Ohio Admin. Code 3701-43-01 - Definitions
As used in
(A) "Adult with cystic fibrosis " means an
Ohio resident who is twenty-one or more years of age, who is diagnosed with
cystic fibrosis and who meets the financial eligibility requirements
established by rule
3701-43-16 of the Administrative
Code.
(B) "Advanced practice nurse "
means a certified registered nurse anesthetist, clinical nurse specialist,
certified nurse-midwife, or certified nurse practitioner who has met the
requirements of section
4723.41 of the Revised Code and
who holds a current valid certificate of authority issued by the board of
nursing pursuant to section
4723.42 of the Revised
Code.
(C) "Applicant " means an
individual for whom application has been made for eligibility for payment for
diagnostic, service coordination or treatment services or goods by the program
for medically handicapped children .
(D) "Diagnostic services " means services
necessary to determine whether an Ohio resident under twenty-one years of age
has a medically handicapping or potentially medically handicapping condition.
Diagnostic services include:
(1) Services
needed to establish or rule out a diagnosis that would allow the Ohio resident
to meet the medical eligibility requirements for payment for treatment goods
and services; and
(2) Services
needed to develop a plan of care for an individual.
(E) "Director " means the director of health
or an appropriately authorized employee of the Ohio department of
health.
(F) "Local health
department " or "LHD " means the official public health agency in a health
jurisdiction as defined in Chapter 3709. of the Revised Code or other agency
which contracts with the Ohio department of health to provide public health
nurse services to children with special health care needs and their families
who reside in the jurisdiction of the contracted agency.
(G) "Managing physician " means a physician
who is a provider and who:
(1) Submits, on
behalf of an applicant , a medical application for eligibility for the program ,
in accordance with rules
3701-43-11 and
3701-43-15 of the Administrative
Code, and other medical information necessary for the director to determine
whether the applicant is medically eligible for the program under rule
3701-43-17 of the Administrative
Code;
(2) Develops, in consultation
with other medical specialists or providers as needed, the individualized plan
of treatment submitted as part of the medical eligibility
application;
(3) Provides direct
medical or surgical treatment services or both to a recipient ;
(4) Refers the recipient for needed services
to other providers; and
(5)
Coordinates the provision of all services and goods for diagnostic or treatment
services identified in the recipient 's individualized plan of
treatment.
(H) "Medicaid
program " means the Ohio medical assistance program established by Title XIX of
the Social Security Act, 98 Stat. 1171 (1984),
42 U.S.C.
1396 (1984) and section
5111.20
5165.01 of the Revised Code.
(I) "Medical advisory council " means the
medically handicapped children's medical advisory council established by
section 3701.025 of the Revised
Code.
(J) "Medically eligible
condition " means a condition, congenital or acquired, that renders an applicant
or recipient medically eligible for payment for treatment goods and services by
the program for medically handicapped children , pursuant to rule
3701-43-17 of the Administrative
Code.
(K) "Medically handicapped
child " or "child with special health care needs " means an Ohio resident under
twenty-one years of age who suffers primarily from an organic disease, defect
or a congenital or acquired physically handicapping and associated condition
that may hinder the achievement of normal growth and development and who meets
the financial and medical eligibility requirements for the program for
medically handicapped children established by rules
3701-43-16 and
3701-43-17 of the Administrative
Code and the operational manual .
(L) "Medical policies " means guidelines
specifying the types and amounts of service coordination, diagnostic and
treatment goods and services that may be authorized for the appropriate
diagnosis and treatment of medically eligible conditions, as adopted by the
director and set forth in the operational manual . In adopting medical policies ,
the director may consult with the medical advisory council , one or more members
of the council or other individuals with expertise in the area.
(M) "Ohio resident " means:
(1) Any person living in the state of Ohio
with the intent to remain in Ohio indefinitely. The term "living in the state
of Ohio" shall be limited to all persons whose primary domicile is located
within Ohio. Intent to remain indefinitely is established through a showing
that a person has significant contacts with the state of Ohio as evidenced by
indicia thereof, such as maintaining a bank account in Ohio, registering to
vote in the state, paying Ohio income taxes, obtaining permanent employment
within the state, owning real estate within the state, or possessing an Ohio
driver's license or similar permits;
(2) Any person who is present in the state of
Ohio for the purpose of performing migrant agricultural labor and who evidenced
a pattern of regularly returning to Ohio to perform such work or who expresses
an intention to establish a pattern of regularly returning to perform such
work. Migrant agricultural labor is defined as agricultural work of a seasonal
or temporary nature which requires that the worker be away from their permanent
place of residence to perform said work overnight. A pattern of regularly
returning to the state to perform such work shall be considered to have been
established if a person is present in Ohio to perform migrant agricultural work
for two successive growing seasons; or
(3) Any person who is an active duty member
of the United States military and on official military assignment within the
state of Ohio, whether or not they maintain residence in another state, or any
person who is an active duty member of the United States military on official
military assignment in another state or country who pays Ohio income
taxes.
(N) "Operational
manual " means the manual of operational procedures, medical policies and
guidelines for the program for medically handicapped children developed
pursuant to division (B) of section
3701.021 of the Revised
Code.
(O) "Program for medically
handicapped children " or "program " means the program established by sections
3701.021 to
3701.028 of the Revised Code for
payment of expenses for:
(1) Diagnostic
services , as defined in paragraph (D) of this rule, provided to eligible
individuals;
(2) Treatment services
and goods, as defined in paragraph (V) of this rule, provided to medically
handicapped children and to adult cystic fibrosis patients; and
(3) Service coordination services as defined
in paragraph (S) of this rule.
(P) "Provider " means a health professional,
hospital , medical equipment supplier and any individual, group or agency that
is approved by the department of health pursuant to division (C) of section
3701.023 of the Revised Code and
rule 3701-43-02 of the Administrative
Code and that provides or intends to provide goods or services to an applicant
or recipient .
(Q) "Public health
nurse services " or "phn services " means activities conducted by registered
nurses employed or contracted by local health departments as defined in
paragraph (F) of this rule or registered nurses contracted by the Ohio
department of health:
(1) That promote the
identification of needs and planning for, facilitating, conducting and
evaluating interventions for children with special health care needs and their
families;
(2) Collaborates with
other child serving agencies and advocates for local systems to address the
needs of special populations in the community.
(R) "Recipient " means a medically handicapped
child or an adult with cystic fibrosis who has been notified of eligibility for
payment for diagnostic, service coordination and treatment services or goods
under this chapter of the Administrative Code.
(S) "Service coordination services " means
case management services provided to medically handicapped children that
promote effective and efficient organization and utilization of public and
private resources and ensure that care rendered is family-centered,
community-based, and coordinated.
(T) "Service coordinator " means a health
professional approved by the department of health pursuant to division (C) of
section 3701.023 of the Revised Code and
rule 3701-43-13 of the Administrative
Code and who provides or works to provide service coordination services to an
applicant or recipient .
(U)
"Standards of care " means criteria for the appropriate treatment or management
of a medically eligible condition that have been adopted by the medical
advisory council and are contained in the operational manual .
(V) "Third-party benefits " means any and all
benefits paid by a third party to or on behalf of a recipient or recipient 's
parent, guardian or other legal representative for treatment services or goods
that are authorized by the director pursuant to division (B) or (D) of section
3701.023 of the Revised Code.
Third-party benefits include, but are not limited to, benefits paid by private
or governmental entities or pursuant to a plan of insurance.
(W) "Third-party payor " means any insurer or
other third party payor licensed by the Ohio superintendent of insurance, any
payor under any individual or group contract, and any other governmental
payor.
(X) "Treatment services or
goods " means medical, surgical or ancillary health care services or related
goods that correct a medically eligible condition , improve functioning or
prevent potential disabilities in an individual with such a condition or
mitigate the effect of the condition. Treatment services do not include:
(1) Experimental or investigational services
that are not effective and proven treatments for the conditions for which they
are being used or are to be used; or
(2) Cosmetic services.
Whether services or goods meet the definition established by
paragraph (X) of this rule shall be determined by the
Notes
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021, 3701022, 3701.023, 3701.024, 3701.025, 3701.026, 3701.027, 3701.028
Prior Effective Dates: 1/2/1989, 12/1/01, 1/29/07, 9/1/08
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