Ohio Admin. Code 5160-1-05.1 - Payment for "Medicare Part C" cost sharing
(A)
For qualified
medicare beneficiaries and medicaid recipients enrolled in medicare part C
managed health care plans (medicare advantage plans) the department will pay as
cost sharing the lesser of the following amounts:
(1)
The provider's
billed charges for the service (except for hospital and nursing facility
services); or
(2)
The deductible, coinsurance and co-payment amount as
provided by the medicare part C plan; or
(3)
The difference
between the medicare part C plan's payment to a provider for a service or
services identified and the medicaid maximum allowable reimbursement rate for
the same identified service or services; or
(4)
The medicaid
liability for the cost sharing if the service had been rendered under medicare
part A or part B (calculated as twenty-five per cent of the medicare maximum
allowed amount).
(B)
The department
will not make any additional payment to the provider, or will make a payment of
zero dollars, when payment for part C cost sharing is made using the method
described in paragraph (A)(3) of this rule, and the sum of the amounts paid by
medicare and all other third party insurers exceeds the medicare or medicaid
maximum allowed amount.
(C)
The medicaid provider is ultimately responsible for
accurate and valid reporting of medicaid claims and retention of relevant
documents to support claims submitted for payment and any other business
transactions in accordance with rule
5160-1-17.2 of the Administrative
Code.
(D)
Any costs beyond the medicare advantage plan's maximum
out-of-pocket (MOOP) limit are not subject to cost sharing pursuant to
42 C.F.R.
422.100 (as in effect January 1, 2023).
Replaces: 5160-1-05.1
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 07/30/2004, 11/09/2014
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.
No prior version found.