# Ohio Admin. Code 5160-1-05.3: Rule 5160-1-05.3. Payment for "Medicare Part B" cost sharing

> Ohio · Regulations · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_05_3

## Section

- **Citation:** Ohio Admin. Code 5160-1-05.3
- **Heading:** Rule 5160-1-05.3. Payment for "Medicare Part B" 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 5160-1-05.3

## Text

119.03 (A) The reimbursement methodology set forth in paragraph (B) of this rule is limited to medicare part B services that meet all of the following criteria: (1) Are not hospital services defined in accordance with Chapter 5160-2 of the Administrative Code; (2) Are not nursing facility services included in the nursing facility per diem as defined in accordance with Chapter 5160-3 of the Administrative Code; (3) Are covered as supplemental medical insurance benefits under the medicare program; and (4) Are provided to dual eligibles, defined in accordance with paragraph (A)(6) of rule 5160-1-05 of the Administrative Code, who elect to receive their medicare part B benefits through the original medicare program. (B) The Ohio department of medicaid (ODM) will pay the lesser of the following calculations for part B cost sharing described in this rule: (1) The sum of the deductible and coinsurance medicare specifies ODM is obligated to pay for crossover claims; or (2) The difference between the medicare approved amount and the sum of the amount medicare paid and all other third party (insurance other than medicare or medicaid) payments; or (3) The difference between the sum of the amount medicare paid and any third party payments, and the medicaid maximum allowable reimbursement rate for the same identified service or services. (C) When payment for part B cost sharing is made using the method described in paragraph (B)(2) or (B)(3) of this rule and the sum of the amounts paid by medicare and all other third party insurers exceeds the medicare or medicaid approved amount, ODM will not make any additional payment to the provider, or will make a payment of zero dollars, and the service(s) are considered to be paid in full to the provider. Supplemental Information Authorized By: 5164.02 Amplifies: Section 323.230 of Am. Sub. HB. 59 11/21/2023 10/29/2009, 1/1/2014

## 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_3. Check the current official text before relying on it. Not legal advice.