Medicaid State Plan

The State Plan is a comprehensive written statement that describes the nature and scope of the Ohio Medicaid program and assures that it is administered in conformity with federal requirements and regulations.  The information provided on this page is for informational purposes only, and ODM disclaims any obligation or liability based upon its use. The formally adopted state plan, statutes, and rules governing the Ohio Medicaid program prevail over any conflicting information provided here.

Please note: The State Plan files on this site are in PDF format only. You must have Acrobat Reader to open the following files. If you do not have Acrobat Reader, get it here.

Submittal Statement
Table of Contents

Medicaid State Plan Amendments – amended when necessary
Ohio Medicaid State Plan Amendments approved by the Centers for Medicare and Medicaid Services (CMS) are available here.
Sections of the Medicaid State Plan

2.1 Application, Determination of Eligibility and Furnishing Medicaid

Attachment A: Definition of an HMO that is NOT Federally Qualified

2.2 Coverage and Conditions of Eligibility

Attachment A: Groups Covered and Agencies Responsible for Eligibility Determinations

Supplement 1: Reasonable classifications of individuals under the age of 18
Supplement 3: Method for determining cost effectiveness of caring for certain disabled children at home

2.3 Residence

2.4 Blindness

2.5 Disability

2.6 Financial Eligibility

Attachment A: Eligibility Conditions and Requirements

Supplement 1: Income eligibility levels
Supplement 2: Resource levels
Supplement 3: Reasonable limits on amounts for necessary medical or remedial care not covered under Medicaid
Supplement 4: Methods for treatment of income that differ from those of the SSI program
Supplement 6: Standards for residential state supplementary payments
Supplement 8a: More liberal methods of treating income under 1902(r)(2)
Supplement 8b: Less restrictive methods of treating resources under 1902(r)(2)
Supplement 8c: More liberal methods of treating resources under 1902(r)(2)
Supplement 9: Transfer of resources
Supplement 9a: Transfer of Assets
Supplement 9b: Transfer of Assets
Supplement 10: Trusts – undue hardship
Supplement 12: Variation from the basic personal needs allowance
Supplement 13: Section 1924 provisions
Supplement 14: Income and resource requirements for tuberculosis infected individuals
Supplement 15: More liberal methods of treating income under Section 1902(r)(2) of the Act
Supplement 16: Asset Verification System
Supplement 17: Disqualification for long-term care assistance for individuals with substantial home equity
Supplement 18: Methodology for Identification of Applicable FMAP Rates
Supplement 19 Medicaid MAGI Eligibility (Ohio SPA TN 13-0025)

2.7 Medicaid Furnished Out of State

4.1 Methods of Administration

4.2 Hearings for Applicants and Recipients

4.3 Safeguarding Information on Applicants and Recipients

4.4 Medicaid Quality Control

4.5 Medicaid Agency Fraud Detection and Investigation Program

4.6 Reports

4.7 Maintenance of Records

4.8 Availability of Agency Program Manuals

4.9 Reporting Provider Payments to the Internal Revenue Service

4.10 Free Choice of Providers

4.11 Relations with Standard-Setting and Survey Agencies

Attachment A: Standards Setting Authority for Institutions

4.12 Consultation to Medical Facilities

4.13 Required Provider Agreement

4.14 Utilization Control

Attachment B: Multiple Utilization Review Methods for Intermediate Care Facilities

4.15 Inspection of Care in Intermediate Care Facilities for the Mentally Retarded, Facilities Providing Inpatient Psychiatric Services for Individuals Under 21, and Mental Hospitals

4.16 Relations with State Health and Vocational Rehabilitation Agencies and Title V Grantees

Attachment A: Cooperative Arrangements with the Ohio Department of Health
Attachment G: Cooperative Arrangements with the Ohio Department of Mental Health and Addiction Services
Attachment N: Cooperative Arrangements with the Ohio Department of Aging
Attachment O: Cooperative Arrangements with the Ohio Department of Developmental Disabilities

4.17 Liens and Adjustments or Recoveries

Attachment A: Liens and Adjustments or Recoveries

4.18 Recipient Cost Sharing and Other Similar Charges

Attachment A: Imposed Service Changes on Categorically Needy
Attachment B: Imposed Enrollment Fee Charges
Attachment C: Imposed Charges for Medically Needy
Attachment D: Premiums Imposed on Low Income Pregnant Women and Infants
Attachment E: Optional Sliding Scale Premiums

4.19 Payments for Services

Attachment A: Table of Contents

Attachment A: Methods and Standards for Establishing Payment Rates

Supplement 1: Episode-Based Payments

Attachment A: Section 5101:3-2-01 Eligible Providers

 Attachment A: Section 5101:3-2-02 General Provisions Hospital Services

 Attachment A: Section 5101:3-2-03 Conditions and Limitations

 Attachment A: Section 5101:3-2-04 Coverage of Hospital Provided Pharmaceutical, Dental, Vision Care, Medical Supply and Equipment, and Ambulance or Ambulette Services

 Attachment A: Section 5101:3-2-07.01 Hospital Services Subject to and Excluded from DRG

 Attachment A: Section 5101:3-2-07.02 Classification of Hospitals

 Attachment A: Section 5101:3-2-07.03 Basic Methodology for Determining Relative Weights

 Attachment A: Section 5101:3-2-07.04 Basic Methodology for Determining Prospective Payment Rates

 Attachment A: Section 5101:3-2-07.07 Medical Education

 Attachment A: Section 5101:3-2-07.08 Redetermination of Prospective Payment Rates

 Attachment A: Section 5101:3-2-07.09 Payment for Outliers

 Attachment A: Section 5101:3-2-07.10 Definitions of Readmissions, Transfers, and Discharges

 Attachment A: Section 5101:3-2-07.11 Payment Methodology

 Attachment A: Section 5101:3-2-07.12 Appeals and Reconsideration of Departmental Determinations

 Attachment A: Section 5101:3-2-07.13 Utilization Control

 Attachment A: Section 5101:3-2-07.17 Provision of Basic Medically Necessary Hospital Level Services

 Attachment A: Section 5101:3-2-08 Assessment Policies for Disproportionate Share and Indigent Care Adjustments for Hospital Services

 Attachment A: Section 5101:3-2-10 Payment Policies for Disproportionate Share and Indigent Care Adjustments for Psychiatric Hospitals

 Attachment A: Section 5101:3-2-23 Cost Reports

 Attachment A: Section 5101:3-2-24 Audits

 Attachment A: Section 5101:3-2-25 Third Party Liability

 Attachment A: Section 5101:3-2-30 Multi-tiered Charge Level for Certain Outpatient Hospital Services

 Attachment A: Section 5101:3-2-40 Precertification Review

 Attachment A: Section 5101:3-2-41 Guidelines for Preadmission Certification

 Attachment A: Section 5101:3-11-04 Laboratory and X-ray Services Provided to Hospital Inpatients

 Attachment A: Section 5101:3-17-01 Abortions

 Attachment A: Section 5160-2-65 Inpatient Hospital Reimbursement on or after 7-1-13

 Attachment B: Health Homes

 Attachment B: Methods and Standards for Establishing Payment Rates

Supplement 1: Payment of Medicare A, B, C Deductibles, Coinsurance

Supplement 2: Episode-Based Payments

Attachment C: Nursing Facilities – Leave Days
Attachment C: ICF/IID - Leave Days (Supplement 2)
Attachment D: Nursing Facilities – Payment for Services (Supplement 1)
Attachment D: ICF-IID (Supplement 2)
Attachment E: Timely Claims Payment

4.20 Direct Payments to Certain Recipients for Physicians' or Dentists’ Services

4.21 Prohibition Against Reassignment of Provider Claims

4.22 Third Party Liability

Attachment A: Third Party Liability
Attachment B: Third Party Liability
Attachment C: State Method on Cost Effectiveness of Employer-Based Group Health Plans

4.23 Use of Contracts

4.24 Standards for Payments for Nursing Facility and Intermediate Care Facility for the Mentally Retarded Services

4.25 Program for Licensing Administrators of Nursing Homes

4.26 Drug Utilization Review Program

4.27 Disclosure of Survey Information and Provider or Contractor Evaluation

4.28 Appeals Process

Section 001.01, Payment During Appeal
Attachment A: Section 5101:3-3-04.1 Payments to NFs and ICFs-MR during the survey agency’s administrative appeals process

4.29 Conflict of Interest Provisions

4.30 Exclusion of Providers and Suspension of Practitioners and Other Individuals

4.31 Disclosure of Information by Providers and Fiscal Agents

4.32 Income and Eligibility Verification System

Attachment A: Income and Eligibility Verification System Procedures Requests to Other State Agencies

4.33 Medicaid Eligibility Cards for Homeless Individuals

Attachment A: Method for Issuance of Medicaid Eligibility Cards to Homeless Individuals

4.35 Remedies for Skilled Nursing and Intermediate Care Facilities that do not Meet Requirements of Participation

Attachment A: Nursing Facilities - Eligibility Conditions and Requirements
Attachment B: Nursing Facilities - Termination of Provider Agreement
Attachment C: Nursing Facilities - Temporary Management
Attachment D: Nursing Facilities - Denial of Payment for New Admissions
Attachment E: Nursing Facilities - Civil Money Penalty
Attachment F: Nursing Facilities - State Monitoring
Attachment G: Nursing Facilities - Transfer of Residents
Attachment H: Nursing Facilities - Additional Remedies

4.36 Required Coordination between the Medicaid and WIC Programs

4.39 Preadmission Screening and Annual Resident Review in Nursing Facilities

Attachment A: Categorical Determinations

4.41 Resident Assessment for Nursing Facilities

4.42 Employee Education About False Claims Recoveries

Attachment A: Reference Preprint Page 3

4.43 Cooperation with Medicaid Integrity Program Efforts

4.44 Medicaid Prohibition on Payments to Institutions or Entities Located Outside of the United States

4.46 Provider Screening and Enrollment

Alternative Benefit Plan (ABP)

The Affordable Care Act (ACA) mandated that expansion states, such as Ohio, must have an ABP for the adult expansion population, also known as Group VIII (because it is defined in Section 1902(a)(10)(A)(i)(VIII) of the Social Security Act). The ABP is a separate state plan from the traditional Medicaid state plan, although in Ohio, the benefits in the ABP mirror the traditional Medicaid state plan with just a few exceptions to assure mental health parity, also mandated by the ACA.

See CMS' State Health Official Letter #13-001, issued January 16, 2013, for more information regarding the application of mental health parity to Medicaid MCOs, CHIP, and Alternative Benefit Plans.

ABP1 - ABP Populations
ABP2a - Voluntary Benefit Package Selection Assurances - Group VIII
ABP3 - Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package
ABP4 - ABP Cost-Sharing
ABP5 - Benefits Description
ABP7 - Benefits Assurances
ABP8 - Service Delivery Systems
ABP9 - Employer-Sponsored Insurance and Payment of Premiums
ABP10 - General Assurances
ABP11 - Payment Methodology