Ohio Administrative Code Search

...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) Program integrity. (1) MPIP legal notice. (a) All eligible professionals and eligible hospitals submitting an application to receive an MPIP payment are required to sign the MPIP legal notice before confirming and submitting their application. (b) All program applicants are bound by the requirements of the MPIP legal notice. (2) Eligible professional and eligible hospital MPIP applications...

...(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) 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...

...(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 either 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) along with either paragraph (A)(4), (A)(5), (A)(6) or (B) of this rule. (1) Be twenty years of ...

...(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan has to 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 medically necessary service is not arbitrarily denied or reduced solely because of the diagnosis, type of illness, ...

...(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan will assign a care coordination tier for all youth eligible for enrollment in the OhioRISE plan. Tier assignment of limited, moderate, or intensive is based on assessed or indicated needs and may be modified to be based on individual circumstances or to best fit the youth or family capacity and choice. (1) Moderate care coordination (M...

...(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan will assign a care coordination tier for all youth eligible for enrollment in the OhioRISE plan. Tier assignment of limited, moderate, or intensive is based on assessed or indicated needs and may be modified to be based on individual circumstances or to best fit the youth or family capacity and choice. (1) Moderate ...

...(A) Scope. This rule sets forth provisions governing coverage for primary flex funds provided as part of the Ohio resilience through integrated systems and excellence (OhioRISE) program. (B) Definitions. (1) "Primary flex funds" are services, equipment, or supplies not otherwise provided through the medicaid state plan benefit or the OhioRISE program that address a youth's identified need as documented in the child...

...(A) Scope. This rule sets forth provisions governing coverage for primary flex funds provided as part of the Ohio resilience through integrated systems and excellence (OhioRISE) program. (B) Definitions. (1) "Primary flex funds" are services, equipment, or supplies not otherwise provided through the medicaid state plan benefit or the OhioRISE program that address a youth's identified need as...

...(A) This rule sets forth provisions governing coverage for the psychiatric residential treatment facility (PRTF) service furnished as part of the Ohio resilience through integrated systems and excellence (OhioRISE) program. (B) Definitions. For purposes of this rule, the following definitions apply: (1) "Bed hold day" means a day for which a bed is reserved for a resident of a PRTF through m...