Ohio Administrative Code Search

...Services furnished by a non-hospice provider pursuant to paragraph (I) of this rule for the concurrent care of an individual under the age of twenty-one. (B) Reimbursement rates paid by ODM to the designated hospice shall be based on the level of care that is appropriate for the individual for each day while receiving hospice care. Based on the methodology set forth in 42 C.F.R. 418.302 (as in ef...

...(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...

... to federal and state regulations. (B) Provider appeals. (1) An eligible professional or eligible hospital may appeal the following issues related to MPIP, by first requesting an informal review: (a) Incentive payment amounts. (b) Provider eligibility determinations (i.e. patient volume, hospital-based). (c) Demonstration of adoption, implementation, or upgrade, and meaningful use eligibility. (...

...r, if appropriate, the primary care provider, specialists, and other providers, as applicable, that is designed to effectively meet the enrollee's needs. (14) "Waiver services plan" is a component of the care plan that identifies specific goals, objectives and measurable outcomes for a waiver-enrolled member's health and functioning expected as a result of HCBS provided by both formal and informa...

...r, if appropriate, the primary care provider, specialists, and other providers, as applicable, that is designed to effectively meet the enrollee's needs. (14) "Waiver services plan" is a component of the care plan that identifies specific goals, objectives and measurable outcomes for a waiver-enrolled member's health and functioning expected as a result of HCBS provided by both formal and informa...

...nistrative Code. (E) When an MCP holds provider agreements with the Ohio department of medicaid (ODM) for the MyCare Ohio and medicaid managed care programs, ODM may apply all of the applicable provisions in Chapter 5160-26 of the Administrative Code separately to each of the contracts.

...nistrative Code. (D) When an MCO holds provider agreements with the Ohio department of medicaid (ODM) for the MyCare Ohio and medicaid managed care programs or the Ohio resilience through integrated systems and excellence (OhioRISE) program, ODM may apply all of the applicable provisions in Chapter 5160-26 of the Administrative Code separately to each of the contracts.

...Ohio department of medicaid (ODM) has a provider agreement with the plan applicable to the eligible individual's county of residence. (5) Nothing in this rule shall be construed to limit or in any way jeopardize an eligible individual's basic medicaid eligibility or eligibility for medicare or other non-medicaid benefits to which he or she may be entitled. (B) MyCare Ohio plan enrollment. (1) The following applies...

... department of medicaid (ODM) has a provider agreement with the MCOP applicable to the eligible individual's county of residence. (5) Nothing in this rule shall be construed to limit or in any way jeopardize an eligible individual's basic medicaid eligibility or eligibility for medicare or other non-medicaid benefits to which he or she may be entitled. (B) MyCare Ohio plan enrollment. (1) The f...

... ODM approves the termination. (6) The provider agreement between ODM and the plan is terminated or not renewed. The effective date of termination shall be the last day of the month of the provider agreement termination or nonrenewal. (7) The member is not eligible for enrollment in a plan for one of the reasons set forth in rule 5160-58-02 of the Administrative Code. (B) All of the following a...

... the third party coverage. (6) The provider agreement between ODM and the MCOP is terminated or not renewed. The effective date of termination shall be the date of provider agreement termination or nonrenewal. (7) The member is not eligible for enrollment in an MCOP for one of the reasons set forth in rule 5160-58-02 of the Administrative Code. (B) All of the following apply when enrollment...

... the third party coverage. (6) The provider agreement between ODM and the MCOP is terminated or not renewed. The effective date of termination shall be the date of provider agreement termination or nonrenewal. (7) The member is not eligible for enrollment in an MCOP for one of the reasons set forth in rule 5160-58-02 of the Administrative Code. (B) All of the following apply when enrollment...

...e alternatives, choice of qualified providers available in the MyCare Ohio plan's provider panel and the options of institutional and community-based care, and he or she elects to receive MyCare Ohio waiver services. If the individual is unable to sign the agreement prior to waiver enrollment, the individual will submit an electronic signature or standard signature via regular mail, or otherwi...

...ry medicaid services from an MCOP panel provider, the plan must adequately and timely cover the services out of panel until the plan is able to provide the services from a panel provider. (B) The MCOP may place appropriate limits on a service; (1) On the basis of medical necessity for the member's condition or diagnosis; or; (2) Except as otherwise specified in this rule, to available panel...

... medicaid services from an MCOP network provider, the MCOP must adequately and timely cover the services out of network until the MCOP is able to provide the services from a network provider. (B) The MCOP may place appropriate limits on a service; (1) On the basis of medical necessity for the member's condition or diagnosis; (2) Except as otherwise specified in this rule, to available network p...

...sure each member has a primary care provider (PCP) who will serve as an ongoing source of primary care and assist with care coordination appropriate to the member's needs. (1) The MCOP will ensure PCPs are in compliance with the following triage requirements. Members with: (a) Emergency care needs will be triaged and treated immediately on presentation at the PCP site; (b) Persistent sympto...

... direction of approved waiver service providers. (A) A member may choose to receive MyCare Ohio waiver services from any combination of providers on the provider panel of the MyCare Ohio plan selected by the member pursuant to paragraph (B) of rule 5160-58-04 of the Administrative Code. (B) A member receiving waiver services from any MyCare Ohio waiver provider shall: (1) Participate with the ...

... services (HCBS) waiver program and the providers eligible to furnish those services to members enrolled in the MyCare Ohio waiver. (B) Providers seeking to furnish services in the MyCare Ohio waiver program shall meet the requirements in Chapter 173-39, 5160-45 or 5160-44 of the Administrative Code, as appropriate. Prior to furnishing services to MyCare Ohio waiver recipients, the services must be ...

...or participant-directed waiver services provider pursuant to paragraph (G) of rule 5160-58-03.2 of the Administrative Code; (e) Failure to provide services in a timely manner as specified in rules 5160-26-03.1 and 5160-58-01.1 of the Administrative Code; (f) Failure to act within the resolution time frames specified in this rule; or (g) Denial of a member's request to dispute a financial liabil...

...ary. (d) For denial of a request for a provider pursuant to paragraph (A)(1)(d) of this rule, the MCOP shall give notice simultaneously with the MCOP's decision. (e) For untimely prior authorization, appeal, or grievance resolution, the MCOP shall give notice simultaneously with the MCOP becoming aware of the untimely resolution. Service authorization decisions not reached within the time frames...

...5(c) waiver services for a youth when a provider is unable to or unresponsive in providing scheduled services. A back-up plan can include natural supports or other certified providers as the substitute of coverage. The child and family team identifies possible back-up options and includes them in the child and family-centered care plan. (2) "Care coordination" means the model described in rule 51...

...s network, and the youth's primary care provider or another provider determines that receiving services separately would subject the youth to unnecessary risk; (d) The youth has experienced poor quality of care and the services are not available from another provider within the OhioRISE plan's network; or (e) The youth cannot access medically necessary medicaid-covered services or cannot access ...

... network, and the youth's primary care provider or another provider determines that receiving services separately would subject the youth to unnecessary risk; (d) The youth has experienced poor quality of care and the services are not available from another provider within the OhioRISE plan's network; or (e) The youth cannot access medically necessary medicaid-covered services or cannot access ...

... network, and the youth's primary care provider or another provider determines that receiving services separately would subject the youth to unnecessary risk; (d) The youth has experienced poor quality of care and the services are not available from another provider within the OhioRISE plan's network; or (e) The youth cannot access medically necessary medicaid-covered services or cannot access ...

...le through an OhioRISE plan network provider, the OhioRISE plan has to adequately and timely cover the services out of network, until the OhioRISE plan is able to provide the services from a network provider. (6) Providers delivering services in the OhioRISE program will adhere to the incident management criteria set forth in rule 5160-44-05 of the Administrative Code. (B) The OhioRISE plan has ...