of rule 3701-43-15 of the Administrative Code;

(2) The services or goods meet the definition of treatment services or goods, as prescribed by paragraph (X) of rule 3701-43-01 of the Administrative Code, with respect to the specific medically eligible or associated condition for which they are requested;

(3) The services or goods are furnished by providers, as defined by paragraph (P) of rule 3701-43-01 of the Administrative Code, who are approved under applicable provisions of this chapter to provide the specific services or goods requested and the goods or services are furnished after the effective date of the provider's approval;

(4) The request for authorization and any additional documentation requested by the director are submitted in compliance with paragraphs (A), (B), and (C) of this rule; and

(5) The services are rendered or the goods furnished in Ohio. The director may waive the requirement prescribed by this paragraph if comparable goods or services are not available in Ohio or if the director determines that travel to obtain comparable services or goods in Ohio would present an undue travel or financial hardship for the recipient. In making determinations under this paragraph, the director may consult with one or more members of the medical advisory council or with other individuals with expertise in the area.

(E) In determining whether provision of requested treatment services or goods may be authorized, the director shall consider whether or not the goods or services are necessary for treatment of the recipient's medically eligible condition, in accordance with the applicable standards of care and medical policies. The director shall not authorize provision of any goods or services that are not listed in the standards of care or medical policies as being necessary for treatment of the condition or that are in excess of a limitation contained in the standards or policies.

(1) If a recipient's condition is not addressed by the standards of care or medical policies, the director may use the standards of care or medical policies applicable to conditions that are similar to the recipient's condition to determine which goods or services may be authorized.

(2) The director may deny authorization for provision of goods or services for treatment of a recipient's medically eligible condition if payment for the services or goods will be made by another governmental or private entity, including the medicaid program, or if payment could have been made by such an entity and was not made because of an act or omission by the recipient, parent, guardian or other legal representative or a provider.

(3) In accordance with the applicable medical policies or standards of care, the director may authorize provision of goods or services for treatment of a recipient's physical health impairment which, as an isolated condition, would not be a medically eligible condition under rule 3701-43-17 of the Administrative Code, if the impairment is associated with a medically eligible condition for which the recipient is receiving treatment goods or services authorized under this rule.

(4) In emergency or extraordinary circumstances that present an undue risk of significant harm to a recipient, the director may waive any of the criteria or procedures established by paragraph (D) or (E) of this rule that would prevent authorization of requested goods or services.

(5) In circumstances which present an undue hardship to a recipient, the director may extend the time requirements of paragraphs (B) and (C) of this rule for a period not to exceed one hundred fifty days if sufficient justification for the extension is provided by the managing physician, the recipient, parent, guardian, or other legal representative, or another recipient advocate.

(6) The director may deny authorization for provision of goods or services that otherwise may be authorized under the applicable medical policies or standards of care upon a determination that the goods or services are not necessary for treatment of the particular recipient's condition.

(F) In authorizing provision of major services or goods such as inpatient or outpatient surgery, inpatient hospital stays, medications, or durable medical equipment, the director may limit the provision of the goods or services to a specified provider or providers, based upon complexity, necessary follow-up care, and other relevant factors.

(G) Notwithstanding paragraph (E) of rule 3701-43-01 of the Administrative Code, provision of treatment services or goods may be authorized only by a licensed registered nurse or a physician employed by the Ohio department of health.

The department shall notify in writing the applicant, parent, guardian or other legal representative of the child and the managing physician of the approval or proposed denial of authorization for provision of goods or services under this rule. A notice of proposed denial shall include a statement of the reasons for denial and a description of the reconsideration procedure under paragraph (B) of rule 3701-43-23 of the Administrative Code.

Effective: 01/16/2014
R.C. 119.032 review dates: 11/01/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.022 , 3701.023
Prior Effective Dates: 1/2/1989, 5/20/91, 12/1/01, 9/1/08

3701-43-19 Third-party payments.

Notwithstanding any contract provision to the contrary, any bureau payments for costs of treatment, supportive services, accessories and their upkeep, shall be in excess of and secondary to payments of any third-party payor, and therefore any bureau payments for costs shall be made after all third-party payment sources are exhausted.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.022 , 3701.023
Prior Effective Dates: 11/16/1978, 12/1/01, 9/6/08

3701-43-20 Providing assistance with health insurance premiums.

(A) As used in this rule:

(1) "Eligible participant" means a recipient who also meets the conditions for eligibility for insurance premium payment assistance set forth in paragraph (B) of this rule.

(2) "Cost-effective" means that the total cost to the program for uncovered services provided to an eligible participant plus the cost for health insurance premiums paid by the program on behalf of the eligible participant plus the associated administrative costs to the program is less than the total anticipated annual costs to the program for authorized services provided to an eligible participant.

(3) "Assistance" means:

(a) The payment of health insurance premiums by the program to a third party or an employer for purposes of providing health insurance coverage for an eligible participant; or

(b) Reimbursement to the eligible participant or the eligible participant's parent, guardian or other legal representative for premiums paid by the eligible participant or the eligible participant's parent, guardian or other legal representative for health insurance coverage for the eligible participant.

Assistance may include payments for premiums for an eligible participant's single coverage under a health insurance plan or payments for premiums for the dependent portion of an insurance plan when the eligible participant is one of a group of dependents who is covered under a health insurance plan.

(4) "Uncovered services" means authorized services provided to an eligible participant that are not covered benefits of the eligible participant's health insurance plan.

(5) "Total anticipated annual costs" means the estimated costs to the department for authorized services if the eligible participant had no health insurance coverage.

(6) "Recipient" has the same meaning as set forth in rule 3701-43-01 of the Administrative Code.

(7) "Family unit" has the same meaning as set forth in rule 3701-43-16 of the Administrative Code.

(B) The director may authorize assistance when a recipient or a recipient's parent, guardian or other legal representative has health insurance coverage for the recipient and both of the following conditions are met:

(1) The health insurance coverage for the recipient is available as a result of a Consolidated Omnibus Budget Reconciliation Act, 26 U.S.C. 4980B(2000) , et.seq. ("COBRA") option or the cost of the family's annual health insurance premiums exceed two and one half per cent of the family unit's gross annual earnings; and

(2) The director determines that it is cost-effective; or

(3) The family is unable to access BCMH authorized benefits as a result of primary payor network mandates.

(C) The director shall require that the following written documentation be submitted by the recipient or the recipient's parent, guardian or other legal representative to determine the recipient's eligibility for assistance:

(1) Insurance explanation of benefits (EOBs) or equivalent documentation as determined acceptable by the director for the recipient for the six months preceding the date of the letter that is sent by the department requesting the eligibility documentation;

(2) A notice of premium or equivalent documentation as determined acceptable by the director to document the amount of the monthly insurance premium;

(3) A copy of the COBRA notification and COBRA election forms if a COBRA option is being exercised; and

(4) Any other documentation as required by the director.

(D) The director shall determine the recipient's eligibility for assistance and provide written notification of the determination within thirty days of the receipt of all the required documentation. Assistance with health insurance premium payments will not begin prior to the first day of the month in which all the required documentation is received.

(E) The director shall establish an initial period of eligibility for assistance not to exceed twelve months. The director may establish a continued period of eligibility for assistance for a period not to exceed an additional twelve months based upon a determination of cost-effectiveness to the program.

(F) The recipient or eligible participant or their parent, guardian or other legal representative shall submit, within thirty days of the date of the change, documentation of any changes to income that result in an increase in annual gross earnings, changes to the recipient's or eligible participant's medical condition or treatment thereof, changes to the recipient's or eligible participant's health insurance coverage, or documentation of any other changes that would affect the recipient's or eligible participant's eligibility for assistance.

(G) The director may discontinue assistance or change the terms of assistance if:

(1) The eligible participant or the eligible participant's parent, guardian or other legal representative fails to meet the requirements set forth in paragraphs (B) to (F) of this rule; or

(2) The eligible participant or the eligible participant's parent, guardian or other legal representative fails to pay the health insurance premiums if reimbursement for premiums paid is the method of assistance provided.

(H) The director shall provide the eligible participant or the eligible participant's parent, guardian or other legal representative written notice of the decision to discontinue or change the terms of assistance. Any such discontinuation or change will become effective no sooner than thirty calendar days from the date of the written notice.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.023
Prior Effective Dates: 9/1/1997, 12/1/01, 1/29/07, 9/1/08

3701-43-21 Providing assistance with medicaid spenddown payments.

(A) As used in this rule:

(1) "Eligible participant" means a recipient who also meets the conditions for eligibility for medicaid spenddown payment assistance as set forth in paragraphs (B) to (F) of this rule.

(2) "Cost-effective" means the total cost to the department for uncovered services provided to an eligible participant plus the cost for medicaid spenddown payments paid by the program on behalf of the eligible participant plus the associated administrative costs to the program is less than the total anticipated annual costs to the program for authorized services provided to an eligible participant.

(3) "Assistance" means the payment of medicaid spenddown liability by the program to a county job and family services agency for the purpose of providing continued medicaid coverage or obtaining medicaid coverage.

(4) "Uncovered services" means authorized services provided to an eligible participant that are not covered benefits of the eligible participant's medicaid health plan.

(5) "Total anticipated annual costs" means the estimated costs to the program for authorized services if the eligible participant had no health insurance coverage.

(6) "Primary source of payment" mean the payment source with primary responsibility for payment.

(B) The director may authorize assistance for a recipient who has a spenddown liability for medicaid and meets the following conditions:

(1) Recipient has been approved for medical assistance disability (MA-D) with a spenddown liability for medicaid as defined in rule 5101:1-39-10 of the Administrative Code.

(2) The recipient is requiring a bone marrow transplant and has insurance, but the recipient's primary source of payment is the program for a bone marrow transplant.

(3) The director determines that it is cost-effective.

(C) The director shall require that the following information be submitted by the recipient or the recipient's parent, guardian or other legal representative to determine the recipient's eligibility for assistance:

(1) A written approval letter from the department of job and family services documenting the spenddown amount and the effective date of the spenddown.

(2) Any other documentation as requested by the director.

(D) The director shall determine the recipient's eligibility for assistance and provide written documentation to the recipient and to the county department of job and family services within thirty days of receipt of all required documentation. Assistance with medicaid spenddown payments will not begin prior to the first of the month in which all required documentation is received.

(E) The director shall establish an initial period of eligibility for assistance not to exceed twelve months. The director may establish a continued period of eligibility for assistance based upon a determination of cost-effectiveness to the program.

(F) The recipient or eligible participant or parent, guardian or other legal representative shall submit within thirty days of the date of the change, documentation of any changes to income that result in an increase in annual gross earnings, changes to the recipient's health insurance coverage, changes in medicaid status, changes in recipient's medicaid spenddown amount or documentation of any other changes that would affect the recipient's eligibility for assistance.

(G) The director may discontinue assistance or change the terms of assistance if:

(1) The eligible participant or the eligible participant's parent, guardian or other legal representative fails to meet the requirements set forth in paragraphs (B) to (F) of this rule.

(2) The eligible participant or the eligible participant's parent, guardian or other legal representative does not comply with the rules, the requirements or follow through with the application process of the involved county department of job and family services.

(H) The director shall provide the eligible participant or the eligible participant's parent, guardian or other legal representative written notification of the decision to discontinue or change the terms of assistance. Any such discontinuation or change will become effective no sooner than thirty calendar days from the date of the written notice.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.022 , 3701.023 , 3701.024 , 3701.025 , 3701.026 , 3701.027 , 3701.028
Prior Effective Dates: 12/1/2001

3701-43-22 Waiver.

(A) Upon request from an applicant, recipient, provider or legal representative of applicant, recipient, or provider, the director may waive any of the requirements in this chapter unless the requirement is specified in statute.

(B) The director may not grant a waiver request if the approval of the request is contrary to public interest or there are not sufficient funds to support a waiver request.

(C) The director's decision pursuant to a waiver request is not appealable. The director is not required to provide an opportunity for a hearing if the wavier request is denied.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.023
Prior Effective Dates: 12/1/2001, 9/1/08

3701-43-23 Appeal procedures for decisions concerning the program for medically handicapped children.

(A) This rule prescribes the procedures for appealing proposed decisions of the director concerning the program for medically handicapped children that are subject to division (H) of section 3701.023 of the Revised Code. These proposed decisions include:

(1) A proposed determination under rules 3701-43-15 and 3701-43-11 of the Administrative Code that an applicant or recipient, as defined in paragraphs (C) and (R) of rule 3701-43-01 of the Administrative Code, does not meet the requirements for financial or medical eligibility for payment for treatment or diagnostic services prescribed by rules 3701-43-11 , 3701-43-16 , and 3701-43-17 of the Administrative Code;

(2) A proposed determination under rule 3701-43-15 of the Administrative Code that an adult cystic fibrosis applicant or recipient, as defined in paragraphs (A), (C), and (R) of rule 3701-43-01 of the Administrative Code, does not meet the financial eligibility requirements under rule 3701-43-16 of the Administrative Code or the medical eligibility requirements for payment for treatment services under rule 3701-43-17 of the Administrative Code;

(3) A proposed determination under rule 3701-43-13 of the Administrative Code that an applicant for or recipient of service coordination, as defined in paragraph (S) of rule 3701-43-01 of the Administrative Code, does not meet the requirements for eligibility for service coordination;

(4) A proposed denial of a request for authorization of provision of treatment services or goods under rule 3701-43-18 of the Administrative Code or provision of diagnostic services under rule 3701-43-12 of the Administrative Code;

(5) A proposed termination of approval under rule 3701-43-10 of the Administrative Code of a provider, as defined in paragraph (P) of rule 3701-43-01 of the Administrative Code; and

(6) A proposed decision to pay an amount less than the charges for authorized goods or services under rule 3701-43-09 of the Administrative Code.

(B) An affected party may request reconsideration of a proposal by the director to make one of the decisions listed in paragraph (A) of this rule by filing a written request for reconsideration with the director no later than forty-five days after the date on the notice of the proposed action issued under the applicable provision of this chapter of the Administrative Code. The request for reconsideration shall contain a statement of the reasons that the affected party believes that the proposed decision is incorrect or inappropriate, a copy of the denial letter, and may also include any written documentation, arguments, or other materials that the affected party wishes to submit for the purposes of this rule:

(1) An item is filed with the director when it is received by the Ohio department of health.

(2) "Affected party" means:

(a) The applicant or recipient, recipient's parent, guardian or other legal representative, in the case of the proposed decisions listed in paragraphs (A)(1) to (A)(4) of this rule. The applicant, recipient, parent, guardian or other legal representative may be represented in proceedings under this rule by any person whom the applicant, recipient, parent, guardian or other legal representative has authorized in writing to represent the interests of the applicant, recipient, parent, guardian or other legal representative relative to the director's proposed decision.

(b) The provider, in the case of a proposed decision listed in paragraph (A)(5) of this rule.

(c) The provider who submitted the request for payment, in the case of a proposed decision listed in paragraph (A)(6) of this rule.

(C) For the purposes of reconsideration, the director may request from the affected party additional, relevant records or documentation within forty-five days of receipt of the request for reconsideration or additional information previously submitted under this paragraph. The affected party shall file any requested information with the director no later than forty-five days after the date on the request for additional information.

(D) Within forty-five days after receipt of a request for reconsideration from an affected party that complies with paragraph (B) of this rule and of all necessary additional information filed in accordance with paragraph (C) of this rule, the director shall issue written notification to the affected party who requested the reconsideration:

(1) That a decision has been rendered in favor of the affected party; or

(2) That the proposal to issue a decision adverse to the affected party remains in effect and that the affected party may request an adjudicatory hearing concerning the proposed decision. The notice of the opportunity for a hearing shall include a statement of the reasons for the proposed decision, citations of the statutes or rules directly involved and a description of the method for requesting a hearing, in accordance with paragraph (E) of this rule.

(E) Following receipt of the notice required under paragraph (D) of this rule, an affected party may request an adjudication hearing concerning a proposed decision listed in paragraph (A) of this rule by filing a written hearing request with the director no later than thirty days after the date of mailing of the notice provided for by paragraph (D) of this rule. If the hearing is requested timely, it shall be conducted and an adjudication order shall be issued. Upon receipt of a timely filed request for a hearing, the hearing shall be scheduled for a date not later than seventy-five days from the date the written request is received by the director. The director shall notify the affected party of the date, time, and location of the hearing no less than seven days before the date set for the hearing. The hearing may be continued at the request of any party with the approval of the director or upon his own motion.

(F) The director shall appoint a hearing officer to preside over the hearing. At the hearing, the rules of evidence shall be liberally construed. A stenographic record may be made upon the request of any party at the expense of the party requesting the record.

(G) The affected party may appear in person at the hearing and may have in attendance legal counsel or such other representative of the affected party's choice and at the affected party's expense. The affected party may present testimony and/or evidence and may question witnesses present at the hearing. In lieu of appearing at the hearing, the affected party may submit written materials to be examined by the hearing officer.

(H) The hearing officer shall submit to the director within thirty days of the date of the conclusion of the hearing a written report setting forth his findings of fact and conclusions of law and a recommendation of the action to be taken. The director shall send by certified mail a copy of the hearing officer's report and recommendation to the affected party within seven days of receipt of the written report. The affected party or the department may file within ten days of receipt of the written report objections to the report, which shall be considered by the director before approving, modifying, or disapproving the recommendation.

(I) The director shall issue an order to approve, modify, or disapprove the report and recommendation of the hearing officer and shall send notice of his action by certified mail to the affected party. The decision of the director under this paragraph shall be final.

Effective: 01/16/2014
R.C. 119.032 review dates: 11/01/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.022 , 3701.023
Prior Effective Dates: 1/2/1989, 5/28/93, 7/12/93, 12/1/01, 2/13/12

3701-43-24 Medically handicapped children's medical advisory council.

(A) The medically handicapped children's medical advisory council, created by section 3701.025 of the Revised Code, shall consist of twenty-one members appointed by the director for terms set by paragraph (B) of this rule. The director shall appoint members based upon the following criteria:

(1) All members shall be licensed physicians, surgeons, dentists and other professionals in the field of medicine;

(2) All members shall be providers; and

(3) The members shall be representative of the various disciplines, geographic areas of Ohio and types of treatment facilities, such as hospitals, private and public health clinics and private physicians' offices, involved in the treatment of children with medically handicapping conditions.

(B) Except as otherwise provided in this paragraph, members of the medical advisory council shall serve terms of seven years. The director may reappoint members for one term.

(C) Members of the medical advisory council shall serve at the pleasure of the director and shall be removed from membership for nonperformance of duties or for failure to continue to meet the qualifications established by paragraph (A) of this rule. The director may appoint a member, subject to the provisions of paragraph (A) of this rule, to fill a vacancy occurring during a member's term because of death, resignation or removal. A member appointed to fill a vacancy shall serve for the duration of the unexpired term and may be reappointed.

(D) The medical advisory council shall meet at least annually. It shall adopt bylaws to govern its meetings and organization and the meetings and organization of its committees and shall review and update the bylaws periodically. The bylaws shall provide for the establishment by the medical advisory council of an executive committee of seven members which shall have and exercise all powers and duties of the medical advisory council. The medical advisory council and the executive committee also may establish standing subcommittees and ad hoc subcommittees to advise the medical advisory council and the director on matters that require special or extended consideration. The subcommittees may include individuals other than members of the medical advisory council.

(E) The medical advisory council shall advise the director regarding:

(1) The suitable quality of medical practice for providers;

(2) The requirements for medical eligibility for the program; and

(3) Other aspects of the administration of the program.

(F) One or more members of the medical advisory council may provide advice to the director, upon request, concerning medical issues such as:

(1) Whether a physician provider applicant should be approved as a provider, based upon an interview with the physician and/or review of the physician's application;

(2) Whether a physician provider applicant has skill and significant experience in the treatment of children or adolescents with handicapping conditions;

(3) The appropriate scope of services for which a provider should be approved or whether a physician provider should be approved as a limited provider under paragraph (D) of rule 3701-43-03 of the Administrative Code;

(4) Whether an out-of-state provider applicant should be approved or provision of goods or services outside of Ohio should be authorized;

(5) Whether particular conditions are medically eligible conditions under rule 3701-43-17 of the Administrative Code;

(6) Whether services or goods requested to be provided to a recipient meet the definition of diagnostic services or treatment services or goods established by paragraphs (D) and (V) of rule 3701-43-01 of the Administrative Code;

(7) Whether treatment goods or services should be authorized for an associated condition under paragraph (E)(3) of rule 3701-43-18 of the Administrative Code;

(8) The development of medical policies; or

(9) Any other medical issue.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.025
Prior Effective Dates: 1/2/1989, 12/1/01

3701-43-25 County financial participation.

For the purposes of division (F) of section 3701.023 of the Revised Code, the board of county commissioners of each county shall annually appropriate to the credit of the medically handicapped children's county assessment fund established pursuant to section 3701.024 of the Revised Code an amount equal to one-tenth of one mill of the county's total general property tax duplicate.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.024
Prior Effective Dates: 12/1/2001

3701-43-26 Manufacturer discount program.

(A) Effective October 1, 2013, all prescription drugs and nutritional formulas for which BCMH made payments on behalf of eligible clients shall be subject to inclusion in the manufacturer discount program. The manufacturer discount program shall aply to all prescription drugs and nutritional formulas for which BCMH made payments on behalf of eligible clients in each state fiscal year.

(B) At the end of each state fiscal year and prior to the end of the first quarter of the subsequent state fiscal year, BCMH shall send a letter to all applicable prescription drug manufacturers requesting participation in the discount program. Each letter shall contain, specific to each manufacturer:

(1) Total net paid by BCMH in the prior fiscal year for prescription drugs, grouped by national drug code (NDC).

(2) Total net paid by BCMH for all drugs produced by the manufacturer.

(3) A requested amount to be paid to BCMH based on the payments made by BCMH for nutritional formulas produced by the manufacturer.

(4) A payment address to which funds may be sent, and the relevant data needed in order for the Ohio department of health to process the payment.

(5) If a written agreement between the parties is necessary, a copy of the approved agreement will be included in the letter.

(C) At the end of each state fiscal year and prior to the end of the first quarter of the subsequent state fiscal year, BCMH shall send a letter to all applicable nutritional manufacturers requesting participation in the discount program. Each letter shall contain, specific to each manufacturer:

(1) Net paid by BCMH in the prior fiscal year for nutritional formulas, grouped by name.

(2) Total net paid by BCMH for all formulas produced by the manufacturer.

(3) A requested amount to be paid to BCMH based on the payments made by BCMH for nutritional formulas produced by the manufacturer.

(4) A payment address to which funds may be sent, and the relevant data needed in order for the Ohio department of health to process the payment.

(5) If a written agreement between the parties is necessary, a copy of the approved agreement will be included in the letter.

(D) In lieu of participating in the discount program, a manufacturer may choose to donate funds to BCMH in order to assure the continued availability of lifesaving prescription drugs and nutritional formula products. BCMH shall only accept donations that it may legally possess and distribute.

(E) In order to be considered for inclusion in the manufacturer discount program, BCMH must have expended a minimum of five thousand dollars during the state fiscal year on products produced by a manufacturer.

Effective: 01/16/2014
R.C. 119.032 review dates: 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.023