Ohio Medicaid adopts three-day window

The Ohio Department of Medicaid amended the hospital definitional regulation, Ohio Administrative Code 5160-2-02, to adopt for the first time a three-day payment window for outpatient services rendered prior to an inpatient admission. The amendment will apply to admissions on and after January 1, 2016.

Section 5160-2-02(B)(2), as amended, provides:

Effective for inpatient admissions that begin on or after January 1, 2016, outpatient services, as described in paragraph (B)(4) of this rule, provided within three calendar days prior to the date of admission in hospitals described in rule 5160-2-01 of the Administrative Code will be covered as inpatient services. This includes emergency room and observation services.

“Outpatient services” are defined at Section 5160-2-02(B)(4) as follows:

Diagnostic, therapeutic, rehabilitative, or palliative treatment or services furnished by or under the direction of a physician or dentist which are furnished to an outpatient by a hospital as defined in rule 5160-2-01 of the Administrative Code. Outpatient services do not include direct-care services provided by physicians, podiatrists and dentists. Outpatient services exclude direct-care physician services except as provided in rule 5160-4-01 of the Administrative Code.

Hospitals “as defined in rule 5160-2-01” include virtually all hospitals. The Ohio Medicaid three-day window appears to encompass all outpatient diagnostic and therapeutic services, whether or not related to the inpatient admission. Unlike the Medicare three-day window rule, the Ohio Medicaid regulation does not address the scope of the rule as applies to the hospital and “to entities that are wholly owned or operated by the admitting hospital.”