5160-28-03.2 Cost-based clinics: OHF services, co-payments, and limitations.

 

 

 

5160-28-03.2               Cost-based     clinics:       OHF     services,       co-payments,                        and limitations.

 

 

 

(A)Each outpatient health facility (OHF) must provide the following preventive, diagnostic, therapeutic, rehabilitative, or palliative items or services, which are collectively termed "comprehensive primary health services":

 

(1) Covered services provided on-site:

 

(a) Medical services, which may be divided into three categories:

 

(i) Services rendered by a physician or podiatrist;

 

(ii) Services rendered by a physician assistant or advanced practice registered nurse; or

 

(iii) Services rendered by a registered nurse or licensed practical nurse acting independently under standing orders of a physician or advanced practice registered nurse, under specific instructions from a previous visit, or under supervision of a physician or advanced practice registered nurse who has no direct contact with the patient during a visit (e.g., administration of an immunization or injection, change of dressing, removal of sutures, dispensing of hormonal contraceptives if vital signs are taken during the visit, follow-up evaluation and management after insertion of an intrauterine device);

 

(b) Early and periodic screening, diagnostic, and treatment (EPSDT) services and other preventive health services, such as children's eye and ear examinations, perinatal services, well-child services, and pregnancy prevention or contraceptive management;

 

(c) Obstetrical care services, including a prenatal risk assessment for every woman receiving prenatal services, and at-risk pregnancy services for every woman diagnosed at risk of premature birth or poor pregnancy outcome;

 

(d)Diagnostic laboratory services including but not limited to the following procedures:

 

(i) Chemical examination of urine (including urine ketones) by test strip, tablet, or both methods;

 

(ii) Microscopic examination of urine sediment;

 

(iii) Hemoglobin test or hematocrit;

 

(iv) Blood sugar test;

 

 

(v) Gram stain;

(vi) Examination of stool specimens for occult blood;

(vii) Pregnancy test;

(viii) Primary culturing of a specimen for transmittal to a certified laboratory;

(ix) Test for pinworm; and

(x) Drawing blood for a lead poisoning screening;

(e) Diagnostic radiological services including but not limited to the following procedures:

(i) Chest x-ray; and

(ii) X-ray necessary to diagnose treatment of a broken foot, ankle, leg, arm, or hand; and

(2) Covered services provided on-site or arranged for by the OHF:

(a) Transportation services; and

(b) Emergency medical services.

(B)In addition, an OHF may provide the following services:

(1) Medical services other than comprehensive primary health services:

(a) Services provided by a doctor of medicine, a doctor of osteopathy, a doctor of podiatric medicine, a physician assistant, or an advanced practice registered nurse;

(b) Services provided by a registered nurse or a licensed practical nurse, under supervision, that would be covered if they were rendered by a physician or an advanced practice registered nurse;

(c) EPSDT services; and

(d)Services for women who have been determined to be at risk of preterm birth or poor pregnancy outcome;

(2) Dental services;

(3) Mental or behavioral health services provided by a clinical psychologist or a

clinical social worker;

(4) Vision services provided by a licensed optometrist, optician, or ocularist;

(5) Speech and hearing services provided by an audiologist or speech pathologist;

(6) Physical  medicine  services  provided  by  a  physician,  podiatrist,  physical therapist, or mechanotherapist;

(7) Laboratory services;

(8) Radiology services; and

(9) Transportation services, excluding ambulance and wheelchair van services addressed in Chapter 5160-15 of the Administrative Code, needed to transport a patient to or from the OHF or between the OHF and other medicaid providers with which the OHF has referral arrangements.

(C)No separate payment is made for medical supplies and drugs dispensed during a visit.

(D) An OHF that is enrolled separately in medicaid as another type of provider may be paid on a fee-for-service basis under its non-OHF medicaid provider number for providing any of the following services or supplies:

(1) Take-home drugs, which must be paid for in accordance with Chapter 5160-9 of the Administrative Code; or

(2) Durable medical equipment (DME) and supplies for take-home use, which must be paid for in accordance with Chapter 5160-10 of the Administrative Code.

(E) Claims for services provided off-site under contract must be submitted separately to the department. The contractor must submit such claims if it has a current medicaid provider number.

(F) With the following exceptions, limits on OHF services are specified in the chapter of the Administrative Code that addresses the type of service:

(1) For medical services, payment may be made for a maximum of twenty-four office visits per year. Physician visits listed in rule 5160-4-06 of the Administrative Code do not count toward this limit.

(2) For vision care services, payment may be made for one vision examination in a twelve-month period for patients younger than twenty-one or older than fifty-nine. Payment may be made for one vision examination in a twenty-four-month period for patients older than twenty and younger than sixty. Corrective eyewear is covered only if it is provided by one of the department's contracted vision laboratories.

Replaces:                                                              Part of 5160-29-01, 5160-29-03, part of 5160-29-04

Effective:                                                             10/01/2016

Five Year Review (FYR) Dates:                         10/01/2021

CERTIFIED ELECTRONICALLY
Certification
09/19/2016
Date
Promulgated Under:	119.03
Statutory Authority:	5164.02
Rule Amplifies:	5164.02, 5164.05
Prior Effective Dates:	11/10/1983, 10/01/1987, 04/18/1988, 11/01/2001,
	05/01/2005