This rule identifies covered services generally available to
medicaid recipients and describes the relationship of such services to those
provided by a NF. Whenever reference is made to payment for services through
the NF per diem, the rules governing such payment are set forth in Chapter
5160-3 of the Administrative Code.
(A)
Acupuncture services.
All covered acupuncture services provided by an eligible
acupuncture provider are paid directly to the provider of acupuncture services
in accordance with rule
5160-8-51 of the Administrative
Code.
(B) Behavioral health
services.
Costs for behavioral health services are paid directly to the
provider of services, not through the NF per diem.
(C) Dental services.
All covered dental services provided by licensed dentists are
paid directly to the provider of the dental services in accordance with Chapter
5160-5 of the Administrative Code. Personal hygiene services related to dental
services provided by facility staff or contracted personnel are paid through
the NF per diem.
(D)
Laboratory and x-ray services.
Costs incurred for the purchase and administration of
tuberculin tests, and for drawing specimens and forwarding specimens to a
laboratory, are paid through the NF per diem. All costs of laboratory and x-ray
procedures covered under the medicaid program are paid directly to the
laboratory or x-ray provider in accordance with Chapter 5160-11 of the
Administrative Code.
(E)
Medical supplier services.
In accordance with rule
5160-10-02 of the Administrative
Code, costs of certain medical supplies are paid through the NF per diem, and
others are paid directly to the medical supply provider as follows:
(1) Items that must be paid for through the
NF per diem include:
(a) "Medical supplies,"
defined as those items that have a very limited life expectancy, such as
atomizers, nebulizers, bed pans, catheters, hypodermic needles, syringes,
incontinence pads, splints, and disposable ventilator circuits.
(b) "Needed medical equipment" (and repair of
such equipment), defined as items that can stand repeated use, are primarily
and customarily used to serve a medical purpose, are not useful to an
individual in the absence of illness or injury, and are appropriate for use in
the facility. Such medical equipment items include hospital beds, wheelchairs
other than custom wheelchairs, and intermittent positive-pressure breathing
machines, except as noted in paragraph (E)(2) of this rule.
(c) Emergency stand-by oxygen.
(2) Items for which payment is
made directly to the provider include:
(a)
Ventilators.
(b) "Prostheses,"
defined as devices that replace all or part of a body organ to prevent or
correct physical deformity or malfunction, such as artificial arms or legs,
electro-larynxes, and breast prostheses.
(c) "Orthoses," defined as devices that
assist in correcting or strengthening a distorted part, such as arm braces,
hearing aids and batteries, abdominal binders, and corsets.
(d) Contents of oxygen cylinders or tanks,
including liquid oxygen; oxygen producing machines (concentrators) for specific
use by an individual recipient; and costs of equipment associated with oxygen
administration, such as carts, regulators/humidifiers, cannulas, masks, and
demurrage.
(F)
Pharmaceuticals.
(1) Costs for
over-the-counter drugs, including selected over-the-counter drugs set forth in
paragraph (I) of rule
5160-9-03 of the Administrative
Code, and nutritional supplements are paid through the NF per diem.
(2) Pharmaceuticals for which payment is made
directly to the pharmacy provider are subject to the limitations found in
Chapter 5160-9 of the Administrative Code, the limitations established by the
Ohio state board of pharmacy, and the following conditions:
(a) When new prescriptions are necessary
following expiration of the last refill, the new prescription may be ordered
only after the physician examines the patient.
(b) A copy of all records regarding
prescribed drugs for all patients must be retained by the dispensing pharmacy
for at least six years. A receipt for drugs delivered to a NF must be signed by
the facility representative at the time of delivery and a copy retained by the
pharmacy.
(G)
Physical therapy, occupational therapy, speech therapy, and audiology services.
Costs incurred for physical therapy, occupational therapy,
speech therapy and audiology services provided by licensed therapists or
therapy assistants are paid through the NF per diem.
(H) Physician services.
(1) Physician services are not paid through
the NF per diem rate. Except as provided in paragraph (H)(2) of this rule,
payment is made directly to a physician for covered services he or she provides
to a resident of a NF.
(2) In
accordance with rule
5160-4-06 of the Administrative
Code, services provided in the capacity of overall medical direction are
payable only to a NF provider. Payment for such services may not be made
directly to a physician.
(3)
Physician visits must be provided to a resident of a NF and must conform to the
following schedule:
(a) The resident must be
seen by a physician at least once every thirty days for the first ninety days
after admission, and at least once every sixty days, thereafter.
(b) A physician visit is considered timely if
it occurs not later than ten days after the date the visit was
required.
(c) For payment of
required physician visits, the physician must:
(i) Review the resident's total program of
care including medications and treatments, at each required visit;
(ii) Write, sign, and date progress notes at
each visit;
and
(iii) Sign and date all orders except
influenza and pneumococcal vaccines, which may be administered per
physician-approved facility policy after an assessment for contraindications;
and
(iv) Personally visit (see) the
patient except as provided in 42 C.F.R. 483.30 (October 4,
2016).
(d) Physician delegation of tasks.
(i) A physician may delegate tasks to a
physician assistant or an advanced practice registered nurse (APRN), as defined
in Chapter 4723-8 of the Administrative Code and Chapter 4723. of the Revised
Code for APRNs, and in Chapter 4730. of the Administrative Code for physician
assistants, who are in compliance with the following criteria:
(a) Are acting within the scope of practice
as defined by state law.
(b) APRNs
are practicing with a standard care arrangement entered into with each
physician with whom the APRN collaborates in accordance with section
4723.431 of the Revised Code. A
copy of the standard care arrangement shall be retained on file at each NF
where the nurse practices.
(c)
Physician assistants are practicing with a supervision agreement with a
physician in accordance with section
4730.19 of the Revised Code. A
copy of the supervision agreement shall be retained on file at each NF where
the physician assistant practices.
(ii) At the option of the physician, required
physician visits may be delegated in accordance with
42 C.F.R.
483.30.
(iii) A physician may not delegate a task
when regulations specify that the physician must perform it personally, or when
delegation is prohibited by state law or the facility's own
policies.
(4)
In accordance with rule
5160-1-18 of the Administrative
Code, physician visits may be provided via telehealth.
(4)
(5)
Services payable directly to the physician, physician assistant, or APRN must:
(a) Be requested by the NF resident, with the
exception of required physician visits; and
(b) Be documented by entries in the
resident's medical records along with any symptoms and findings. Every entry
must be signed and dated by the applicable physician, physician assistant, or
APRN.
(I)
Podiatry services.
Costs of covered services provided by licensed podiatrists are
paid directly to the authorized podiatric provider in accordance with Chapter
5160-7 of the Administrative Code.
(J) Respiratory therapy services.
Costs incurred for physician-ordered administration of aerosol
therapy that is rendered by a licensed respiratory care professional are paid
through the NF per diem. No payment for respiratory therapy services shall be
made to a provider other than the NF through the NF per diem.
(K) Transportation services.
Payment for transporting residents by ambulance or wheelchair
van to receive medical services is made directly to the transportation supplier
in accordance with Chapter 5160-15 of the Administrative Code. Transportation
of residents to receive medical services when the resident does not require an
ambulance or wheelchair van is paid through the NF per diem.
(L) Vision care services.
All costs for covered vision care services, including
examinations, dispensing, and the fitting of eyeglasses, are paid directly to
authorized vision care providers in accordance with Chapter 5160-6 of the
Administrative Code.
Notes
Ohio Admin. Code
5160-3-19
Effective:
12/31/2020
Five Year Review (FYR) Dates:
1/1/2023
Promulgated Under:
119.03
Statutory
Authority: 5165.02
Rule
Amplifies: 5165.01
Prior
Effective Dates: 07/01/1980, 03/01/1984, 09/01/1989, 10/01/1990 (Emer.),
12/31/1990, 09/30/1993, 07/04/2002, 02/02/2006, 10/24/2008, 07/31/2009 (Emer.),
10/29/2009, 06/11/2015, 01/01/2018
