Ohio Administrative Code Search

... hospital services as defined in rule 5160-2-01 of the Administrative Code and assigned to prospective payment peer group as described in rule 5160-2-05 of the Administrative Code are subject to the enhanced ambulatory patient grouping system (EAPG) prospective payment methodology utilized by the Ohio department of medicaid (ODM) as described in this rule. (A) Definitions. (1) "Enhanced ambulatory pati...

... services as authorized by section 5162.20 of the Revised Code. (B) For purposes of this rule, the following definitions apply. (1) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent lay person, as defined in paragraph (B)(2) of this rule, could reasonably expect the absence of immedi...

...xcept as otherwise provided in Chapter 5160-3 of the Administrative Code, and in addition to the definitions in section 5165.01 of the Revised Code: (A) "Allowable costs" has the same meaning as in section 5165.01 of the Revised Code and are determined in accordance with the following reference material, in the following priority: (1) Title 42 Code of Federal Regulations (C.F.R.) Chapter IV (Oct...

...In addition to provisions in Chapters 5164. and 5165. of the Revised Code regarding provider agreements, and provisions in rules 5160-3-02.1 and 5160-3-02.2 of the Administrative Code, execution and maintenance of a provider agreement between the Ohio department of medicaid (ODM) and the operator of a NF also are contingent upon compliance with requirements set forth in this rule. (A) Definitions. (1) "Cl...

...(A) Definitions. (1) "Reasonable assurance period" means a certain period of time, determined by the centers for medicare and medicaid services (CMS), for which a nursing facility operator whose provider agreement has been involuntarily terminated is required to operate without recurrence of the deficiencies that were the basis for termination. Participation in the medicare and medicaid programs ...

...(A) Written notice. (1) The Ohio department of medicaid (ODM) may terminate, deny, or not revalidate a NF provider agreement upon thirty days written notice to the NF. (2) Notices and termination orders must comply with provisions set forth in sections 5164.38 and 5165.77 of the Revised Code. (B) Reasons for which ODM may terminate, deny, or not revalidate a NF provider agreement. (1) In accor...

...(A) Definitions. (1) "Certification" means the process by which the state survey agency certifies its findings to the federal centers for medicare and medicaid services (CMS) or the Ohio department of medicaid (ODM) with respect to a facility's compliance with health, safety, and resident rights requirements of divisions (a), (b), (c), and (d) of section 1919 of the Social Security Act, 42 U.S.C....

... requirements set forth in sections 5165.77, 5165.80, and 5165.81 of the Revised Code, and in rule 3701-17-25 of the Administrative Code. (B) Emergencies and disasters. "Emergencies and disasters" are unexpected situations or sudden occurrences of a serious or urgent nature that create a substantial likelihood that one or more of a facility's residents may be harmed and/or may need to be relo...

...(A) Definitions. (1) "Fines" means civil money penalties (CMPs) and other assessments imposed against a NF as a remedy for deficiencies or a cluster of deficiencies that were not substantially corrected before a survey. (2) "Interest" means the interest rate determined by the tax commissioner on the fifteenth day of October each year by rounding the federal short-term rate to the nearest who...

... following definitions shall apply: (1) "State survey agency" means for the purpose of medicaid certification, the Ohio department of health (ODH). (2) "Effective date of termination" means the date set by the state survey agency or the United States department of health and human services for the termination of certification. (B) When medicaid certification is either terminated or not re...

...otherwise defined in a specific rule: (1) "Activity of daily living (ADL)" means a personal or self-care task that enables an individual to meet basic life needs. "ADL" includes the following defined activities: (a) "Bathing" means the ability of an individual to cleanse one's body by showering, tub, or sponge bath, or any other generally accepted method. (b) "Dressing" means the ability of an ...

...n a specific rule. (B) Definitions. (1) "Active Treatment" means a continuous treatment program including aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services for individuals with mental retardation and/or other developmental disabilities that are directed toward the following: (a) The acquisition of the behaviors necessary for th...

...ermitted in 42 C.F.R. 438.6(e) (October 1, 2016). (B) Definitions. (1) "At risk facility". A NF is considered to be an at risk facility if it meets two or more of the IMD evaluation criteria set forth in paragraph (C)(2)(b) of this rule but has not been determined to meet the definition of IMD set forth in paragraph (B)(2) of this rule. (2) "Institution for mental diseases (IMD)" means a hospital, nursing facility...

...care determination, as defined in rule 5160-3-05 of the Administrative Code, for a nursing facility (NF)-based level of care program, as defined in rule 5160-3-05 of the Administrative Code. (1) The processes described in this rule will not be used for a determination for an ICF-IID-based level of care, as defined in rule 5160-3-05 of the Administrative Code. (2) A level of care determinatio...

...determination process, generally: (1) A level of care determination may occur in-person, by a desk review, or by telephone and is one component of medicaid eligibility to receive medicaid payment for services provided in a nursing facility (NF) or through a NF-based home and community-based services (HCBS) waiver or other NF-based level of care program. (2) An individual who is seeking admis...

...finitions for terms contained in rules 5160-3-15.1, 5160-3-15.2, 5122-21-03 and 5123-14-01 of the Administrative Code. (B) Definitions: (1) "Adverse determination" means a determination made in accordance with rules 5160-3-15.1, 5160-3-15.2, 5122-21-03 and 5123-14-01 of the Administrative Code, that an individual does not require the level of services provided by a nursing facility or that the i...

...ng requirements pursuant to section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019, to ensure that individuals seeking admission, as defined in rule 5160-3-15 of the Administrative Code, to a medicaid-certified nursing facility (NF) who have serious mental illness (SMI) and/or a developmental disability (DD) as defined in rules 5122-21-03 and 5123-14-01 of the Administrative Code...

...requirements in compliance with section 1919(e)(7) of the Social Security Act, as in effect on July 1, 2019, which prohibits nursing facilities (NF) from retaining individuals with serious mental illness (SMI) as defined in rule 5160-3-15 of the Administrative Code and/or developmental disabilities (DD) as defined in rule 5160-3-15 of the Administrative Code unless a thorough evaluation indicates ...

...mmodations, if available, as follows: (1) For a medicaid eligible resident if the resident requires a private room due to medical necessity such as the need for infection control or for therapeutic purposes; or (2) Semi-private or ward accommodations are not available; or (3) In accordance with sections 5165.01 and 5165.158 of the Revised Code. (B) Reimbursement for private rooms (1) Unle...

...(A) Definitions. (1) "Home and community-based services" (HCBS) means services that enable individuals to live in a community setting rather than in an institutional setting such as a NF, an intermediate care facility for individuals with intellectual disabilities (ICF-IID), or a hospital. (2) "Hospitalization" means transfer of a NF resident to a medical institution as defined in paragraph (A)(4) of this rule. A N...

...) Purpose. In accordance with section 5165.157 of the Revised Code, this rule establishes an alternative purchasing model for the provision of nursing facility (NF) services to ventilator dependent individuals which may include ventilator weaning. (B) Definitions. For purposes of this rule the following definitions apply: (1) "Discrete unit" means an area in a NF that is set aside from the lar...

...uch 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 ...

...the provisions contained in sections 5165.10 to 5165.109 of the Revised Code, the following provisions apply. (A) For reporting purposes NFs shall use the chart of accounts for NFs as set forth in rule 5160-3-42 of the Administrative Code, or relate its chart of accounts directly to the cost report. (B) Unless an extension is granted by the Ohio department of medicaid (ODM), NF cost reports should...

...e FPF program, pursuant to section 5168.42 of the Revised Code. (C) Notification. ODM shall notify each facility previously assessed the FPF of the effective date of the termination of the FPF program, and what impact this change will have on the facility. (D) Reconciliation procedure. ODM shall conduct an accounting of the funds paid to or collected from each facility as a result of the FPF p...

...in calculating the debt estimate: (1) Overpayments determined due to ODM pursuant to section 5165.108 of the Revised Code, including the following: (a) Overpayments owed to ODM for adjudicated final fiscal audit periods. (b) Overpayments identified in proposed adjudication orders that have been issued but not adjudicated. (c) Overpayment amounts for any outstanding periods where a final fi...