Ohio Administrative Code Search

...et all of the following requirements: (1) Be enrolled in the MyCare Ohio demonstration at the time of application for the MyCare Ohio waiver; (2) Be determined to have a nursing facility-based level of care (i.e., intermediate or skilled) in accordance with rule 5160-3-08 or 5160-3-09 of the Administrative Code; (3) In the absence of the MyCare Ohio waiver, require hospitalization or institutio...

...et all of the following requirements: (1) Be enrolled in the MyCare Ohio demonstration at the time of application for the MyCare Ohio waiver; (2) Be determined to have a nursing facility-based level of care (i.e., intermediate or skilled) in accordance with rule 5160-3-08 or 5160-3-09 of the Administrative Code; (3) In the absence of the MyCare Ohio waiver, require hospitalization or institutio...

...ing medicare coverage pursuant to rule 5160-26-09.1 of the Administrative Code, the MCOP must ensure: (1) Services are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished; (2) The amount, duration, or scope of a required service is not arbitrarily denied or reduced solely because of the diagnosis, type of illness, or condi...

...ing medicare coverage pursuant to rule 5160-26-09.1 of the Administrative Code, the MCOP must ensure: (1) Services are sufficient in amount, duration and scope to reasonably be expected to achieve the purpose for which the services are provided; (2) The amount, duration, and scope of a required service is not arbitrarily denied or reduced solely because of the diagnosis, type of illness, or cond...

...ppropriate to the member's needs. (1) The MCOP will ensure PCPs are in compliance with the following triage requirements. Members with: (a) Emergency care needs will be triaged and treated immediately on presentation at the PCP site; (b) Persistent symptoms will be treated no later than the end of the following working day after their initial contact with the PCP site; and (c) Requests fo...

...re Ohio waiver in accordance with rule 5160-58-02.2 of the Administrative Code has choice and control over the arrangement and provision of home and community-based services (HCBS). Members also have choice over the selection and control over the direction of approved waiver service providers. (A) A member may choose to receive MyCare Ohio waiver services from any combination of providers on the provider...

... pursuant to paragraph (B) of rule 5160-58-04 of the Administrative Code. (B) A member receiving waiver services from any MyCare Ohio waiver provider will: (1) Participate with the waiver service coordinator in the development of the person-centered services plan as defined in rule 5160-44-02 of the Administrative Code. (2) Decide who from their trans-disciplinary care management team will pa...

...(A) Definitions. (1) "Adverse benefit determination" is a MyCare Ohio plan (MCOP)'s: (a) Denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit; (b) Reduction, suspension, or termination of services prior to the member receiving the...

...OA) by a MyCare Ohio plan (MCOP). (1) When an MCOP adverse benefit determination has or will occur, the MCOP shall provide the affected member with a NOA. (2) The NOA shall explain: (a) The adverse benefit determination the MCOP has taken or intends to take; (b) The reasons for the adverse benefit determination, including the right of the member to be provided, upon request and free of cha...

...OA) by a MyCare Ohio plan (MCOP). (1) When an MCOP adverse benefit determination has or will occur, the MCOP shall provide the affected member with a NOA. (2) The NOA shall explain: (a) The adverse benefit determination the MCOP has taken or intends to take; (b) The reasons for the adverse benefit determination, including the right of the member to be provided, upon request and free of cha...

... The definitions set forth in rule 5160-26-01 of the Administrative Code, with the exceptions noted in paragraphs (A)(1) and (A)(2) of this rule, apply to the Ohio resilience through integrated systems and excellence (OhioRISE) rules set forth in Chapter 5160-59 of the Administrative Code. Definitions that reference managed care organizations (MCOs) in Chapter 5160-26 of the Administrative Code ap...

...tities (MCEs) in the following rules: (1) Rule 5160-26-05 of the Administrative Code with the exception of paragraphs (B)(4), (B)(5), (D)(21), (D)(25), and (D)(26); (2) Rule 5160-26-05.1 of the Administrative Code with the exception of paragraph (B)(1); (3) Rule 5160-26-06 of the Administrative Code; (4) Rule 5160-26-08.3 of the Administrative Code with the exception of paragraphs (A)(19) and ...

...eligibility and enrollment in rule 5160-59-02.1 of the Administrative Code or the criteria in paragraphs (A)(1) to (A)(3) and either paragraph (A)(4), (A)(5), (A)(6) or (B) of this rule. (1) Be twenty years of age or younger at the time of enrollment; (2) Be determined eligible for Ohio medicaid in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code; (3) Not be enrolled...

...eligibility and enrollment in rule 5160-59-02.1 of the Administrative Code or the criteria in paragraphs (A)(1) to (A)(3) and either paragraph (A)(4), (A)(5), (A)(6) or (B) of this rule. (1) Be twenty years of age or younger at the time of enrollment; (2) Be determined eligible for Ohio medicaid in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code; (3) Not be enrolled...

...eligibility and enrollment in rule 5160-59-02.1 of the Administrative Code or the criteria in paragraphs (A)(1) to (A)(3) and either paragraph (A)(4), (A)(5), (A)(6) or (B) of this rule. (1) Be twenty years of age or younger at the time of enrollment; (2) Be determined eligible for Ohio medicaid in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code; (3) Not be enrolled...

...eligibility and enrollment in rule 5160-59-02.1 of the Administrative Code or the criteria in paragraphs (A)(1) to (A)(3) along with either paragraph (A)(4), (A)(5), (A)(6) or (B) of this rule. (1) Be twenty years of age or younger at the time of enrollment; (2) Be determined eligible for Ohio medicaid in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code; (3) Not be e...

...olled in OhioRISE as set forth in rule 5160-59-02 of the Administrative Code. (B) Eligibility. For individuals who meet criteria in paragraphs (B)(1) to (B)(4) of this rule, enrollment will be mandatory in the OhioRISE program on the first day the program is in effect: (1) Be twenty years of age or younger; (2) Be determined eligible for Ohio medicaid in accordance with Chapters 5160:1-1 to...

...llence (OhioRISE) plan has to ensure: (1) Services are sufficient in amount, duration, and scope to reasonably be expected to achieve the purpose for which the services are provided; (2) The amount, duration, and scope of a medically necessary service is not arbitrarily denied or reduced solely because of the diagnosis, type of illness, or condition; (3) Prior authorization is available for ser...

... of the care provided to the member. (1) The OhioRISE plan has to ensure decisions rendered through the UM program are based on medical necessity. (2) The UM program has to be based on written policies and procedures that include, at a minimum: (a) The information sources used to make determinations of medical necessity; (b) The criteria, based on sound clinical evidence, to make UM decision...

... youth or family capacity and choice. (1) Moderate care coordination (MCC) is recommended for youth six years of age and older when paragraph (A)(1)(a) and either paragraph (A)(1)(b) or (A)(1)(c) of this rule are met: (a) An Ohio children's initiative child and adolescent needs and strengths (CANS) assessment, the tool available on https://www.medicaid.ohio.gov (September 20, 2021), indicates for behavioral/emotion...

... youth or family capacity and choice. (1) Moderate care coordination (MCC) is recommended for youth six years of age and older when paragraph (A)(1)(a) and either paragraph (A)(1)(b) or (A)(1)(c) of this rule are met: (a) An Ohio children's initiative child and adolescent needs and strengths (CANS) assessment, the tool available on https://www.medicaid.ohio.gov (September 20, 2021), indicates fo...

... addiction services (OhioMHAS) in rule 5122-29-28 of the Administrative Code. (C) Eligible providers of IHBT services. (1) Providers eligible for medicaid payment for IHBT will: (a) Meet the criteria in paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code; and (b) Provide the service in accordance with rule 5122-29-28 of the Administrative Code. (D) Coverage. (1) Payment may be made for IHBT...

...iction services (OhioMHAS) in rule 5122-29-28 of the Administrative Code. (C) Eligible providers of IHBT services. (1) Providers eligible for medicaid payment for IHBT will: (a) Meet the criteria in paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code; and (b) Provide the service in accordance with rule 5122-29-28 of the Administrative Code. (D) Coverage. (1) Payment may ...

...ule, the following definitions apply: (1) "Behavioral health respite services" are services that provide short-term, temporary relief to the primary caregiver of an OhioRISE plan enrolled youth, in order to support and preserve the primary caregiving relationship. (2) "Foster home" has the same meaning as "certified foster home" in rule 5101:2-1-01 of the Administrative Code. (3) "Kin" has the same meaning as in r...

... the following definitions apply: (1) "Behavioral health respite services" are services that provide short-term, temporary relief to the primary caregiver of an OhioRISE plan enrolled youth, in order to support and preserve the primary caregiving relationship. (2) "Foster home" has the same meaning as "certified foster home" in rule 5101:2-1-01 of the Administrative Code. (3) "Kin" has ...