5160-29-03 Coverage and limitation policies for outpatient health facility services.

 

 

 

TO BE RESCINDED

 

5160-29-03                  Coverage and limitation policies for outpatient health facility services.

 

 

 

(A)  General provisions

 

Paragraph (E) of rule 5101:3-29-01 of the Administrative Code identifies the minimal range of services an outpatient health facility must provide either directly or under arrangement in order to participate in the outpatient health facility program. In addition to these basic services, an outpatient health facility may provide other supplemental ambulatory services within the scope of the medicaid program except for institutional care. The following paragraphs identify the coverage and limitation policies applicable to items and services provided by an outpatient health facility as a basic or supplemental service.

 

(1)   Medical services covered under this category include those services necessary for the diagnosis and/or treatment of an illness or injury rendered by an eligible provider of services within the scope of his practice and within the scope of the medicaid program. Preventative medicine as such is not a recognized service item under Ohio's medicaid program except for a specialized program known as early and periodic screening, diagnosis and treatment (EPSDT) also known as healthchek, for individuals under twenty-one years of age identified in Chapter 5101:3-14 of the Administrative Code, and at-risk pregnancy services for women who have been determined to be at risk of preterm birth or poor pregnancy outcome on JFS 03535 "Prenatal Risk Assessment" form identified in rules 5101:3-4-10 and 5101:3-4-11 of the Administrative Code. The following provisions are applicable to medical services provided by various practitioner groupings:

 

(a)     "Physician services" are those covered services identified in Chapter 5101:3-4 of the Administrative Code provided by a licensed doctor of medicine or osteopathy and those covered services identified in Chapter 5101:3-7 of the Administrative Code furnished by a licensed doctor of podiatric medicine.

 

(b)    "Physician's assistant and nurse practitioner services" are those covered services provided by a physician's assistant who holds a certificate of registration in accordance with Chapter 4730. of the Revised Code or nurse practitioner as defined in section 4723.43 of the Revised Code. Professional services of both physician's assistants and nurse practitioners are covered if:

 

(i)    Furnished in accordance with rules 5101:3-8-21 to 5101:3-8-27 of the   Administrative   Code   addressing   nurse   practitioner   and

 

 

advanced practice nurses services.

(ii)         Furnished in accordance with rule 5101:3-4-03 of the Administrative Code which describes physician assistant services.

(iii)    Furnished in accordance with the limitations placed on registered nurse or physician's assistant under applicable state law.

(c)   "Registered nurse and licensed practical nurse services" are those covered services provided by a registered nurse or a licensed practical nurse as defined in Chapter 4723. of the Revised Code. Professional services of both registered nurses and licensed practical nurses are covered if:

(i)      Furnished under the personal supervision of a physician and otherwise provided as incidental to a physician's service as defined in paragraph (A)(1)(a) of this rule; or

(ii)      Furnished independently of a physician but under the general direction of a physician within the scope of state law governing registered nurses and licensed practical nurses. Services covered under this provision are limited to those that would otherwise be covered if furnished by an M.D. or D.O., identified in Chapter 5101:3-4 of the Administrative Code, or if furnished by a D.P.M. Chapter 5101:3-7 of the Administrative Code.

(2)    "Dental services" are those covered services identified in Chapter 5101:3-4 of the Administrative Code provided by a licensed dentist or a person under the personal supervision of a dentist. Prior authorization shall be obtained for any service subject to prior authorization.

(3)       "Mental health services" are those covered services identified in rule 5101:3-8-05 of the Administrative Code which are provided by a clinical psychologist and those covered mental health services identified in rule 5101:3-4-29 of the Administrative Code provided by a clinical social worker, identified in rule 5101:3-16-01 of the Administrative Code. A licensed social worker may provide mental health services within the scope and limitations of rule 5101:3-4-29 of the Administrative Code. Prior authorization must be obtained for any service subject to prior authorization.

(4)     "Vision care services" are those covered items and services identified in Chapter 5101:3-6 of the Administrative Code provided by a licensed optometrist or optician. Prior authorization shall be obtained for any service

subject to prior authorization.

(5)   "Speech and hearing services" are those covered services identified in Chapter 5101:3-13 of the Administrative Code provided by a licensed audiologist or speech pathologist.

(6)     "Physical medicine services" are those covered services identified in rule 5101:3-4-26 of the Administrative Code provided by a physician, podiatrist, licensed physical therapist, or mechanotherapist. Services provided by nonlicensed personnel under the personal supervision of a licensed physical therapist or mechanotherapist are not covered.

(7)       "Laboratory services" are those covered services identified in Chapter 5101:3-11 of the Administrative Code provided by the OHF. All laboratory services must be provided by a Clinical Laboratory Improvement Act (CLIA) certified laboratory as specified in Chapter 5101:3-11 of the Administrative Code.

(8)    "Radiology services" are those covered services identified in rule 5101:3-4-25 of the Administrative Code provided by the OHF.

(9)    "Transportation services" are those services needed to transport the patient to and from the OHF or to and from other medicaid providers with whom the OHF has referral arrangements. Such transportation services do not include ambulance or ambulette services as defined in Chapter 5101:3-15 of the Administrative Code.

(10)    "Other services" are those covered services furnished as incident to and in conjunction with services identified in paragraphs (A)(1) to (A)(9) of this rule. Other services are considered part of the services provided as part of each encounter type such as medical, vision, or dental services. "Other services" would include drugs or supplies used during a visit to the OHF. Durable medical equipment and orthotics and prosthetics as identified in Chapter 5101:3-10 of the Administrative Code and medical supplies that are given to a patient to use at home are to be billed and reimbursed as specified in paragraph (C) of rule 5101:3-29-04 of the Administrative Code.

(11)    Abortion services are described in rule 5101:3-17-01 of the Administrative Code.

(12)   Sterilization services are described in rule 5101:3-21-01 of the Administrative Code.

(B)  Service limitations

(1)   Medical -- The maximum number of office visits is twenty-four per year. Visits excluded from the twenty-four visit limitation are those listed in rule 5101:3-4-06 of the Administrative Code.

(2)    Mental health -- The maximum number of therapeutic services is specified in rule 5101:3-8-05 of the Administrative Code. Diagnostic testing is limited to the number specified in rule 5101:3-8-05 of the Administrative Code..

(3)    Speech and hearing -- The maximum number of therapeutic services is the number specified for ambulatory clinics in Chapter 5101:3-13 of the Administrative Code.

(4)      Vision care services -- For each twelve-month period, only one vision examination is covered for patients age twenty or younger and age sixty and older. For each twenty-four-month period, only one vision examination is covered for patients age twenty-one or older, but younger than age sixty. Corrective eyewear (e.g. eyeglasses) are covered only when provided by the department's contracted vision laboratories.

(5)   Physical medicine -- Services are limited to those specified in rule 5101:3-8-02 of the Administrative Code.

(6)    Dental services -- Due to the complexity of dental services, limitations cannot be listed. Reference Chapter 5101:3-5 of the Administrative Code for limitations to dental services.

Effective:	10/01/2016
Five Year Review (FYR) Dates:	02/10/2016
CERTIFIED ELECTRONICALLY
Certification
09/19/2016
Date
Promulgated Under:	119.03
Statutory Authority:	5164.02
Rule Amplifies:	5162.03, 5164.02, 5164.05
Prior Effective Dates:	11/10/1983, 04/18/1988, 11/01/2001, 05/01/2005