Chapter 5101:3-23 Disability Assistance Medical Program

(A) Definitions.

(1) “Acknowledgment process” is the signing, explanation, and/or completion of necessary forms by or on behalf of an applicant.

(2) “Applicant” is any person applying for DMA.

(3) “Covered services” are those mandatory health care benefits defined and set forth in paragraph (B) of this rule.

(4) “Disability medical assistance (DMA) is a program that pays for medical services with state and county funds for those individuals who have been determined to be medication dependent by a licensed physician and other eligibility criteria as set forth in Chapter 5101:1-42 of the Administrative Code.

(5) “Dental services” are those services rendered by eligible dental providers as set forth in Chapter 5101:3-5 of the Administrative Code. DMA coverage for dental services shall be those services set forth in paragraph (B) of this rule.

(6) “Hospital services” are those inpatient and/or outpatient services that are generally and customarily provided by hospitals and that are prescribed, directed, or expressly authorized by a provider.

(7) “Pharmacy services” are those services rendered by eligible providers as set forth in Chapter 5101:3-9 of the Administrative Code. DMA coverage for pharmacy services shall be those services set forth in paragraph (B) of this rule.

(8) “Physician services” are those services rendered by eligible physician providers as set forth in Chapter 5101:3-4 of the Administrative Code. DMA coverage for physician services shall be those services set forth in paragraph (B) of this rule.

(9) “Podiatric services” are those services rendered by eligible podiatric providers as set forth in Chapter 5101:3-7 of the Administrative Code. DMA coverage for podiatric services shall be those services set forth in paragraph (B) of this rule.

(10) “Prior authorization” is a whereby the medical need for services is reviewed prior to the delivery of that service, as set forth in Chapter 5101:3-1 of the Administrative Code.

(11) “Provider” is any person or entity who has a valid medicaid provider agreement with the Ohio department of job and family services (ODJFS) in accordance with Chapter 5101:3-1 of the Administrative Code.

(B) Covered services.

(1) Physician services provided in an outpatient setting shall be limited to twelve physician visits during a six-month period. “Outpatient physician services” are services provided in an office, home, clinic, emergency room, or any other non-inpatient setting. Doctors of podiatric medicine and dental surgery are included within the definition of “physician” but only in respect to the functions each is legally authorized to perform under section 4731.51 of the Revised Code as identified in Chapters 5101:3-5 and 5101:3-7 of the Administrative Code. Outpatient and inpatient services shall be counted separately.

(2) Physician services provided in an inpatient setting shall be limited to one visit per day and will not exceed a maximum of twelve visits in a six-month period. Doctors of podiatric medicine and dental surgery are included within the definition of “physician” but only in respect to the functions each is legally authorized to perform under section 4731.51 of the Revised Code as identified in Chapters 5101:3-5 and 5101:3-7 of the Administrative Code. Outpatient and inpatient services shall be counted separately.

(3) Outpatient hospital, inpatient hospital and emergency room services shall be covered as a part of the hospital care assurance program (HCAP) and are not covered benefits under the DMA program.

(4) Prescription drug services shall be the same as the covered items identified in appendix A of rule 5101:3-9-12 of the Administrative Code.

(5) Medical supply services shall be limited to syringes, needles, glucose reagent strips (blood and urine), lancets, glucose monitors, alcohol swabs, canes, walkers, crutches, ostomy supplies and oxygen services and shall be provided and billed in accordance with Chapter 5101:3-10 of the Administrative Code.

(6) Laboratory and radiology services shall be the same as those services covered by the medicaid program as set forth in Chapter 5101:3-4 of the Administrative Code.

(7) Dental services.

(a) For DMA consumers twenty years of age and younger, dental services shall be limited to extractions and radiographs which support the medical necessity of the extraction and shall be provided and billed in accordance with Chapter 5101:3-5 of the Administrative Code.

(b) For DMA consumers twenty-one years of age and older, dental services shall be limited to simple extractions and radiographs which support the medical necessity of the extraction and shall be provided and billed in accordance with Chapter 5101:3-5 of the Administrative Code

(C) Reimbursement for covered services.

(1) Reimbursement for DMA services is contingent upon providers having a valid provider agreement on file with ODJFS in accordance with Chapter 5101:3-1 of the Administrative Code.

(2) Reimbursement for all DMA covered services shall be based upon a fee-for-service methodology. Reimbursement amounts for rendered services are in accordance with rule 5101:3-1-60 of the Administrative Code.

(3) The maximum reimbursement amount for DMA covered services shall be the lesser of the provider’s billed charge or the medicaid maximum, except for services requiring a co-payment as defined in paragraph (D) of this rule. For services that are subject to a co-payment, reimbursement will be decreased by the amount equal to the co-payment that is to be billed to the consumer as defined in paragraph (D) of this rule.

(4) Because the DMA program provides fewer covered medical services than are covered by the medicaid program, federally qualified health centers (FQHCs), rural health clinics (RHC), and outpatient health facilities (OHFs) must bill ODJFS for covered DMA services on a fee-for-service basis as an ambulatory health care clinic provider.

(5) All covered DMA services must be billed to ODJFS in accordance with the requirements of the medicaid program for physician, dental, pharmacy, medical supply, laboratory and radiology services, and ambulatory health centers respectively, as set forth in Chapters 5101:3-4, 5101:3-5, 5101:3-9, 5101:3-10, 5101:3-11, and 5101:3-13 of the Administrative Code.

(6) Providers shall submit DMA claims to ODJFS within three hundred sixty-five calendar days from the date of service. ODJFS will process the claims in accordance with provisions set forth in Chapter 5101:3-1 of the Administrative Code.

(7) Providers must fully and accurately report any discount received (including a rebate check) for a DMA good or service when submitting a claim for reimbursement. A “discount” means a reduction in the amount a seller charges a provider who buys either directly or through a wholesaler or a group purchasing organization. “Fully and accurately reporting a discount” means deducting the amount of the discount from billed charges when submitting a claim for payment and if prior authorization is required, indicating on the JFS 03142 “Prior Authorization Form” (rev. 2/2003), or attached documentation, the amount of the discount.

(D) Co-payments.

(1) Prescription medications.

(a) Beginning January 1, 2004, in accordance with rule 5101:3-9-09 of the Administrative Code, consumers eligible for the DMA program will pay a three dollar co-payment for prescription medications not found in appendix A of rule 5101:3-9-12 of the Administrative Code.

(b) Beginning January 1, 2006, in accordance with rule 5101:3-9-09 of the Administrative Code, consumers eligible for the DMA program must pay a two dollar co-payment for selected trade name medications found in appendix A of rule 5101:3-9-12 of the Administrative Code.

(2) Beginning January 1, 2006, consumers eligible for the DMA program that receive dental services must pay a three dollar co-payment for each date the consumer visits a dentist and receives services in accordance with rule 5101:3-5-01 of the Administrative Code .

(3) Beginning January 1, 2006, consumers eligible for the DMA program that receive vision services provided by a physician must pay a two dollar co-payment for each routine eye examination provided by a physician in accordance with Chapter 5101:3-6 of the Administrative Code.

(4) Exclusions to the co-payment program are defined in rule 5101:3-1-09 of the Administrative Code.

(5) Co-payment requirements for DMA consumers are also subject to the provisions of rules 5101:3-1-09, 5101:3-9-09 and 5101:3-1-60 of the Administrative Code.

(E) DMA consumers have the same consumer liability obligations as consumers enrolled in the medicaid program as defined in rule 5101:3-1-13.1 of the Administrative Code.

Effective: 01/01/2006

R.C. 119.032 review dates: 10/17/2005 and 01/01/2011

Promulgated Under: 111.15

Statutory Authority: 5115.12

Rule Amplifies: 5115.10, 5115.12

Prior Effective Dates: 12/31/87 (Emer), 3/30/88, 7/1/88 (Emer), 9/29/88, 1/13/89 (Emer), 4/13/89, 10/1/91 (Emer), 12/30/91, 7/1/92 (Emer), 7/31/92, 9/10/92, 1/1/93 (Emer), 4/1/93, 7/1/94, 8/1/95 (Emer), 10/13/95, 7/1/98, 10/19/03

(A) “Access-determined health care” is a system where a designated provider or group of providers arrange and deliver all or a portion of a consumer’s health care services. A county department of job and family services (CDJFS) may have a plan to require that all DMA consumers in the county, or only those exceeding established utilization parameters, receive their DMA health care coverage through an access-determined system.

(B) If the CDJFS elects to have an access-determined health care system, the following plan conditions, at a minimum, must be met:

(1) The plan must identify which services are to be access-determined. For example, a plan would need to identify whether pharmacy services, pharmacy and physician services, or all services, are to be access-determined. The plan must also identify how emergency situations will be covered.

(2) The plan must identify conditions under which consumers may change the designated providers that determine their access to care. At a minimum, the CDJFS must resolve situations where the consumer is unable to get to the assigned provider due to distance from the provider and/or lack of transportation to that provider. If the CDJFS denies the request to change a designated health care provider, it must notify the consumer in accordance with rule 5101:6-2-04 of the Administrative Code.

(3) The plan must identify how consumers will choose or be assigned their health care provider and how they will be notified of their designated provider, as well as the manner in which this information will be shared with providers of health care services.

(4) The plan must comply with paragraphs (B)(1) to (B)(3) of this rule if the access-determined system includes less than the total DMA population for a particular CDJFS and must identify the criteria under which the access-determined population will be identified.

(a) The county must develop written criteria to identify which consumers will participate in an access-determined health care system based upon the recommendations of a committee that includes, at a minimum, a physician, a pharmacist, if drugs are included, and a CDJFS representative. These criteria must be uniformly applied to all DMA consumers in the county.

(b) The consumers must be provided notice of enrollment, notice of continuing enrollment, and notice of denial of a provider change, and must be advised of the right to a state hearing in accordance with Chapter 5101:6-2 of the Administrative Code. These notices are subject to ODJFS approval.

(c) The plan must identify how long the consumer will be enrolled in access-determined health prior to each case being reviewed and a determination made as to whether access-determined health care will continue.

(d) The CDJFS must maintain records that substantiate that the consumer exceeded the utilization parameters established by the CDJFS. Additionally, these records must also substantiate a consumer’s continued enrollment in an access-determined health care program.

Effective: 01/01/2006

R.C. 119.032 review dates: 10/17/2005 and 01/01/2011

Promulgated Under: 111.15

Statutory Authority: 5115.12

Rule Amplifies: 5115.10, 5115.12

Prior Effective Dates: 7/1/98, 9/18/03