Rule 5160-3-19 | Nursing facilities (NFs): relationship of NF services to other covered medicaid services.
This rule identifies covered services generally available to medicaid recipients and describes the relationship of such services to those provided by a NF. Whenever reference is made to payment for services through the NF per diem, the rules governing such payment are set forth in Chapter 5160-3 of the Administrative Code.
(A) Acupuncture services.
All covered acupuncture services provided by an eligible acupuncture provider are paid directly to the provider of acupuncture services in accordance with rule 5160-8-51 of the Administrative Code.
(B) Behavioral health services.
Costs for behavioral health services are paid directly to the provider of services, not through the NF per diem.
(C) Dental services.
All covered dental services provided by licensed dentists are paid directly to the provider of the dental services in accordance with Chapter 5160-5 of the Administrative Code. Personal hygiene services related to dental services provided by facility staff or contracted personnel are paid through the NF per diem.
(D) Laboratory and x-ray services.
Costs incurred for the purchase and administration of tuberculin tests, and for drawing specimens and forwarding specimens to a laboratory, are paid through the NF per diem. All costs of laboratory and x-ray procedures covered under the medicaid program are paid directly to the laboratory or x-ray provider in accordance with Chapter 5160-11 of the Administrative Code.
(E) Medical supplier services.
In accordance with rule 5160-10-02 of the Administrative Code, costs of certain medical supplies are paid through the NF per diem, and others are paid directly to the medical supply provider as follows:
(1) Items that must be paid for through the NF per diem include:
(a) "Medical supplies," defined as those items that have a very limited life expectancy, such as atomizers, nebulizers, bed pans, catheters, hypodermic needles, syringes, incontinence pads, splints, and disposable ventilator circuits.
(b) "Needed medical equipment" (and repair of such equipment), defined as items that can stand repeated use, are primarily and customarily used to serve a medical purpose, are not useful to an individual in the absence of illness or injury, and are appropriate for use in the facility. Such medical equipment items include hospital beds, wheelchairs other than custom wheelchairs, and intermittent positive-pressure breathing machines, except as noted in paragraph (E)(2) of this rule.
(c) Emergency stand-by oxygen.
(2) Items for which payment is made directly to the provider include:
(a) Ventilators.
(b) "Prostheses," defined as devices that replace all or part of a body organ to prevent or correct physical deformity or malfunction, such as artificial arms or legs, electro-larynxes, and breast prostheses.
(c) "Orthoses," defined as devices that assist in correcting or strengthening a distorted part, such as arm braces, hearing aids and batteries, abdominal binders, and corsets.
(d) Contents of oxygen cylinders or tanks, including liquid oxygen; oxygen producing machines (concentrators) for specific use by an individual recipient; and costs of equipment associated with oxygen administration, such as carts, regulators/humidifiers, cannulas, masks, and demurrage.
(F) Pharmaceuticals.
(1) Costs for over-the-counter drugs, including selected over-the-counter drugs set forth in paragraph (I) of rule 5160-9-03 of the Administrative Code, and nutritional supplements are paid through the NF per diem.
(2) Pharmaceuticals for which payment is made directly to the pharmacy provider are subject to the limitations found in Chapter 5160-9 of the Administrative Code, the limitations established by the Ohio state board of pharmacy, and the following conditions:
(a) When new prescriptions are necessary following expiration of the last refill, the new prescription may be ordered only after the physician examines the patient.
(b) A copy of all records regarding prescribed drugs for all patients must be retained by the dispensing pharmacy for at least six years. A receipt for drugs delivered to a NF must be signed by the facility representative at the time of delivery and a copy retained by the pharmacy.
(G) Physical therapy, occupational therapy, speech therapy, and audiology services.
Costs incurred for physical therapy, occupational therapy, speech therapy and audiology services provided by licensed therapists or therapy assistants are paid through the NF per diem.
(H) Physician services.
(1) Physician services are not paid through the NF per diem rate. Except as provided in paragraph (H)(2) of this rule, payment is made directly to a physician for covered services he or she provides to a resident of a NF.
(2) In accordance with rule 5160-4-06 of the Administrative Code, services provided in the capacity of overall medical direction are payable only to a NF provider. Payment for such services may not be made directly to a physician.
(3) Physician visits must be provided to a resident of a NF and must conform to the following schedule:
(a) The resident must be seen by a physician at least once every thirty days for the first ninety days after admission, and at least once every sixty days, thereafter.
(b) A physician visit is considered timely if it occurs not later than ten days after the date the visit was required.
(c) For payment of required physician visits, the physician must:
(i) Review the resident's total program of care including medications and treatments, at each required visit;
(ii) Write, sign, and date progress notes at each visit; and
(iii) Sign and date all orders except influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications; and
(d) Physician delegation of tasks.
(i) A physician may delegate tasks to a physician assistant or an advanced practice registered nurse (APRN), as defined in Chapter 4723-8 of the Administrative Code and Chapter 4723. of the Revised Code for APRNs, and in Chapter 4730. of the Administrative Code for physician assistants, who are in compliance with the following criteria:
(a) Are acting within the scope of practice as defined by state law.
(b) APRNs are practicing with a standard care arrangement entered into with each physician with whom the APRN collaborates in accordance with section 4723.431 of the Revised Code. A copy of the standard care arrangement shall be retained on file at each NF where the nurse practices.
(c) Physician assistants are practicing with a supervision agreement with a physician in accordance with section 4730.19 of the Revised Code. A copy of the supervision agreement shall be retained on file at each NF where the physician assistant practices.
(ii) At the option of the physician, required physician visits may be delegated in accordance with 42 C.F.R. 483.30.
(iii) A physician may not delegate a task when regulations specify that the physician must perform it personally, or when delegation is prohibited by state law or the facility's own policies.
(4) In accordance with rule 5160-1-18 of the Administrative Code, physician visits may be provided via telehealth.
(5) Services payable directly to the physician, physician assistant, or APRN must:
(a) Be requested by the NF resident, with the exception of required physician visits; and
(b) Be documented by entries in the resident's medical records along with any symptoms and findings. Every entry must be signed and dated by the applicable physician, physician assistant, or APRN.
(I) Podiatry services.
Costs of covered services provided by licensed podiatrists are paid directly to the authorized podiatric provider in accordance with Chapter 5160-7 of the Administrative Code.
(J) Respiratory therapy services.
Costs incurred for physician-ordered administration of aerosol therapy that is rendered by a licensed respiratory care professional are paid through the NF per diem. No payment for respiratory therapy services shall be made to a provider other than the NF through the NF per diem.
(K) Transportation services.
Payment for transporting residents by ambulance or wheelchair van to receive medical services is made directly to the transportation supplier in accordance with Chapter 5160-15 of the Administrative Code. Transportation of residents to receive medical services when the resident does not require an ambulance or wheelchair van is paid through the NF per diem.
(L) Vision care services.
All costs for covered vision care services, including examinations, dispensing, and the fitting of eyeglasses, are paid directly to authorized vision care providers in accordance with Chapter 5160-6 of the Administrative Code.
Supplemental Information