(A) Medicaid will not pay for services
provided under the conditions set out in paragraph (C) of this rule, even if an
individual has been found eligible for a medical assistance category and is
enrolled in medicaid.
(B)
Definitions.
(1) "Administrative control"
exists:
(a) When a facility is an
organizational part of a governmental unit; or
(b) When a governmental unit owns
and controls the physical facilities and grounds; or
(c) When a governmental unit is
responsible for the ongoing daily activities of a facility; or
(d) When a private entity is
appointed by or contracts with a state, federal, or local governmental entity
to act as its agent to manage the incarceration or care of inmates in a prison,
jail, detention facility, or other penal facility.
(2)
(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.
(3)
(2) "Inmate of a public institution" means a person
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:
(i) He or she is
residing in a public educational or vocational training institution for
purposes of securing education or vocational training; or
(ii) He or she is 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 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 parole or probation
and living in the community.
(4)
(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.
(5) "Inpatient hospital services" is
defined in rule
5160-2-02
of the Administrative Code.
(6) "Institution for mental
diseases" (IMD) is defined in 42 C.F.R. 435.1010 (as in effect on October 1,
2015).
(7)
(4) "Intermediate care
facility for individuals with intellectual disabilities" (ICF-IID) is defined
in Chapter 5160-3 of the Administrative Code.
(8)
(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.
(9)
(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.
(10)
(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.
(11) "Public institution" means an
institution that is under the responsibility of a governmental unit or over
which a governmental unit exercises administrative control and that is not a
medical institution as defined in paragraph (B)(7) of this
rule.
(C) As required by
42 C.F.R.
435.1009 (as in effect
on October 1,
2015
2020), medicaid
will not pay for services provided to:
(1) An
individual who is an inmate of a public institution; 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
as permitted in 42 C.F.R.
438.6(e) (as in effect October 1, 2016).
:
(a)
As permitted in
42
C.F.R. 438.6(e) (as in
effect October 1, 2020); or
(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).
(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 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
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).
Notes
Ohio Admin. Code
5160:1-1-03
Effective:
7/1/2021
Five Year Review (FYR) Dates:
4/5/2021 and
07/01/2026
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