Ohio Admin. Code 5160-1-60.2 - [Effective until7/1/2022]Direct reimbursement for out-of-pocket expense incurred for medicaid covered service
(A)
For purposes of
this rule only:
(1)
"Medicaid covered service" is defined as a service that
is eligible for coverage by the Ohio medicaid program and is delivered by a
medical provider that qualifies for a medicaid provider
agreement.
(2)
"Applicant for reimbursement" is defined as:
(a)
An individual who
has been erroneously determined ineligible for the medicaid program or whose
determination was incorrectly delayed, and who is seeking reimbursement for
medical expenses incurred during the time period when the individual should
have been covered by medicaid but was not due to an error or incorrect delay
and for which the applicant paid; or
(b)
An individual who
has been erroneously charged a medicaid co-pay for a service eligible for a
co-pay in accordance with rule
5160-1-09 of the
Administrative Code, and who is seeking reimbursement of the co-pay amount
incurred during the time period when the individual should not have been
subject to a co-pay and for which the applicant paid; or.
(c)
A person not
legally obligated to pay for an individual's medical bills but who does, in
fact, contribute payment toward the individual's medical bills incurred during
the time period when the individual should have been covered by medicaid but
was not due to an error or incorrect delay as specified in paragraph (B)(3) of
this rule and for which an applicant paid.
(B)
In the
case of an erroneous determination of ineligibility or an incorrect delay in
determining eligibility, the Ohio department of medicaid (ODM) will directly
reimburse an applicant for medical expenses only if all of the following
requirements are met:
(1)
The individual was erroneously determined ineligible
for medicaid, or the individual was found to be eligible for medicaid but the
determination of eligibilty was incorrectly delayed, and the date on which the
individual received the medicaid-covered service was within the period of
coverage for which the individual should have been eligible for
medicaid.
(2)
The service was a medicaid-covered service as defined
in paragraph (A)(1) of this rule, and the service was not a nursing facility
service included in the nursing facility's per diem rate;
(3)
For an erroneous
determination of eligibility or an incorrect delay in determining eligibility,
the individual requests and receives a documented county department of job and
family services (CDJFS) determination of a CDJFS error, or a state hearing, or
administrative review, or judicial action to dispute the CDJFS' erroneous
finding of ineligibility or incorrect delay in determining
eligibility;
(4)
The applicant for reimbursement contacts the provider
and requests reimbursement, and the provider either does not agree to reimburse
the applicant or does agree to reimburse the applicant but does not do so in a
timely fashion;
(5)
Within ninety days from the date the provider does not
agree to reimburse the applicant, the applicant requests direct reimbursement
from ODM. The applicant can also request direct reimbursement from ODM if the
provider does agree to reimburse the applicant but does not do so within ninety
days of the date of the applicant's request;
(6)
Within ninety
days from the date the applicant asks ODM for direct reimbursement as described
in paragraph (B)(5) of this rule, the applicant provides the following
documentation to ODM:
(a)
Written verification of a bill from the provider which
specifies the medicaid-covered services provided;
(b)
Written
verification that the applicant paid the provider;
(c)
Any other
documentation that may be requested by ODM, including proof that the provider
did not agree to reimburse the applicant, or did agree to reimburse the
applicant but did not do so within ninety days of the request, as specified in
paragraph (B)(5) of this rule; and
(d)
The name,
address, and phone number of the provider who rendered the medicaid-covered
services to the applicant and the name of the billing provider.
(C)
In the case of an erroneous co-pay, ODM will directly
reimburse an applicant for co-pay charges only if all of the following
requirements are met:
(1)
The date of service for the co-pay charge was a date in
which the applicant for reimbursement was eligible for coverage by
ODM.
(2)
The co-pay was applied to a service eligible for a
co-pay under rule
5160-1-09 of the
Administrative Code.
(3)
The date of service for the co-pay charge was within a
date in which the applicant for reimbursement was exempt from co-pay
requirements by either rule
5160-1-09 of the
Administrative Code or
42 CFR
447.56 (January 1, 2015).
(4)
The applicant
erroneously paid the co-pay.
(5)
The applicant for
reimbursement contacts the provider and requests reimbursement, and the
provider either does not agree to reimburse the applicant or does not agree to
reimburse the applicant but does not do so in a timely fashion.
(6)
Within ninety
days from the date the provider does not agree to reimburse the applicant, the
applicant requests direct reimbursement from ODM. The applicant can also
request direct reimbursement from ODM if the provideer does agree to reimburse
the applicant but does not do so within ninety days of the date of the
applicant's request.
(7)
Within ninety days from the date the applicant asks ODM
for direct reimbursement as described in paragraph (B)(5) of this rule, the
applicant provides the following documentation to ODM:
(a)
Written
verification of a bill from the provider which specifies the medicaid-covered
services provided;
(b)
Written verification that the applicant paid the
provider;
(c)
Any other documentation that may be requested by ODM,
including proof that the provider did not agree to reimburse the applicant, or
did agree to reimburse the applicant but did not do so within ninety days of
the request, as specified in paragraph (B)(5) of this rule; and
(d)
The name,
address, and phone number of the provider who rendered the medicaid-covered
services to the applicant.
(D)
Within ninety
days of meeting the conditions specified in paragraph (B) or (C) of this rule,
ODM will process the request for reimbursement. Applicants for reimbursement
who receive an approval for reimbursement will be reimbursed either the full
documented amount of their out-of-pocket medical expenses or the co-pay charges
incurred while the individual received medical care.
(E)
The bills
identified as satisfying a person's spenddown obligation or paid to the county
to meet medicaid eligibilty are not reimbursable by the medicaid
program.
(F)
All the provisions set forth in agency 5160 of the
Administrative Code remain in effect, except that direct reimbursement by ODM
to applicants for reimbursement is permitted under the circumstances set forth
in this rule. All notice and hearing provisions set forth in division 5101:6 of
the Administrative Code apply to determinations made under this rule, and
hearing officers have authority to direct ODM to make a determination for
reimbursement in accordance with this rule.
Replaces: 5160-1- 60.2
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.01, 5164.02
Prior Effective Dates: 4/22/99
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