5101:3-1-05.3 Payment for "Medicare Part B" cost sharing.

(A) The reimbursement set forth in paragraph (B) of this rule is limited to medicare part B services that meet all of the following criteria:

(1) Are not hospital services as defined in Chapter 5101:3-2 of the Administrative Code;

(2) Are covered as supplemental medical insurance (SMI) benefits under medicare; and

(3) Are provided to dual eligibles listed in paragraph (A)(6) of rule 5101:3-1-05 of the Administrative Code who elected to receive their medicare benefits under original medicare.

(B) The Ohio department of job and family services (ODJFS) will pay the lesser of the sum of the medicare deductible and coinsurance amounts or the difference between the medicare approved (allowed/covered) amount and the sum of the payments made by medicare and all other third party payers. If the payment made by medicare and all other third party payers exceeds the medicare approved amount, ODJFS will not make any additional payment to the provider.

Effective: 12/18/2006

R.C. 119.032 review dates: 12/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02