Ohio Admin. Code 5160-21-05 - Nurse home visiting services

(A) Unless otherwise noted, any limitations or requirements conditions specified in the Revised Code or in agency 5160 of the Administrative Code apply to services addressed in this rule.

(B) Definitions.

(1) "Advanced practice registered nurse (APRN)" has the same meaning as in Chapter 4723-08 of the Administrative Code.

(2) "Registered nurse (RN)" has the same meaning as in Chapter 4723. of the Revised Code.

(3) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code.

(4) "Home visiting" has the same meaning as in Chapter 3701-8 of the Administrative Code.

(5) "Nurse home visiting" is home visiting provided by an APRN or RN. Within the package of home visiting services, emphasis is placed on the following services performed within the scope of the practitioner:

(a) Prenatal visits;

(b) Postpartum visits;

(c) Training in pediatric care;

(d) Nursing examinations, which focus on assessment of social determinants of health, on education, and on emotional support;

(e) Health education;

(f) Maternal depression screening; and

(g) Lactation counseling.

(C) Providers.

(1) Rendering provider. Medicaid payment may be made for a covered nurse home visiting service rendered by an eligible provider.

(2) Billing ("pay-to") provider. The following eligible providers may receive medicaid payment for submitting a claim for a covered nurse home visiting service:

(a) An ambulatory health care clinic as defined in Chapter 5160-13 of the Administrative Code;

(b) A federally qualified health center (FQHC);

(c) A rural health clinic (RHC); or

(d) A professional medical group.

(D) Coverage.

(1) Payment may be made only for a nurse home visiting service for which the following criteria are met:

(a) The service is medically necessary in accordance with rule 5160-1-01 of the Administrative Code;

(b) The service is performed at the order of a practitioner in accordance with rule 5160-1-17 of the Administrative Code;

(c)(b) The individual receiving the service has at least one of the following medically complex conditions that may put an individual at a high risk for preterm birth:

(i) Asthma;

(ii) Diabetes;

(iii) Cardiovascular disease;

(iv) Substance use disorder; or

(v) History of pre-term birth; and

(d)(c) The individual is not currently receiving another service that substantially duplicates a nurse home visiting service.

(2) No payment is made for a separate evaluation and management service in addition to a nurse home visiting service rendered by the same provider to the same individual on the same day.

(E) Claim payment.

(1) For a covered nurse home visiting service rendered by an FQHC or RHC, payment is made in accordance with Chapter 5160-28 of the Administrative Code.

(2) For a covered nurse home visiting service rendered at any other valid place of service, payment is the lesser of the provider's submitted charge or the maximum amount specified in appendix DD to rule 5160-1-60 of the Administrative Code.

Notes

Ohio Admin. Code 5160-21-05

Effective: 1/1/2024
Five Year Review (FYR) Dates: 1/1/2025
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5164.758
Rule Amplifies: 5164.02, 5164.758
Prior Effective Dates: 01/01/2022