Chapter 5160-21 | Reproductive Health Services

Rule 5160-21-02 | Reproductive health services: pregnancy prevention.

• Effective: November 1, 2021
• Promulgated Under: 119.03

(A) Principles.

(1) Medicaid-eligible individuals have access to medicaid-covered pregnancy prevention services. This access is not restricted by factors including but not limited to religion, race, color, national origin, disability, age, sex, sexual orientation, gender identity, gender expression, military status, health status, number of pregnancies, or marital status.

(2) Medicaid-eligible individuals can obtain medicaid-covered pregnancy prevention services voluntarily, free from coercion or pressure and free to choose the type or method of service to be used.

(3) The receipt of pregnancy prevention services cannot be made a prerequisite to eligibility for, receipt of, or participation in any other services offered by a provider.

(4) Medicaid-eligible individuals cannot be denied other medicaid-covered medically necessary services on the basis of fertility or infertility.

(B) Coverage. Payment may be made for the following pregnancy prevention services:

(1) Temporary pregnancy prevention, including the following services:

(a) Evaluation and management services (office visits) and consultations for either or both of two purposes:

(i) Contraceptive management; or

(ii) Pregnancy examination and testing, with either a negative or an inconclusive result, that includes provision of information about pregnancy prevention; and

(b) Individual preventive medicine counseling and health education on topics including but not limited to fertility awareness, natural family planning (the use of fertility awareness to track ovulation), and risk factor reduction;

(2) Permanent pregnancy prevention, including the following services:

(a) Sterilization performed in accordance with rule 5160-21-02.2 of the Administrative Code; and

(b) Hysterectomy performed in accordance with rule 5160-21-02.2 of the Administrative Code;

(3) Associated medical or surgical services;

(4) Associated laboratory tests or procedures performed in accordance with Chapter 5160-11 of the Administrative Code, including but not limited to the following services:

(a) Screening, diagnostic, and counseling services for the detection of genetic anomalies or hereditary metabolic disorders including but not limited to the following conditions:

(i) Chromosomal anomalies (in non-pregnant patients) that have neonatal implications;

(ii) Sickle cell and other abnormal hemoglobin syndromes;

(iii) Metabolic disorders such as phenylketonuria (PKU), galactosemia, or homocystinuria; and

(iv) Cystic fibrosis (carrier status); and

(b) Screening, diagnosis, and treatment services for sexually transmitted diseases and infections;

(5) Associated drugs prescribed in accordance with Chapter 5160-9 of the Administrative Code or administered in accordance with Chapter 5160-4 of the Administrative Code; and

(6) Associated medical supplies provided in accordance with Chapter 5160-10 of the Administrative Code.

(C) Non-coverage. No payment is made for the following services:

(1) Infertility treatment, including but not limited to the following modalities:

(a) Assisted reproductive technologies (ART);

(b) In vitro fertilization;

(c) Intrauterine insemination (artificial insemination);

(d) Surgery to promote or restore fertility, including procedures for the reversal of voluntary sterilization; and

(e) Drugs for the treatment of infertility, even if they are prescribed in accordance with Chapter 5160-9 of the Administrative Code or administered in accordance with Chapter 5160-4 of the Administrative Code; or

(2) Hysterectomy that would not have been performed except for the purpose of rendering the individual permanently incapable of reproduction.

Last updated November 1, 2021 at 2:05 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 11/1/2026
Prior Effective Dates: 5/25/1991, 12/31/1992 (Emer.), 7/1/1994, 3/20/1995

Rule 5160-21-02.2 | Medicaid covered reproductive health services: permanent contraception/sterilization services and hysterectomy.

• Effective: January 1, 2012
• Promulgated Under: 119.03

(A) Definitions.

(1) For the purposes of this rule, "hysterectomy" means, in accordance with 42 C.F.R. 441.251 (October 1, 2010 edition), a medical procedure or operation for the purpose of removing the uterus.

(2) For the purposes of this rule, "institutionalized individual" means, in accordance with 42 C.F.R. 441.251 (October 1, 2010 edition), an individual who is:

(a) Involuntarily confined or detained, under a civil or criminal statute, in a correctional or rehabilitative facility, including a mental hospital or other facility for the care and treatment of mental illness; or

(b) Confined, under a voluntary commitment, in a mental hospital or other facility for the care and treatment of mental illness.

(3) For the purposes of this rule, "mentally incompetent individual" means, in accordance with 42 C.F.R. 441.251 (October 1, 2010 edition), an individual who has been declared mentally incompetent by a federal, state, or local court of competent jurisdiction for any purpose, unless the individual has been declared competent for purposes which include the ability to consent to sterilization.

(4) For the purposes of this rule, "sterilization" means, in accordance with 42 C.F.R. 441.251 (October 1, 2010 edition), any medical procedure, treatment, or operation for the purpose of rendering an individual permanently incapable of reproducing.

(5) For the purposes of this chapter, "permanent pregnancy prevention" has the same meaning as "sterilization."

(B) Sterilization.

(1) Medicaid covered sterilization services include:

(a) Management and evaluation (office) visits and consultations for the purpose of providing sterilization services;

(b) Health education and counseling visits for the purpose of providing sterilization services;

(c) Medical/surgical services/procedures covered in accordance with appendix DD to rule 5101:3-1-60 of the Administrative Code and provided in association with the provision of sterilization services;

(d) Laboratory tests and procedures provided in accordance with Chapter 5101:3-11 of the Administrative Code and in association with the provision of sterilization services;

(e) Drugs administered in accordance with Chapter 5101:3-4 of the Administrative Code and in association with the provision of sterilization services; and

(f) Supplies provided in accordance with appendix A to rule 5101:3-10-03 of the Administrative Code and associated with the provision of sterilization services.

(2) The department will reimburse medicaid providers for sterilization services only if all the requirements of this rule and 42 C.F.R. part 441 subpart F (October 1, 2010 edition), are met:

(a) The individual is at least twenty-one years old at the time consent is obtained;

(b) The individual is not a mentally incompetent individual;

(c) The individual is not institutionalized;

(d) The individual has voluntarily given informed consent in accordance with paragraph (B)(3) of this rule;

(e) At least thirty days, but not more than one hundred eighty days, have passed between the date of the informed consent and the date of the sterilization, except in the case of premature delivery or emergency abdominal surgery. An individual may consent to be sterilized at the time of a premature delivery or emergency abdominal surgery, if at least seventy-two hours have passed since he or she gave informed consent for the sterilization. In the case of premature delivery, the informed consent must have been given at least thirty days before the expected date of delivery; and

(f) The medicaid provider requesting payment for the sterilization submits to the department a copy of the consent form, completed in accordance with paragraph (B)(3) of this rule.

(3) Informed consent for sterilization.

(a) For the purposes of this rule, an individual has given informed consent only if:

(i) The person who obtained consent for the sterilization procedurehas:

(a) Offered to answer any questions the individual to be sterilized may have had concerning the procedure;

(b) Provided a copy of one of the following to the individual to be sterilized:

(i) "Consent for Sterilization," HHS-687 (5/2010), available at www.hhs.gov/forms/HHS-687.pdf;

(ii) "CONSENTIMIENTO PARA LA ESTERILIZACIN," HHS-687-1 (11/2006), available at www.hhs.gov/forms/HHS-687-1.pdf;

(iii) "Consent for Sterilization Form," JFS 03198 (rev. 7/2009), available at www.odjfs.state.oh.us/forms/inter.asp, which may be used for consent forms signed during the period from July 1, 2009 through June 30, 2012 by the individual to be sterilized; or

(iv) "Consent for Sterilization Form," JFS 03198 (rev. 2/2003), which may be used for consent forms signed before July 1, 2010 by the individual to be sterilized, if the person obtaining consent has copies of this form available.

(c) Provided orally all the following information or advice to the individual to be sterilized:

(i) Advice that the individual is free to withhold or withdraw consent to the procedure at any time before the sterilization without affecting the right to future care or treatment and without loss or withdrawal of any federally-funded program benefits to which the individual might be otherwise entitled;

(ii) A description of available alternative methods of family planning and birth control;

(iii) Advice that the sterilization procedure is considered to be irreversible;

(iv) A thorough explanation of the specific sterilization procedure to be performed;

(v) A full description of the discomforts and risks that may accompany or follow the performance of the procedure, including an explanation of the type and possible effects of any anesthetic to be used;

(vi) A full description of the benefits or advantages that may be expected as a result of the sterilization; and

(vii) Advice that the sterilization will not be performed for at least thirty days, except under the circumstances specified in paragraph (B)(2)(e) of this rule;

(ii) Suitable arrangements were made to insure that the information specified in paragraph (B)(3)(a)(i) of this rule was effectively communicated to any individual who is blind, deaf, or otherwise handicapped;

(iii) An interpreter was provided if the individual to be sterilized did not understand the language used on the consent form or the language used by the person obtaining consent;

(iv) The individual to be sterilized was permitted to have a witness of his or her choice present when consent was obtained;

(v) The consent form requirements of this rule and of 42 C.F.R. 441.258 (October 1, 2010 edition) were met; and

(vi) Any additional requirement of state or local law for obtaining consent, except a requirement for spousal consent, was followed.

(b) For the purposes of this rule, informed consent may not be obtained while the individual to be sterilized is:

(i) In labor or childbirth; or

(ii) Seeking to obtain or obtaining an abortion; or

(iii) Under the influence of alcohol or other substances that affect the individual's state of awareness.

(c) Informed consent must be documented on one of the forms specified in paragraph (B)(3)(a)(i)(b) of this rule.

(i) The consent form must be signed and dated by:

(a) The individual to be sterilized;

(b) The interpreter, if one was provided;

(c) The person who obtained the consent; and

(d) The physician who performed the sterilization procedure.

(ii) The person securing the consent must certify, by signing the consent form, that:

(a) Before the individual to be sterilized signed the consent form, he or she advised the individual to be sterilized that no federal benefits may be withdrawn because of the decision not to be sterilized;

(b) He or she explained orally to the individual to be sterilized the requirements for informed consent as set forth in this rule and on the consent form; and

(c) To the best of his or her knowledge and belief, the individual to be sterilized appeared to the person securing the consent to be mentally competent and knowingly and voluntarily consented to be sterilized.

(iii) The physician performing the sterilization must certify, by signing the consent form, that:

(a) Shortly before the performance of sterilization, he or she advised the individual to be sterilized that no federal benefits may be withdrawn because of the decision not to be sterilized;

(b) He or she explained orally to the individual to be sterilized the requirements for informed consent as set forth in this rule and on the consent form;

(c) To the best of his or her knowledge and belief, the individual to be sterilized appeared to the physician to be mentally competent and knowingly and voluntarily consented to be sterilized; and

(d) In the case of premature delivery or emergency abdominal surgery (except for induced abortion in the first trimester of pregnancy) performed within thirty days of consent, the physician must certify that the sterilization was performed less than thirty days, but not less than seventy-two hours after informed consent was obtained because of premature delivery or emergency abdominal surgery and:

(i) In the case of premature delivery, must state the expected date of delivery; or

(ii) In the case of abdominal surgery, must describe the emergency.

(iv) If an interpreter is provided, the interpreter must certify that he or she translated the information and advice presented orally and read the consent form and explained its contents to the individual to be sterilized and that, to the best of the interpreter's knowledge and belief, the individual understood what the interpreter told him or her.

(C) Hysterectomy.

(1) The department will not reimburse medicaid providers for hysterectomy if:

(a) The hysterectomy was performed solely for the purpose of rendering an individual permanently incapable of reproducing;

(b) There was more than one purpose to the hysterectomy, and it would not have been performed but for the purpose of rendering the individual permanently incapable of reproducing; or

(c) The requirements of this rule and 42 C.F.R. part 441 subpart F (October 1, 2010 edition) are not met.

(2) The department will reimburse medicaid providers for hysterectomy only if:

(a) All the requirements of this rule and 42 C.F.R. part 441 subpart F (October 1, 2010 edition) are met; and

(b) The medicaid provider requesting payment for the hysterectomy submits a copy of the JFS 01399, completed in accordance with paragraph (C)(3) of this rule, with the claim to the department.

(c) For a hysterectomy performed during a period of an individual's retroactive medicaid eligibility, the physician who performed the hysterectomy certifies in writing that:

(i) The individual was informed before the operation that the hysterectomy would make her permanently incapable of reproducing; or

(ii) The conditions of paragraph (C)(3)(a)(ii) of this rule were met.

(3) Informed consent for hysterectomy.

For the purposes of this rule, an individual has given informed consent only if:

(a) The person who secures authorization to perform the hysterectomy has:

(i) Informed the individual and her representative, if any, orally and in writing that the hysterectomy will make the individual permanently incapable of reproducing;

(ii) Offered to answer any questions the individual to have the hysterectomy may have concerning the procedure;

(iii) Offers the individual to have the hysterectomy a copy of one of the following:

(a) "Acknowledgement of Hysterectomy Information," JFS 03199 (rev. 04/2011), available at www.odjfs.state.oh.us/forms/inter.asp, which may be used for consent forms signed by the individual on or after January 1, 2012;

(b) "Acknowledgement of Hysterectomy Information," JFS 03199 (rev. 7/2009), which may be used for consent forms signed by the individual on and after July 1, 2009 but before June 30, 2012 if the person obtaining consent has copies of this form available; or

(c) "Acknowledgement of Hysterectomy Information," JFS 03199 (rev. 7/2003), which may be used for consent forms signed by the individual before July 1, 2010 if the person obtaining consent has copies of this form available; and

(b) The individual to have the hysterectomy or her representative, if any, has signed the JFS 01399 as a written acknowledgment of receipt of the information specified in paragraph (C)(3)(a)(i) of this rule unless the individual:

(i) Was already sterile before the hysterectomy; or

(ii) Requires a hysterectomy because of a life-threatening emergency situation in which the physician determines that prior acknowledgement is not possible.

(D) Claims.

(1) Claims for sterilization and hysterectomy procedures must be submitted to the department with either an original or a copy of the appropriate consent form.

For dual eligibles, the JFS 03199 must not be attached to the medicare claim, but must be forwarded separately to the department. If the claim is rejected by medicare, the provider should submit a separate invoice to the department with the medicare rejection attached. The date that the JFS 03199 form was sent to the department should be entered in the provider remarks section of the medicaid claim.

(2) The department will not reimburse medicaid providers for services, procedures, and supplies associated with the provision of sterilization or hysterectomy services that do not meet the requirements of this rule.

Last updated September 1, 2023 at 1:09 PM

Supplemental Information

Authorized By: –
Amplifies: –
Five Year Review Date:
Prior Effective Dates: 1/8/1979, 2/6/1979, 12/3/1982, 7/1/1983, 5/19/1986, 9/1/1989, 5/25/1991, 7/1/1992, 4/1/1993, 7/1/1994, 3/20/1995, 1/1/2001, 8/17/2001, 10/1/2003, 3/1/2005, 3/27/2006, 7/1/2009

Rule 5160-21-04 | Reproductive health services: pregnancy-related services.

• Effective: January 1, 2022
• Promulgated Under: 119.03

(A) Coverage.

(1) Unless a different time period is specified, services described in this rule are covered through the pregnancy and the delivery.

(2) Basic pregnancy-related services include but are not limited to antepartum care, delivery, outpatient postpartum care, and family planning services.

(a) Antepartum care. Payment for a visit may be made for either of two purposes:

(i) Basic care (including the taking and subsequent updating of a medical history, physical examination, the recording of vital signs, and routine chemical urinalysis) provided monthly up to twenty-eight weeks' gestation, biweekly thereafter up to thirty-six weeks' gestation, and weekly thereafter until delivery; or

(ii) Initial establishment of a relationship with a pediatrician or other primary care provider who will subsequently furnish early and continuous well-child and primary care for the newborn and will discuss care of the infant with the individual and, as appropriate, the individual's family.

(b) Delivery. Payment may be made for admission to a facility (hospital or freestanding birth center), the taking of a medical history during admission, physical examinations, the management of labor (intrapartum management), and either vaginal delivery (with or without episiotomy and with or without forceps) or delivery by cesarean section.

(i) Separate payment may be made for intrapartum management and for delivery performed as distinct procedures by different providers who are not part of the same practice.

(ii) Additional payment may be made for multiple-birth delivery.

(iii) Additional payment may be made for evaluation and management (E&M) services or medical services rendered for the diagnosis and treatment of medical conditions that complicate labor and delivery management.

(iv) No additional payment will be made for complex delivery nor for additional professional services (e.g., assistance by a second practitioner during delivery).

(c) Outpatient postpartum care. Payment may be made for hospital and office visits involving routine, uncomplicated follow-up care rendered during the postpartum period specified in rule 5160:1-2-16 of the Administrative Code. Postpartum care rendered prior to discharge from the facility is considered incidental to the delivery.

(d) Family planning services. Policies governing payment for these services are set forth in rules 5160-21-02 and 5160-21-02.2 of the Administrative Code.

(3) Payment may be made for one report of a pregnancy that is diagnosed in conjunction with an E&M service not associated with a normal obstetrics/gynecology visit, submitted on either form ODM 10257, "Report of Pregnancy (ROP)" (7/2021), or its web-based equivalent. This payment is separate from the payment for the E&M service (or the encounter or visit of which the E&M service is part).

(4) A pregnancy risk assessment may be used to screen an individual for medical and social factors that may place that individual at risk for preterm birth or other poor pregnancy outcome and to substantiate the individual's need for enhanced pregnancy-related services and other support services. Payment may be made for one such assessment, performed at the initial antepartum visit by a practitioner of obstetric services and submitted on either form ODM 10207, "Pregnancy Risk Assessment" (rev. 7/2021), or its web-based equivalent.

(a) If an individual is determined to be at risk and the practitioner obtains the individual's informed consent, then the practitioner sends to the entity responsible for managing the individual's pregnancy-related care a report with recommendations, in the form and format specified by the entity.

(b) If the individual needs additional support services during the course of pregnancy, then (with the individual's informed consent) the practitioner may relay that information to the entity responsible for managing the individual's pregnancy-related care.

(5) Enhanced pregnancy-related services promote general health, improve the quality of life, and produce better outcomes for a pregnant individual or a fetus during pregnancy or the postpartum period. Coverage of such services include but are not limited to the following services:

(a) High-risk patient monitoring (the additional monitoring of an individual who has been determined to be at risk for a preterm birth) performed by a healthcare professional qualified to identify the signs of preterm labor, which has three components:

(i) Counseling and education to assist the individual in identifying and reducing the risk of preterm labor;

(ii) Regular contact with the individual, either in person or by telecommunication, to identify signs of preterm labor; and

(iii) Ready access to the provider in the event the individual begins to show signs of preterm labor;

(b) Group pregnancy education (the face-to-face presentation by a medical professional to a group of two or more participants but no more than twenty ) in a session that may consist of one or more classes. Group pregnancy education provides information utilizing culturally sensitive communication and facilitates family-centered collaboration and support. Group pregnancy education classes will meet the following criteria:

(i) Cover subjects related to pregnancy, including:

(a) Childbirth preparation (e.g., Lamaze);

(b) Childbirth refresher;

(c) Nutrition;

(d) Parenting; and

(e) Infant safety; or

(ii) Consist of an evidence-based or evidence-informed curriculum that has been demonstrated to result in improved health outcomes and/or improved health equity for pregnant and postpartum women and their infants.

(c) Individual counseling and education, given during an antepartum visit, that entails a face-to-face encounter of at least fifteen minutes in which the primary focus is the specific needs of the individual;

(d) Medical nutrition therapy in accordance with rule 5160-8-41 of the Administrative Code;

(e) Family planning-related services in accordance with rule 5160-21-02 of the Administrative Code; and

(f) Tobacco cessation counseling and treatment.

(B) Claim payment.

(1) Payment for covered antepartum care provided in a federally qualified health center (FQHC) or rural health clinic (RHC) is determined in accordance with Chapter 5160-28 of the Administrative Code.

(2) The maximum payment amount for a covered evaluation and management service reported as antepartum care provided in a setting other than an FQHC or RHC is the lesser of the following two figures:

(a) The provider's submitted charge; or

(b) The product of the amount specified in appendix DD to rule 5160-1-60 of the Administrative Code and any applicable place-of-service multiplier.

(3) The maximum payment amount for covered delivery is the lesser of the following two figures:

(a) The provider's submitted charge; or

(b) The product of the amount specified in appendix DD to rule 5160-1-60 of the Administrative Code, any applicable place-of-service multiplier, and the relevant percentage from the following list:

(i) For a single delivery or the first delivery of a multiple birth, one hundred per cent;

(ii) For the second delivery of a multiple birth, fifty per cent;

(iii) For the third delivery of a multiple birth, twenty-five per cent; or

(iv) For each additional delivery of a multiple birth, zero.

(4) Payment for a report of pregnancy or a pregnancy risk assessment is the amount specified in appendix DD to rule 5160-1-60 of the Administrative Code.

(5) Payment of all other claims is made in accordance with the applicable rule of the Administrative Code.

Last updated November 15, 2024 at 9:13 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 2/1/1980, 7/1/2003

Rule 5160-21-05 | Nurse home visiting services.

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

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

(B) Definitions.

(1) "Advanced practice registered nurse (APRN)" has the same meaning as in Chapter 4723-08 of the Administrative Code.

(2) "Registered nurse (RN)" has the same meaning as in Chapter 4723. of the Revised Code.

(3) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code.

(4) "Home visiting" has the same meaning as in Chapter 3701-8 of the Administrative Code.

(5) "Nurse home visiting" is home visiting provided by an APRN or RN. Within the package of home visiting services, emphasis is placed on the following services performed within the scope of the practitioner:

(a) Prenatal visits;

(b) Postpartum visits;

(c) Training in pediatric care;

(d) Nursing examinations, which focus on assessment of social determinants of health, on education, and on emotional support;

(e) Health education;

(f) Maternal depression screening; and

(g) Lactation counseling.

(C) Providers.

(1) Rendering provider. Medicaid payment may be made for a covered nurse home visiting service rendered by an eligible provider.

(2) Billing ("pay-to") provider. The following eligible providers may receive medicaid payment for submitting a claim for a covered nurse home visiting service:

(a) An ambulatory health care clinic as defined in Chapter 5160-13 of the Administrative Code;

(b) A federally qualified health center (FQHC);

(c) A rural health clinic (RHC); or

(d) A professional medical group.

(D) Coverage.

(1) Payment may be made only for a nurse home visiting service for which the following criteria are met:

(a) The service is medically necessary in accordance with rule 5160-1-01 of the Administrative Code;

(b) The individual receiving the service has at least one of the following medically complex conditions that may put an individual at a high risk for preterm birth:

(i) Asthma;

(ii) Diabetes;

(iii) Cardiovascular disease;

(iv) Substance use disorder; or

(v) History of pre-term birth; and

(c) The individual is not currently receiving another service that substantially duplicates a nurse home visiting service.

(2) No payment is made for a separate evaluation and management service in addition to a nurse home visiting service rendered by the same provider to the same individual on the same day.

(E) Claim payment.

(1) For a covered nurse home visiting service rendered by an FQHC or RHC, payment is made in accordance with Chapter 5160-28 of the Administrative Code.

(2) For a covered nurse home visiting service rendered at any other valid place of service, payment is the lesser of the provider's submitted charge or the maximum amount specified in appendix DD to rule 5160-1-60 of the Administrative Code.

Last updated January 2, 2024 at 9:32 AM

Supplemental Information

Authorized By: 5164.02, 5164.758
Amplifies: 5164.02, 5164.758
Five Year Review Date: 1/1/2027