Chapter 5160-13 | Ambulatory Health Care Clinic Services

Rule 5160-13-01 | Clinic services.

• Effective: April 10, 2023
• Promulgated Under: 119.03

(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) This rule does not apply to federally qualified health centers (FQHCs) nor to rural health clinics (RHCs), policies for which are set forth in Chapter 5160-28 of the Administrative Code.

(C) Definition. "Clinic" is an entity that meets all of the following criteria:

(1) It renders healthcare services on an outpatient basis under the direction of a physician or dentist.

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

(3) 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.

(4) It does not provide overnight accommodations.

(D) The following entities that meet the definition of a clinic may enroll with the Ohio department of medicaid (ODM) as a clinic provider:

(1) A dialysis center, defined as a "dialysis facility" in 42 C.F.R. 494.10 (October 1, 2022), that meets the following criteria:

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

(b) It operates in accordance with Chapter 3701-83 of the Administrative Code or, if it is located outside of Ohio, operates in accordance with 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 C.F.R. Part 59 (October 1, 2022);

(c) It is qualified to receive 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, 2022), or at a medicare-certified comprehensive outpatient rehabilitation facility (CORF), defined in 42 C.F.R. 485.51 (October 1, 2022);

(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 is an accredited provider of primary care services as recognized 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 a local health department created by a city health district, a general health district, or a combined health district in accordance with Chapter 3709. of the Revised Code; and

(b) It meets the standards set forth under the authority of 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 meet the American speech-language-hearing association (ASHA) certification standards as determined by ASHA.

(E) Payment for a covered service furnished in a clinic is made in accordance with the chapter or rule of agency 5160 of the Administrative Code that pertains to that service.

Last updated April 11, 2023 at 8:14 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 4/10/2028
Prior Effective Dates: 12/21/1977, 1/14/1983, 4/1/1988, 9/1/1989, 5/17/2001, 3/1/2005, 1/1/2008, 7/1/2017

Rule 5160-13-02 | Dialysis services rendered by a dialysis center.

• Effective: January 1, 2024
• Promulgated Under: 119.03

(A) Coverage and limitations.

(1) Payment may be made for dialysis performed for the treatment of kidney dysfunction resulting from conditions such as end-stage renal disease (ESRD) or acute kidney injury (AKI).

(2) If an individual is eligible for both medicare and medicaid, then coverage by medicaid as the primary payer continues only until medicare coverage begins.

(3) Payment may be made for hemodialysis (HD) or for any of three types of peritoneal dialysis: intermittent peritoneal dialysis (IPD), continuous ambulatory peritoneal dialysis (CAPD), or continuous cycling peritoneal dialysis (CCPD).

(4) CAPD or CCPD is peritoneal dialysis normally performed in a setting other than a dialysis center.

(5) Dialysis self-care training is instruction of the individual or a caregiver on how to perform self-dialysis with little or no professional assistance. It is customarily provided in conjunction with a session of dialysis treatment.

(6) The following frequency limits apply:

(a) HD - one session per day, three sessions per week;

(b) IPD, CAPD, or CCPD - one session per day, seven sessions per week;

(c) HD self-care training - a total of twenty-five sessions to be conducted within a period not to exceed ninety-one days;

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

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

(7) 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) Medicaid payment for a covered dialysis service rendered by a dialysis center is made as a per-visit payment amount (PVPA). This medicaid PVPA includes all applicable related services, tests, equipment, supplies, and incidental instruction furnished on the same date. A list of these related items, designated by medicare as items that are "subject to consolidated billing," is published by the centers for medicare and medicaid services (CMS) in the end-stage renal disease (ESRD) section of its website, http://www.cms.gov.

(2) PVPAs for covered dialysis services are listed in the appendix to this rule.

(3) Payment separate from the PVPA may be made for the following items and services:

(a) Covered professional dialysis services provided by a medical practitioner, addressed in rule 5160-4-14 of the Administrative Code; and

(b) Covered laboratory services and pharmaceuticals, addressed in Chapter 5160-11 of the Administrative Code, that are not designated by medicare as "subject to consolidated billing."

(4) Nothing in this rule precludes a medicaid managed care organization (described in Chapters 5160-26 and 5160-58 of the Administrative Code) from paying amounts other than those listed in the appendix to this rule.

View Appendix

Last updated January 2, 2024 at 9:01 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02, 5164.70
Five Year Review Date: 1/1/2029
Prior Effective Dates: 4/2/1983, 10/1/2003