Chapter 5160-13 Ambulatory Health Care Clinic Services

5160-13-01 Service-based ambulatory health care clinics: general provisions.

(A) Unless otherwise noted, any limitations or requirements specified in the Revised Code or in agency 5160 of the Administrative Code apply to services addressed in this rule.

(B) Definitions.

(1) "Clinic" is an entity that meets all of the following criteria:

(a) It renders clinic services on an outpatient basis under the direction of a physician or dentist. Clinic services are defined in 42 CFR 440.90 (October 1, 2016).

(b) It operates from a fixed location, a specifically designed mobile unit, or both.

(c) It is freestanding-administratively, organizationally, and financially independent of an institution such as a hospital or long-term care facility. It may be physically located in a hospital or long-term care facility so long as it remains independent.

(d) It does not provide overnight accommodations.

(2) "Service-based ambulatory health care clinic" is a clinic to which medicaid makes separate payment for each service or item provided. Policies governing cost-based clinics (federally qualified health centers, rural health clinics, and outpatient health facilities-to which medicaid makes payment on the basis of a visit or encounter) are set forth in Chapter 5160-28 of the Administrative Code.

(C) The following entities may enroll in medicaid as a service-based ambulatory health care clinic:

(1) An end-stage renal disease (ESRD) dialysis clinic, defined in 42 C.F.R. 494.10 (October 1, 2016), that meets the following criteria:

(a) It is certified by medicare as a dialysis facility;

(b) It is licensed by the Ohio department of health in accordance with Chapter 3701-83 of the Administrative Code or, if it is located outside of Ohio, is licensed by its respective state's authority; and

(c) It provides services in accordance with rule 5160-13-02 of the Administrative Code;

(2) A family planning clinic that meets the following criteria:

(a) It is a public or nonprofit organization;

(b) It complies with federal guidelines set forth in 42 U.S.C. 300 (as in effect October 1, 2016);

(c) It receives funding for pregnancy prevention services through Title X of the Public Health Services Act; and

(d) It provides pregnancy prevention services in accordance with Chapter 5160-21 of the Administrative Code;

(3) An outpatient rehabilitation clinic that delivers rehabilitation services at a medicare-certified rehabilitation agency, defined in 42 C.F.R. 485.703 (October 1, 2016), or at a medicare certified comprehensive outpatient rehabilitation facility (CORF), defined in 42 C.F.R. 485.51 (October 1, 2016);

(4) A primary care clinic that meets either of the following criteria:

(a) It receives state or federal grant funds for the provision of health services;

or

(b) It provides primary care services by virtue of certification or accreditation by one of the following entities:

(i) The joint commission;

(ii) The accreditation association for ambulatory health care (AAAHC);

(iii) The healthcare facilities accreditation program of the American osteopathic association (AOA); or

(iv) The community health accreditation program (CHAP);

(5) A professional dental school clinic associated with an accredited dental school;

(6) A professional optometry school clinic associated with an accredited optometry school;

(7) A public health department clinic that meets the following criteria:

(a) It has legal status as local health department created by a city health district, general health district, or combined health district in accordance with Chapter 3709. of the Revised Code; and

(b) It meets the standards set forth in section 3701.342 of the Revised Code; or

(8) A speech-language-audiology clinic that specializes in and provides speech, language, or audiology services delivered by professionals who have been certified by the American speech-language-hearing association (ASHA).

Replaces: 5160-13-01, 5160-13- 01.1, 5160-13- 01.3, 5160-13- 01.4, 5160-13- 01.5, 5160-13- 01.6, 5160-13- 01.7, 5160-13- 01.8

Cite as Ohio Admin. Code 5160-13-01

Effective: 7/1/2017
Five Year Review (FYR) Dates: 07/01/2022
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 01/08/1979, 01/14/1983, 04/02/1983, 06/03/1983, 10/01/1987, 04/01/1988, 09/01/1989, 07/01/1993, 07/12/1993 (Emer), 10/01/1993, 05/17/2001, 03/01/2005, 01/01/2008, 07/01/2009

5160-13-01.1 [Rescinded] Fee-for-service ambulatory health care clinics (AHCCs): primary care clinics.

Cite as Ohio Admin. Code 5160-13-01.1

Effective: 7/1/2017
Five Year Review (FYR) Dates: 03/10/2017
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 01/08/1979, 04/01/1988, 01/01/2008

5160-13-01.3 [Rescinded] Fee-for-service ambulatory health care clinics (AHCCs): public health department clinics.

Cite as Ohio Admin. Code 5160-13-01.3

Effective: 7/1/2017
Five Year Review (FYR) Dates: 03/10/2017
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 01/08/1979, 01/14/1983, 04/02/1983, 04/01/1988, 01/01/2008

5160-13-01.4 [Rescinded] Fee-for-service ambulatory health care clinics (AHCCs): outpatient rehabilitation clinics.

Cite as Ohio Admin. Code 5160-13-01.4

Effective: 7/1/2017
Five Year Review (FYR) Dates: 03/10/2017
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 01/08/1979, 01/14/1983, 04/02/1983, 04/01/1988, 01/01/2008

5160-13-01.5 [Rescinded] Fee-for-service ambulatory health care clinics (AHCCs): family planning clinics.

Cite as Ohio Admin. Code 5160-13-01.5

Effective: 7/1/2017
Five Year Review (FYR) Dates: 03/10/2017
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 01/08/1979, 01/14/1983, 04/02/1983, 10/01/1987, 04/01/1988, 09/01/1989, 01/01/2008, 07/01/2009

5160-13-01.6 [Rescinded] Fee-for-service ambulatory health care clinics (AHCCs): professional optometry school clinics.

Cite as Ohio Admin. Code 5160-13-01.6

Effective: 7/1/2017
Five Year Review (FYR) Dates: 03/10/2017
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02
Prior Effective Dates: 04/07/1977, 12/30/1977, 01/14/1983, 04/02/1983, 01/01/2008

5160-13-01.7 [Rescinded] Fee-for-service ambulatory health care clinics (AHCCs): professional dental school clinics.

Cite as Ohio Admin. Code 5160-13-01.7

Effective: 7/1/2017
Five Year Review (FYR) Dates: 03/10/2017
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 04/07/1977, 12/30/1977, 01/14/1983, 04/02/1983, 01/01/2008

5160-13-01.8 [Rescinded] Fee-for-service ambulatory health care clinics (AHCCs): speech-language/audiology clinics and diagnostic imaging clinics.

Cite as Ohio Admin. Code 5160-13-01.8

Effective: 7/1/2017
Five Year Review (FYR) Dates: 03/10/2017
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02
Prior Effective Dates: 04/07/1977, 12/30/1977, 01/14/1983, 04/02/1983, 01/01/2008

5160-13-01.9 [Rescinded] Fee-for-service ambulatory health care clinics (AHCCs): end-stage renal disease (ESRD) dialysis clinics.

Cite as Ohio Admin. Code 5160-13-01.9

Effective: 7/1/2017
Five Year Review (FYR) Dates: 03/10/2017
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 04/02/1983, 03/30/2001, 10/01/2003, 01/01/2008

5160-13-02 Service-based ambulatory health care clinics: end-stage renal.

(A) Coverage and limitations.

(1) Medicaid coverage of dialysis services for eligible individuals with end-stage renal disease (ESRD) begins with the first dialysis treatment. If an individual is eligible for both medicare and medicaid, then coverage by medicaid as the primary payer continues only until medicare coverage begins.

(2) Payment may be made to an ESRD dialysis clinic for hemodialysis or for any of three types of peritoneal dialysis: intermittent peritoneal dialysis (IPD), continuous ambulatory peritoneal dialysis (CAPD), or continuous cycling peritoneal dialysis (CCPD). These four types of dialysis service may be delivered in any of three ways:

(a) Chronic maintenance dialysis is defined in rule 3701-83-23 of the Administrative Code. It is available to individuals in either an ESRD dialysis clinic or a home setting. In a home setting, it is often called "Method I home dialysis," a medicare term for a payment option under which a dialysis provider assumes responsibility for furnishing all equipment, supplies, and support services.

(b) Dialysis support services include but are not limited to periodic monitoring of an individual's adaptation to home dialysis, visits by trained personnel, certain ESRD-related laboratory tests, maintenance of home dialysis equipment, ordering of supplies, and record-keeping. The individual receiving dialysis support services makes arrangements for securing necessary supplies and equipment, in either an ESRD dialysis clinic or a home setting. The delivery of dialysis support services in a home setting is often called "Method II home dialysis," a medicare term for a payment option under which a dialysis provider assumes responsibility for furnishing only treatment-related services and a separate provider (usually a supplier of durable medical equipment) furnishes the dialysis equipment and supplies.

(c) Dialysis with self-care training includes dialysis treatment along with instruction of the individual or a caregiver on how to perform self-dialysis with little or no professional assistance.

(3) The following frequency limits apply:

(a) Chronic maintenance dialysis performed in an ESRD dialysis clinic - one session per day, three sessions per week;

(b) Chronic maintenance dialysis performed in a home setting - one session per day;

(c) Dialysis support services - one session per month;

(d) Hemodialysis with self-care training - a total of fifteen sessions to be conducted within a period not to exceed ninety-one days;

(e) IPD with self-care training - a total of twelve sessions to be conducted within a period not to exceed twenty-eight days; and

(f) CAPD or CCPD with self-care training - a total of fifteen sessions.

(4) Frequency limits may be exceeded only if the medical necessity of the additional service is documented in the medical record by the practitioner who is primarily responsible for the dialysis services.

(B) Payment.

(1) Payment for covered dialysis services rendered by an ESRD dialysis clinic is made as an all-inclusive composite amount per visit. This composite amount includes all related services, tests, equipment, supplies, and training furnished on the same date.

(2) The medicaid maximum composite payment amount for a covered dialysis service is the product of two figures:

(a) The calendar year 2016 ESRD prospective payment system (PPS) base rate published by the centers for medicare and medicaid services (CMS), which can be found on the CMS website at http://www.cms.gov; and

(b) The applicable percentage from the following list:

(i) Chronic maintenance dialysis performed in an ESRD dialysis clinic - fifty-eight and three quarters per cent;

(ii) Chronic maintenance dialysis performed in a home setting - three sevenths of the percentage for chronic maintenance dialysis performed in an ESRD dialysis clinic;

(iii) Dialysis support services - thirty-three and three quarters per cent; or

(iv) Dialysis with self-care training - sixty-seven and three quarters per cent.

(3) Separate payment may be made to an ESRD dialysis clinic for covered professional services of a medical practitioner and for covered laboratory services and pharmaceuticals that are not directly related to dialysis treatment. Payment methods and amounts for such items and services are determined in accordance with the relevant portion of agency 5160 of the Administrative Code.

Replaces: 5160-13- 01.9

Cite as Ohio Admin. Code 5160-13-02

Effective: 7/1/2017
Five Year Review (FYR) Dates: 07/01/2022
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 04/02/1983, 03/30/2001, 10/01/2003, 01/01/2008