(A) This rule establishes a consumer co-payment for non-emergency emergency department services as authorized by section 5111.0112 of the Revised Code. The provisions in this rule do not apply to consumers enrolled in the medicaid managed health care program.
(1) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent lay person, as defined in paragraph (B)(2) of this rule, could reasonably expect the absence of immediate medical attention to result in any of the following: placing the health of the individual (or, with respect to a pregnant woman, the health of her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.
(2) "Prudent lay person" means a person with an average knowledge of health and medicine to determine, within reason, that emergency services are necessary.
(3) "Non-emergency emergency department service" means an emergency department service that does not meet the definition of emergency medical condition, as defined in paragraph (B)(1) of this rule.
(C) Application of co-payment.
For dates of service on or after January 1, 2006, medicaid consumers shall pay a co-payment equal to three dollars for non-emergency emergency department services, as defined in paragraph (B)(3) of this rule, except as excluded in paragraphs (D) and (E) of this rule. Hospital providers shall report, through claim submission, the applicable co-payment to the department in accordance with hospital billing instructions.
(D) Exclusions and additional limitations to the co-payment requirement for non-emergency care provided in an emergency department are in accordance with rule 5101:3-1-09 of the Administrative Code, except as provided in paragraph (E) of this rule.
(E) A hospital may take action to collect a co-payment by providing, at the time services are rendered to a medicaid recipient, notice that a co-payment may be owed. If the hospital provides the notice and chooses not to take further action to pursue collection of the co-payment, the prohibition against waiving co-payments, as described in paragraph (B)(3) of rule 5101:3-1-09 of the Administrative Code, does not apply.
(F) Reimbursement for services subject to the co-payment for non-emergency emergency department services. The department shall reimburse the emergency department claim the allowable medicaid payment, in accordance with rule 5101:3-2-21 of the Administrative Code, minus the applicable co-payment as described in paragraph (C) of this rule and any third party resources available to the patient, in accordance with rule 5101:3-2-25 of the Administrative Code.
R.C. 119.032 review dates: 06/27/2006 and 09/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.0112, 5111.02
Rule Amplifies: 5111.01, 5111.0112, 5111.02, 5111.021
Prior Effective Dates: 1/1/2006