Ohio Admin. Code 4123-6-38.2 - Payment of nursing home and residential care/assisted living services
(A) Payment to a
nursing home or residential care/assisted living facility for the care of
a claimant
an
injured worker who sustained an injury or contracted an occupational
disease in the course of and arising out of employment shall be made only when
the need for such care is the direct result of the allowed conditions in the
claim.
(B) Payment will be made
only for care provided in nursing homes and residential care/ assisted living
facilities meeting the qualifications specified in paragraph (C) of rule
4123-6-02.2 of the Administrative Code.
(C) Nursing home or residential care/assisted
living facility care must be pre-authorized, except when a nursing home or
residential care/assisted living facility is used immediately following an
approved or emergency hospitalization.
(1) The
allowed per diem rate for a claimant
an injured worker shall be no greater than the
bureau's fee schedule or the rate negotiated between the nursing home or
residential care/assisted living facility and the bureau, MCO, QHP, or
selfinsuring employer.
(2) Nursing
home care shall be provided on a semiprivate bed basis, unless a situation
exists when the use of a private room is medically necessary due to the allowed
industrial condition. In these cases, the
use of such a private room must be preauthorized, except in cases of emergency,
as defined in rule
4123-6-01 of the
Administrative Code, or where the claimant's
injured
worker's condition would be endangered by delay.
(3)
Fee bills for
prescription medication provided to claimants in nursing homes and residential
care/assisted living facilities for the treatment of the allowed industrial
injury or occupational disease shall be submitted by the providing pharmacy in
compliance with the rules of this chapter of the Administrative
Code
Prescription medication provided to an
injured worker in a nursing home for the treatment of an allowed injury or
occupational disease is included in the nursing home's per diem rate, and is
not separately payable .
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Prior Effective Dates: 02/14/2005, 02/01/2010, 07/01/2013
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(A) Payment to a nursing home or residential care/assisted living facility for the care of a claimant an injured worker who sustained an injury or contracted an occupational disease in the course of and arising out of employment shall be made only when the need for such care is the direct result of the allowed conditions in the claim.
(B) Payment will be made only for care provided in nursing homes and residential care/ assisted living facilities meeting the qualifications specified in paragraph (C) of rule 4123-6-02.2 of the Administrative Code.
(C) Nursing home or residential care/assisted living facility care must be pre-authorized, except when a nursing home or residential care/assisted living facility is used immediately following an approved or emergency hospitalization.
(1) The allowed per diem rate for a claimant an injured worker shall be no greater than the bureau's fee schedule or the rate negotiated between the nursing home or residential care/assisted living facility and the bureau, MCO , QHP, or selfinsuring employer.
(2) Nursing home care shall be provided on a semiprivate bed basis, unless a situation exists when the use of a private room is medically necessary due to the allowed industrial condition. In these cases, the use of such a private room must be preauthorized, except in cases of emergency , as defined in rule 4123-6-01 of the Administrative Code, or where the claimant's injured worker's condition would be endangered by delay.
(3) Fee bills for prescription medication provided to claimants in nursing homes and residential care/assisted living facilities for the treatment of the allowed industrial injury or occupational disease shall be submitted by the providing pharmacy in compliance with the rules of this chapter of the Administrative Code Prescription medication provided to an injured worker in a nursing home for the treatment of an allowed injury or occupational disease is included in the nursing home's per diem rate, and is not separately payable .
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Prior Effective Dates: 02/14/2005, 02/01/2010, 07/01/2013