Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-1 - General Provisions
Section 5160-1-60.2 - Direct reimbursement for out-of-pocket expenses incurred for medicaid covered services during approved eligibility periods
Universal Citation: OH Admin Code 5160-1-60.2
Current through all regulations passed and filed through September 16, 2024
(A) For purposes of this rule:
(1)
"Applicant for reimbursement" is:
(a)
An individual who has been determined eligible for a
retroactive eligibility period in accordance with rule
5160:1-2-01 of the
Administrative Code, and who is seeking reimbursement for medical expenses for
which the individual paid for during this approved time period;
or
(b)
An individual who, as a result of an eligibility
determination or state hearing decision, now has effective dates of eligibility
and is seeking reimbursement for medical expenses for which the individual paid
during this approved time period; or
(c)
An individual who
has been erroneously charged a medicaid co-pay for services 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 individual paid; or
(d)
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 approved eligibility period.
(2)
"Effective dates
of eligibility" means the period described in rule
5160:1-2-01 of the
Administrative Code.
(3)
"Medicaid covered service" is a service or product that
meets all the following criteria:
(a)
Medically necessary in accordance with rule
5160-1-01 of the Administrative
Code;
(b)
Delivered by an eligible provider who qualifies for one
of the following:
(i)
A medicaid provider agreement as described in rule
5160-1-17.12 of the
Administrative Code; or
(ii)
An approved contract or single case agreement with a
medicaid managed care entity (MCE);
(c)
A reimbursable
medical service as defined in rule
5160-1-02 of the Administrative
Code.
(d)
A physician service as defined in Chapter 5160-4 of the
Administrative Code, or a dental service as defined in Chapter 5160-5 of the
Administrative Code.
(4)
"Payer" is the
Ohio department of medicaid (ODM), an MCE contracted with ODM, or any entity
ODM designates with the authority to issue direct
reimbursements.
(5)
"Retroactive eligibility period" means the period
described in rule
5160:1-2-01 of the
Administrative Code.
(B) For any application for reimbursement, the payer will make direct reimbursement, including applicable co-pays, in accordance with 42 C.F.R. 447.25 only if all of the following are met:
(1)
The
individual has an eligibility period as defined in paragraph (A)(2) or (A)(5)
of this rule and the date on which the individual received the medicaid covered
service was within the period of eligibility;
(2)
The service was a
medicaid covered service, and the service was not a nursing facility service
included in the nursing facility's per diem rate;
(3)
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 within ninety days;
(4)
Within ninety
days from the date the provider does not agree or fails to reimburse the
applicant, the applicant requests direct reimbursement from the appropriate
payer;
(5)
Within ninety days from the date the applicant asks the
payer for direct reimbursement described in paragraph (B)(4) of this rule, the
applicant provides the following documentation to the payer:
(a)
Written
verification of a bill from the provider which specifies the medicaid covered
services provided;
(b)
Written verification that the individual paid the
provider;
(c)
Any other documentation that may be requested by the
payer, 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)(4) of this
rule;
(d)
The name, address, and phone number of the provider who
rendered the medicaid covered services to the individual and the name of the
billing provider; and
(e)
The name, address and phone number of any third party
that paid or was liable to pay for any portion of the medicaid covered
service.
(6)
Requests for direct reimbursement will qualify for
reimbursement consideration only if submitted to the payer within three hundred
sixty-five days of the date of service or hospital discharge, or within one
hundred eighty days of the notice of state hearing decision or eligibility
determination;
(7)
Reimbursement from a third party as defined in section
5160.35 of the Revised Code is
not available;
(8)
The request is not for reimbursement of medicare part A
out-of-pocket expenses.
(C) Within ninety days of meeting the conditions specified in paragraph (B) of this rule, the payer will process the request for reimbursement. Applicants for reimbursement who receive an approval for reimbursement will be reimbursed either the amount of their out-of-pocket medical expenses or the co-pay charges, whichever is applicable, but in no event will the reimbursement exceed the medicaid maximum allowed amount identified in rule 5160-1-60 of the Administrative Code.
(D) The bills identified as satisfying a person's spenddown obligation or paid to the county to meet medicaid eligibility are not reimbursable by the medicaid program.
(E) All notice and hearing provisions set forth in division 5101:6 of the Administrative Code apply to determinations made under this rule.
Replaces: 5160-1- 60.2
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