2023 Ohio Revised Code › Title 37 | Health-Safety-Morals › Chapter 3701 | Department of Health › Section 3701.023 | Program for Children and Youth With Special Health Care Needs.

Effective:
October 3, 2023
Latest Legislation:
House Bill 33 - 135th General Assembly
(A) The department of health shall review applications for eligibility for the program for children and youth with special health care needs that are submitted to the department by city and general health districts and physician providers approved in accordance with division (C) of this section. The department shall determine whether the applicants meet the medical and financial eligibility requirements established by the director of health pursuant to division (A)(1) of section 3701.021 of the Revised Code, and by the department in the manual of operational procedures and guidelines for the program for children and youth with special health care needs developed pursuant to division (B) of that section. Referrals of potentially eligible children and youth for the program may be submitted to the department on behalf of the child or youth by parents, guardians, public health nurses, or any other interested person. The department of health may designate other agencies to refer applicants to the department of health.
(B) In accordance with the procedures established in rules adopted under division (A)(4) of section 3701.021 of the Revised Code, the department of health shall authorize a provider or providers to provide to any Ohio resident under twenty-one years of age, without charge to the resident or the resident's family and without restriction as to the economic status of the resident or the resident's family, diagnostic services necessary to determine whether the resident has a medical diagnosis resulting in, or potentially resulting in, special health care needs.
(C) The department of health shall review the applications of health professionals, hospitals, medical equipment suppliers, and other individuals, groups, or agencies that apply to become providers. The department shall enter into a written agreement with each applicant who is determined, pursuant to the requirements set forth in rules adopted under division (A)(2) of section 3701.021 of the Revised Code, to be eligible to be a provider in accordance with the provider agreement required by the medicaid program. No provider shall charge a child or youth with special health care needs or the child or youth's parent or guardian for services authorized by the department under division (B) or (D) of this section.
The department, in accordance with rules adopted under division (A)(3) of section 3701.021 of the Revised Code, may disqualify any provider from further participation in the program for violating any requirement set forth in rules adopted under division (A)(2) of that section. The disqualification shall not take effect until a written notice, specifying the requirement violated and describing the nature of the violation, has been delivered to the provider and the department has afforded the provider an opportunity to appeal the disqualification under division (H) of this section.
(D) The department of health shall evaluate applications from city and general health districts and approved physician providers for authorization to provide treatment services, service coordination, and related goods to children or youth determined to be eligible for the program for children and youth with special health care needs pursuant to division (A) of this section. The department shall authorize necessary treatment services, service coordination, and related goods for each eligible child or youth in accordance with an individual plan of treatment for the child or youth. As an alternative, the department may authorize payment of health insurance premiums on behalf of eligible children or youth when the department determines, in accordance with criteria set forth in rules adopted under division (A)(9) of section 3701.021 of the Revised Code, that payment of the premiums is cost-effective.
(E) The department of health shall pay, from appropriations to the department, any necessary expenses, including but not limited to, expenses for diagnosis, treatment, service coordination, supportive services, transportation, and accessories and their upkeep, provided to children and youth with special health care needs, provided that the provision of the goods or services is authorized by the department under division (B) or (D) of this section. Money appropriated to the department of health may also be expended for reasonable administrative costs incurred by the program. The department of health also may purchase liability insurance covering the provision of services under the program for children and youth with special health care needs by physicians and other health care professionals.
Payments made to providers by the department of health pursuant to this division for inpatient hospital care, outpatient care, and all other medical assistance furnished to eligible recipients shall be made in accordance with rules adopted by the director of health pursuant to division (A) of section 3701.021 of the Revised Code.
The departments of health and medicaid shall jointly implement procedures to ensure that duplicate payments are not made under the program for children and youth with special health care needs and the medicaid program and to identify and recover duplicate payments.
(F) At the time of applying for participation in the program for children and youth with special health care needs, a child or youth with special health care needs or the child or youth's parent or guardian shall disclose the identity of any third party against whom the child or youth or the child or youth's parent or guardian has or may have a right of recovery for goods and services provided under division (B) or (D) of this section. The department of health shall require a child or youth with special health care needs who receives services from the program or the child or youth's parent or guardian to apply for all third-party benefits for which the child or youth may be eligible and require the child or youth, parent, or guardian to apply all third-party benefits received to the amount determined under division (E) of this section as the amount payable for goods and services authorized under division (B) or (D) of this section. The department is the payer of last resort and shall pay for authorized goods or services, up to the amount determined under division (E) of this section for the authorized goods or services, only to the extent that payment for the authorized goods or services is not made through third-party benefits. When a third party fails to act on an application or claim for benefits by a child or youth with special health care needs or the child or youth's parent or guardian, the department shall pay for the goods or services only after ninety days have elapsed since the date the child or youth, parents, or guardians made an application or claim for all third-party benefits. Third-party benefits received shall be applied to the amount determined under division (E) of this section. Third-party payments for goods and services not authorized under division (B) or (D) of this section shall not be applied to payment amounts determined under division (E) of this section. Payment made by the department shall be considered payment in full of the amount determined under division (E) of this section. Medicaid payments for persons eligible for the medicaid program shall be considered payment in full of the amount determined under division (E) of this section.
(G) The department of health shall administer a program to provide services to Ohio residents who are twenty-one or more years of age who have cystic fibrosis and who meet the eligibility requirements established in rules adopted by the director of health pursuant to division (A)(7) of section 3701.021 of the Revised Code, subject to all provisions of this section, but not subject to section 3701.024 of the Revised Code.
(H) The department of health shall provide for appeals, in accordance with rules adopted under section 3701.021 of the Revised Code, of denials of applications for the program for children and youth with special health care needs under division (A) or (D) of this section, disqualification of providers, or amounts paid under division (E) of this section. Appeals under this division are not subject to Chapter 119. of the Revised Code.
The department may designate ombudspersons to assist children and youth with special health care needs or their parents or guardians, upon the request of the children or youth, parents, or guardians, in filing appeals under this division and to serve as children or youth's, parents', or guardians' advocates in matters pertaining to the administration of the program for children and youth with special health care needs and eligibility for program services. The ombudspersons shall receive no compensation but shall be reimbursed by the department, in accordance with rules of the office of budget and management, for their actual and necessary travel expenses incurred in the performance of their duties.
(I) The department of health, and city and general health districts providing service coordination pursuant to division (A)(2) of section 3701.024 of the Revised Code, shall provide service coordination in accordance with the standards set forth in the rules adopted under section 3701.021 of the Revised Code, without charge, and without restriction as to economic status.
(J)(1) The department of health may establish a manufacturer discount program under which a manufacturer of a drug or nutritional formula is permitted to enter into an agreement with the department to provide a discount on the price of the drug or nutritional formula distributed to children and youth with special health care needs participating in the program for children and youth with special health care needs. The program shall be administered in accordance with rules adopted under section 3701.021 of the Revised Code.
(2) If a manufacturer enters into an agreement with the department as described in division (J)(1) of this section, the manufacturer and the department may negotiate the amount and terms of the discount.
(3) In lieu of establishing a discount program as described in division (J)(1) of this section, the department and a manufacturer of a drug or nutritional formula may discuss a donation of drugs, nutritional formulas, or money by the manufacturer to the department.
(K) As used in this division "209(b) option" has the same meaning as in section 5166.01 of the Revised Code.
The program for children and youth with special health care needs and the program the department of health administers pursuant to division (G) of this section shall continue to assist individuals who have cystic fibrosis and are enrolled in those programs in qualifying for medicaid under the spenddown process in the same manner it assists such individuals on September 29, 2015, regardless of whether the department of medicaid continues to implement the 209(b) option.
Last updated September 21, 2023 at 5:58 PM