Regional Generic Provider Agreement - Ohio Department of Job and ...

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Appendix G Covered Families and Children (CFC) population Page 2 • Durable medical equipment and medical supplies • Vision care services, including eyeglasses • Short-term rehabilitative stays in a nursing facility as specified in OAC rule 5101:3-26-03 • Hospice care • Behavioral health services (see section G.2.b.iii of this appendix) 2. Exclusions, Limitations and Clarifications a. Exclusions MCPs are not required to pay for Ohio Medicaid FFS program (Medicaid) non-covered services. For information regarding Medicaid noncovered services, MCPs must refer to the ODJFS website. The following is a general list of the services not covered by the Ohio Medicaid fee-forservice program: • Services or supplies that are not medically necessary • Experimental services and procedures, including drugs and equipment, not covered by Medicaid • Organ transplants that are not covered by Medicaid • Abortions, except in the case of a reported rape, incest, or when medically necessary to save the life of the mother • Infertility services for males or females • Voluntary sterilization if under 21 years of age or legally incapable of consenting to the procedure • Reversal of voluntary sterilization procedures • Plastic or cosmetic surgery that is not medically necessary* • Immunizations for travel outside of the United States • Services for the treatment of obesity unless medically necessary* • Custodial or supportive care not covered by Medicaid
Appendix G Covered Families and Children (CFC) population Page 3 • Sex change surgery and related services • Sexual or marriage counseling • Acupuncture and biofeedback services • Services to find cause of death (autopsy) • Comfort items in the hospital (e.g., TV or phone) • Paternity testing MCPs are also not required to pay for non-emergency services or supplies received without members following the directions in their MCP member handbook, unless otherwise directed by ODJFS. *These services could be deemed medically necessary if medical complications/conditions in addition to the obesity or physical imperfection are present. b. Limitations & Clarifications i. Member Cost-Sharing As specified in OAC rules 5101:3-26-05(D) and 5101:3-26-12, MCPs are permitted to impose the applicable member co-payment amount(s) for dental services, vision services, non-emergency emergency department services, or prescription drugs, other than generic drugs. MCPs must notify ODJFS if they intend to impose a co-payment. ODJFS must approve the notice to be sent to the MCP’s members and the timing of when the co-payments will begin to be imposed. If ODJFS determines that an MCP’s decision to impose a particular co-payment on their members would constitute a significant change for those members, ODJFS may require the effective date of the co-payment to coincide with the “Open Enrollment” month. Notwithstanding the preceding paragraph, MCPs must provide an ODJFS-approved notice to all their members 90 days in advance of the date that the MCP will impose the co-payment. With the exception of member co-payments the MCP has elected to implement in accordance with OAC rules 5101:3-26-05(D) and 5101:3-26-12, the MCP’s payment constitutes payment in full for any covered services and their subcontractors must not charge members or ODJFS any additional co-payment, cost sharing, down-payment, or similar charge, refundable or otherwise.
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Baseline Covered Families and Child
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APPENDIX A OAC RULES 5101:3-26 The
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Appendix C Covered Families and Chi
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Page 45: APPENDIX E RATE METHODOLOGY CFC ELI
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Appendix I Covered Families and Chi
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Appendix J Page 2 h. Prompt Pay Rep
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Appendix J Page 4 If the financial
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Appendix J Page 6 Penalty for nonco
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Appendix J Page 8 6. NOTIFICATION O
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Appendix K Covered Families and Chi
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Appendix L Covered Families and Chi
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Appendix M Covered Families and Chi
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Appendix N Covered Families and Chi
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Appendix O Covered Families and Chi
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Appendix P Covered Families and Chi
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Appendix P Covered Families and Chi
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