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Acute Care Services
Long-Term Care Services


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Benefits by State: Ohio (October 2008) Notes
 
 
 
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Acute Care Services

Is the Benefit Covered? Copayment Requirement Prior Approval Requirement Coverage Limitations Reimbursement Methodology Populations Covered


Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes Fee for service using surgical group rates, ancillaries paid separately CN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes 24 visits/year that count toward physician visit limit Fee for service CN
Federally Qualified Health Center Services
Yes 24 visits/year included in physician visit limit Prospective cost based rate/visit CN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes Prospective payment/discharge using DRG and peer groups, facility specific rates for children's hospitals, cost based payment for LTC, rehab and cancer hospitals CN
Outpatient Hospital Services
Yes $3/non-emergency visit in ER Fee for service or prospective payment based on percentage of charge CN
Rehabilitation Services: Mental Health and Substance Abuse
Yes Cost based payment CN
Rural Health Clinic Services
Yes 24 visits/year that count toward physician visit limit Prospective cost based rate/visit CN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes Fee for service CN
Chiropractor Services
Yes 15 visits/year Fee for service CN
Dental Services
Yes $3/date of service/provider Specified services Exam and cleaning 1/year; frequency of x-rays limited by type; crowns, root canals, posts and related services not covered Fee for service CN
Medical and Remedial Care - Other Practitioners
Medical/Surgical Services of a Dentist
Yes Limited to extractions, surgical excisions and incisions Fee for service CN
Nurse Midwife Services
Yes Fee for service CN
Nurse Practitioner Services
Yes Fee for service CN
Optometrist Services
Yes $2/refractive exam visit, $1/dispensing date of service 1 refractive exam/2 years for over age 20 and under 60, 1 exam/year for age 60 and older Fee for service CN
Physician Services
Yes 24 visits/year irrespective of setting Fee for service CN
Podiatrist Services
Yes Specified services 24 visits/year that count toward physician visit limit Fee for service CN
Psychologist Services
Yes 25 dates of service/year in non-hospital setting, 8 hours/month of psychological testing Fee for service CN
Prescription Drugs
Prescription Drugs
Yes $2/selected brand Rx, $3/Rx if prior approval required Specified drugs WAC+7% (or AWP-14.4% if WAC unknown), plus $3.70 dispensing fee for non-compounded Rx CN
Physical Therapy and Other Services
Occupational Therapy Services
Yes 30 dates of service/year in non-institutional setting, combined with limit for physical therapy Fee for service CN
Physical Therapy Services
Yes 30 dates of service/year in non-institutional setting, combined with limit for occupational therapy Fee for service CN
Services for Speech, Hearing and Language Disorders
Yes Specified services 30 dates of service/year in non-institutional setting Fee for service CN
Products and Devices
Dentures
Yes Yes 1 full upper and/or lower denture or 1 partial denture/8 years if not repairable, 1 reline/4 years Fee for service CN
Eyeglasses
Yes $1/date of service for dispensing Specified services, including contact lenses and items from other than state's contractor 1 pair eyeglasses/year for over age 59, 1 pair/2 years for age 21-59, specified diopter criteria must be met Most products provided by state's volume purchase contractor, dispensing provider paid fee for service CN
Hearing Aids
Yes Yes 1 hearing aid/4 years, limited to conventional aids Fee for service CN
Medical Equipment and Supplies
Yes Specified med equipment and supply items, certain specified repairs costing more than $100 Fee for service, some items paid percentage of item's list price CN
Prosthetic and Orthotic Devices
Yes Specified items and repairs costing more than $120 Orthopedic shoes must be attached to brace and are limited to 2 pair/year Fee for service, some items paid percentage of item's list price CN
Transportation Services
Ambulance Services
Yes Fee for service CN
Non-Emergency Medical Transportation Services
Yes See service-specific FN CN
Other Services
Diagnostic, Screening and Preventive Services
Yes Limited to preventive services Fee for service CN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women
Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes Fee for service CN
Targeted Case Management
Yes Fee for service CN


Long-Term Care Services

Community Based Care
Home and Community Based Services Waiver
Yes Services for the following populations: 2, 4 & 8 - See service-specific FN Dependent upon the services provided CN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes Fee for service for nursing, home health aide and therapies; med supplies paid 75% average list price if no payment limit available CN
Hospice Care
Yes All-inclusive rate per day for applicable level of care CN
Personal Care Services
No
Private Duty Nursing Services
Yes Yes Fee for service CN
Program of All-Inclusive Care for the Elderly
Yes See service-specific FN Capitated payment CN
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes Services limited to hospital settings, leave days not covered Prospective payment/discharge using DRG CN
Inpatient Psychiatric Services, under age 21
Yes Prospective payment/discharge using DRG CN
Intermediate Care Facility Services for the Mentally Retarded
Yes 30 hosp or therapeutic leave days/year Prospective cost based per diem with limits, leave days paid full per diem rate CN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes 30 hosp or therapeutic leave days/year Prospective per diem with limits and acuity adjustment, leave days paid one-half of per diem rate CN
Religious Non-Medical Health Care Institution and Practitioner Services
Yes Must be a licensed nursing facility Prospective per diem using peer groups and acuity adjustment CN


Notes: None
 
 
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