Ohio Administrative Code Search

...ed personnel pursuant to 42 C.F.R. 418.114 (October 1, 2017), who are employed by the hospice, under an individual contract, or under arrangement with another provider. (D) The following services are covered by medicaid when furnished or arranged by the designated hospice based on the individual's needs, appropriate level of care, and plan of care: (1) Core hospice services may be provided ...

...ed personnel pursuant to 42 C.F.R. 418.114 (October 1, 2023), who are employed by the hospice, under an individual contract, or under arrangement with another provider. (D) The following services are covered by medicaid when furnished or arranged by the designated hospice based on the individual's needs, appropriate level of care, and plan of care: (1) Core hospice services: (a) Nursing ca...

...r the array of services listed in rule 5160-56-05 of the Administrative Code, except for: (1) Services pursuant to paragraph (E) of this rule which are paid directly to the physician; and (2) Services furnished by a non-hospice provider pursuant to paragraph (I) of this rule for the concurrent care of an individual under the age of twenty-one. (B) Reimbursement rates paid by ODM to the designat...

...r the array of services listed in rule 5160-56-05 of the Administrative Code, except for: (1) Services pursuant to paragraph (E) of this rule which are paid directly to the physician; and (2) Services furnished by a non-hospice provider pursuant to paragraph (I) of this rule for the concurrent care of an individual under the age of twenty-one. (B) Reimbursement rates paid by ODM to the designat...

... Ohio's program implementing section 4201 of the American Recovery and Reinvestment Act of 2009 (ARRA), Pub. L. No. 111-5, and the published regulations in 42 C.F.R. Part 495. Certain medicaid eligible professionals and hospitals are eligible to participate in MPIP. Funding for this program ends in 2021. (B) An eligible professional participating in Ohio's MPIP program is a provider that meets el...

... The definitions set forth in rule 5160-26-01 of the Administrative Code apply to the MyCare Ohio rules set forth in Chapter 5160-58 of the Administrative Code. (B) In addition to the definitions set forth in rule 5160-26-01 of the Administrative Code, the following definitions apply to Chapter 5160-58 of the Administrative Code: (1) "Assessment" means a comprehensive evaluation of an individual...

... The definitions set forth in rule 5160-26-01 of the Administrative Code apply to the MyCare Ohio rules set forth in Chapter 5160-58 of the Administrative Code. (B) In addition to the definitions set forth in rule 5160-26-01 of the Administrative Code, the following definitions apply to Chapter 5160-58 of the Administrative Code: (1) "Assessment" means a comprehensive evaluation of an individual...

... The definitions set forth in rule 5160-26-01 of the Administrative Code apply to the MyCare Ohio rules set forth in Chapter 5160-58 of the Administrative Code. (B) In addition to the definitions set forth in rule 5160-26-01 of the Administrative Code, the following definitions apply to Chapter 5160-58 of the Administrative Code: (1) "Assessment" means a comprehensive evaluation of an individual...

...ns (MCPs) in the following rules: (1) Rule 5160-26-05 of the Administrative Code; (2) Rule 5160-26-05.1 of the Administrative Code; (3) Rule 5160-26-06 of the Administrative Code; (4) Rule 5160-26-08.3 of the Administrative Code; (5) Rule 5160-26-09 of the Administrative Code; (6) Rule 5160-26-09.1 of the Administrative Code; (7) Rule 5160-26-10 of the Administrative Code; and ...

...(A) Eligibility. (1) Except as specified in paragraph (A)(2) of this rule, in mandatory service areas as permitted by 42 C.F.R. 438.52 (October 1, 2016), an individual must be enrolled in a MyCare Ohio plan (also known as "plan") if he or she meets all of the following criteria: (a) Age eighteen or older at the time of enrollment in the plan; (b) Eligible for medicare parts A, B and D, and full benefits under the ...

...(A) Eligibility. (1) Except as specified in paragraph (A)(2) of this rule, in mandatory service areas as permitted by 42 C.F.R. 438.52 (October 1, 2021), an individual must be enrolled in a MyCare Ohio plan (MCOP) if he or she meets all of the following criteria: (a) Age eighteen or older at the time of enrollment in the MCOP; (b) Eligible for medicare parts A, B and D, and full benefits under ...

...n") for any of the following reasons: (1) The member becomes ineligible for full medicaid or medicare parts A or B or D. Termination of plan enrollment is effective the end of the last day of the month in which the member became ineligible. (2) The member's permanent place of residence is moved outside the plan's service area. Termination of plan enrollment is effective the end of the last day o...

...OP) for any of the following reasons: (1) The member becomes ineligible for full medicaid or medicare parts A or B or D. Termination of MCOP enrollment is effective the end of the last day of the month in which the member became ineligible. (2) The member's permanent place of residence is moved outside the plan's service area. Termination of MCOP enrollment is effective the end of the last day o...

...OP) for any of the following reasons: (1) The member becomes ineligible for full medicaid or medicare parts A or B or D. Termination of MCOP enrollment is effective the end of the last day of the month in which the member became ineligible. (2) The member's permanent place of residence is moved outside the plan's service area. Termination of MCOP enrollment is effective the end of the last day o...

...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...