LAW
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Ohio Laws and Rules
(A) Most medical procedures are reimbursable within certain administrative limitations; some are reimbursable if approved in advance by the department through prior authorization or pre-certification; and, some are ordinarily not reimbursable.
(B) The following general principles determine whether a particular medical service is reimbursable:
(1) The service is determined to be medically necessary as defined in rule 5101:3-1-01 of the Administrative Code.
(2) The consumer or authorized representative originates all requests for medicaid services.
(3) Services are provided within the limits of the medicaid benefit package, within the scope and practice of the provider as defined by applicable federal, state, and local laws and regulations.
As required by the centers for medicare and medicaid services (CMS), habilitation services (as defined in 42 U.S.C. 1396n(c)(5) release date: December 27, 2005) are covered under medicaid only when:
(a) They are a part of services provided in an intermediate care facility for persons with mental retardation (ICF/MR), or
(b) They are included under a federally approved home and community-based services (HCBS) waiver, and are medically necessary services identified in an enrollee’s particular HCBS waiver. Special education and related services that otherwise are available to the individual through a local educational agency and vocational rehabilitation services that otherwise are available to the individual through a program funded under 29 U.S.C. 730 (release date: September 29, 2005) are not reimbursable through federally approved waivers.
(4) The consumer selects the eligible provider of his or her choice, with the exception of consumers enrolled in the primary alternative care and treatment (PACT) program as defined in Chapter 5101:3-20 of the Administrative Code.
(5) The service is rendered by an eligible provider.
(6) The consumer makes no payment for medicaid-covered services, except as noted in rule 5101:3-1-13.1 of the Administrative Code.
(7) The consumer receives medical services at the same cost as or less than non-medicaid individuals. This means that the department will not pay for services that are free to the general public, except when medicaid reimbursement for such services is prescribed by federal law as referenced in rule 5101:3-1-03 of the Administrative Code. In addition, the department will not pay for services that are charged at a rate greater than the provider’s usual and customary charge to other patients. For inpatient hospital services billed by hospitals reimbursed on a prospective payment basis, as defined in Chapter 5101:3-2 of the Administrative Code, the department will not pay, in the aggregate, more than the provider’s customary and prevailing charges for comparable services. Chapter 5101:3-3 of the Administrative Code defines these provisions as they apply to providers of long-term care services.
(C) The consumer has the right to appeal to the department, in accordance with division-level 5101:6 of the Administrative Code, any decision that adversely affects the consumer.
Effective: 07/01/2006
R.C. 119.032 review dates: 03/24/2006 and 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02
Prior Effective Dates: 4/7/77, 9/19/77, 12/21/77, 12/30/77, 7/1/80, 2/19/82, 10/1/84, 10/1/87, 6/1/91, 5/30/02