Ohio Admin. Code 5160-3-64 - Nursing facilities (NFs): payment for medicare part A cost sharing

(A) For nursing facility services the nursing facility provides on or after January 1, 2012, "medicaid maximum allowable amount" means one hundred per cent of the nursing facility's medicaid rate on the date that the service was provided.

(B) For qualified medicare beneficiaries (QMB) including QMB plus as defined in rule 5101:3-1- 05.2 5160:1-3- 02.1 of the Administrative Code and medicaid consumers admitted to a nursing facility as a medicare part A benefit, the Ohio department of job and family services (ODJFS) medicaid (ODM) will pay as cost sharing for nursing facility services the lesser of:

(1) The coinsurance amount as provided by the medicare part A plan; or

(2) The medicaid maximum allowable amount for the identified service or services minus the medicare part A plan's payment to a nursing facility for the same service or services. If the medicare part A plan's payment to a nursing facility for a service or services identified is greater than the medicaid maximum allowable amount, ODJFS ODM will pay nothing for the same identified service or services.

(C) The medicaid provider is ultimately responsible for accurate and valid reporting of medicaid claims submitted for payment. Providers submitting medicare part A crossover claims to the medicaid program must be able to provide upon request documentation that supports supporting that the information provided on the claim matches the information on the part A plan's remittance advice.

Notes

Ohio Admin. Code 5160-3-64

Effective: 8/31/2017
Five Year Review (FYR) Dates: 6/15/2017 and 08/31/2022
Promulgated Under: 119.03
Statutory Authority: 5165.02
Rule Amplifies: 5165.155
Prior Effective Dates: 7/1/05, 3/19/12