Ohio Administrative Code Search

...(A) For purposes of this rule only: (1) "Medicaid covered service" is defined as a service that is eligible for coverage by the Ohio medicaid program and is delivered by a medical provider that qualifies for a medicaid provider agreement. (2) "Applicant for reimbursement" is defined as: (a) An individual who has been erroneously determined ineligible for the medicaid program or whose determination was incorrectly ...

...(A) For purposes of this rule: (1) "Applicant for reimbursement" is: (a) An individual who has been determined eligible for a retroactive eligibility period in accordance with rule 5160:1-2-01 of the Administrative Code, and who is seeking reimbursement for medical expenses for which the individual paid for during this approved time period; or (b) An individual who, as a result of an eligibili...

...(A) For the purpose of this rule, the following definitions apply. (1) "Attributed individual" is the Ohio medicaid covered individual for whom a qualified behavioral health entity eligible under this rule has accountability for providing behavioral health care coordination. (2) "Attribution" is the process through which medicaid covered individuals are assigned to a specific qualified behaviora...

...(A) Definitions. (1) "Practitioner," for purposes of this rule, is a collective term for the following professionals: (a) Doctor of medicine or osteopathy; (b) Advanced practice registered nurse; (c) Dentist; (d) Optometrist; (e) Podiatrist; or (f) Chiropractor. (2) "Regular practitioner" is a practitioner enrolled in the Ohio medicaid program who regularly takes care of an individual's health ...

...(A) Definitions. (1) "Practitioner," for purposes of this rule, is a collective term for the following professionals: (a) Doctor of medicine or osteopathy; (b) Advanced practice registered nurse; (c) Dentist; (d) Optometrist; (e) Podiatrist; or (f) Chiropractor. (2) "Regular practitioner" is a practitioner enrolled in the Ohio medicaid program who regularly takes care of an individual's health car...

...The department of medicaid (ODM) will make relief payments available to Ohio medicaid hospitals defined in paragraph (A) of this rule, as authorized under Section 270.15 of Amended Substitute House Bill 45 of the 134th General Assembly: (A) ODM will make available a one-time lump sum payment to the following hospital types: (1) "Critical access hospitals," as defined in rule 5160-2-05 of the Administ...

...(A) The Ohio department of medicaid (ODM) will deposit a portion of the intergovernmental transfers (IGT) that are paid under any state directed payment (SDP) program as authorized under 42 CFR 438.6(c) effective as of July 9, 2024. (B) On or after the effective date of this rule and for each year thereafter: (1) Pursuant to paragraph (A) of this rule, each provider eligible to receive a direc...

...(A) All hospitals, except those excluded in paragraphs (A)(1) and (A)(2) of this rule, that meet medicare (Title XVIII) conditions of participation as described in 42 C.F.R 482 effective as of October 1, 2016, are eligible to participate in the Ohio medicaid (Title XIX) program upon execution of a provider agreement. Also considered to be eligible is a hospital that is currently determined to meet the requirements fo...

...(A) All hospitals, except those excluded in paragraphs (A)(1) and (A)(2) of this rule, that meet medicare (Title XVIII) conditions of participation as described in 42 C.F.R 482 effective as of October 1, 2022, are eligible to participate in the Ohio medicaid (Title XIX) program upon execution of a provider agreement. Also considered to be eligible is a hospital that is currently determined to meet...

...(A) All hospitals, except those excluded in paragraph (A)(2) of this rule, that meet medicare (Title XVIII) conditions of participation as described in 42 C.F.R. 482 effective as of October 1, 2025, are eligible to participate in the Ohio medicaid (Title XIX) program upon execution of a provider agreement. (1) The following hospitals are also considered to be eligible: (a) Hospitals that are currently determined t...

...(A) This rule provides information about the general provisions for covering hospital services. (B) The following words and terms, when used in this chapter have the following meanings, unless the context clearly indicates otherwise: (1) "Inpatient" - A patient who is admitted to a hospital based upon the written orders of a physician or dentist and whose inpatient stay continues beyond midnight of the day of admi...

...For purposes of Chapter 5160-2 of the Administrative Code, the following definitions apply, unless the context clearly indicates otherwise: (A) "Diagnosis related groups (DRGs)" - a patient classification system that reflects clinically cohesive groupings of services that consume similar amounts of hospital resources in an inpatient setting. The groupings used to assign cases to a DRG for claims ...

...For purposes of Chapter 5160-2 of the Administrative Code, the following definitions apply, unless the context clearly indicates otherwise: (A) "Diagnosis related groups (DRGs)" is a patient classification system that reflects clinically cohesive groupings of services that consume similar amounts of hospital resources in an inpatient setting. The groupings used to assign cases to a DRG for claim payment and the grou...

...For purposes of Chapter 5160-2 of the Administrative Code, the following definitions apply, unless the context clearly indicates otherwise: (A) "Diagnosis related groups (DRGs)" is a patient classification system that reflects clinically cohesive groupings of services that consume similar amounts of hospital resources in an inpatient setting. The groupings used to assign cases to a DRG for claim ...

...(A) Conditions and limitations applicable to both inpatient and outpatient hospital services. (1) Coverage of provider-based physician services reimbursable as an inpatient or outpatient hospital service is limited to those services reimbursable under medicare, part A, except as provided in rule 5160-4-01 of the Administrative Code. (2) Inpatient or outpatient services related to the provision of the services descr...

...(A) Drugs. (1) Drugs are classified as: administered inpatient (drugs administered to a patient while an inpatient); administered outpatient (drugs administered to a patient at the hospital in connection with outpatient services); take-home (drugs dispensed on an outpatient basis for use away from the hospital). (2) Administered inpatient drugs are considered inpatient services and are reimbursed as an inpatient se...

...(A) Drugs. (1) Drugs are classified as: administered inpatient (drugs administered to a patient while an inpatient); administered outpatient (drugs administered to a patient at the hospital in connection with outpatient services); take-home (drugs dispensed on an outpatient basis for use away from the hospital). (2) Administered inpatient drugs are considered inpatient services and are reimburse...

...Effective for services or discharges on or after the effective date of this rule, hospitals shall be classified into mutually exclusive peer groups for purposes of setting rates and making payments under the "All Patient Refined-Diagnosis Related Group" (APR-DRG) inpatient prospective payment system, the "Enhanced Ambulatory Patient Grouping" (EAPG) outpatient prospective payment system or to those hospit...

...This rule describes how hospitals are classified into mutually exclusive peer groups for purposes of setting rates and making payments under the "All Patient Refined-Diagnosis Related Group" (APR-DRG) inpatient prospective payment system, the "Enhanced Ambulatory Patient Grouping" (EAPG) outpatient prospective payment system or to those hospitals excluded from the prospective payment systems. (A) Definitio...

...(A) Definitions in Chapter 5160-2 of the Administrative Code. (1) "Cancer hospitals" are hospitals recognized by medicare that primarily treat neoplastic disease in accordance with 42 C.F.R. 412.23(f), effective October 1, 2025. (2) "Children's hospitals" are hospitals that primarily serve patients eighteen years of age and younger, have at least seventy-five beds, and are excluded from medicare prospective payment...

...This rule sets forth the data used to determine assessments and adjustments, and the data policies that are applicable for each program year for all providers of hospital services included in the definition of "hospital" as described under section 5168.01 of the Revised Code. (A) Definitions. (1) "Disproportionate share hospital" means a hospital that meets the requirements for disproportionate share st...

...(A) Applicability. The requirements of this rule apply as long as the United States centers for medicare and medicaid services (CMS) determines that the assessment imposed under section 5168.06 of the Revised Code is a permissible health care related tax. Whenever the department of medicaid is informed that the assessment is an impermissible health care-related tax, the department shall promptly ...

...This rule is applicable for each program year for all medicaid-participating providers of hospital services included in the definition of "hospital" as described under section 5168.01 of the Revised Code. (A) Definitions. (1) "Total fee for service (FFS) medicaid costs" for each hospital means the sum of inpatient program costs reported on ODM 02930, schedule H, section I, columns 1 and 3, line 1 ...

...This rule is applicable for each program year for all medicaid-participating psychiatric hospitals as described in paragraphs (B) to (D) of rule 5160-2-01 of the Administrative Code. (A) Definitions for each psychiatric hospital. (1) "Cash subsidies for inpatient services received directly from state and local governments" is the amount of cash subsidies each psychiatric hospital has received from ...

...This rule is applicable for each program year for all medicaid-participating psychiatric hospitals as described in paragraphs (B) to (D) of rule 5160-2-01 of the Administrative Code. (A) Definitions for each psychiatric hospital. (1) "Cash subsidies for inpatient services received directly from state and local governments" is the amount of cash subsidies each psychiatric hospital has received from ...