# Ohio Admin. Code 5160-1-05.1: Rule 5160-1-05.1. Payment for "Medicare Part C" cost sharing

> Ohio · Regulations · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_05_1

## Section

- **Citation:** Ohio Admin. Code 5160-1-05.1
- **Heading:** Rule 5160-1-05.1. Payment for "Medicare Part C" cost sharing
- **Jurisdiction:** Ohio
- **Kind:** Regulations
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** Ohio Administrative Code / Agency 5160 / Chapter 5160-1 / Rule 5160-1-05.1

## Text

119.03 (A) For qualified medicare beneficiaries and medicaid recipients enrolled in medicare part C managed health care plans (medicare advantage plans) the department will pay as cost sharing the lesser of the following amounts: (1) The provider's billed charges for the service (except for hospital and nursing facility services); or (2) The deductible, coinsurance and co-payment amount as provided by the medicare part C plan; or (3) The difference between the medicare part C plan's payment to a provider for a service or services identified and the medicaid maximum allowable reimbursement rate for the same identified service or services; or (4) The medicaid liability for the cost sharing if the service had been rendered under medicare part A or part B (calculated as twenty-five per cent of the medicare maximum allowed amount). (B) The department will not make any additional payment to the provider, or will make a payment of zero dollars, when payment for part C cost sharing is made using the method described in paragraph (A)(3) of this rule, and the sum of the amounts paid by medicare and all other third party insurers exceeds the medicare or medicaid maximum allowed amount. (C) The medicaid provider is ultimately responsible for accurate and valid reporting of medicaid claims and retention of relevant documents to support claims submitted for payment and any other business transactions in accordance with rule 5160-1-17.2 of the Administrative Code. (D) Any costs beyond the medicare advantage plan's maximum out-of-pocket (MOOP) limit are not subject to cost sharing pursuant to 42 C.F.R. 422.100 (as in effect January 1, 2023). Last updated June 25, 2025 at 5:47 PM Supplemental Information Authorized By: 5164.02 Amplifies: 5164.02 7/1/2028 7/30/2004, 11/9/2014

## Nearby sections

- [Ohio Admin. Code 5160-1-01 Rule 5160-1-01. Medicaid medical necessity: definitions and principles](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_01.md)
- [Ohio Admin. Code 5160-1-02 Rule 5160-1-02. General reimbursement principles](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_02.md)
- [Ohio Admin. Code 5160-1-04 Rule 5160-1-04. Employee access to confidential personal information](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_04.md)
- [Ohio Admin. Code 5160-1-05 Rule 5160-1-05. Medicaid coordination of benefits with the medicare program (Title XVIII)](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_05.md)
- [Ohio Admin. Code 5160-1-05.1 Rule 5160-1-05.1. Payment for "Medicare Part C" cost sharing](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_05_1.md)
- [Ohio Admin. Code 5160-1-05.3 Rule 5160-1-05.3. Payment for "Medicare Part B" cost sharing](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_05_3.md)
- [Ohio Admin. Code 5160-1-06.1 Rule 5160-1-06.1. Home and community-based service waivers: PASSPORT](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_06_1.md)
- [Ohio Admin. Code 5160-1-06.5 Rule 5160-1-06.5. Home and community based services (HCBS)](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_06_5.md)
- [Ohio Admin. Code 5160-1-08 Rule 5160-1-08. Coordination of benefits](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_08.md)
- [Ohio Admin. Code 5160-1-09 Rule 5160-1-09. Co-payments](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_09.md)
- [Ohio Admin. Code 5160-1-10 Rule 5160-1-10. Limitations on elective obstetric deliveries](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_10.md)
- [Ohio Admin. Code 5160-1-11 Rule 5160-1-11. Out-of-state coverage](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_11.md)
- [Ohio Admin. Code 5160-1-13.1 Rule 5160-1-13.1. Medicaid recipient liability](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_13_1.md)
- [Ohio Admin. Code 5160-1-14 Rule 5160-1-14. Healthchek: early and periodic screening, diagnostic, and treatment (EPSDT) covered services](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_14.md)

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_05_1. Check the current official text before relying on it. Not legal advice.