5160-1-11 Out-of-state-coverage [except as provided through medicaid contracting managed care plans (MCPs)].

(A) Out-of-state providers must be licensed, accredited, or certified by their respective states to be considered eligible to provide services to Ohio medicaid consumers. Any standards applicable to the provision of the service in the state in which the service is being furnished must be met, as well as those standards set forth in the Ohio medicaid program and in the Ohio Administrative Code. Out-of-state providers must enroll as Ohio medicaid providers in order to obtain reimbursement and must follow appropriate billing procedures in accordance with Chapter 5101:3-1 of the Administrative Code and Chapter 5101:3-3 of the Administrative Code for long term care nursing facility services.

(B) Ohio medicaid covered services will be reimbursed when rendered by out-of-state providers only under the following circumstances:

(1) The medically necessary services are not available within the state of Ohio, and the use of out-of-state providers to perform the services is prior-authorized by the department or its' designee in accordance with rule 5101:3-1-31 of the Administrative Code; or

(2) The medical need arose as a result of an emergency, an accident, and/or an illness which occurred during the period the consumer was temporarily absent from Ohio and the consumers' health would have been endangered if care was postponed until the consumer returned to Ohio or attempted to return to Ohio; or

(3) The provider location for the medically necessary service is in a bordering state, and it is the usual practice of residents in that community to utilize out-of-state providers, so long as the cost of the service does not exceed the cost of the service provided by in-state providers; or

(4) The state determines on the basis of medical advice, that the needed medical services or necessary supplementary resources are more readily available in another state.

Effective: 07/01/2005
R.C. 119.032 review dates: 04/15/2005 and 07/01/2010
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 7/1/80, 10/1/87, 5/30/02