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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5160 Medicaid |
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Chapter5160-13. Ambulatory Health Care Clinic Services |
5160-13-02. Service-based ambulatory health care clinics: end-stage renal
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(A) Coverage and limitations.
(1) Medicaid coverage of dialysis services for eligible individuals with end-stage renal disease (ESRD) begins with the first dialysis treatment. If an individual is eligible for both medicare and medicaid, then coverage by medicaid as the primary payer continues only until medicare coverage begins.
(2) Payment may be made to an ESRD dialysis clinic for hemodialysis or for any of three types of peritoneal dialysis: intermittent peritoneal dialysis (IPD), continuous ambulatory peritoneal dialysis (CAPD), or continuous cycling peritoneal dialysis (CCPD). These four types of dialysis service may be delivered in any of three ways:
(a) Chronic maintenance dialysis is defined in rule 3701-83-23 of the Administrative Code. It is available to individuals in either an ESRD dialysis clinic or a home setting. In a home setting, it is often called "Method I home dialysis," a medicare term for a payment option under which a dialysis provider assumes responsibility for furnishing all equipment, supplies, and support services.
(b) Dialysis support services include but are not limited to periodic monitoring of an individual's adaptation to home dialysis, visits by trained personnel, certain ESRD-related laboratory tests, maintenance of home dialysis equipment, ordering of supplies, and record-keeping. The individual receiving dialysis support services makes arrangements for securing necessary supplies and equipment, in either an ESRD dialysis clinic or a home setting. The delivery of dialysis support services in a home setting is often called "Method II home dialysis," a medicare term for a payment option under which a dialysis provider assumes responsibility for furnishing only treatment-related services and a separate provider (usually a supplier of durable medical equipment) furnishes the dialysis equipment and supplies.
(c) Dialysis with self-care training includes dialysis treatment along with instruction of the individual or a caregiver on how to perform self-dialysis with little or no professional assistance.
(3) The following frequency limits apply:
(a) Chronic maintenance dialysis performed in an ESRD dialysis clinic - one session per day, three sessions per week;
(b) Chronic maintenance dialysis performed in a home setting - one session per day;
(c) Dialysis support services - one session per month;
(d) Hemodialysis with self-care training - a total of fifteen sessions to be conducted within a period not to exceed ninety-one days;
(e) IPD with self-care training - a total of twelve sessions to be conducted within a period not to exceed twenty-eight days; and
(f) CAPD or CCPD with self-care training - a total of fifteen sessions.
(4) Frequency limits may be exceeded only if the medical necessity of the additional service is documented in the medical record by the practitioner who is primarily responsible for the dialysis services.
(B) Payment.
(1) Payment for covered dialysis services rendered by an ESRD dialysis clinic is made as an all-inclusive composite amount per visit. This composite amount includes all related services, tests, equipment, supplies, and training furnished on the same date.
(2) The medicaid maximum composite payment amount for a covered dialysis service is the product of two figures:
(a) The calendar year 2016 ESRD prospective payment system (PPS) base rate published by the centers for medicare and medicaid services (CMS), which can be found on the CMS website at http://www.cms.gov; and
(b) The applicable percentage from the following list:
(i) Chronic maintenance dialysis performed in an ESRD dialysis clinic - fifty-eight and three quarters per cent;
(ii) Chronic maintenance dialysis performed in a home setting - three sevenths of the percentage for chronic maintenance dialysis performed in an ESRD dialysis clinic;
(iii) Dialysis support services - thirty-three and three quarters per cent; or
(iv) Dialysis with self-care training - sixty-seven and three quarters per cent.
(3) Separate payment may be made to an ESRD dialysis clinic for covered professional services of a medical practitioner and for covered laboratory services and pharmaceuticals that are not directly related to dialysis treatment. Payment methods and amounts for such items and services are determined in accordance with the relevant portion of agency 5160 of the Administrative Code.