Ohio Admin. Code 5160-18-01 - Freestanding birth center services

(A) Definitions.

(1) "Freestanding birth center (FBC)" is an entity defined in 42 U.S.C. 1396d(l)(3)(B) (in effect as of January 1, 2023) that is operated in conformity with rules 3701-83-33 to 3701-83-42 of the Administrative Code.

(2) "Independent practitioner" and "non-independent practitioner" have the same meaning as in rule 5160-4-02 of the Administrative Code.

(3) "Low-risk expectant mother" has the same meaning as in rule 3701-83-33 of the Administrative Code.

(B) Coverage. Payment may be made for covered services provided to a low-risk expectant mother.

(1) Facility services. A single "bundled" payment is made to an FBC for all covered obstetrical care (antepartum, delivery, postpartum, and newborn care services), including healthcare services listed in rule 3701-83-36 of the Administrative Code. If delivery does not occur at the FBC, payment is made for the discrete covered services.

(2) Professional services. Additional professional payment is also made to an independent practitioner, or to an FBC on behalf of either an independent practitioner or a non independent practitioner, for the performance of discrete covered services including but limited to the following examples:

(a) Antepartum services;

(b) Intrapartum services, delivery, postpartum, and newborn care services listed in rule 3701-83-36 of the Administrative Code;

(c) A covered medicine, radiology, clinical laboratory, or evaluation and management (E&M) service;

(d) The administration of a pharmaceutical;

(e) Reproductive health services (including the provision of contraceptive supplies); or

(f) The professional component of a covered service comprising both professional and technical components.

(C) Claim payment. The maximum payment for a covered item or service in the following list is established in accordance with the indicated rules of the Administrative Code:

(1) "Bundled" or discrete covered services payment made to an FBC - appendix DD to rule 5160-1-60;

(2) Professional payment:

(a) Medical or radiological service - Chapter 5160-4, for which maximum payment amounts are published in appendix DD to rule 5160-1-60;

(b) Immunization, injection or infusion (including trigger-point injection), skin substitute, or provider-administered pharmaceutical - rule 5160-4-12;

(c) Applicable durable medical equipment, prostheses, orthoses, and medical supply items - Chapter 5160-10;

(d) Laboratory service - rule 5160-11-11; or

(e) Reproductive health service - Chapter 5160-21, for which maximum payment amounts are published in appendix DD to rule 5160-1-60.

Replaces: 5160-18-01

Notes

Ohio Admin. Code 5160-18-01

Effective: 1/1/2023
Five Year Review (FYR) Dates: 01/01/2028
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02, 5164.70
Prior Effective Dates: 01/01/2012, 01/01/2018