(A) The reimbursement methodology 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 defined in accordance with Chapter 5160-2 of the Administrative Code;
(2) Are not nursing facility services included in the nursing facility per diem as defined in accordance with Chapter 5160-3 of the Administrative Code;
(3) Are covered as supplemental medical insurance benefits under the medicare program; and
(4) Are provided to dual eligibles, defined in accordance with paragraph (A)(6) of rule 5160-1-05 of the Administrative Code, who elect to receive their medicare part B benefits through the original medicare program.
(B) The Ohio department of medicaid (ODM) will pay the lesser of the following calculations for part B cost sharing described in this rule:
(1) The sum of the deductible and coinsurance medicare specifies ODM is obligated to pay for crossover claims; or
(2) The difference between the medicare approved amount and the sum of the amount medicare paid and all other third party (insurance other than medicare or medicaid) payments; or
(3) The difference between the sum of the amount medicare paid and any third party payments, and the medicaid maximum allowable reimbursement rate for the same identified service or services.
(C) When payment for part B cost sharing is made using the method described in paragraph (B)(2) or (B)(3) of this rule and the sum of the amounts paid by medicare and all other third party insurers exceeds the medicare or medicaid approved amount, ODM will not make any additional payment to the provider, or will make a payment of zero dollars, and the service(s) are considered to be paid in full to the provider.
Cite as Ohio Admin. Code 5160-1-05.3
Five Year Review (FYR) Dates: 01/01/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: Section 323.230 of Am. Sub. HB. 59
Prior Effective Dates: 12/18/06, 7/31/09 (Emer), 10/29/2009, 01/01/2014