Ohio Administrative Code Search

...(A) Definitions. (1) "Adverse benefit determination" is a MyCare Ohio plan (MCOP)'s: (a) Denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit; (b) Reduction, suspension, or termination of services prior to the member receiving the...

...(A) Notice of action (NOA) by a MyCare Ohio plan (MCOP). (1) When an MCOP adverse benefit determination has or will occur, the MCOP shall provide the affected member with a NOA. (2) The NOA shall explain: (a) The adverse benefit determination the MCOP has taken or intends to take; (b) The reasons for the adverse benefit determination, including the right of the member to be provided, upon ...

...(A) Notice of action (NOA) by a MyCare Ohio plan (MCOP). (1) When an MCOP adverse benefit determination has or will occur, the MCOP shall provide the affected member with a NOA. (2) The NOA shall explain: (a) The adverse benefit determination the MCOP has taken or intends to take; (b) The reasons for the adverse benefit determination, including the right of the member to be provided, upon ...

...(A) The definitions set forth in rule 5160-26-01 of the Administrative Code, with the exceptions noted in paragraphs (A)(1) and (A)(2) of this rule, apply to the Ohio resilience through integrated systems and excellence (OhioRISE) rules set forth in Chapter 5160-59 of the Administrative Code. Definitions that reference managed care organizations (MCOs) in Chapter 5160-26 of the Administrative Code...

...(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan has to adhere to all of the requirements applicable to managed care organizations (MCOs) or managed care entities (MCEs) in the following rules: (1) Rule 5160-26-05 of the Administrative Code with the exception of paragraphs (B)(4), (B)(5), (D)(21), (D)(25), and (D)(26); (2) Rule 5160-26-05.1 of the Administrat...

...(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) Scope. This rule sets forth the provisions for eligibility and enrollment into Ohio resilience through integrated systems and excellence (OhioRISE) on the first day the program is effective. Individuals that do not meet the OhioRISE first day eligibility criteria described in paragraph (B) of this rule will have the opportunity to be enrolled in OhioRISE as set forth in rule 5160-59-02 of the ...

...(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 have a utilization management (UM) program with clearly defined structures and processes designed to maximize the effectiveness of the care provided to the member. (1) The OhioRISE plan has to ensure decisions rendered through the UM program are based on medical necessity. (2) The UM program has to be based ...

...(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 medicaid coverage of intensive home-based treatment (IHBT) services. (B) Definition. IHBT is the service and activities as set forth by the Ohio department of mental health and addiction services (OhioMHAS) in rule 5122-29-28 of the Administrative Code. (C) Eligible providers of IHBT services. (1) Providers eligible for medicaid payment for IHBT will: (a) Meet ...

...(A) Scope. This rule sets forth provisions governing medicaid coverage of intensive home-based treatment (IHBT) services. (B) Definition. IHBT is the service and activities as set forth by the Ohio department of mental health and addiction services (OhioMHAS) in rule 5122-29-28 of the Administrative Code. (C) Eligible providers of IHBT services. (1) Providers eligible for medicaid payment f...

...(A) This rule sets forth provisions governing coverage for behavioral health respite services delivered as part of the Ohio resilience through integrated systems and excellence (OhioRISE) program. (B) Definitions. For this rule, the following definitions apply: (1) "Behavioral health respite services" are services that provide short-term, temporary relief to the primary caregiver of an OhioRISE plan enrolled youth,...

...(A) This rule sets forth provisions governing coverage for behavioral health respite services delivered as part of the Ohio resilience through integrated systems and excellence (OhioRISE) program. (B) Definitions. For this rule, the following definitions apply: (1) "Behavioral health respite services" are services that provide short-term, temporary relief to the primary caregiver of an OhioR...

...(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...

...(A) To be eligible for the Ohio resilience through integrated systems and excellence (OhioRISE) home and community-based services (HCBS) 1915(c) waiver (waiver), a youth will be determined by the Ohio department of medicaid (ODM) to meet all of the following: (1) Meet eligibility criteria set forth in paragraphs (A)(1) to (A)(3) of rule 5160-59-02 of the Administrative Code; (2) Be determined to meet the following ...

...(A) To be eligible for the Ohio resilience through integrated systems and excellence (OhioRISE) home and community-based services (HCBS) 1915(c) waiver (waiver), a youth will be determined by the Ohio department of medicaid (ODM) to meet all of the following: (1) Meet eligibility criteria set forth in paragraphs (A)(1) to (A)(3) of rule 5160-59-02 of the Administrative Code; (2) Be determine...

...(A) To be eligible for the Ohio resilience through integrated systems and excellence (OhioRISE) home and community-based services (HCBS) 1915(c) waiver (waiver), a youth will be determined by the Ohio department of medicaid (ODM) to meet all of the following: (1) Meet eligibility criteria set forth in paragraphs (A)(1) to (A)(3) of rule 5160-59-02 of the Administrative Code; (2) Be determined to meet the following ...

...(A) This rule establishes the services available under the Ohio resilience through integrated systems and excellence (OhioRISE) home and community-based services (HCBS) 1915(c) waiver program (waiver) established in accordance with 1915(c) of the Social Security Act 42 U.S.C. 1396n (January 1, 2022), and the providers eligible to deliver those services to youth enrolled on the waiver. (B) Providers seeking to deliv...