Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-59 - OhioRISE
Section 5160-59-03 - OhioRISE: covered services
Universal Citation: OH Admin Code 5160-59-03
Current through all regulations passed and filed through December 16, 2024
(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan has to ensure:
(1)
Services are sufficient in amount, duration, and scope to reasonably be
expected to achieve the purpose for which the services are
provided;
(2)
The amount, duration, and scope of a medically
necessary service is not arbitrarily denied or reduced solely because of the
diagnosis, type of illness, or condition;
(3)
Prior
authorization is available for services on which the OhioRISE plan has placed a
preidentified limitation to ensure the limitation may be exceeded when
medically necessary;
(4)
Coverage decisions are based on the coverage and
medical necessity criteria published in agency 5160 of the Administrative Code
and practice guidelines specified in rule
5160-26-05.1 of the
Administrative Code; and
(5)
If a member is unable to obtain medically necessary
services described in this rule through an OhioRISE plan network provider, the
OhioRISE plan has to adequately and timely cover the services out of network,
until the OhioRISE plan is able to provide the services from a network
provider.
(6)
Providers delivering services in the OhioRISE program
will adhere to the incident management criteria set forth in rule
5160-44-05 of the Administrative
Code.
(B) The OhioRISE plan has to ensure members have access to the following services when medically necessary:
(1)
Care
coordination as described in rule
5160-59-03.2 of the
Administrative Code.
(2)
Intensive home-based treatment (IHBT) as described in
rule 5160-59-03.3 of the
Administrative Code.
(3)
Respite services for members twenty years of age or
younger with behavioral health needs in accordance with rule
5160-59-03.4 of the
Administrative Code.
(4)
Inpatient hospital services provided in accordance with
Chapter 5160-2 of the Administrative Code in a free-standing psychiatric
hospital or a general acute care hospital that are:
(a)
Inpatient
psychiatric services; or
(b)
Inpatient substance use disorder (SUD) services
(including withdrawal management) provided in accordance with American society
of addiction medicine (ASAM) level of care four.
(5)
Psychiatric
residential treatment facility (PRTF) services as described in
42 C.F.R.
441.150 (October 1, 2021) to
42 C.F.R
441.184 (October 1, 2021).
(6)
Opioid treatment
program (OTP) services delivered by community SUD programs licensed by Ohio
department of mental health and addiction services and/ or certified by the
substance abuse and mental health services administration (SAMHSA) as an
OTP.
(7)
Behavioral health services provided in accordance with
Chapter 5160-27 of the Administrative Code.
(8)
Behavioral health
services provided in accordance with rule
5160-8-05 of the Administrative
Code.
(9)
Behavioral health services rendered by psychiatrists
and physician assistants under the supervision of psychiatrists in accordance
with Chapter 5160-4 of the Administrative Code and psychiatric advanced
practice registered nurses in accordance with rule
5160-4-04 of the Administrative
Code.
(10)
Behavioral health services rendered by outpatient
hospital providers in accordance with Chapter 5160-2 of the Administrative Code
except for emergency department services.
(11)
Behavioral
health services rendered in federally qualified health centers (FQHCs) and
rural health clinics (RHCs) in accordance with Chapter 5160-28 of the
Administrative Code.
(12)
Physician administered drugs in accordance with rule
5160-4-12 of the Administrative
Code for the treatment of mental health and SUD conditions.
(13)
Primary flex
funds as described in rule
5160-59-03.5 of the
Administrative Code.
(14)
Services and supports included in the OhioRISE 1915(c)
home and communitybased services waiver in accordance with rule
5160-59-05 of the Administrative
Code.
(C) The OhioRISE plan may place appropriate limits on a service:
(1)
On
the basis of medical necessity for the member's condition or diagnosis;
or
(2)
For the purposes of utilization control, provided the
services can be reasonably expected to achieve their purpose as specified in
paragraph (A)(1) of this rule.
(D) The OhioRISE plan has to ensure that the services described in paragraph (B) of this rule that are emergency services, as described in rule 5160-26-01 of the Administrative Code, are provided and covered twenty-four hours a day, seven days a week. At a minimum, covered services described in paragraph (B) of this rule that are emergency services have to be provided and reimbursed in accordance with the following:
(1)
The OhioRISE plan will not deny reimbursement for treatment
obtained when a member had an emergency medical condition.
(2)
The OhioRISE plan
cannot limit what constitutes an emergency medical condition on the basis of
diagnoses or symptoms.
(3)
The OhioRISE plan has to cover emergency services
without requiring prior authorization.
(4)
The OhioRISE plan
has to cover services as described in paragraph (B) of this rule related to the
member's emergency medical condition when the member is instructed to go to an
emergency facility by a representative of the OhioRISE plan, the member's
managed care organization (MCO), or the member's primary care provider
(PCP).
(5)
The OhioRISE plan cannot deny reimbursement of
emergency services based on the treating provider, hospital, or fiscal
representative not notifying the member's PCP of the visit.
(6)
The OhioRISE plan
has to cover the services described in paragraph (B) of this rule that are
emergency services when the services are delivered by a noncontracting provider
of emergency services. Such services will be reimbursed by the OhioRISE plan at
the lesser of billed charges or one hundred per cent of the Ohio medicaid
program fee-for-service reimbursement rate (less any reimbursements for
indirect costs of medical education and direct costs of graduate medical
education that is included in the Ohio medicaid program fee-for-service
reimbursement rate) in effect for the date of service. If an inpatient
admission results, the OhioRISE plan has to reimburse at this rate only until
the member can be transferred to a provider designated by the OhioRISE
plan.
(7)
The OhioRISE plan has to cover the services as
described in paragraph (B) of this rule that are emergency services until the
member is stabilized and can be safely discharged or
transferred.
(8)
The OhioRISE plan has to adhere to the judgment of the
attending provider when the attending provider requests a member's transfer to
another facility or discharge. The OhioRISE plan may establish arrangements
with hospitals whereby the OhioRISE plan may designate one of its contracting
providers to assume the attending provider's responsibilities to stabilize,
treat and transfer the member.
(9)
A member who has
had an emergency medical condition will not be held liable for reimbursement of
any subsequent screening and treatment needed to diagnose the specific
condition or stabilize the member.
(E) The OhioRISE plan has to establish, in writing, the process and procedures for the submission of claims for services delivered by non-contracting providers, including non-contracting providers of emergency services. Such information will be made available upon request to non-contracting providers, including non-contracting providers of emergency services. The OhioRISE plan will not establish claims filing and processing procedures for non-contracting providers, including non-contracting providers of emergency services, that are more stringent than those established for their contracting providers.
(F) The OhioRISE plan has to ensure any services described in paragraph (B) of this rule that are post-stabilization care services, as described in rule 5160-26-01 of the Administrative Code, are provided and covered twenty-four hours a day, seven days a week.
(1)
The
OhioRISE plan has to designate a telephone line that is available twenty-four
hours a day to receive provider requests for coverage of post-stabilization
care services. The OhioRISE plan has to document that the telephone number and
process for obtaining authorization has been provided to each emergency
facility in the service area. The OhioRISE plan has to maintain a record of any
request for coverage of post-stabilization care services that is denied
including, at a minimum, the time of the provider's request and the time the
OhioRISE plan communicated the decision in writing to the
provider.
(2)
At a minimum, the services described in paragraph (B)
of this rule that are poststabilization care services have to be provided and
reimbursed in accordance with the following:
(a)
The OhioRISE plan
has to cover services obtained within or outside the OhioRISE plan's network
that are pre-approved in writing to the requesting provider by a plan provider
or other OhioRISE plan representative.
(b)
The OhioRISE plan
has to cover services obtained within or outside the OhioRISE plan's network
that are not pre-approved by a plan provider or other OhioRISE plan
representative but are administered to maintain the member's stabilized
condition within one hour of a request to the OhioRISE plan for pre-approval of
further post-stabilization care services.
(c)
The OhioRISE plan
has to cover services obtained within or outside the OhioRISE plan's network
that are not pre-approved by a plan provider or other OhioRISE plan
representative but are administered to maintain, improve or resolve the
member's stabilized condition if:
(i)
The OhioRISE plan fails to respond within one hour to a
provider request for authorization to provide such services;
(ii)
The provider has
documented an attempt to contact the OhioRISE plan to request authorization,
but the OhioRISE plan cannot be contacted; or
(iii)
The OhioRISE
plan's representative and treating provider cannot reach an agreement
concerning the member's care and a plan provider is not available for
consultation. In this situation, the OhioRISE plan will give the treating
provider the opportunity to consult with an OhioRISE plan provider and the
treating provider may continue with care until a plan provider is reached or
one of the criteria specified in paragraph (F)(3) of this rule is
met.
(3)
The OhioRISE
plan's financial responsibility for services described in paragraph (B) of this
rule that are post-stabilization care services not pre-approved ends
when:
(a)
An
OhioRISE plan provider with privileges at the treating hospital assumes
responsibility for the member's care;
(b)
An OhioRISE plan
provider assumes responsibility for the member's care through
transfer;
(c)
An OhioRISE plan representative and the treating
provider reach an agreement concerning the member's care; or
(d)
The member is
discharged.
(G) OhioRISE plan responsibilities for reimbursement of other services.
(1)
ODM may approve
referral of the OhioRISE plan's members to certain OhioRISE plan
non-contracting hospitals, as specified in rule
5160-26-11 of the Administrative
Code, for non-emergency hospital services that are OhioRISE covered services as
described in paragraph (B) of this rule. When ODM permits such authorization,
ODM will notify the OhioRISE plan and the OhioRISE plan's non-contracting
hospital of the terms and conditions of the approval, including the duration,
and the OhioRISE plan will reimburse the OhioRISE plan's non-contracting
hospital at one hundred per cent of the current Ohio medicaid program
fee-for-service reimbursement rate in effect for the date of service for all
medicaid-covered non-emergency hospital services delivered by the OhioRISE
plan's non-contracting hospital. ODM will base its determination of when an
OhioRISE plan's members can be referred to an OhioRISE plan non-contracting
hospital pursuant to the following:
(a)
The OhioRISE plan's submission of a written request to
ODM for the approval to refer members to a hospital that has declined to
contract with the OhioRISE plan. The request will document the OhioRISE plan's
contracting efforts and why the OhioRISE plan believes it will be necessary for
members to be referred to this hospital; and
(b)
ODM consultation
with the OhioRISE plan non-contracting hospital to determine the basis for the
hospital's decision to decline to contract with the OhioRISE plan, including
but not limited to whether the OhioRISE plan's contracting efforts were
unreasonable and/or that contracting with the OhioRISE plan would have
adversely impacted the hospital's business.
(2)
Paragraph (G)(1)
of this rule is not applicable when the OhioRISE plan and an OhioRISE plan
non-contracting hospital have mutually agreed that the noncontracting hospital
will provide non-emergency OhioRISE covered hospital services to the OhioRISE
plan's members. The OhioRISE plan will ensure that such arrangements comply
with rule
5160-26-05 of the Administrative
Code.
(3)
The OhioRISE plan is not responsible for reimbursement
of services provided through the medicaid school program (MSP) pursuant to
Chapter 5160-35 of the Administrative Code. The OhioRISE plan will ensure
access to services described in paragraph (B) of this rule for members who are
unable to timely access services or are unwilling to access services through
MSP providers.
(4)
The OhioRISE plan is not required to cover services
provided to members outside the United States.
(5)
The OhioRISE plan
will ensure that eligible members receive all behavioral health early and
periodic screening, diagnosis and treatment (EPSDT) services in accordance with
rule 5160-1-14 of the Administrative
Code.
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