Ohio Administrative Code Search

...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...

...This rule describes the pre-certification review program for inpatient services. Paragraph (C) of this rule is specific to the medical/surgical pre-certification program. Paragraph (D) of this rule is specific to the psychiatric pre-certification program. (A) Definitions. (1) An "emergency admission" is an admission to treat a condition requiring medical and/or surgical treatment within the next forty-eight hou...

...(A) Definitions. For purposes of this rule, the following definitions apply: (1) A "hospital" is a provider eligible under rule 5160-2-01 of the Administrative Code. (2) "Medical necessity" is as defined in rule 5160-1-01 of the Administrative Code. (3) "Pre-certification" is a process whereby the Ohio department of medicaid (ODM) or its contracted medical review entity assures that covered psychiatric services a...

...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 hospital services in rule 5160-2-01 of the Administrative Code and 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) pros...

...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) ...

...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 hospital services in rule 5160-2-01 of the Administrative Code and 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) pros...

...This rule outlines the calculation of capital payments for hospitals that are subject to the all patient refined diagnosis related groups (APR-DRG) prospective payment methodology, effective for dates of discharges occurring on or after July 1, 2017. (A) For purposes of this rule, capital costs include the categories of costs recognized by medicare on the centers for medicare and medicaid services (CMS) CMS 2552-10 ...

...This rule outlines the calculation of capital payments for hospitals that are subject to the all patient refined diagnosis related groups (APR-DRG) prospective payment methodology, effective for dates of discharges occurring on or after January 1, 2024. (A) For purposes of this rule, capital costs include the categories of costs recognized by medicare on the centers for medicare and medicaid services (...

...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...

...(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) Definitions. (1) "Reasonable assurance period" means a certain period of time, determined by the centers for medicare and medicaid services (CMS), for which a nursing facility operator whose provider agreement has been involuntarily terminated is required to operate without recurrence of the deficiencies that were the basis for termination. Participation in the medicare and medicaid programs ...

...(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) Purpose. The purpose of this rule is to set forth provisions for the preparation for, response to, and recovery from an emergency or disaster at a NF. The provisions of this rule are in addition to the requirements set forth in sections 5165.77, 5165.80, and 5165.81 of the Revised Code, and in rule 3701-17-25 of the Administrative Code. (B) Emergencies and disasters. "Emergencies and disast...

...(A) Definitions. (1) "Fines" means civil money penalties (CMPs) and other assessments imposed against a NF as a remedy for deficiencies or a cluster of deficiencies that were not substantially corrected before a survey. (2) "Interest" means the interest rate determined by the tax commissioner on the fifteenth day of October each year by rounding the federal short-term rate to the nearest who...

...(A) For the purposes of this rule, the following definitions shall apply: (1) "State survey agency" means for the purpose of medicaid certification, the Ohio department of health (ODH). (2) "Effective date of termination" means the date set by the state survey agency or the United States department of health and human services for the termination of certification. (B) When medicaid certific...

...(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 ...