Ohio Admin. Code 5160:1-1-03 - [Effective until 7/1/2025] Medicaid: restrictions on payment for services
(A) Medicaid will not pay for services
provided under the conditions set out in paragraph (C) of this rule, even
if
when an
individual has been found eligible for a medical assistance category and is
enrolled in medicaid.
(B)
Definitions.
(1) "Inmate" means an individual
who is serving time for a criminal offense or who is confined in a state or
federal prison, jail, detention facility, or other penal facility.
(2) "Inmate of a public institution" means
a person
an
individual who is living in a public institution as defined in rule
5160:1-1-01 of the
Administrative Code.
(a) An individual who is
residing in a public institution awaiting criminal proceedings, penal
dispositions, or other detainment determinations is considered an inmate. The
duration of time that an individual is residing in the public institution
awaiting these arrangements does not determine inmate status.
(b) An individual is not considered an inmate
if
when:
(i)
He or she is
residing
Residing in a public educational
or vocational training institution for purposes of securing education or
vocational training; or
(ii)
He or she is residing
Residing in a public institution for a temporary
period pending other living arrangements appropriate to his or her needs;
or
(iii)
He or she is residing
Residing in a detention center, jail, or county penal
facility after his or her case has been adjudicated and other living
arrangements are being decided; or
(iv)
He or she is
on
On parole or probation and living in
the community.
;
or
(v)
Serving the remainder of the criminal sentence in a
halfway house licensed as such by the Ohio department of rehabilitation and
correction (DRC), in accordance with section
2967.14 of the Revised Code,
which allows for freedom of movement and association as determined by the Ohio
department of medicaid (ODM) or its designee.
(3) "Inpatient" means a patient
who has been admitted to a medical institution as an inpatient on
recommendation of a physician or dentist and who:
(a) Receives room, board, and medical
services in the institution for a twenty-four hour period or longer;
or
(b) Is expected by the
institution to receive room, board, and medical services in the institution for
a twenty-four-hour period or longer even though it later develops that the
patient dies, is discharged, or is transferred to another facility and does not
actually stay in the institution for twenty-four hours.
(4) "Intermediate care facility for
individuals with intellectual disabilities" (ICF-IID) is defined in Chapter
5160-3 of the Administrative Code.
(5) "Medical institution" means an
institution that:
(a) Is organized to provide
medical care, including nursing and convalescent care; and
(b) Has the necessary professional personnel,
equipment, and facilities to manage the medical, nursing, and other health
needs of patients on a continuing basis in accordance with accepted standards;
and
(c) Is authorized under state
law to provide medical care; and
(d) Is staffed by professional personnel who
are responsible to the institution for professional medical and nursing
services. The services must include:
(i)
Adequate and continual medical care and supervision by a physician;
and
(ii) Registered nurse or
licensed practical nurse supervision and services and nurses' aid services,
sufficient to meet nursing care needs; and
(iii) A physician's guidance regarding the
professional aspects of operating the institution.
(6) "Outpatient" means a patient
of an organized medical facility or distinct part of that facility who is
expected by the facility to receive, and who does receive, professional
services for less than a twenty-four-hour period regardless of the hour of
admission, whether or not a bed is used, and whether or not the patient remains
in the facility past midnight.
(7)
"Patient" means an individual who is receiving needed professional services
that are directed by a licensed practitioner of the healing arts toward
maintenance, improvement, or protection of health, or lessening of illness,
disability, or pain.
(C)
As required by 42 C.F.R.
435.1009 (as in effect October 1,
2020
2023),
medicaid will not pay for services provided to:
(1) An individual who is an inmate of a
public institution, except as outlined in paragraph (D)
of this rule; or
(2) An
individual who is a patient in an institution for mental diseases (IMD), as
defined in rule
5160:1-1-01 of the
Administrative Code, who is age twenty-two or older, but under age sixty-five,
except:
(b) As permitted under a demonstration waiver
approved by the centers for medicare and medicaid services (CMS) under section
1115 of the Social Security Act (as in effect October 1,
2020
2023).
(D) An exception to the prohibition against
medicaid payment for services is permitted during the part of the month in
which an individual is not an inmate of a public institution.
(1) An individual is not an inmate of a
public institution during such time as he or
she
the individual is admitted as an
inpatient in a hospital, nursing facility, juvenile psychiatric facility, or
ICF-IID.
(2) There is no time limit
on medicaid payment for services as long as the individual continues to be
eligible for medicaid and is receiving services as an inpatient in the medical
facility.
(3) An inmate is not
considered a patient in a medical institution when:
(a) Services are provided on an outpatient
basis at a hospital, nursing facility, juvenile psychiatric facility, ICF-IID,
clinic, or physician office; or
(b)
Medical care is provided to an inmate in a prison hospital or
dispensary.
(E)
An individual on conditional release or convalescent leave from an IMD is not
considered to be a patient in that institution.
(1) An individual on conditional release is
an individual who is on definite leave from the institution, but who is not
discharged.
(2) An individual who
is released from the institution on the condition that
he or she
the
individual receives outpatient treatment or on other comparable
conditions is on conditional release.
(3) An individual who is sent home or to
another setting for a trial visit is on convalescent leave.
(F) In accordance with the
Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment
(SUPPORT) for Patients and Communities Act (Pub. L. No. 115-271 ), medical
assistance for the following individuals will be suspended, not discontinued,
when the individual becomes an inmate of a public institution on or after
October 24, 2019. Prior to the individual's release from the public institution
a redetermination of eligibility will be processed without a new application
from the individual.
(1) Individuals under the
age of twenty-one; or
(2) Former
foster care children up to the age of twenty-six as described in
42 C.F.R.
435.150(b) (as in effect
October 1, 2020
2023).
Notes
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02, 5163.45
Prior Effective Dates: 10/01/2013, 08/01/2016, 01/01/2017, 07/01/2021
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(A) Medicaid will not pay for services provided under the conditions set out in paragraph (C) of this rule, even if when an individual has been found eligible for a medical assistance category and is enrolled in medicaid.
(B) Definitions.
(1) "Inmate" means an individual who is serving time for a criminal offense or who is confined in a state or federal prison, jail, detention facility , or other penal facility .
(2) "Inmate of a public institution " means a person an individual who is living in a public institution as defined in rule 5160:1-1-01 of the Administrative Code.
(a) An individual who is residing in a public institution awaiting criminal proceedings, penal dispositions, or other detainment determinations is considered an inmate. The duration of time that an individual is residing in the public institution awaiting these arrangements does not determine inmate status.
(b) An individual is not considered an inmate if when:
(i) He or she is residing Residing in a public educational or vocational training institution for purposes of securing education or vocational training; or
(ii) He or she is residing Residing in a public institution for a temporary period pending other living arrangements appropriate to his or her needs; or
(iii) He or she is residing Residing in a detention center, jail, or county penal facility after his or her case has been adjudicated and other living arrangements are being decided; or
(iv) He or she is on On parole or probation and living in the community. ; or
(v) Serving the remainder of the criminal sentence in a halfway house licensed as such by the Ohio department of rehabilitation and correction (DRC), in accordance with section 2967.14 of the Revised Code, which allows for freedom of movement and association as determined by the Ohio department of medicaid (ODM) or its designee.
(3) "Inpatient" means a patient who has been admitted to a medical institution as an inpatient on recommendation of a physician or dentist and who:
(a) Receives room, board, and medical services in the institution for a twenty-four hour period or longer; or
(b) Is expected by the institution to receive room, board, and medical services in the institution for a twenty-four-hour period or longer even though it later develops that the patient dies, is discharged, or is transferred to another facility and does not actually stay in the institution for twenty-four hours.
(4) "Intermediate care facility for individuals with intellectual disabilities" (ICF-IID) is defined in Chapter 5160-3 of the Administrative Code.
(5) "Medical institution" means an institution that:
(a) Is organized to provide medical care, including nursing and convalescent care; and
(b) Has the necessary professional personnel, equipment, and facilities to manage the medical, nursing, and other health needs of patients on a continuing basis in accordance with accepted standards; and
(c) Is authorized under state law to provide medical care; and
(d) Is staffed by professional personnel who are responsible to the institution for professional medical and nursing services. The services must include:
(i) Adequate and continual medical care and supervision by a physician; and
(ii) Registered nurse or licensed practical nurse supervision and services and nurses' aid services, sufficient to meet nursing care needs; and
(iii) A physician's guidance regarding the professional aspects of operating the institution.
(6) "Outpatient" means a patient of an organized medical facility or distinct part of that facility who is expected by the facility to receive, and who does receive, professional services for less than a twenty-four-hour period regardless of the hour of admission, whether or not a bed is used, and whether or not the patient remains in the facility past midnight.
(7) "Patient" means an individual who is receiving needed professional services that are directed by a licensed practitioner of the healing arts toward maintenance, improvement, or protection of health, or lessening of illness, disability, or pain.
(C) As required by 42 C.F.R. 435.1009 (as in effect October 1, 2020 2023), medicaid will not pay for services provided to:
(1) An individual who is an inmate of a public institution , except as outlined in paragraph (D) of this rule; or
(2) An individual who is a patient in an institution for mental diseases (IMD), as defined in rule 5160:1-1-01 of the Administrative Code, who is age twenty-two or older, but under age sixty-five, except:
(b) As permitted under a demonstration waiver approved by the centers for medicare and medicaid services (CMS) under section 1115 of the Social Security Act (as in effect October 1, 2020 2023).
(D) An exception to the prohibition against medicaid payment for services is permitted during the part of the month in which an individual is not an inmate of a public institution .
(1) An individual is not an inmate of a public institution during such time as he or she the individual is admitted as an inpatient in a hospital, nursing facility , juvenile psychiatric facility , or ICF-IID.
(2) There is no time limit on medicaid payment for services as long as the individual continues to be eligible for medicaid and is receiving services as an inpatient in the medical facility .
(3) An inmate is not considered a patient in a medical institution when:
(a) Services are provided on an outpatient basis at a hospital, nursing facility , juvenile psychiatric facility , ICF-IID, clinic, or physician office; or
(b) Medical care is provided to an inmate in a prison hospital or dispensary.
(E) An individual on conditional release or convalescent leave from an IMD is not considered to be a patient in that institution.
(1) An individual on conditional release is an individual who is on definite leave from the institution, but who is not discharged.
(2) An individual who is released from the institution on the condition that he or she the individual receives outpatient treatment or on other comparable conditions is on conditional release.
(3) An individual who is sent home or to another setting for a trial visit is on convalescent leave.
(F) In accordance with the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (Pub. L. No. 115-271 ), medical assistance for the following individuals will be suspended , not discontinued, when the individual becomes an inmate of a public institution on or after October 24, 2019. Prior to the individual 's release from the public institution a redetermination of eligibility will be processed without a new application from the individual .
(1) Individuals under the age of twenty-one; or
(2) Former foster care children up to the age of twenty-six as described in 42 C.F.R. 435.150(b) (as in effect October 1, 2020 2023).
Notes
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02, 5163.45
Prior Effective Dates: 10/01/2013, 08/01/2016, 01/01/2017, 07/01/2021