Ohio Administrative Code Search

...(A) "Home health services" includes home health nursing, home health aide services and skilled therapies. (B) Home health services are reimbursable only if a qualifying treating physician, advance practice nurse or physician assistant certifying the need for home health services documents that he or she had a face-to-face encounter with the individual within ninety days prior to the start of ...

...(A) "Private duty nursing (PDN)" is a continuous nursing service that requires the skills of and is performed by either a registered nurse (RN) or a licensed practical nurse (LPN) at the direction of a registered nurse. A service is not considered a PDN service merely because it was performed by a licensed nurse. A covered PDN visit must meet the definition in paragraph (A) of rule 5160-12-04 of t...

...(A) As a prerequisite to receiving private duty nursing (PDN) services, an individual must meet the requirements set forth in rule 5160-12-02 of the Administrative Code, as applicable, which require the individual to receive PDN authorization from the Ohio department of medicaid (ODM) or its designee. (B) The procedures set forth in this paragraph must be followed when securing a PDN authorization for individuals wh...

...(A) A medicare certified home health agency (MCHHA) that meets the requirements of this rule is eligible to participate in the Ohio medicaid program upon execution of a provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code. (B) MCHHAs are required to: (1) Be certified for medicare participation by the Ohio department of health (ODH) in accordance with Chapter 3701-60 of the Administrati...

...(A) "Non-agency nurses" and "otherwise-accredited agencies" who meet the qualifications and requirements of this rule can provide private duty nursing (PDN) in accordance with rule 5160-12-02 of the Administrative Code. (B) A "non-agency nurse" that meets the requirements in accordance with this rule is eligible to participate in the Ohio medicaid program upon execution of a provider agreement in accordance with rul...

...(A) Reimbursement of home health or private duty nursing (PDN) services in accordance with this chapter are on a per visit basis. A "visit" is the duration of time that a covered home health service or private duty nursing (PDN) service is provided during an in-person or telehealth encounter to one or more individuals receiving medicaid at the same residence on the same date during the same time p...

...(A) For the purpose of this rule: (1) A "plan of care" is the medical treatment plan that is established, approved, and signed by a treating physician, advance practice nurse or physician's assistant in accordance with the Coronavirus Aid, Relief, and Economic Security (CARES) Act, S.3548 (2020), prior to a provider requesting reimbursement for a service. The plan of care has the same meaning...

...(A) For the purpose of this rule: (1) A "plan of care" is the medical treatment plan that is established, approved, and signed by a treating physician, advance practice nurse or physician's assistant in accordance with the Coronavirus Aid, Relief, and Economic Security (CARES) Act, S.3548 (2020), prior to a provider requesting reimbursement for a service. The plan of care has the same meaning...

...(A) Provisions in this chapter do not necessarily apply to transportation furnished in accordance with other chapters of agency 5160 of the Administrative Code. (B) The following definitions apply to this chapter: (1) Terms that have the same meaning as in 42 C.F.R. 414.605 (October 1, 2020) include the following items: (a) "Advanced life support, level 1 (ALS1)"; (b) "Advanced life suppor...

...(A) Pursuant to 42 C.F.R. 431.53, the Ohio department of medicaid (ODM) is obligated to ensure necessary transportation for medicaid-eligible individuals to and from providers of covered healthcare services. ODM fulfills this obligation in large measure through three-way subgrant agreements with the Ohio department of job and family services (ODJFS) and with each county department of job and famil...

...(A) Definitions. (1) "Private transportation vendor (PTV)" is an entity that meets the following criteria: (a) It seeks to establish or to maintain a contract with a county department of job and family services (CDJFS) to supply transportation service to medicaid recipients in accordance with rule 5160-15-10 of the Administrative Code; and (b) It is not a government agency, transit authority, p...

...(A) Definitions. (1) "Private transportation vendor (PTV)" is an entity that meets the following criteria: (a) It seeks to establish or to maintain a contract with a county department of job and family services (CDJFS) to supply transportation service to medicaid recipients in accordance with rule 5160-15-10 of the Administrative Code; and (b) It is not a government agency, transit authority, p...

...(A) Definitions. (1) "Freestanding birth center (FBC)" has the same meaning as in 42 U.S.C. 1396d(l)(3)(B) (October 1, 2016). (2) "Independent practitioner" and "non-independent practitioner" have the same meaning as in rule 5160-4-02 of the Administrative Code. (3) "Low-risk expectant mother" has the same meaning as in rule 3701-83-33 of the Administrative Code. (B) Provider requirements....

...(A) Definitions. (1) "Freestanding birth center (FBC)" is an entity defined in 42 U.S.C. 1396d(l)(3)(B) (in effect as of January 1, 2023) that is operated in conformity with rules 3701-83-33 to 3701-83-42 of the Administrative Code. (2) "Independent practitioner" and "non-independent practitioner" have the same meaning as in rule 5160-4-02 of the Administrative Code. (3) "Low-risk expectant...

...(A) Definitions. (1) "Abuse potential drug" as used in the appendix to this rule, means any drug that contains substances which have a potential for abuse because of depressant or stimulant effects on the central nervous system or hallucinogenic effects. Abuse potential drugs include any drug that is reportable to Ohio automated RX reporting system (OARRS) as described in rules 4729:8-2-01 and 47...

...(A) Definitions. (1) For the purposes of this rule, "hysterectomy" means, in accordance with 42 C.F.R. 441.251 (October 1, 2010 edition), a medical procedure or operation for the purpose of removing the uterus. (2) For the purposes of this rule, "institutionalized individual" means, in accordance with 42 C.F.R. 441.251 (October 1, 2010 edition), an individual who is: (a) Involuntarily confined or detained, under a...

...(A) Coverage. (1) Unless a different time period is specified, services described in this rule are covered through the pregnancy and the delivery. (2) Basic pregnancy-related services include but are not limited to antepartum care, delivery, outpatient postpartum care, and family planning services. (a) Antepartum care. Payment for a visit may be made for either of two purposes: (i) Basic...

...(A) Coverage. (1) Unless a different time period is specified, services described in this rule are covered through the pregnancy and the delivery. (2) Basic pregnancy-related services include but are not limited to antepartum care, delivery, outpatient postpartum care, and family planning services. (a) Antepartum care. Payment for a visit may be made for either of two purposes: (i) Basic...

...Effective for dates of service on or after the effective date of this rule, eligible ambulatory surgery centers as defined in paragraphs (A)(1) and (B) of this rule are subject to the enhanced ambulatory patient grouping system (EAPG) and prospective payment methodology utilized by the Ohio department of medicaid as described in this rule. (A) Definitions, for the purposes of this rule the following mean...

...Effective for dates of service on or after the effective date of this rule, eligible ambulatory surgery centers as defined in paragraphs (A)(1) and (B) of this rule are subject to the enhanced ambulatory patient grouping system (EAPG) and prospective payment methodology utilized by the Ohio department of medicaid (ODM) as described in this rule. (A) Definitions, for the purposes of this rule the following ...

...Effective for dates of service on or after the effective date of this rule, eligible ambulatory surgery centers, as defined in paragraphs (A)(1) and (B) of this rule, are subject to the enhanced ambulatory patient grouping system (EAPG) and prospective payment methodology utilized by the Ohio department of medicaid (ODM) as described in this rule. (A) Definitions, for the purposes of this rule, the following meaning...

...As used in Chapter 5160-26 of the Administrative Code: (A) "Abuse" means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practi...

...(A) This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code. (B) Eligibility for managed care organization (MCO) enrollment. (1) Except as specified in paragraphs (B)(3) to (B)(5) of this rule, in mandatory servic...

...(A) This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code. (B) The Ohio department of medicaid (ODM) will terminate a member from enrollment in a managed care organization (MCO) for any of the following reasons: ...

...(A) This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code. (B) The managed care organization (MCO) is responsible for payment of long-term services and supports (LTSS) respite services as defined in rule 5160-26-...