2006 Ohio Revised Code - 5111. Medicaid Program.

• 5111.01. Eligibility for medical program; rules establishing standards, procedures and other requirements.
• · · · [5111.01.1] 5111.011.Rules establishing eligibility requirements for medicaid program.
• · · · [5111.01.2] 5111.012.County department to determine eligibility for assistance.
• · · · [5111.01.3] 5111.013.Healthy start program applications.
• · · · [5111.01.4] 5111.014.Medicaid plan amendment making pregnant individual eligible.
• · · · [5111.01.5] 5111.015.Effect of tuition trust authority contract or scholarship.
• · · · [5111.01.6] 5111.016.Dissemination of information concerning healthcheck.
• · · · [5111.01.7] 5111.017.[Repealed]
• · · · [5111.01.8] 5111.018.Inpatient and follow-up care minimums for mother and newborn; prohibitions.
• · · · [5111.01.9] 5111.019.Eligibility of parent residing with child.
• · · · [5111.01.10] 5111.0110.Breast and cervical cancer prevention and treatment act.
• · · · [5111.01.11] 5111.0111.Eligibility of recipient of independent living services.
• · · · [5111.01.12] 5111.0112.Copayment program.
• · · · [5111.01.13] 5111.0113.Eligibility of children in custody of agency or in subsidized adoption for Medicaid.
• · · · [5111.01.14] 5111.0114.Multiple-state drug purchasing program.
• · · · [5111.01.15] 5111.0115.Assistance to former Ohio works first participant ineligible due to employment.
• · · · [5111.01.16] 5111.0116.Ineligibility of institutionalized individual based on disposing of assets for less than fair market value.
• · · · [5111.01.17] 5111.0117.When real property ceases to be considered principal place of residence.
• · · · [5111.01.18] 5111.0118.Ineligibility due to substantial home equity.
• 5111.02. Rules establishing amount, duration, and scope of medicaid services; procedures for enforcement.
• · · · [5111.02.1] 5111.021.Reimbursement of providers; deduction of amounts owed to state; final fiscal audits.
• · · · [5111.02.2] 5111.022.State's lien for amount owed by provider; cancellation of claim.
• · · · [5111.02.3] 5111.023.Mental health services to be included in state plan.
• · · · [5111.02.4] 5111.024.Provisions for screening mammography and cytologic screening for cervical cancer.
• · · · [5111.02.5] 5111.025.Manner of paying for community mental health services and alcohol and drug addiction services.
• · · · [5111.02.7] 5111.027.Reimbursement for erectile dysfunction drugs prohibited.
• 5111.03. Offenses by providers; penalties; termination of agreement.
• 5111.04. Outpatient health facilities.
• · · · [5111.04.1] 5111.041.[Repealed]
• · · · [5111.04.2] 5111.042.Actions affecting services for recipient with mental retardation or developmental disability.
• 5111.05. Contracts for examination, processing, and determination of medical assistance claims.
• 5111.06. Department to act by adjudication order; appeals; exceptions; withholding payment.
• · · · [5111.06.1] 5111.061.Recovery of medicaid overpayments.
• · · · [5111.06.2] 5111.062.Final medicaid orders when hearing is not requested.
• 5111.07. Survey of retail pharmacies to determine maximum dispensing fee.
• · · · [5111.07.1] 5111.071.Dispensing fee for pharmacist-providers.
• 5111.08. Outpatient drug use review program.
• · · · [5111.08.1] 5111.081.Supplemental drug rebate program.
• · · · [5111.08.2] 5111.082.State maximum allowable cost program for medicaid drug reimbursement.
• · · · [5111.08.3] 5111.083.Medicaid e-prescribing system.
• · · · [5111.08.4] 5111.084.Pharmacy and therapeutics committee.
• · · · [5111.08.5] 5111.085.Renumbered.
• 5111.09. Annual report on meeting needs of low-income pregnant women, infants and children.
• · · · [5111.09.1] 5111.091.Quarterly reports on controlling cost increases.
• 5111.10. Reviews of medicaid program; corrective action plan; sanctions.
• · · · [5111.10.1] 5111.101.Fraud, waste, and abuse prevention and detection.
• 5111.11. Estate recovery program.
• · · · [5111.11.1] 5111.111.Medicaid estate recovery liens.
• · · · [5111.11.2] 5111.112.Attorney general may contract for collection of amounts due under estate recovery program.
• · · · [5111.11.3] 5111.113.Duty of adult care facility or home to transfer decedent's personal needs allowance account.
• · · · [5111.11.4] 5111.114.Deduction of personal needs allowance from recipient's income.
• 5111.12. Action to recover benefits incorrectly paid.
• · · · [5111.12.1] 5111.121.Recovery of cost of health care provided to child.
• 5111.13. Enrollment in group health plan.
• 5111.14. Case management of nonemergency transportation services; federal reimbursement.
• 5111.15. Effective until 1-1-07.
• 5111.15. Effective 1-1-07.
• · · · [5111.15.1] 5111.151.Effective until 1-1-07.
• · · · [5111.15.1] 5111.151.Effective 1-1-07.
• 5111.16. Care management system.
• · · · [5111.16.1] 5111.161.Care management working group.
• · · · [5111.16.2] 5111.162.Care management reimbursement rates for noncontracting providers.
• · · · [5111.16.3] 5111.163.Emergency services by noncontracting providers.
• 5111.17. Contracts with managed care organizations; financial incentive program.
• · · · [5111.17.1] 5111.171.Financial incentive awards; health care compliance fund.
• · · · [5111.17.2] 5111.172.Prescription drug coverage.
• · · · [5111.17.3] 5111.173.Appointment of temporary manager for managed care organization.
• · · · [5111.17.4] 5111.174.Disenrollment of recipients.
• · · · [5111.17.5] 5111.175.Records for each hospital concerning costs of providing services and other utilization data.
• · · · [5111.17.6] 5111.176.Franchise permit fee paid by medicaid health insuring corporations.
• · · · [5111.17.7] 5111.177.Grievance process for recipients.
• · · · [5111.17.8] 5111.178.Prompt payment requirements for health insuring corporations covering medicaid recipients.
• 5111.18. Qualified state long-term care insurance partnership program.
• · · · [5111.18.1] 5111.181.Life insurance policies on recipients.
• 5111.19. Graduate medical education costs.
• · · · [5111.19.1] 5111.191.Denial of payment for direct graduate medical education costs.

Nursing Facilities and Intermediate Care Facilities for Mentally Retarded.

• 5111.20. Definitions.
• · · · [5111.20.1] 5111.201.Reference to or designation of particular type of facility.
• · · · [5111.20.2] 5111.202.Conditions for admission of mentally ill person to nursing facility.
• · · · [5111.20.3] 5111.203.Hearing on adverse determination on need for nursing facility services.
• · · · [5111.20.4] 5111.204.Assessment of whether recipient needs level of care provided by nursing facility.
• · · · [5111.20.5] 5111.205.[Repealed]
• 5111.21. Operator's duties to be eligible for medicaid payments.
• · · · [5111.21.1] 5111.211.Responsibility of mental retardation and developmental disabilities department for nonfederal share of claims.
• 5111.22. Required provisions of provider agreements; term; renewal; department's discretion to avoid agreement.
• · · · [5111.22.1] 5111.221.Time table for calculating rates and making payments; adjustments.
• · · · [5111.22.2] 5111.222.Amount of payments to provider; adjustments.
• · · · [5111.22.3] 5111.223.Provider agreements covering multiple facilities.
• 5111.23. Payment of per resident per day rate for direct care costs to eligible nursing facilities and intermediate care facilities for mentally retarded.
• · · · [5111.23.1] 5111.231.Determination of cost per case-mix unit for each peer group.
• · · · [5111.23.2] 5111.232.Determination of case-mix scores for each facility.
• · · · [5111.23.5] 5111.235.Per resident per day rate for other protected costs.
• 5111.24. Per resident per day rate ancillary and support costs; determination of rate for each peer group.
• · · · [5111.24.1] 5111.241.Per resident per day rate for indirect care costs of intermediate care facility; inflation adjustments.
• · · · [5111.24.2] 5111.242.Per resident per day rate for tax costs.
• · · · [5111.24.3] 5111.243.Per resident per day rate for franchise permit fees.
• · · · [5111.24.4] 5111.244.Quality incentive payments.
• 5111.25. Per resident per day rate for capital costs of nursing facility.
• · · · [5111.25.1] 5111.251.Per resident per day rate for reasonable capital costs of intermediate care facility.
• · · · [5111.25.2] 5111.252.Renumbered.
• · · · [5111.25.4] 5111.254.Initial rates for new or replacement facility or newly certified facility.
• · · · [5111.25.5] 5111.255.Initial rates for facilities licensed on or after 1-1-93; relocated or replaced beds at existing facility.
• · · · [5111.25.7] 5111.257.Rate for added, replaced, or renovated bed.
• · · · [5111.25.8] 5111.258.Methodology for calculating prospective rates for facilities with residents whose care costs are not otherwise adequately measured.
• 5111.26. Annual cost report for each facility; report by new provider.
• · · · [5111.26.1] 5111.261.Only limit on specific categories of costs to be on compensation of owners, their relatives, administrators, and resident meals outside facility.
• · · · [5111.26.2] 5111.262.[Repealed]
• · · · [5111.26.3] 5111.263.Claims for covered therapy services; services provided by nurses or nurse aides.
• · · · [5111.26.4] 5111.264.Pass-through of related party costs.
• · · · [5111.26.5] 5111.265.Amortization cost concerning relocated beds not allowable cost.
• · · · [5111.26.6] 5111.266.Franchise permit fee reported as nonreimbursable expense.
• 5111.27. Desk review of cost report; preliminary determination; audits; exception reviews of assessment information; withholding of payments; rate adjustments.
• 5111.28. Operators required to refund certain payments; interest, penalties; rate adjustments.
• 5111.29. Process by which facility may seek reconsideration of rate; appeals from adverse actions.
• · · · [5111.29.1] 5111.291.Computation of rates according to reasonable cost principles.
• 5111.30. Termination of agreement for non-compliance with fire protection duties.
• 5111.31. Agreement to prohibit certain discriminatory actions.
• 5111.32. Patient's cause of action against provider for breach of agreement or other duties.
• 5111.33. Payments to reserve bed during temporary absence of resident.
• 5111.34. Report on recommendations for transitioning provider payments from one fiscal year to next.
• · · · [5111.34.1] 5111.341.[Repealed]

Nursing Facility Deficiencies.

• 5111.35. Definitions.
• 5111.36. Rules for administration and enforcement.
• 5111.37. Department may enforce provisions directly or through contracting agencies.
• 5111.38. Contracts with other state agencies.
• 5111.39. Surveys of every nursing facility.
• 5111.40. Survey team to conduct exit interview.
• 5111.41. Determination of whether actions, practices, situations or incidents can be justified; declaration and citing of findings.
• · · · [5111.41.1] 5111.411.Use of results of survey.
• 5111.42. Statement of deficiencies; notice of possible issuance of order denying payment or terminating facility's participation.
• 5111.43. Facility to submit plan of correction for each finding cited.
• 5111.44. On-site monitoring of nursing facility; qualifications of monitors.
• 5111.45. Conditions for continuing participation where certain deficiencies not corrected; order of termination.
• 5111.46. Remedies for uncorrected deficiencies constituting severity level four findings; termination order.
• 5111.47. Remedies for uncorrected deficiencies constituting severity level three and scope level three or four findings.
• 5111.48. Remedies for uncorrected deficiencies constituting severity level one or two or severity level three, scope level two finding.
• 5111.49. Considerations in imposing remedies and fines; statement provided to facility.
• 5111.50. Fine collected if termination order does not take effect.
• 5111.51. Remedies where emergency exists.
• 5111.52. Procedure for terminating provider agreements; payments after termination.
• 5111.53. Transfer of residents when facility is closed; appointment of temporary manager or special master.
• 5111.54. Qualifications, compensation and powers of temporary manager or special master; warning notice prior to action; termination of court's jurisdiction.
• 5111.55. Residents to whom denial of medicaid payments applies; effective date; restrictions on new admissions; notice of correction of deficiency; follow-up survey; publication of orders.
• 5111.56. Amount and number of fines; effect of correction of deficiency; interest; means of collection.
• 5111.57. Order denying payment when deficiency is not corrected within 90 days or after three consecutive findings of substandard care.
• 5111.58. Termination of participation for failure to correct deficiency within six months; repayment of interim payments.
• 5111.59. Delivery or mailing of notice, statement or order.
• 5111.60. Remedies subject to appeal under RC Chapter 119.
• 5111.61. Confidentiality of information; false complaints.
• 5111.62. Deposit of fines in residents protection fund.
• 5111.63. Hearing on transfer or discharge of resident.

Change of Operator, Facility Closure, Voluntary Termination, Voluntary Withdrawal of Participation.

• 5111.65. Definitions.
• · · · [5111.65.1] 5111.651.Exception for actions before October 1, 2005.
• 5111.66. Prior written notice of certain planned actions.
• · · · [5111.66.1] 5111.661.Compliance with federal law on voluntary withdrawal.
• 5111.67. Notice of change of operator where entering operator seeks to continue facility's participation.
• · · · [5111.67.1] 5111.671.Requirements for entering into agreement with entering operator immediately upon change of operator.
• · · · [5111.67.2] 5111.672.Determination of different effective date of agreement with entering operator.
• · · · [5111.67.3] 5111.673.Duties of entering operator.
• · · · [5111.67.4] 5111.674.Exiting operator considered to be operator until effective date of new agreement.
• · · · [5111.67.5] 5111.675.Agreement where entering operator does not agree to all terms and conditions of exiting operator's agreement.
• · · · [5111.67.6] 5111.676.Rate adjustment following change of operator.
• · · · [5111.67.7] 5111.677.Determinations unaffected by licensing determinations by other departments.
• 5111.68. Determination of overpayments and other actual or potential debts exiting operator may owe.
• · · · [5111.68.1] 5111.681.Withholding from payment due to exiting operator.
• · · · [5111.68.2] 5111.682.Exiting operator to file cost report.
• · · · [5111.68.3] 5111.683.Sanctions for failing to file complying cost report.
• · · · [5111.68.4] 5111.684.Final payment prohibited until cost reports received.
• · · · [5111.68.5] 5111.685.Determination of actual debt owed by exiting operator; debt summary report.
• · · · [5111.68.6] 5111.686.Time frames for release of amount withheld.
• · · · [5111.68.7] 5111.687.Release of withholding where action is postponed or canceled.
• · · · [5111.68.8] 5111.688.Rules.
• 5111.74-5111.77 Repealed.
• · · · [5111.77.1] 5111.771.[Repealed]
• 5111.78-5111.80 Repealed.
• 5111.81. Renumbered.
• · · · [5111.81.1] 5111.811.[Repealed]
• 5111.82. [Repealed]
• 5111.85. Rules governing medicaid waiver components.

General Requirements for Home and Community-Based Services Waivers.

• · · · [5111.85.1] 5111.851.Requirements applicable to home and community-based services medicaid waiver components.
• · · · [5111.85.2] 5111.852.Review, approval, modification, or denial of written plans of care and individual service plans.
• · · · [5111.85.3] 5111.853.Financial records documenting costs of services.
• · · · [5111.85.4] 5111.854.Agency financially accountable for funds expended.
• · · · [5111.85.5] 5111.855.State agencies and political subdivisions to provide written assurance of compliance.
• · · · [5111.85.6] 5111.856.Transfer of individual enrolled in medicaid waiver component.
• 5111.86. Requests for federal approval of medicaid waiver programs concerning home and community-based services.
• 5111.87. Medicaid waivers for individuals with autism or developmental delays or disabilities.
• · · · [5111.87.1] 5111.871.Home and community-based services under department of MR/DD.
• · · · [5111.87.2] 5111.872.Allocation of enrollment numbers to county boards.
• · · · [5111.87.3] 5111.873.Statewide fee schedules for home and community-based services.

ICF/MR Conversion Pilot Program.

• 5111.88. Definitions; application for waiver authorizing program, amendment to state medicaid plan.
• · · · [5111.88.1] 5111.881.ICF/MR conversion advisory council.
• · · · [5111.88.2] 5111.882.Implementation of program; adjustments.
• · · · [5111.88.3] 5111.883.Individual service plan.
• · · · [5111.88.4] 5111.884.Participant's right to choose provider.
• · · · [5111.88.5] 5111.885.Participant's right to state hearing.
• · · · [5111.88.6] 5111.886.Conversion of facilities prohibited.
• · · · [5111.88.7] 5111.887.Assignment of day-to-day administration of program to department of MR/DD; transfer of funds.
• · · · [5111.88.8] 5111.888.Rules.
• · · · [5111.88.9] 5111.889.Evaluation of program; reports.
• · · · [5111.88.10] 5111.8810.Authorization of statewide implementation.
• · · · [5111.88.11] 5111.8811.Reconversion of facility after program terminates.
• · · · [5111.88.12] 5111.8812.Department of MR/DD to be responsible for portion of nonfederal share of expenditures.
• · · · [5111.88.13] 5111.8813.Partial conversion of facility.
• · · · [5111.88.14] 5111.8814.License as residential facility or certification to provide supported living.
• · · · [5111.88.15] 5111.8815.Notice of resident's enrollment in conversion pilot program; reduction in licensed capacity.
• · · · [5111.88.16] 5111.8816.Notice of number of beds converted; reduction in certified capacity.
• · · · [5111.88.17] 5111.8817.Amendment or termination of provider agreement.

Assisted Living Program.

• 5111.89. Definitions; request for waiver needed to implement assisted living program; department of aging to administer program; rules.
• · · · [5111.89.1] 5111.891.Eligibility for program.
• · · · [5111.89.2] 5111.892.Facility staffing requirements.
• · · · [5111.89.3] 5111.893.Evaluation of cost effectiveness.
• 5111.90. Contracts with subdivisions to pay nonfederal share.
• 5111.91. Contracts for administration of components; medicaid administrative reimbursement fund.
• · · · [5111.91.1] 5111.911.Contracts subject to approval of director of budget and management.
• · · · [5111.91.2] 5111.912.Payment of nonfederal share under contract with mental health department.
• · · · [5111.91.3] 5111.913.Payment of nonfederal share under contract with alcohol and drug addiction services department.
• · · · [5111.91.4] 5111.914.Recovery of medicaid overpayments by other state agencies.
• · · · [5111.91.5] 5111.915.Medicaid data system.
• 5111.92. Department may retain or collect percentage of federal financial participation.
• 5111.93. Retention or collection of percentage of supplemental payment.
• 5111.94. Health care services administration fund.
• · · · [5111.94.1] 5111.941.Medicaid revenue and collections fund.
• · · · [5111.94.2] 5111.942.Prescription drug rebates fund.
• · · · [5111.94.3] 5111.943.Health care - federal fund.
• 5111.95. Criminal records check of applicant for employment in providing home and community-based waiver services to persons with disabilities; ineligibility due to certain convictions; application to current employees.
• 5111.96. Criminal records check of independent provider; ineligibility due to certain convictions.
• 5111.97. Access success project to help recipients make the transition from a nursing facility to residing in a community setting.
• · · · [5111.97.1] 5111.971.Medicaid voucher pilot program.
• 5111.98. Department's duties under medicare prescription drug, improvement, and modernization act of 2003.
• 5111.99. Penalties.