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MEDICAID 101  >  Medicaid State Plan
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

1.0 Single State Agency Organization

2.0 Coverage and Eligibility

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 5: More restrictive methods of treating resources than those of the SSI program
Supplement 6: Standards for residential state supplementary payments
Supplement 7: Income levels for 1902(f) states – categorically needy who are covered under requirements more restrictive than SSI

Supplement 8: Resource standards for 1902(f) states categorically needy

 

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

2.7 Medicaid Furnished Out of State

3.0 Services: General Provisions

4.0 General Program Administration

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: Coordination of Material and Child Health Services

 

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
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 5101:3-2-07.06 Capital Costs
Attachment A: Section 5101:3-2-07.07 Medical Equipment
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 5101:3-2-22 Reasonable Cost and Cost-Related Reimbursement for Hospital Services
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 5101:3-2-50 Supplemental Inpatient Hospital Upper Limit Payments for Public Hospitals
Attachment A: Section 5101:3-2-51 Supplemental Inpatient Hospital Upper Limit Payments for State Hospitals
Attachment A: Section 5101:3-2-52 Supplemental Inpatient Hospital Payments for Private Hospitals
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 B: Health Homes 

Attachment B: Methods and Standards for Establishing Payment Rates
Attachment C: Nursing Facilities – Leave Days
Attachment C: ICF – Coverage of Bed-Hold Days

Attachment D: Nursing Facilities – Payment for Services (Supplement 1)

 

Attachment D: ICF – MR (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

Attachment A: Section 5101:3-3-04 Payment during the ODJFS administrative appeals process for denial or termination of a provider agreement

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 State Plan Under Title XIX of the Social Security Act

 

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

 

4.46 Provider Screening and Enrollment

5.0 Personnel Administration

6.0 Financial Administration

7.0 General Provisions

7.1 Plan Amendments

 

7.2 Nondiscrimination

Attachment A: State Plan Under Title XIX of the Social Security Act

 

7.4 State Governor's Review