Ohio Administrative Code Search

...This rule sets forth the requirements for discharging an individual from the designated hospice's care and/or the hospice benefit. (A) Discharge refers to the end the hospice benefit and/or the designated hospice's care: (1) Discharge from the designated hospice's care shall occur when the individual: (a) Dies/expires; (b) No longer meets the hospice enrollment or eligibility criteria; (c) No lon...

...This rule sets forth the requirements for discharging an individual from the designated hospice's care and/or the hospice benefit. (A) Discharge refers to the end the hospice benefit or the designated hospice's care: (1) Discharge from the designated hospice's care should occur when the individual: (a) Dies; (b) No longer meets the hospice enrollment or eligibility criteria; (c) No longer is term...

...This rule sets forth the requirement for recording the hospice provider span for individuals receiving medicaid hospice care in accordance with Chapter 5160-56 of the Administrative Code, including individuals who may be covered by third-party insurance, such as medicare, for which the hospice seeks reimbursement. (A) The designated hospice shall report the required enrollment information to the Ohio dep...

...This rule sets forth the requirement for recording the hospice provider span for individuals receiving medicaid hospice care in accordance with Chapter 5160-56 of the Administrative Code, including individuals who may be covered by third-party insurance, such as medicare, for which the hospice seeks reimbursement. (A) The designated hospice should report the necessary enrollment information to the Ohio d...

...This rule sets forth the Ohio department of medicaid (ODM) payment for hospice services and care. (A) ODM will directly pay the designated hospice to care for an individual enrolled in medicaid hospice. Payment to the designated hospice shall cover 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 p...

...This rule sets forth the Ohio department of medicaid (ODM) payment for hospice services and care. (A) ODM will directly pay the designated hospice to care for an individual enrolled in medicaid hospice. Payment to the designated hospice will cover 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 pa...

...(A) The medicaid provider incentive program (MPIP) is 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 partic...

...(A) 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 individ...

...(A) 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 individ...

...(A) 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 individ...

...(A) The general definitions set forth in rule 5160-26-01 of the Administrative Code regarding managed care entities (MCEs) 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"...

...(A) MyCare Ohio plans must comply with all of the requirements applicable to managed care plans (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 5160-2...

...(A) Eligibility. (1) An individual is enrolled in a MyCare Ohio plan (MCOP) if he or she meets all of the following criteria: (a) Age twenty-one or older at the time of enrollment in the MCOP; (b) Eligible for medicare parts A, B, and D, and full benefits under the medicaid program. (2) The following individuals are not eligible for enrollment in an MCOP: (a) Individuals enrolled in the program of all-inclusive ...

...(A) Disenrollment from the MyCare Ohio program occurs for the following reasons: (1) The member becomes ineligible for full benefits under the medicaid program or medicare parts A or B or D. Termination of MyCare Ohio plan (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 ...

...(A) To be eligible for enrollment in the MyCare Ohio waiver, a member must meet 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...

...(A) To be eligible for enrollment in the MyCare Ohio waiver, a member must meet 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...

...(A) To be eligible for enrollment in the MyCare Ohio waiver, a member meets all of the following requirements: (1) Is enrolled in the MyCare Ohio program at the time of application for the MyCare Ohio waiver; (2) Is determined to have a nursing facility-based level of care (i.e., intermediate or skilled) in accordance with rule 5160-3-08 of the Administrative Code; (3) In the absence of the MyCare Ohio waiver, re...

...(A) A MyCare Ohio plan (MCOP) must ensure members have access to all medically-necessary medical, drug, behavioral health, nursing facility and home and community-based services (HCBS) covered by Ohio medicaid. After consideration of verified third party liability including medicare coverage pursuant to rule 5160-26-09.1 of the Administrative Code, the MCOP must ensure: (1) Services are suffi...

...(A) A MyCare Ohio plan (MCOP) ensures each member has a primary care provider (PCP) who serves as an ongoing source of primary care and assists with care coordination appropriate to the member's needs. (1) The MCOP ensures PCPs are in compliance with the following triage requirements. Members with: (a) Emergency care needs are triaged and treated immediately on presentation at the PCP site; ...

...(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...

...(A) Notice of action (NOA) 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 ...

...(A) Notice of action (NOA) 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 ...

...(A) Grievances and appeals vary depending on the MyCare Ohio enrollment of the member. (1) If the member is enrolled as a dual-benefits member, as defined in rule 5160-58-01 of the Administrative Code, then all grievances and appeals are conducted by the MyCare Ohio plan (MCOP). (2) If the member is enrolled as a medicaid-only member, as defined in rule 5160-58-01 of the Administrative Code, then the grievances and...

...(A) To be eligible for enrollment in the Ohio resilience through integrated systems and excellence (OhioRISE) program, an individual has to meet the criteria for first day 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 younge...

...(A) To be eligible for enrollment in the Ohio resilience through integrated systems and excellence (OhioRISE) program, an individual has to meet the criteria for first day 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 younge...