Lawriter - OAC - 5123:2-7-11 Intermediate care facilities for individuals with intellectual disabilities - relationship of other covered medicaid services.

5123:2-7-11 Intermediate care facilities for individuals with intellectual disabilities - relationship of other covered medicaid services.

(A) Purpose

This rule identifies covered services generally available to individuals who are eligible for medicaid and describes the relationship of such services to those provided to residents of an intermediate care facility for individuals with intellectual disabilities (ICFIID) other than a state-operated ICFIID. Reimbursement of services through the "ICFIID cost report mechanism" referenced in this rule is governed by rule 5123:2-7-12 of the Administrative Code.

(B) Dental services

All covered dental services provided by licensed dentists are reimbursed directly to the provider of the dental services in accordance with Chapter 5160-5 of the Administrative Code. Personal hygiene services provided by staff or contracted personnel of the ICFIID are reimbursed through the ICFIID cost report mechanism.

(C) Laboratory and x-ray services

Costs incurred for the purchase and administration of tuberculin tests, and for drawing specimens and forwarding specimens to a laboratory, are reimbursed through the ICFIID cost report mechanism. All laboratory and x-ray procedures covered under the medicaid program are reimbursed directly to the laboratory or x-ray provider in accordance with Chapter 5160-11 of the Administrative Code.

(D) Medical supplier services

(1) Medical supplier services that are reimbursed through the ICFIID cost report mechanism include:

(a) Costs incurred for "needed medical and program supplies," defined as items that have a very limited life expectancy. Such items include atomizers, nebulizers, bed pans, catheters, electric pads, hypodermic needles, syringes, incontinence pads, splints, and disposable ventilator circuits.

(b) Costs incurred for the purchase and repair of "needed medical equipment," defined as items that can stand repeated use, are primarily and customarily used to serve a medical purpose, are not useful to a person in the absence of illness or injury, and are appropriate for use in the ICFIID. Such items include hospital beds, wheelchairs, and intermittent positive-pressure breathing machines, except as noted in paragraph (D)(2) of this rule.

(c) Costs of equipment associated with oxygen administration such as carts, regulators, humidifiers, cannulas, masks, and demurrage.

(2) Medical supplier services that are reimbursed directly to the medical supplier provider in accordance with Chapter 5160-10 of the Administrative Code include:

(a) Certain durable medical equipment items, specifically, ventilators and custom-made wheelchairs that have parts which are actually molded to fit the resident.

(b) "Prostheses," defined as devices that replace all or part of a body organ to prevent or correct physical deformity or malfunction. Such devices include artificial arms or legs, electro-larynxes, and breast prostheses.

(c) "Orthoses," defined as devices that assist in correcting or strengthening a distorted part. Such devices include arm braces, hearing aids and batteries, abdominal binders, and corsets.

(d) Contents of oxygen cylinders or tanks including liquid oxygen, except emergency stand-by oxygen which is reimbursed through the ICFIID cost report mechanism.

(e) Oxygen-producing machines (concentrators) for specific use by an individual resident.

(E) Pharmaceuticals

(1) Over-the-counter drugs covered in accordance with rule 5160-9-03 of the Administrative Code and nutritional supplements are reimbursed through the ICFIID cost report mechanism.

(2) Pharmaceuticals reimbursed directly to the pharmacy provider are subject to the limitations in Chapter 5160-9 of the Administrative Code, the limitations established by the Ohio state board of pharmacy, and the following conditions:

(a) When new prescriptions are necessary following expiration of the last refill, the new prescription may be ordered only after the physician examines the resident.

(b) A copy of all records regarding prescribed drugs for a resident of an ICFIID shall be retained by the dispensing pharmacy for at least six years. A receipt for drugs delivered to an ICFIID shall be signed by a representative of the ICFIID at the time of delivery and a copy retained by the pharmacy.

(F) Therapy services

(1) Costs incurred for physical therapy, occupational therapy, speech therapy, and audiology services provided by licensed therapists or therapy assistants that are covered for residents of an ICFIID by medicaid are reimbursed through the ICFIID cost report mechanism.

(2) Costs incurred for psychology services provided by licensed psychologists or psychology assistants that are covered for residents of an ICFIID by medicaid are reimbursed through the ICFIID cost report mechanism. No reimbursement for psychology services shall be made to a provider other than the ICFIID or a community mental health center certified by the Ohio department of mental health and addiction services. Services provided by an employee of the community mental health center shall be billed directly to medicaid by the community mental health center.

(3) Costs incurred for respiratory therapy services provided by licensed respiratory care professionals that are covered for residents of an ICFIID by medicaid are reimbursed through the ICFIID cost report mechanism. No reimbursement for respiratory therapy services shall be made to a provider other than the ICFIID.

(4) Reasonable costs for rehabilitative, restorative, or maintenance therapy services rendered to residents of an ICFIID by staff or contracted personnel of the ICFIID and the overhead costs to support the provision of such services are reimbursed through the ICFIID cost report mechanism.

(G) Physician services

(1) A physician may be directly reimbursed for providing the following services to a resident of an ICFIID:

(a) All covered diagnostic and treatment services in accordance with Chapter 5160-4 of the Administrative Code.

(b) All medically necessary physician visits in accordance with rule 5160-4-06 of the Administrative Code.

(c) All required physician visits as described in this rule when the services are billed in accordance with rule 5160-4-06 of the Administrative Code.

(i) Physician visits provided to a resident of an ICFIID are considered timely if they occur no later than ten calendar days after the date the visit was requested.

(ii) For reimbursement of the required physician visits, the physician shall:

(a) Review the resident's total program of care including medications and treatments at each visit required by this rule;

(b) Write, sign, and date progress notes at each visit;

(c) Sign all orders; and

(d) Personally visit the resident except as provided in paragraph (G)(1)(c)(iii) of this rule.

(iii) At the option of the physician, required visits after the initial visit may be delegated in accordance with paragraph (G)(1)(c)(iv) of this rule and alternate between physician and visits by a physician assistant or certified nurse practitioner.

(iv) A physician may delegate tasks to a physician assistant (in accordance with Chapter 4730. of the Revised Code and Chapter 4730-1 of the Administrative Code) or a certified nurse practitioner (in accordance with Chapter 4723. of the Revised Code and Chapter 4723-4 of the Administrative Code) provided the physician assistant or certified nurse practitioner is acting within the scope of his or her practice and is under supervision and employment of the billing physician. A physician may not delegate a task when regulations specify that the physician must perform it personally or when delegation is prohibited by state law or the ICFIID's policies.

(2) Services directly reimbursed to the physician shall be:

(a) Based on medical necessity, as defined in rule 5160-1-01 of the Administrative Code, and requested by the resident of the ICFIID with the exception of the required visits described in paragraph (G)(1)(c) of this rule.

(b) Documented by entries in the resident's medical record along with any symptoms and findings. Each entry shall be signed and dated by the physician.

(3) Services provided in the capacity of overall medical direction are reimbursed only to an ICFIID and may not be directly reimbursed to a physician.

(H) Podiatry services

Covered services provided by licensed podiatrists are reimbursed directly to the authorized podiatric provider in accordance with Chapter 5160-7 of the Administrative Code.

(I) Transportation services

Costs incurred by the ICFIID for transporting residents by means other than covered ambulance or ambulette services are reimbursed through the ICFIID cost report mechanism. Payment is made directly to authorized providers for covered ambulance and ambulette services as set forth in Chapter 5160-15 of the Administrative Code.

(J) Vision care services

All covered vision care services, including examinations, dispensing, and the fitting of eyeglasses, are reimbursed directly to authorized vision care providers in accordance with Chapter 5160-6 of the Administrative Code.

Replaces: 5123:2-7-11

Cite as Ohio Admin. Code 5123:2-7-11

Effective: 7/1/2017
Five Year Review (FYR) Dates: 07/01/2022
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5124.03
Rule Amplifies: 5123.04, 5124.03
Prior Effective Dates: 01/10/2013