Ohio Administrative Code Search

...per job bid rate negotiated between the provider and the individual's case manager. (3) "Billing unit," as used in table B, column 3 of paragraph (B) of this rule, means a single fixed item, amount of time or measurement (e.g., a meal, a day, or mile, etc.). (4) "Caretaker relative" has the same meaning as in rule 5160:1-1-01 of the Administrative Code. (5) "Group rate," as used in paragraph (D)(1) of this rule, m...

..."Group rate" means the amount that HCAS providers will be reimbursed when the service is provided in a group setting. (4) "Group setting" means a situation in which an HCAS provider furnishes HCAS in accordance with rule 5160-44-27 of the Administrative Code, and as authorized by the Ohio department of medicaid (ODM), to two or three individuals who reside at the same address. (5) "HCAS visit" is a visit during whi...

...graph (C) of this rule and by qualified providers as defined in paragraph (E) of this rule. Payment for targeted case management services may not duplicate payments made to public agencies or private entities under other program authorities for this same purpose. Medicaid reimbursable TCM services are: (a) Assessment. Activities reimbursable under the assessment category are limited to the following: (i) Activities...

...h (C) of this rule and by qualified providers as defined in paragraph (E) of this rule. Payment for targeted case management services may not duplicate payments made to public agencies or private entities under other program authorities for this same purpose. Medicaid reimbursable TCM services are: (a) Assessment. Activities reimbursable under the assessment category are limited to the following:...

...h (C) of this rule and by qualified providers as defined in paragraph (E) of this rule. Payment for TCM services will not duplicate payments made to public agencies or private entities under other program authorities for this same purpose. Medicaid reimbursable TCM services are: (a) Assessment. Activities reimbursable under the assessment category are limited to the following: (i) Activities per...

...able date on which a designated hospice provider delivers hospice services to an individual. (F) "Benefit period" or "election benefit period" refers to a span for which the individual is enrolled in the hospice benefit. Benefit periods consist of two ninety day benefit periods, followed by an unlimited number of sixty day benefit periods. The benefit periods may be used consecutively or at inter...

...able date on which a designated hospice provider delivers hospice services to an individual. (F) "Benefit period" or "election benefit period" refers to a span for which the individual is enrolled in the hospice benefit. Benefit periods consist of two ninety day benefit periods, followed by an unlimited number of sixty day benefit periods. The benefit periods may be used consecutively or at inter...

...ices through the PACE site's network of providers. (E) If the individual is enrolled in a medicaid managed care organization (MCO) , the individual should access hospice services through the MCO's network of providers. (F) If the individual is enrolled in a home and community based services (HCBS) waiver, the designated hospice will assist the individual in coordinating concurrent care and waiver se...

... of the hospice staff. (2) The hospice provider must notify the Ohio department of medicaid (ODM) through the medicaid information technology system (MITS) or its designee of the individual's discharge from the designated hospice's care so that the designated hospice's services and billings coincide with the date of the individual's discharge and/or so that hospice services may continue with ...

...(d) Moves out of the designated hospice provider's service area; (e) Enters a facility where the designated hospice has no access or cannot enter to provide care; (f) Revokes the hospice benefit in accordance with paragraph (B) of this rule; (g) Transfers to another hospice in accordance with paragraph (E) of this rule; or (h) Is discharged for cause, such as compromising the safety of self or...

...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 department of medicaid using...

...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 department of medicaid usi...

...edicaid program upon execution of a provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code. (B) Meet the medicare guidelines in accordance with 42 C.F.R. part 418 (October 1, 2017). (C) Be licensed under Ohio law in accordance with Chapter 3712. of the Revised Code by the Ohio department of health. (D) Comply with all requirements for medicaid providers in Chapter 516...

...re and services with other medicaid providers for which the individual under age twenty-one is eligible. As a responsibility for the professional management of the individual's hospice care, the designated hospice will: (1) Ensure hospice services are maintained and coordinated with concurrent care services; (2) Document the delineation in which services and the assessment process are coordi...

...edicaid covered services that hospice providers may or must furnish to individuals to the extent specified by the individual's plan of care. (A) The designated hospice shall ensure the hospice services furnished to an individual in accordance with this rule are reasonable and necessary for the palliation and management of the terminal illness and related conditions. (B) Unless otherwise specified, c...

...edicaid covered services that hospice providers should furnish to individuals to the extent specified by the individual's plan of care. (A) The designated hospice will ensure the hospice services furnished to an individual in accordance with this rule are reasonable and necessary for the palliation and management of the terminal illness and related conditions. (B) Unless otherwise specified, covered...

...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...

...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 will 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 eff...

...(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...

...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.