Ohio Admin. Code 5160-1-05.3 - Payment for "Medicare Part B" cost sharing
(A) The reimbursement methodology set forth
in paragraph (B) of this rule is limited to medicare part B services that meet
all of the following criteria:
(1) Are not
hospital services defined in accordance with Chapter 5160-2 of the
Administrative Code;
(2) Are not
nursing facility services included in the nursing facility per diem as defined
in accordance with Chapter 5160-3 of the Administrative Code;
(3) Are covered as supplemental medical
insurance benefits under the medicare program; and
(4) Are provided to dual eligibles, defined
in accordance with paragraph (A)(6) of rule
5160-1-05
of the Administrative Code, who elect to receive their medicare part B benefits
through the original medicare program.
(B) The Ohio department of medicaid (ODM)
will pay the lesser of the following calculations for part B cost sharing
described in this rule:
(1) The sum of the
deductible and coinsurance medicare specifies ODM is obligated to pay for
crossover claims; or
(2) The
difference between the medicare approved amount and the sum of the amount
medicare paid and all other third party (insurance other than medicare or
medicaid) payments; or
(3)
Except for physician services, the
The difference between the sum of the amount
medicare paid and any third party payments, and the medicaid maximum allowable
reimbursement rate for the same identified service or services.
(C) When payment for part B cost
sharing is made using the method described in paragraph (B)(2) or (B)(3) of
this rule and the sum of the amounts paid by medicare and all other third party
insurers exceeds the medicare or medicaid approved amount, ODM will not make
any additional payment to the provider, or will make a payment of zero dollars,
and the service(s) are considered to be paid in full to the provider.
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 12/18/2006 (Emer.), 07/31/2009 (Emer.), 10/29/2009, 01/01/2014, 01/01/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: Section 323.230 of Am. Sub. HB. 59
Prior Effective Dates: 12/18/06, 7/31/09 (Emer), 10/29/2009, 01/01/2014
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