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Ohio Laws and Rules
As used in this chapter:
(A) “AIDS” means acquired immune deficiency syndrome.
(B) “Core medical services” means the medical, dental, mental health, substance abuse and medical case management services.
(C) “Department” means the Ohio department of health.
(D) “Director” means the director of health or his or her designee.
(E) “Family” means a group of individuals who are related by blood, marriage, or adoption.
(F) “HIV” means human immunodeficiency virus.
(G) “HIV care consortia” means a regional community planning body consisting of public and nonprofit health care and support service providers, consumers and community based organizations that plan, develop, and arrange for core medical and support services for people living with HIV disease.
(H) “HIV medical case management” means a range of client-centered services that link clients with health care, psychosocial, and other services. Medical case management includes coordination and follow up of medical treatment and the provision of treatment adherence counseling to ensure readiness for, and adherence to, complex HIV/AIDS treatments.
(I) “Ohio HIV drug assistance program” or “OHDAP” means the program established under the Ryan White part B program and administered by the department that provides payment for medications and treatment for HIV disease
(J) “Ryan White part B program” means the program established by the Ryan White HIV/AIDS Treatment Modernization Act, 42 U.S.C. 300ff et seq. (as in effect on January 1, 2009), and administered by the director of health under division (D) of section 3701.241 of the Revised Code.
(K) “Support services” means the services needed by individuals with HIV/AIDS to achieve medical outcomes, such as respite care, outreach, medical transportation, linguistic services and referrals for health care and support services.
Replaces: 3701-44-01
Effective: 08/02/2009
R.C. 119.032 review dates: 08/01/2014
Promulgated Under: 119.03
Statutory Authority: 3701.241
Rule Amplifies: 3701.241
Prior Effective Dates: 9/23/1991, 12/22/91, 5/20/99, 7/20/01, 12/18/06
(A) The director shall designate through the department’s grant process regional HIV care consortia.
(B) Selected HIV care consortia shall comply with the requirements of the Ryan White part B program, sections 3701.24 to 3701.249 of the Revised Code and Chapter 3701-44 of the Administrative Code.
(C) HIV care consortia shall provide or arrange with other entities to provide core medical services and support services as specified in their grant award.
Replaces: 3701-44-02
Effective: 08/02/2009
R.C. 119.032 review dates: 08/01/2014
Promulgated Under: 119.03
Statutory Authority: 3701.241
Rule Amplifies: 3701.241
Prior Effective Dates: 9/23/91 (Emer), 12/22/91, 5/20/1999
(A) The director shall designate community based HIV medical case managers through the department’s grant process.
(B) Selected HIV medical case managers shall comply with the Ryan White part B program, sections 3701.24 to 3701.249 of the Revised Code and Chapter 3701-44 of the Administrative Code.
(C) HIV medical case managers shall provide medical case management services to individuals with HIV as specified in their grant awards. The services shall include the following:
(1) Make authorization decisions for payment for services requested by individuals eligible for benefits under the Ryan White part B program. Authorization may be given orally or in writing. If authorization is given orally, the HIV medical case manager must make a notation of the specific services authorized and the date and manner of such authorization. The HIV medical case manager shall authorize payment for services only after making all of the following determinations:
(a) The individual requesting the service is eligible for the service pursuant to rule 3701-44-05 of the Administrative Code;
(b) The individual is not covered by a third-party source for that service, including medical assistance established by Chapter 5111. of the Revised Code for the service requested. Except for home health services, an individual shall be considered to be covered by a third-party source if the source will provide any payment for the service, even if the payment does not cover the provider’s full costs. Payment for home health services may be authorized to supplement payment by a third party payment source;
(c) The provider who will provide the service is authorized by the director pursuant to rule 3701-44-06 of the Administrative Code; and
(d) There are sufficient funds to cover payment for the service.
(2) If the HIV medical case manager denies payment for a requested service, the manager shall provide written notice of the denial to the individual requesting the service. The written notice shall include the reasons for the denial, a statement that the individual may request reconsideration of the decision in accordance with rule 3701-44-07 of the Administrative Code, and an explanation of the process for requesting the reconsideration.
Replaces: 3701-44-03, 3701-44-04
Effective: 08/02/2009
R.C. 119.032 review dates: 08/01/2014
Promulgated Under: 119.03
Statutory Authority: 3701.241
Rule Amplifies: 3701.241
Prior Effective Dates: 9/23/91 (Emer), 12/22/91, 5/20/1999
(A) The director may contract with a third-party administrator to make payments for core medical services.
(B) The director or third-party administrator shall pay only for services authorized by the director or HIV medical case manager in accordance with rule 3701-44-03 of the Administrative Code and only upon submission of a detailed invoice. A detailed invoice must include the identification of the individual or family for whom the service was provided, a list of itemized services and the date of each service.
(C) Payment shall be made as follows:
(1) Payment for core medical services shall not exceed the usual, customary, and reasonable charges in the community for the authorized service.
(2) Payment for health insurance premiums, co-payments for core medical services, and support services shall not exceed the actual cost of the premium, co-payment or support service.
(3) Payment for home health services shall be made in accordance with the annual fee schedule established by the director and posted on the department’s website at www.odh.ohio.gov/odhPrograms/chss/aids/aids1.aspx.
(D) The third-party administrator shall not make payment for a service if the amount to be paid causes the total payments for the geographical area where the individual receiving the service lives to exceed the amount that the director has allocated for that area, unless the director authorizes such payment.
Replaces: 3701-44-04, 3701-44-09, 3701-44-10
Effective: 08/02/2009
R.C. 119.032 review dates: 08/01/2014
Promulgated Under: 119.03
Statutory Authority: 3701.241
Rule Amplifies: 3701.241
Prior Effective Dates: 9/23/91 (Emer), 12/22/91, 5/20/1999, 7/20/2001
(A) To be eligible for benefits under the Ryan White part B program, an individual shall meet all of the following requirements:
(1) The individual must be an Ohio resident;
(2) The individual must have a verified HIV infection; and
(3) The individual or individual’s family must have a gross income, excluding taxes and any mandatory retirement deduction that meets the financial guidelines established by the director. The financial guidelines shall be provided to the HIV medical case managers and published on the department’s website at www.odh.ohio.gov/odhPrograms/chss/aids/aids1.aspx by the first of April of each year. The financial guidelines shall be based on the amount of funding available for the Ryan White part B program and percentage of the poverty income.
(B) The HIV medical case manager for the area where the applicant resides shall determine whether the applicant meets the requirements specified in paragraph (A) of this rule. Upon determining that the applicant is eligible for benefits, the HIV medical case manager shall assign the eligible individual an identification number and shall report the individual’s number to the director and the third-party administrator responsible for making payments under rule 3701-44-04 of the Administrative Code.
(C) The director or HIV medical case manager may deny an individual’s application and future applications or terminate an individual’s eligibility if the director or HIV medical case manager determines that the individual submitted false information related to the application for Ryan White part B benefits or abused approved benefits.
Replaces: 3701-44-05, 3701-44-11
Effective: 08/02/2009
R.C. 119.032 review dates: 08/01/2014
Promulgated Under: 119.03
Statutory Authority: 3701.241
Rule Amplifies: 3701.241
Prior Effective Dates: 9/23/91 (Emer), 12/22/91, 5/20/1999, 7/20/2001
(A) An individual or entity that wishes to provide core medical services under the Ryan White part B program must request a provider agreement with the director. To be eligible for a provider agreement, the individual or entity must meet the following criteria;
(1) The individual or entity shall possess appropriate licenses and regulatory approvals required by Ohio law and be in good standing with the licensing or approving agency to provide the core services for which they are applying.
(2) The individual or entity shall participate in the Ohio medical assistance program established under section 5111.01 of the Revised Code, if providers of that type are eligible to be providers under the medical assistance program.
(3) The individual or entity shall have a current federal tax identification number.
(4) The individual or entity has not been denied an application to be a provider or had a provider agreement terminated by the department or other Ohio state agency.
(5) The individual or entity meets all federal and state requirements to enter into a provider agreement with the department to provide Ryan White part B services.
(B) An individual who is authorized as a Ryan White part B provider shall execute an agreement with the director. The provider agreement shall include, but not be limited to, the following provisions.
(1) The provider shall agree to provide core medical services to eligible Ryan White part B recipients upon receipt of authorization of such services.
(2) The provider shall bill other applicable payers, such as the medical assistance program or third party insurance prior to billing the Ryan White part B program.
(3) The provider shall agree to bill the director at the provider’s usual, customary, and reasonable rates for services.
(4) The provider shall agree to accept as payment in full the amount paid by the director or third-party administrator as set forth in rule 3701-44-04 of the Administrative Code.
(5) The provider shall agree to not bill the eligible Ryan White part B recipient or any other person for services for which payment is made under the Ryan White part B program.
(6) The provider shall agree to comply with all applicable provisions of the Ryan White part B program, sections 3701.24 to 3701.249 of the Revised Code, Chapter 3701-44 of the Administrative Code and the provider agreement.
(C) The director may deny a provider agreement application or terminate a provider’s eligibility upon determining the applicant or provider does not meet the eligibility requirements specified in this rule or the provider agreement.
(D) The director shall provide written notification of any decision regarding eligibility of a provider. If the director denies or terminate a provider agreement, the director shall state in the notice the reasons for denial or termination and the process for reconsideration under rule 3701-44-07 of the Administrative Code.
Replaces: 3701-44-06, 3701-44-12
Effective: 08/02/2009
R.C. 119.032 review dates: 08/01/2014
Promulgated Under: 119.03
Statutory Authority: 3701.241
Rule Amplifies: 3701.241
Prior Effective Dates: 9/23/91 (Emer), 12/22/91, 5/20/1999, 7/20/2001
(A) The following individuals may seek reconsideration of a denial or termination decision pertaining to the Ryan White part B program:
(1) An individual who has applied for eligibility for benefits and whose application has been denied;
(2) An individual eligible for Ryan White part B program who has been denied payment for a requested service or whose eligibility determination has been terminated;
(3) An individual or entity who has been denied a provider agreement; and
(4) A provider whose provider agreement has been terminated.
(B) An individual seeking reconsideration of a decision listed in paragraph (A) of this rule shall file a written request for reconsideration with the HIV medical case manager or director as directed in writing by the agency issuing the adverse decision. The request for reconsideration must be received within thirty days from the date the individual or entity received the denial or termination decision from the HIV medical case manager or director. The request for reconsideration must contain a statement of the reasons that the individual or entity believes that the denial or termination decision is incorrect or inconsistent with the Ryan White part B program requirements, and may include any written documentation, arguments or other materials that the affected party wishes to submit for the purposes of the reconsideration.
(C) Upon receiving a timely request for reconsideration, the HIV medical case manager or director, as applicable, shall:
(1) Review the information submitted by the individual or entity within thirty days of receipt of the request. The review may request additional information from the individual or entity. The individual or entity shall submit additional information within forty-five days of receiving a request for additional information.
(2) Submit a written decision to the individual or entity who requested the reconsideration within thirty days of the receipt of the request for reconsideration or receipt of additional information, whichever is later. The written decision shall include the reasons for the decision and the following information:
(a) If the decision was made by the director, the notice shall state that the decision is final and there is no further review.
(b) If the decision was made by the HIV case manager, the notice shall state that the individual or entity affected by the decision may request further review by the director by submitting a written request for review of the HIV case manager’s decision to the director within thirty days of receipt of the HIV case manager’s decision.
(3) Upon timely receipt of a request to review HIV case manager’s decision, the director shall review the record and issue a final written decision to the individual or entity within thirty days of receipt of the request.
Replaces: 3701-44-07, 3701-44-13
Effective: 08/02/2009
R.C. 119.032 review dates: 08/01/2014
Promulgated Under: 119.03
Statutory Authority: 3701.241
Rule Amplifies: 3701.241
Prior Effective Dates: 9/23/91 (Emer), 12/22/91, 5/20/1999, 7/20/2001
(A) To be eligible for the OHDAP program, an individual must meet the eligibility criteria outlined in paragraph (A) of rule 3701-44-05 of the Administrative Code and the following:
(1) The individual shall submit a complete, accurate, and truthful OHDAP application, a copy of any health insurance policy under which the applicant has coverage and documentation of CD4 and viral load testing results from tests taken not more than six months prior to the date of application;
(2) The individual shall cooperate with the department in applying for all potential third party benefits for which the individual may be eligible. Refusal to cooperate in obtaining third party benefits shall result in ineligibility for the OHDAP program; and
(3) If the individual’s or family’s gross income is at or below the current federal poverty level as reported in the “Federal Register” by the United States department of health and human services, the individual shall submit documentation demonstrating the applicant applied for the medical assistance program established in section 5111.01 of the Revised Code and that the individual is enrolled in an HIV medical case management program approved by the department.
(B) Applications for OHDAP shall be reviewed to determine which of the following benefits is the most appropriate for the applicant to secure HIV medications.
(1) Individuals who have public or private health insurance coverage may be enrolled in the health insurance premium payment or “HIPP” program. Individuals enrolled in the HIPP program may also be eligible for assistance from Ryan White part B resources for payment of co-payments and deductibles for medications that are covered by the OHDAP program.
(2) Individuals who are eligible for medicare part D prescription coverage may be eligible for assistance from Ryan White part B resources for payment of the medicare part D premiums, co-payments and deductibles.
(3) Individuals who are eligible for the medical assistance program through the spenddown provisions of rule 5101:1-39-10 of the Administrative Code may be eligible for the OHDAP spenddown payment program.
(C) Approval for the OHDAP program shall not exceed eighteen months from the date of application. Prior to the end of the approved OHDAP eligibility period, the individual must complete a new application for a new eligibility period.
(D) Ryan White part B resources must be used as a “payer of last resort” and all other options for obtaining medication must be exhausted.
(E) The director may deny an individual’s application and future applications or terminate an individual’s eligibility if the director determines that the individual submitted false information related to the application for Ryan White part B benefits, cancelled an insurance policy under which the individual was covered in order to receive Ryan White part B benefits, or fraudulently accepted Ryan White part B benefits or abused the payment of benefits.
(F) An individual who is denied OHDAP eligibility or is terminated from ODHAP may request reconsideration of the denial or termination in accordance with rule 3701-44-07 of the Administrative Code.
Replaces: 3701-44-08
Effective: 08/02/2009
R.C. 119.032 review dates: 08/01/2014
Promulgated Under: 119.03
Statutory Authority: 3701.241
Rule Amplifies: 3701.241
Prior Effective Dates: 7/20/2001, 12/18/06
Rescinded eff 8-2-09
Rescinded eff 8-2-09
Rescinded eff 8-2-09
Rescinded eff 8-2-09
Rescinded eff 8-2-09