5101:3-28-03 Federally qualified health centers (FQHCs): coverage and limitation policies.

(A) Covered core medical services for FQHCs are:

(1) "Physician services," as defined in Chapter 5101:3-4 of the Administrative Code. The limitations found in the physician chapter also apply to physician services furnished under the auspices of an FQHC.

(2) "Physician assistant services," as defined in Chapter 5101:3-4 of the Administrative Code. The limitations found in the physician chapter also apply to physician assistant services furnished under the auspices of an FQHC.

(3) "Advanced practice nurse services," as defined in rule 5101:3-8-23 of the Administrative Code, except for services relating to mental health as defined in paragraph (B)(8) of this rule, provided by an advanced practice nurse as defined in rules 5101:3-8-20 to 5101:3-8-23 of the Administrative Code. The limitations found in rule 5101:3-8-23 of the Administrative Code also apply to advanced practice nurse services provided under the auspices of an FQHC.

(4) "Services and supplies furnished as incident to professional services by a physician, physician assistant, advanced practice nurse, clinical social worker, or psychologist" are those services and supplies that are commonly furnished in physicians' offices; and commonly rendered without charge or included in the physician visit charge or provided as an incidental but integral part of the physician's services provided under the direct supervision of a physician as described in paragraph (A)(1) of rule 5101:3-4-02 of the Administrative Code; and, furnished by an employee of the clinic.

(B) Covered noncore services for FQHCs are:

(1) "Physical therapy services" are those services identified in rule 5101:3-1-60 of the Administrative Code. These services must be provided in accordance with the physical therapy licensure requirements found in Chapter 4755. of the Revised Code. Limitations found in rule 5101:3-8-02 of the Administrative Code also apply to services rendered in an FQHC.

(2) "Speech pathology and audiology services" are those services identified in rule 5101:3-1-60 of the Administrative Code. These services must be provided in accordance with the licensure requirements found in Chapter 4753. of the Revised Code. Limitations found in Chapter 5101:3-13 of the Administrative Code also apply to services rendered by an FQHC.

(3) "Dental services," as defined in Chapter 5101:3-5 of the Administrative Code. Limitations found in the dental chapterChapter 5101:3-5 of the Administrative Code also apply to dental services rendered under the auspices of an FQHC, with the exception of denture services. Full and partial dentures shall be prior authorized by the department. For dates of service on and after the effective date of this rule, FQHCs may submit up to three claims for the provision of dentures, including not more than two follow-up encounters. Follow-up visits shall be medically necessary for the provision of full or partial dentures.

(4) "Podiatry services" are those services identified in Chapter 5101:3-7 of the Administrative Code. Limitations found in Chapter 5101:3-7 of the Administrative Code also apply to podiatry services rendered under the auspices of an FQHC.

(5) "Optometric and/or optician services" are those services identified in Chapter 5101:3-6 of the Administrative Code. Limitations found in Chapter 5101:3-6 of the Administrative Code also apply to vision services rendered under the auspices of an FQHC. Services rendered by an ophthalmologist are physician services and considered a core service.

(6) "Chiropractic services" are those services identified in rule 5101:3-8-11 of the Administrative Code. Limitations found in rule 5101:3-8-11 of the Administrative Code also apply to chiropractic services rendered under the auspices of an FQHC.

(7) "Transportation services" are those instances of transportation to and/or from a medicaid service site of an FQHC. The transportation must be provided on the same date as another Medicaid covered encounter occurs;.

(8) "Mental health services" are those services provided by a clinical psychologist or advanced practice nurse certified by a national-certifying organization in the specialty of psychiatry in accordance with Chapter 5101:3-8 of the Administrative Code and services provided by a licensed social worker, clinical social worker, professional counselor, professional clinical counselor, in accordance with rule 5101:3-4-29 of the Administrative Code. FQHCs shall be able to bill Medicaid for therapy and testing. The limitations found in rules 5101:3-8-05 and 5101:3-4-29 of the Administrative Code also apply to mental health services provided under the auspices of an FQHC.

(C) Provisions regarding outpatient hospital services identified in rule 5101:3-2-03 of the Administrative Code also apply to FQHCs.

(D) For dates of service on and after January 1, 2006, the Ohio department of job and family services (ODJFS) shall institute a co-payment program under medicaid in accordance with rule 5101:3-1-09 of the Administrative Code. This co-payment program shall also apply to services rendered by an FQHC. Specific information regarding implementation of co-payments in managed care settings are located in Chapter 5101:3-26 of the Administrative Code.

Effective: 07/01/2006
R.C. 119.032 review dates: 03/09/2006 and 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.0112 , 5111.02 , 5111.021
Prior Effective Dates: 4/10/91, 3/1/02