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.
(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.
(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.
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