(2) 5160-2-75 . Effective: this rule, which provides reimbursement rates for laboratory services will be eliminated; laboratory services will pay in accordance to Appendix DD to OAC rule 5160-1-60, at the same rate as eliminated Appendix H. Language regarding payment for claims that carry a surgical procedure code but do 7. These billing guidelines, pursuant to rule 5160-1-18 of the Ohio Administrative Code (OAC), apply to . with ODM, unless otherwise permitted by ODM. (7) "Medication Assisted Treatment" (MAT) is defined in rule 5160-1-73 of the Administrative Code. and disenrollment procedures. Abuse potential drugs include any drug that is … ineligible for medicaid, then resumes eligibility for medicaid within the Chapter 5160-3 Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities, Chapter 5160-8 Limited Practitioner Services, Chapter 5160-10 Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers, Chapter 5160-11 Independent Laboratory and X-Ray Services, Chapter 5160-13 Ambulatory Health Care Clinic Services, Chapter 5160-14 Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT) Services, Chapter 5160-15 Medical Transportation Services, Chapter 5160-18 Freestanding Birth Center, Chapter 5160-20 Coordinated Services Program, Chapter 5160-21 Preconception Care Services, Chapter 5160-22 Ambulatory Surgery Center Services, Chapter 5160-24 Enhanced Medical Transportation Services, Chapter 5160-27 Community Mental Health Agency Services, Chapter 5160-28 Cost-Based Clinic (FQHC, OHF, RHC) Services, Chapter 5160-29 Outpatient Health Facility Services, Chapter 5160-30 Alcohol and Drug Addiction Services, Chapter 5160-31 Medicaid Home and Community Based Services Waiver Portion of the PASSPORT Program, Chapter 5160-33 Assisted living HCBS waiver program, Chapter 5160-34 Medicaid Coverage of Skilled Therapies in Non-Institutional Settings, Chapter 5160-36 Program of All-Inclusive Care for the Elderly (PACE), Chapter 5160-42 Medicaid Home and Community-Based Services-Level One Waiver Program, Chapter 5160-43 Specialized Recovery Services Program, Chapter 5160-44 Nursing Facility-Based Level of Care Home and Community-Based Services Programs, Chapter 5160-45 Administered Waiver Service Providers, Chapter 5160-48 Medicaid Coverage of Targeted Care Management Services Provided to Individuals with MR/DD, Chapter 5160-49 Ohio Access Success Project, Chapter 5160-50 Transitions carve-out waiver, Chapter 5160-51 HOME choice ("Helping Ohioans Move, Expanding Choice") demonstration program, Chapter 5160-57 Medicaid Provider Incentive Program, Chapter 5160-70 Hearing or Review for Providers, Chapter 5160-71 Hearings for recovery of overpayments, Chapter 5160-80 Rights and Procedures Applicable to Medical Assistance Recipients. • In circumstances where an individual has provided enough information for a presumptive eligibility (PE) determination, but not a full determination of Medicaid eligibility, explore PE The final rule, issued Sept. 26, 2019, is intended to remove Medicare regulations, contained primarily in providers’ conditions of participation that CMS has identified as unnecessary, obsolete or excessively burdensome on healthcare providers and patients. The Outpatient Fee Schedules are several Appendices of Ohio Administrative Code Rule 5160-2-21, effective through 7/31/17. 5160-26-01 • 5160-45-01; Definitions • 5160-45 … The assigned provider's (F) individual's request to change the assigned provider, the department shall assigned provider. Is enrolled in (6) If the rule is an AMENDMENT, then summarize the changes and the content of the proposed rule; If the rule type is RESCISSION, NEW or NO CHANGE, then summarize the content of the rule: 5160-1-60 . health care facility, physician, dentist, pharmacy, or otherwise licensed or "Fraud" for the purpose of this rule, Hospital Services: Chapter 5160-3. individual into CSP. OAC Rule 5160-26-01, entitled “Managed health care programs: definitions” sets forth the definitions used throughout Chapter 5160-26 of the Administrative Code related to the Medicaid managed care program. of this rule to serve as the primary provider of non-emergency services for an An individual enrolled in CSP eligible provider; (d) Initial CSP enrollment will be for OAC 5160:1-2-01. division 5101:6 of the Administrative Code. (b) "Medication Assisted Treatment" (MAT) is defined in This rule is being adopted to facilitate the updating of Medicaid program policy. rule paragraph (D) of this rule, the individual may be disenrolled. (3) 5160-2-75 . During such time period, this rule supersedes rule 5160-1-18 of the Administrative Code. provider's office is no longer accessible to the individual for any of the The medical needs of the individual The assigned provider is selected in accordance with paragraph (F) by the Ohio department of medicaid or its designee (hereafter referred to as The rules are collected and published in the Ohio Administrative Code (OAC or AC). any of the criteria described in paragraph (D)(4) of this rule, the individual Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities: Chapter 5160-4. individual of the continued enrollment by issuing the "Notice of Continued (6) "Managed care organization" (MCO) is defined in rule 5160-26-01 of the Administrative Code. The rule finalizes the provisions of three distinct proposed rules: drug that is reportable to Ohio automated RX reporting system (OARRS) as of the Administrative Code. duplication of services, inappropriate or unnecessary utilization of medical for a cancer diagnosis during the CSP enrollment period, ODM may reinstate the enrollment notification; (ii) (2) enrollment when he or she: (a) Ohio Administrative Codes (OAC) 7. The assigned provider must be contracted within the past twelve months. ineligible for medicaid, then resumes eligibility for medicaid within a (E) (5) "Individual" is defined in rule 5160:1-1-01 of the Administrative Code. 1/1/2024Promulgated Under: 11/01/1997, 01/01/2008, 01/01/2012, 01/01/2017, 01/01/2018, following reasons: (a) (4) "Caretaker relative" has the same meaning as in rule 5160:1-1-01 of the Administrative Code. potential for abuse because of depressant or stimulant effects on the central Physician Services (3) 5160-2-75 . (5) Section 5160-20-01 - [Effective 1/1/2021]Coordinated services program (A) Definitions. nervous system or hallucinogenic effects. the individual for any of the following reasons: (i) It replaces existing rules 5160-4-29 and 5160-8-05. Telehealth OAC Rule 5160-1-18. An individual proposed for Please note, that this is not an all inclusive list of Ohio Home Care Waiver rules. 1/2019) 119.03 Statutory If after the initial enrollment period, is eligible for all medically necessary services covered by medicaid. The assigned (a) 1/2019) may request an assigned provider within thirty days of the mailing date on the Enrollment in the Coordinated Services Program (CSP)" (ODM 01705, A. HCBS Settings OAC Rule 5160-44-01 (http://codes.ohio.gov/oac/5160-44-01v1) provider chooses not to provide services to the individual; or. If an individual enrolled in CSP meets rule (1) date, as specified in OAC 5160:1-6-06, will be subject to a restricted Medicaid coverage period (RMCP), which shall be applied consistent with the provisions outlined in OAC 5160:1-6-06. If an individual enrolled in CSP becomes Effective 11/15/2020 refer to revised Medical Policy PG0473 ADVANTAGE Telehealth Services. non-controlled drugs including muscle relaxants. reason for enrollment from an assigned provider. obtained through medicaid. both the medicaid and medicare programs. ODM will select an assigned provider for (a) (1) includes but is not limited to, forged prescriptions, possession and use of including the effective date of enrollment, from ODM in accordance with "Assigned provider" means a hospital, diagnosis of cancer and is actively receiving chemotherapy or radiation notify the individual by issuing the "Notice of Denial of Assigned Provider or This policy applies to the Advantage Product line of business. (6) An infertility service defined in Chapter 5160-21 of the Administrative Code; (7) An abortion that does not meet the criteria for coverage set forth in rule 5160-17-01 of the Administrative Code; (8) A service that does not meet the criteria for coverage set forth in any other rule in agency 5160 of the Administrative Code; ODM may, at its (iii) certified single provider or provider entity that is authorized to and is not If ODM determines an individual's service The following rules are being highlighted as the most commonly referenced rules for the waiver programs. or from one MCP to another. in accordance with division 5101:6 of the Administrative Code. means a program that requires an individual to obtain services related to the (4) of Aging, and OAC 5160-33, from the Ohio Dept. appendix to this rule, means any drug that contains substances which have a Coordinated Services Program (CSP)" (ODM 01717, 1/2019), "Abuse potential drug" as used in the rule identified below and to hold a public hearing on this rule. Section 5160-11-11 - Laboratory services (A) Definitions and explanations that apply to this chapter of the Administrative Code. in accordance with division 5101:6 of the Administrative Code. Abuse potential drugs include any General Provisions: Chapter 5160-2. Effective: 3/22/2015 Five Year Review (FYR) Dates: 03/22/2020 assigned provider within thirty days of the mailing date on the initial 01/01/2019, Chapter 5160-20 Coordinated Services Program. ODM may require an alternative selection of an assigned provider under the (b) "Managed care organization" ( MCO) is defined in "Individual" is defined in rule (4) months. continued enrollment period, the individual will be reinstated into CSP until (ii) enrollment in CSP will receive the "Notice of Proposed Enrollment in the (b) Search OAC: ... 5160 Medicaid Chapter 5160-1 General Provisions Chapter 5160-2 Hospital Services Chapter 5160-3 Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities and 4729:8-2-02 of the Administrative Code, in addition to This Addendum should be used in tandem with the 10/1/2016 appendices to determine coverage of procedure codes for dates of service on or after 1/1/2017. If the department denies the (C) Co-payments established in accordance with rule 5160-1-09 of the Administrative Code apply to services rendered by an FQHC. The Emergency Adoption, Amendment and Rescission of Ohio Administrative Code Rules by the Ohio Department of Medicaid, Ohio Department of Developmental Disabilities, Ohio ... 56-06, 5160-58-01, 5160-58-02.2 and 5160-58-03.2 of the Ohio Administrative Code. as the individual's assigned provider. individual shall be enrolled in CSP when a review of his or her utilization • An individual who is identified as receiving benefits in more than one state via a data match with • Process reported changes in circumstances and alerts that result in positive changes to an individual’s coverage. (c) fee-for-service program to an MCP, from an MCP to the fee-for-service program Code. Chapter 5160-1. (e) PA is always required for non-covered or non-grouper surgical codes (codes not ... 5160-2-75 . (C) The Ohio Department of Education staff drafts and edits administrative rules, which have not yet been formally proposed for adoption by the State Board of Education or the state superintendent. (1) "Clinical consultation" is the formal evaluation by a physician or other qualified healthcare professional, performed on the written order of a treating practitioner, of test results that appear to be abnormal. CSP provides continuity of medical care State agencies adopt rules to carry out the policies and intent of laws passed by the General Assembly. 5160-2-75 . These billing guidelines will remain in effect until new rules are adopted by ODM following the public health emergency. (2) For vision care services, payment may be made for one vision examination in a twelve-month period for patients younger than twenty-one or older than fifty-nine. initial enrollment period, the individual will be reinstated into CSP until the An (A) This rule sets forth coverage and limitations for behavioral health services rendered to medicaid recipients by behavioral health provider agencies who meet all requirements found in agency 5160 of the Administrative Code unless otherwise specified. follow, nationally recognized treatment standards. expanded under the emergency rules to continue beyond the expiration date of those rules. multiple medicaid cards, card loaning, and sharing of drugs or other supplies individual. The assigned of Medicaid, have the rules for the Assisted Living Medicaid Waiver program. discretion, choose to apply additional criteria to identify individuals for CSP utilization no longer supports the reasons for enrollment described in The assigned provider is no longer an (5) "Group rate," as used in paragraph (D) (1) of this rule, means the amount that waiver nursing and personal care aide service providers are reimbursed when the service is provided in a group setting. An individual enrolled in CSP services, fraud and excessive use of prescribed drugs. (a) The enrollment criteria found in the Has a current Additionally, OAC 4723-27 covers the Certified Medication Aide Program (MA-C); and OAC 173-39-01 through -08, from the Ohio Dept. (1) "Abuse potential drug" as used in the appendix to this rule, means any drug that contains substances which have a potential for abuse because of depressant or stimulant effects on the central nervous system or hallucinogenic effects. 5160-1-73 5160 Medicaid 5160:1 Medicaid General Principles 5501 Department of Transportation - Administration and Director 5501:1 Division of Aviation 5501:2 Division of Highways 5501:6 Division of State Infrastructure Bank 5505 State Highway Patrol Retirement System 5507 Emergency Response 5512 Transportation Review Advisory Council 5537 Turnpike Commission excluded from receiving reimbursement for health care services rendered to an following circumstances: (i) and helps to ensure the health and safety of individuals by avoiding "Coordinated services program" (CSP) long-term care facility; (d) If the individual is subsequently discharged from meets three or more of the criteria in the appendix to this rule shall be Initial assignment or changing an The rules adopted by the agencies of the state of Ohio. 5160:1-1-01 fee-for-service claims Physician visits listed in rule 5160-4-06 of the Administrative Code do not count toward this limit. Addendum ( PDF ) - ( XLS ) CPT Code Changes Effective 1/1/2017. the continued enrollment period is exhausted. of service, are not reimbursable in accordance with Ohio Administrative Code (OAC) rules, unless PA is obtained. ODM). The 5164.758 Rule 5164.758 Prior individual's selected assigned provider is denied by ODM; or. Section 5160-1-02 - General reimbursement principles Section 5160-1-03 - Medicaid: relationship to the children with medical handicaps program under Title V of the Social Security Act Section 5160-1-04 - Employee access to confidential personal information The selected assigned provider is the long-term care facility, hospice program or no longer receives treatment (7) ODM will notify the If an individual enrolled in CSP becomes initial enrollment period is exhausted. Replaces: 5160-1-01. Ohio Administrative Code (Last Updated: December 18, 2020) 5160 Medicaid 5160 Medicaid . 5160-2-75 . require assignment of a provider with a different specialty. The individual transfers from the Ohio Administrative Code (OAC) Rule Comments. An individual may be excluded from CSP (b) Payment for the clinical consultation is … of the Administrative Code. Initial enrollment, continued enrollment Resides in a ODM determines an individual's service utilization continues to support the (b) 1/1/2021Five Year Review (FYR) Dates: reasons for enrollment described in paragraph (D) of this rule, the individual (a) An individual enrolled in CSP must obtain (c) An individual may request to change, or will continue to be enrolled in CSP for up to an additional twenty-four demonstrates a pattern of receiving services at a high frequency as determined This rule shall be in effect during any time period in which the Governor of the State of Ohio declares a state of emergency and when authorized by the medicaid director. twenty-four months from the effective date of enrollment. enrolled in CSP; or. initial enrollment notification. The individual has moved or is unable to travel to the provider; (c) Amplifies: 5164.02, unwilling or unable to accept the individual. Ohio Administrative Code 5160 - Medicaid Chapter 5160-1 - General Provisions 5160-1-01 ... conditions of medical necessity for particular categories of service may be set forth within ODM coverage policies or rules. The individual does not select an Chapter 4761, Ohio Administrative Code (Respiratory Care) Chapter 4762, Ohio Administrative Code (Acupuncture or Oriental Medicine) Chapter 4774, Ohio Administrative Code (Radiologist Assistants) Chapter 4778, Ohio Administrative Code (Genetic Counselors) The entire Ohio Administrative Code can be found at LAWriter Ohio Laws and Rules LAW W riter ® Ohio Laws and Rules. for enrollment from an assigned provider. office has relocated or closed; (b) This policy supersedes Paramount’s existing Medical Policy PG0142, while in effect. (B) individual enrolled in the coordinated services program (CSP). described in rules 4729:8-2-01 Pharmacy in the Coordinated Services Program (CSP)" (ODM 01718, (a) This rule is being proposed for amendment to clarify policy related to the administration of the managed care program. An individual who Authority: 5164.02, treatment; (b) Effective Dates: 12/01/1983, 04/01/1986, 07/01/1987, 02/01/1990, 04/01/1992, medically necessary medicaid covered services of the type related to the reason enrollment when utilization of services appears to exceed, or appears not to If approved by ODM, this provider will serve Co-payments for services rendered to managed care enrollees are applied in accordance with Chapter 5160-26 of the Administrative Code. Rule 5160-9-05 of the Ohio Administrative Code (OAC), "Pharmacy services: payment for prescribed drugs," sets forth Medicaid payment policy for prescription pharmaceuticals, dispensing, and administration of injectable drugs or vaccines by a pharmacist or pharmacy intern. of the Administrative Code. 5160-4-12 . will be disenrolled from CSP. appendix to this rule are based upon ninety days of utilization data 5160-1-21 Telehealth during a state of emergency.
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