Lawriter - OAC - 5160-1-13.1 Medicaid consumer liability.

5160-1-13.1 Medicaid consumer liability.

(A) The medicaid payment for a covered service constitutes payment-in-full and may not be construed as a partial payment even when the reimbursement amount is less than the provider's charge. The provider may not collect and/or bill the consumer for any difference between the medicaid payment and the provider's charge or request the consumer to share in the cost through a deductible, coinsurance, co-payment or other similar charge, other then medicaid co-payments as defined in rule 5160-1-09 of the Administrative Code. The provider may not charge the consumer a down payment, refundable or otherwise.

(B) A medicaid consumer cannot be billed when a medicaid claim has been denied due to:

(1) Unacceptable or untimely submissions of claims;

(2) Failure to request a prior authorization; or

(3) A peer review organization (PRO) retroactively denying services for lack of medical necessity.

(C) Providers are not required to bill the Ohio department of medicaid (ODM) for medicaid-covered services rendered to eligible consumers. However, providers may not bill consumers in lieu of ODM unless:

(1) The consumer is notified in writing prior to the service being rendered that the provider will not bill ODM for the covered service; and

(2) The consumer agrees to be liable for payment of the service and signs a written statement to that effect prior to the service being rendered; and

(3) The provider explains to the consumer that the service is a covered medicaid service and other medicaid providers may render the service at no cost to the consumer.

(D) Services that are not covered by the medicaid program, including services requiring prior authorization that have been denied by ODM, may be billed to the consumer when the provisions in paragraphs (C)(1) and (C)(2) of this rule are met.

Effective: 11/28/2014
Five Year Review (FYR) Dates: 09/08/2014 and 11/28/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 6/3/83, 2/11/84, 10/1/84, 7/1/85 (Emer), 9/30/85, 10/1/87, 5/30/02, 1/1/04, 7/1/05, 1/6/06, 02/01/2010