3701-43-17. Medical eligibility requirements for payment for treatment

(A) The director shall apply the requirements prescribed by this rule in determining whether an applicant or recipient is medically eligible for payment for treatment services and goods by the program for medically handicapped children. An applicant or recipient is medically eligible if he or she has been diagnosed as having a medically eligible condition. In determining whether an applicant's or recipient's condition is a medically eligible condition under paragraphs (B) and (C) of this rule, the director may consult with one or more members of the medical advisory council or with other individuals with expertise in the area.

(B) A condition is a medically eligible condition if:

(1) The condition is a "chronic, physically handicapping condition," defined, for purposes of this chapter as a condition which has a degree of severity that restricts physical development and is expected to impair health functioning for a period of one year or more or at frequently recurring intervals;

(2) The condition is amenable to treatment through treatment services or goods, as defined in paragraph (X) of rule 3701-43-01 of the Administrative Code;

(3) The condition either is a neoplasm or a congenital anomaly or affects one or more of the following:

(a) Endocrine system;

(b) Immune system;

(c) Nervous system;

(d) Integumentary system;

(e) Cardiovascular system;

(f) Respiratory system;

(g) Digestive system;

(h) Genitourinary system;

(i) Musculoskeletal system;

(j) Sensory organs;

(k) Metabolic diseases;

(l) Diseases of the blood.

(C) Notwithstanding paragraph (B) of this rule, conditions that are classified in one or more of the following categories are not medically eligible conditions:

(1) Mental retardation and related diagnoses;

(2) Psychological and emotional disorders;

(3) Learning disabilities;

(4) Acute, infectious or common childhood conditions unless treatment of the condition is necessary to prevent the occurrence or exacerbation of a chronic, physically handicapping condition, as defined in paragraph (B)(1) of this rule;

(5) Common refractive errors;

(6) Parasitic diseases;

(7) Pregnancy and pregnancy-related diagnoses;

(8) Conditions that are self-correcting through maturation;

(9) Developmental delays;

(10) Routine dental problems and common malocclusions;

(11) Conditions listed in the operational manual as not medically eligible because the director has determined that the program does not have sufficient funding to permit payment for treatment of the conditions. In deciding whether specific conditions should be added to or deleted from the list of conditions not eligible under this paragraph, the director may consult with the medical advisory council, one or more members of the council or other individuals with expertise in the area.

(D) None of the conditions listed in paragraph (C) of this rule precludes treatment of a medically eligible condition as defined in paragraph (B) of this rule.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.022, 3701.023
Prior Effective Dates: 1/2/1989, 4/1/94, 12/1/01, 9/1/08

Prior History: (Effective: 09/01/2008
R.C. 119.032 review dates: 05/23/2008 and 09/01/2013
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021, 3701.022, 3701.023
Prior Effective Dates: 1/2/1989, 4/1/94, 12/1/01 )