Ohio Administrative Code|Rule 5160:1-1-03 | Medicaid: restrictions on payment for services.

                                                
(A) Medicaid will not pay for services
		  provided under the conditions set out in paragraph (C) of this rule, even if an
		  individual has been found eligible for a medical assistance category and is
		  enrolled in medicaid.
(B) Definitions.
(1) "Inmate" means an
			 individual who is serving time for a criminal offense or who is confined in a
			 state or federal prison, jail, detention facility, or other penal
			 facility.
(2) "Inmate of a public
			 institution" means a person who is living in a public institution as
			 defined in rule 5160:1-1-01 of the Administrative Code.
(a) An individual who is residing in a public institution
				awaiting criminal proceedings, penal dispositions, or other detainment
				determinations is considered an inmate. The duration of time that an individual
				is residing in the public institution awaiting these arrangements does not
				determine inmate status.
(b) An individual is not considered an inmate if:
(i) He or she is residing
				  in a public educational or vocational training institution for purposes of
				  securing education or vocational training; or
(ii) He or she is
				  residing in a public institution for a temporary period pending other living
				  arrangements appropriate to his or her needs; or
(iii) He or she is
				  residing in a detention center, jail, or county penal facility after his or her
				  case has been adjudicated and other living arrangements are being decided;
				  or
(iv) He or she is on
				  parole or probation and living in the community.
(3) "Inpatient" means a patient
			 who has been admitted to a medical institution as an inpatient on
			 recommendation of a physician or dentist and who:
(a) Receives room, board, and medical services in the institution
				for a twenty-four hour period or longer; or
(b) Is expected by the institution to receive room, board, and
				medical services in the institution for a twenty-four-hour period or longer
				even though it later develops that the patient dies, is discharged, or is
				transferred to another facility and does not actually stay in the institution
				for twenty-four hours.
(4) "Intermediate care facility for
			 individuals with intellectual disabilities" (ICF-IID) is defined in
			 Chapter 5160-3 of the Administrative Code.
(5) "Medical institution" means
			 an institution that:
(a) Is organized to provide medical care, including nursing and
				convalescent care; and
(b) Has the necessary professional personnel, equipment, and
				facilities to manage the medical, nursing, and other health needs of patients
				on a continuing basis in accordance with accepted standards; and
(c) Is authorized under state law to provide medical care;
				and
(d) Is staffed by professional personnel who are responsible to
				the institution for professional medical and nursing services. The services
				must include:
(i) Adequate and
				  continual medical care and supervision by a physician; and
(ii) Registered nurse or
				  licensed practical nurse supervision and services and nurses' aid
				  services, sufficient to meet nursing care needs; and
(iii) A physician's
				  guidance regarding the professional aspects of operating the
				  institution.
(6) "Outpatient" means a
			 patient of an organized medical facility or distinct part of that facility who
			 is expected by the facility to receive, and who does receive, professional
			 services for less than a twenty-four-hour period regardless of the hour of
			 admission, whether or not a bed is used, and whether or not the patient remains
			 in the facility past midnight.
(7) "Patient" means an
			 individual who is receiving needed professional services that are directed by a
			 licensed practitioner of the healing arts toward maintenance, improvement, or
			 protection of health, or lessening of illness, disability, or
			 pain.
(C) As required by 42 C.F.R. 435.1009 (as in effect October 1,
		  2020), medicaid will not pay for services provided to:
(1) An individual who is an inmate of a
			 public institution; or
(2) An individual who is a patient in an
			 institution for mental diseases (IMD), as defined in rule 5160:1-1-01 of the
			 Administrative Code, who is age twenty-two or older, but under age sixty-five,
			 except:
(a) As permitted in 42 C.F.R. 438.6(e) (as in effect
				October 1, 2020); or
(b) As permitted under a demonstration waiver approved by
				the centers for medicare and medicaid services (CMS) under section 1115 of the
				Social Security Act (as in effect October 1, 2020).
(D) An exception to the prohibition
		  against medicaid payment for services is permitted during the part of the month
		  in which an individual is not an inmate of a public institution.
(1) An individual is not
			 an inmate of a public institution during such time as he or she is admitted as
			 an inpatient in a hospital, nursing facility, juvenile psychiatric facility, or
			 ICF-IID.
(2) There is no time
			 limit on medicaid payment for services as long as the individual continues to
			 be eligible for medicaid and is receiving services as an inpatient in the
			 medical facility.
(3) An inmate is not
			 considered a patient in a medical institution when:
(a) Services are provided on an outpatient basis at a hospital,
				nursing facility, juvenile psychiatric facility, ICF-IID, clinic, or physician
				office; or
(b) Medical care is provided to an inmate in a prison hospital or
				dispensary.
(E) An individual on conditional release
		  or convalescent leave from an IMD is not considered to be a patient in that
		  institution.
(1) An individual on
			 conditional release is an individual who is on definite leave from the
			 institution, but who is not discharged.
(2) An individual who is
			 released from the institution on the condition that he or she receives
			 outpatient treatment or on other comparable conditions is on conditional
			 release.
(3) An individual who is
			 sent home or to another setting for a trial visit is on convalescent
			 leave.
(F) In accordance with the Substance
		  Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT)
		  for Patients and Communities Act (Pub. L. No. 115-271), medical assistance for
		  the following individuals will be suspended, not discontinued, when the
		  individual becomes an inmate of a public institution on or after October 24,
		  2019. Prior to the individual's release from the public institution a
		  redetermination of eligibility will be processed without a new application from
		  the individual.
(1) Individuals under the
			 age of twenty-one; or
(2) Former foster care
			 children up to the age of twenty-six as described in 42 C.F.R. 435.150(b) (as
			 in effect October 1, 2020). 


Last updated July 1, 2021 at 10:38 AM