(A)
Purpose
This rule identifies covered services
generally available to individuals who are eligible for medicaid and describes
the relationship of such services to those provided to residents of an
intermediate care facility for individuals with intellectual disabilities
(ICFIID) other than a department-operated ICFIID. Reimbursement of services
through the "ICFIID cost report mechanism" referenced in this rule is governed
by rule 5123-7-12 of the Administrative
Code.
(B)
Dental services
All covered dental services provided by
licensed dentists are reimbursed directly to the provider of the dental
services in accordance with Chapter 5160-5 of the Administrative Code. Personal
hygiene services provided by staff or contracted personnel of the ICFIID are
reimbursed through the ICFIID cost report mechanism.
(C)
Laboratory and
x-ray services
Costs incurred for the purchase and
administration of tuberculin tests, and for drawing specimens and forwarding
specimens to a laboratory, are reimbursed through the ICFIID cost report
mechanism. All laboratory and x-ray procedures covered under the medicaid
program are reimbursed directly to the laboratory or x-ray provider in
accordance with Chapter 5160-11 of the Administrative Code.
(D)
Medical supplier services
(1)
Medical supplier
services that are reimbursed through the ICFIID cost report mechanism
include:
(a)
Costs incurred for "needed medical and program supplies,"
defined as items that have a very limited life expectancy. Such items include
atomizers, nebulizers, bed pans, catheters, electric pads, hypodermic needles,
syringes, incontinence pads, splints, and disposable ventilator
circuits.
(b)
Costs incurred for the purchase and repair of "needed
medical equipment," defined as items that can stand repeated use, are primarily
and customarily used to serve a medical purpose, are not useful to a person in
the absence of illness or injury, and are appropriate for use in the ICFIID.
Such items include hospital beds, wheelchairs, and intermittent
positive-pressure breathing machines, except as noted in paragraph (D)(2) of
this rule.
(c)
Costs of equipment associated with oxygen
administration such as carts, regulators, humidifiers, cannulas, masks, and
demurrage.
(2)
Medical supplier services that are reimbursed directly
to the medical supplier provider in accordance with Chapter 5160-10 of the
Administrative Code include:
(a)
Certain durable medical equipment items, specifically,
ventilators and custom-made wheelchairs that have parts which are actually
molded to fit the resident.
(b)
"Prostheses,"
defined as devices that replace all or part of a body organ to prevent or
correct physical deformity or malfunction. Such devices include artificial arms
or legs, electro-larynxes, and breast prostheses.
(c)
"Orthoses,"
defined as devices that assist in correcting or strengthening a distorted part.
Such devices include arm braces, hearing aids and batteries, abdominal binders,
and corsets.
(d)
Contents of oxygen cylinders or tanks including liquid
oxygen, except emergency stand-by oxygen which is reimbursed through the ICFIID
cost report mechanism.
(e)
Oxygen-producing machines (concentrators) for specific
use by an individual resident.
(E)
Pharmaceuticals
(1)
Over-the-counter drugs covered in accordance with rule
5160-9-03 of the Administrative
Code and nutritional supplements are reimbursed through the ICFIID cost report
mechanism.
(2)
Pharmaceuticals reimbursed directly to the pharmacy
provider are subject to the limitations in Chapter 5160-9 of the Administrative
Code, the limitations established by the Ohio state board of pharmacy, and the
following conditions:
(a)
When new prescriptions are necessary following
expiration of the last refill, the new prescription may be ordered only after
the physician examines the resident.
(b)
A copy of all
records regarding prescribed drugs for a resident of an ICFIID will be retained
by the dispensing pharmacy for at least six years. A receipt for drugs
delivered to an ICFIID will be signed by a representative of the ICFIID at the
time of delivery and a copy retained by the pharmacy.
(F)
Therapy services
(1)
Costs incurred
for physical therapy, occupational therapy, speech therapy, and audiology
services provided by licensed therapists or therapy assistants that are covered
for residents of an ICFIID by medicaid are reimbursed through the ICFIID cost
report mechanism.
(2)
Costs incurred for psychology services provided by
licensed psychologists or psychology assistants that are covered for residents
of an ICFIID by medicaid are reimbursed through the ICFIID cost report
mechanism. No reimbursement for psychology services will be made to a provider
other than the ICFIID or a community mental health center certified by the Ohio
department of mental health and addiction services. Services provided by an
employee of the community mental health center will be billed directly to
medicaid by the community mental health center.
(3)
Costs incurred
for respiratory therapy services provided by licensed respiratory care
professionals that are covered for residents of an ICFIID by medicaid are
reimbursed through the ICFIID cost report mechanism. No reimbursement for
respiratory therapy services will be made to a provider other than the
ICFIID.
(4)
Reasonable costs for rehabilitative, restorative, or
maintenance therapy services rendered to residents of an ICFIID by staff or
contracted personnel of the ICFIID and the overhead costs to support the
provision of such services are reimbursed through the ICFIID cost report
mechanism.
(G)
Physician services
(1)
A physician may
be directly reimbursed for providing the following services to a resident of an
ICFIID:
(a)
All
covered diagnostic and treatment services in accordance with Chapter 5160-4 of
the Administrative Code.
(b)
All medically necessary physician visits in accordance
with rule
5160-4-06 of the Administrative
Code.
(c)
All required physician visits as described in this rule
when the services are billed in accordance with rule
5160-4-06 of the Administrative
Code.
(i)
Physician visits provided to a resident of an ICFIID are
considered timely if they occur no later than ten calendar days after the date
the visit was requested.
(ii)
For reimbursement of the required physician visits, the
physician shall:
(a)
Review the resident's total program of care including
medications and treatments at each visit required by this rule;
(b)
Write, sign, and
date progress notes at each visit;
(c)
Sign all orders;
and
(d)
Personally visit the resident except as provided in
paragraph (G)(1)(c)(iii) of this rule.
(iii)
At the option
of the physician, required visits after the initial visit may be delegated in
accordance with paragraph (G)(1)(c)(iv) of this rule and alternate between
physician and visits by a physician assistant or certified nurse
practitioner.
(iv)
A physician may delegate tasks to a physician assistant
(in accordance with Chapter 4730. of the Revised Code and Chapter 4730-1 of the
Administrative Code) or a certified nurse practitioner (in accordance with
Chapter 4723. of the Revised Code and Chapter 4723-4 of the Administrative
Code) provided the physician assistant or certified nurse practitioner is
acting within the scope of practice and is under supervision and employment of
the billing physician. A physician will not delegate a task when regulations
specify that the physician must perform it personally or when delegation is
prohibited by state law or the ICFIID's policies.
(2)
Services directly reimbursed to the physician will be:
(a)
Based on medical
necessity, as defined in rule
5160-1-01 of the Administrative
Code, and requested by the resident of the ICFIID with the exception of the
required visits described in paragraph (G)(1)(c) of this rule.
(b)
Documented by
entries in the resident's medical record along with any symptoms and findings
that are signed and dated by the physician.
(3)
Services provided
in the capacity of overall medical direction are reimbursed only to an ICFIID
and will not be directly reimbursed to a physician.
(H)
Podiatry
services
Covered services provided by licensed
podiatrists are reimbursed directly to the authorized podiatric provider in
accordance with Chapter 5160-7 of the Administrative Code.
(I)
Transportation services
Costs incurred by the ICFIID for
transporting residents by means other than covered ambulance or ambulette
services are reimbursed through the ICFIID cost report mechanism. Payment is
made directly to authorized providers for covered ambulance and ambulette
services as set forth in Chapter 5160-15 of the Administrative
Code.
(J)
Vision care services
All covered vision care services,
including examinations, dispensing, and the fitting of eyeglasses, are
reimbursed directly to authorized vision care providers in accordance with
Chapter 5160-6 of the Administrative Code.
Replaces: 5123:2-7-11
Notes
Ohio Admin. Code
5123-7-11
Effective:
4/27/2023
Five Year Review (FYR) Dates:
04/27/2028
Promulgated
Under: 119.03
Statutory
Authority: 5123.04,
5124.03
Rule
Amplifies: 5123.04,
5124.03
Prior
Effective Dates: 01/10/2013, 07/01/2017
