5160-1-13.1. Medicaid recipient liability

(A) In accordance with 42 C.F.R. 447.15 (as in effect October 1, 2018), the medicaid payment for a covered service constitutes payment-in-full. It shall not be construed as a partial payment even when the payment amount is less than the provider's charge.

(1) The provider shall not collect nor bill a medicaid recipient for any difference between the medicaid payment and the provider's charge, nor shall the provider ask a medicaid recipient to share in the cost through a deductible, coinsurance, co-payment, missed appointment fee or other similar charge, other than medicaid co-payments as defined in rule 5160-1-09 of the Administrative Code and patient liability as described in Chapter 5160-3 and rule 5160:1-6-07 of the Administrative Code.

(2) The provider shall not charge a medicaid recipient a down payment, refundable or otherwise.

(3) Should the individual become eligible for medicaid after the date of service and the eligibility span includes the date of service, the individual may not be financially responsible.

(B) A medicaid recipient cannot be billed when a medicaid claim has been denied for any of the following reasons:

(1) Unacceptable or untimely submission of a claim;

(2) Failure to request a prior authorization; or

(3) A retroactive finding by a peer review organization (PRO) that a rendered service was not medically necessary.

(C) A provider may bill a medicaid recipient for a medicaid covered service in lieu of submitting a claim to the Ohio department of medicaid (ODM) only if all of the following conditions are met:

(1) The provider explains to the medicaid recipient that the service is a covered medicaid service and other medicaid providers may render the service at no cost to the individual;

(2) Prior to each date of service for the specific service rendered, the provider notifies the medicaid recipient in writing that the provider will not submit a claim to ODM for the service;

(3) The medicaid recipient agrees to be liable for payment of the service and signs a written statement to that effect before the service is rendered; and

(4) The medicaid covered service is not a prescription for a controlled substance as defined in section 3719.01 of the Revised Code.

(D) Services that are not covered by the medicaid program, including services requiring prior authorization that have been denied by ODM, may be billed to a medicaid recipient when the conditions in paragraphs (C)(2) to (C)(4) of this rule are met.

(E) Any individual not covered by medicaid on the date of service is financially responsible for those services unless the individual qualifies for the hospital care assurance program (HCAP) in accordance with section 5168.14 of the Revised Code.

Replaces: 5160-1- 13.1

Effective: 1/1/2020
Five Year Review (FYR) Dates: 01/01/2025
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 06/03/1983, 02/11/1984, 10/01/1984, 07/01/1985 (Emer.), 09/30/1985, 10/01/1987, 05/30/2002, 01/01/2004, 07/01/2005, 01/06/2006, 02/01/2010, 11/28/2014