Ohio Admin. Code 5160:1-1-03 - [Effective 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 when
an individual has been found eligible for a medical assistance category and is
enrolled in medicaid.
(B)
Definitions. For the purposes of this rule:
(1)(2) "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)(3) "Inmate of a public
institution" means an individual who is living in a public institution as
defined in rule
5160:1-1-01 of the
Administrative Code.
(3)(4)
"Inpatient" means a patient who has been admitted to a medical institution as
an inpatient on recommendation of a physician or dentist and who:
(4)(5)
"Intermediate care facility for individuals with intellectual disabilities"
(ICF-IID) is defined in Chapter 5160-3 of the Administrative Code.
(5)(6)
"Medical institution" means an institution that:
(6)(7) "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)(8) "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.
(1)
"Eligible
juvenile" means:
(a)
An individual under the age of twenty-one;
or
(b)
A former foster care child up to the age of twenty-six
as described in 42 C.F.R.
435.150(b) (as in effect
October 1, 2024).
(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
when:
(i) Residing in a public educational or
vocational training institution for purposes of securing education or
vocational training; or
(ii) Residing in a public institution for a
temporary period pending other living arrangements appropriate to his or her
needs; or
(iii) 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)
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.
(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.
(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.
(C) As required by
42 C.F.R.
435.1009 (as in effect October 1,
2023
2024),
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,
2023
2024).
(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 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
medical assistance 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 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
an eligible juvenile, as described in paragraph (B)(1) of
this rule, 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, 2023).
(G)
In accordance
with section 5121 of the Consolidated Appropriations Act, 2023 (Pub. L. No.
117-328 ), in the thirty days prior to release, any
state plan screening and diagnostic services which meet reasonable standards of
medical and dental practice, or otherwise indicated as medically necessary, and
targeted case management services are available to an eligible juvenile, as
described in paragraph (B)(1) of this rule.
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, 11/01/2023
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