Ohio Administrative Code Search

...(A) Appeals. Pursuant to Chapter 5160-70 of the Administrative Code, final settlements that are based upon final audits by the department may be appealed by hospitals under Chapter 119. of the Revised Code. Rule 5160-2-24 of the Administrative Code describes final fiscal audits and final settlements performed by the department. Rules 5160-1-27 and 5160-1-29 of the Administrative Code describe the audits performed b...

...(A) The Ohio department of medicaid (ODM) will perform or contract with a medical review entity to perform utilization review for medicaid inpatient services regardless of the payment methodology used for reimbursement of those services. For the purposes of this rule, "ODM" means ODM or its contracted medical review entity. During the course of its analyses, ODM may request information or records from the hospital an...

...(A) In accordance with section 5168.14 of the Revised Code, each hospital that receives payment under the provisions of Chapter 5168. of the Revised Code, will provide, without charge to the individual, basic, medically necessary hospital-level services to the individual who is a resident of this state, is not a recipient of the medicaid program, and whose income is at or below the federal poverty...

...Rule 5160-1-08 of the Administrative Code sets forth general provisions regarding requirements that the department make payment for covered services only after any available third-party benefits are exhausted. In addition to those general provisions, this rule identifies other requirements applicable to services provided by hospitals. (A) All hospitals are to utilize third-party resources for all services a consumer...

...Rule 5160-1-08 of the Administrative Code sets forth general provisions that the department make payment for covered services only after any available third-party benefits are exhausted. In addition, this rule identifies other provisions applicable to services provided by hospitals. (A) All hospitals are to use third-party resources for all services a consumer receives while in the hospital. If a hos...

...This rule sets forth the assessment rate for the hospital franchise fee program implemented under sections 5168.20 to 5168.28 of the Revised Code. (A) Definitions For purposes of the hospital franchise fee program only, ''total facility costs'' are as defined in section 5168.20 of the Revised Code, and also exclude a hospital's costs associated with providing care to recipients of the medicare progr...

...Effective for services or discharges on or after the effective date of this rule, payments made to Ohio hospitals under the prospective payment systems or non-diagnostic related groups (DRG) prospective payment system will receive a cost coverage add-on. The provisions of this rule do not apply to the medicaid maximum allowed amount calculation described in rule 5160-2-25 of the Administrative Code. (A) De...

...Effective for services or discharges on or after the effective date of this rule, payments made to Ohio hospitals under the prospective payment systems or non-diagnostic related groups (DRG) and non-ambulatory patient grouping (EAPG) prospective payment systems will receive a cost coverage add-on. The provisions of this rule do not apply to the medicaid maximum allowed amount calculation described in rule 5...

...This rule sets forth the payment policies for inpatient hospital services for discharges on or after the effective date of this rule. (A) Hospitals defined as eligible providers of hospitals services in rule 5160-2-01 of the Administrative Code and are grouped in paragraph (B)(1) of rule 5160-2-05 of the Administrative Code are subject to the all patient refined diagnosis related groups (APR-DRG) ...

...Effective for dates of discharge on or after the effective date of this rule, to qualify for a medical education payment as described in this rule, Ohio hospitals must have an approved medical education program as defined in 42 C.F.R. 415.152 (October 1, 2016) and the costs of the approved medical education program were reflected in their state fiscal year (SFY) 2014 Ohio medicaid hospital cost report (ODM ...

...Effective for dates of service on or after the effective date of this rule, eligible providers of hospital services as defined in rule 5160-2-01 of the Administrative Code and assigned to prospective payment peer group as described in rule 5160-2-05 of the Administrative Code are subject to the enhanced ambulatory patient grouping system (EAPG) prospective payment methodology utilized by the Ohio department...

...For purposes of this rule, eligible providers of hospital services as defined in rule 5160-2-01 of the Administrative Code and assigned to prospective payment peer group as described in rule 5160-2-05 of the Administrative Code are subject to the enhanced ambulatory patient grouping system (EAPG) prospective payment methodology utilized by the Ohio department of medicaid (ODM) as described in this rule. (A...

...For the purposes of this rule, eligible providers of hospital services, as defined in rule 5160-2-01 of the Administrative Code, and assigned to prospective payment peer groups as defined in rule 5160-2-05 of the Administrative Code, are subject to the enhanced ambulatory patient grouping(EAPG) system. This is a prospective payment methodology utilized by the Ohio department of medicaid (ODM) as described in this rul...

...(A) This rule establishes a consumer co-payment for non-emergency emergency department services as authorized by section 5162.20 of the Revised Code. (B) For purposes of this rule, the following definitions apply. (1) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent lay person, as d...

...Except as otherwise provided in Chapter 5160-3 of the Administrative Code, and in addition to the definitions in section 5165.01 of the Revised Code: (A) "Allowable costs" has the same meaning as in section 5165.01 of the Revised Code and are determined in accordance with the following reference material, in the following priority: (1) Title 42 Code of Federal Regulations (C.F.R.) Chapter IV (Oc...

...In addition to provisions in Chapters 5164. and 5165. of the Revised Code regarding provider agreements, and provisions in rules 5160-3-02.1 and 5160-3-02.2 of the Administrative Code, execution and maintenance of a provider agreement between the Ohio department of medicaid (ODM) and the operator of a NF also are contingent upon compliance with requirements set forth in this rule. (A) Definitions. (1) "Cl...

...(A) Written notice. (1) The Ohio department of medicaid (ODM) may terminate, deny, or not revalidate a NF provider agreement upon thirty days written notice to the NF. (2) Notices and termination orders must comply with provisions set forth in sections 5164.38 and 5165.77 of the Revised Code. (B) Reasons for which ODM may terminate, deny, or not revalidate a NF provider agreement. (1) In accor...

...(A) Definitions. (1) "Certification" means the process by which the state survey agency certifies its findings to the federal centers for medicare and medicaid services (CMS) or the Ohio department of medicaid (ODM) with respect to a facility's compliance with health, safety, and resident rights requirements of divisions (a), (b), (c), and (d) of section 1919 of the Social Security Act, 42 U.S.C....

...(A) Definitions. (1) For purposes of this rule, the terms "certified beds," "dually participating," "facility," and "religious non-medical health care institution" (RNHCI) are defined in rule 5160-3-02.3 of the Administrative Code. (2) For purposes of this rule, the term "reasonable assurance period" is defined in rule 5160-3-02.1 of the Administrative Code. (3) "Fully participating" me...

...(A) For purposes of determining an individual's nursing-facility (NF) based level of care, the following definitions apply unless a term is otherwise defined in a specific rule: (1) "Activity of daily living (ADL)" means a personal or self-care task that enables an individual to meet basic life needs. "ADL" includes the following defined activities: (a) "Bathing" means the ability of an individu...

...(A) This rule contains the definitions used in the process of making a determination of an individual's level of care. The definitions in this rule apply unless a term is otherwise defined in a specific rule. (B) Definitions. (1) "Active Treatment" means a continuous treatment program including aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and ...

...(A) The criteria for the protective level of care is met when: (1) The individual's needs for long-term services and supports (LTSS) are less than the criteria for the intermediate or skilled levels of care, as described in paragraphs (A)(4), (B), and (C) of rule 5160-3-08 of the Administrative Code. (2) The individual's LTSS needs are less than the criteria for the developmental disabilities le...

...(A) This rule describes the criteria for an individual to meet the protective level of care. (B) The criteria for the protective level of care is met when: (1) The individual's needs for long-term services and supports (LTSS), as defined in rule 5101:3-3-05 of the Administrative Code, are less than the criteria for the intermediate or skilled levels of care, as described in paragraphs (B)(4), (C), and (D)(4) of ru...

...(A) The purpose of this rule is to set forth the process by which the Ohio department of medicaid (ODM) shall identify nursing facilities (NFs) that are at risk of becoming IMDs, the preventive measures to be taken by ODM when such facilities have been identified, and the course of action to be taken if a NF is identified as an IMD. Medicaid payment is not available for services provided to individuals in an IMD wh...

...(A) This rule describes the criteria for an individual to meet the nursing facility (NF)-based level of care. The NF-based level of care includes the intermediate and skilled levels of care. An individual is determined to meet the NF-based level of care when the individual meets the criteria as described in paragraphs (B) to (D) of this rule. (B) The criteria for the intermediate level of care is met when: (1) The...