reglab/statecodes huggingface dataset:
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.071 | Doula Program.

Effective:
October 3, 2023
Latest Legislation:
House Bill 33 - 135th General Assembly
(A) As used in this section, "doula" has the same meaning as in section 4723.89 of the Revised Code.
(B) The medicaid program shall operate a program to cover doula services that are provided by a doula if the doula has a valid provider agreement and is certified under section 4723.89 of the Revised Code.
(C) The medicaid director shall adopt rules under section 5164.02 of the Revised Code to implement this section. Notwithstanding any provision of section 121.95 of the Revised Code to the contrary, a regulatory restriction contained in a rule adopted under this section is not subject to sections 121.95 to 121.953 of the Revised Code.
Last updated February 12, 2024 at 9:13 AM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.072 | Coverage of Donor Breast Milk and Fortifiers.

Effective:
October 3, 2023
Latest Legislation:
House Bill 33 - 135th General Assembly
(A) As used in this section, "licensed health professional" means the following:
(1) A physician authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery;
(2) An advanced practice registered nurse who holds a current, valid license issued under Chapter 4723. of the Revised Code that authorizes the practice of nursing as an advanced practice registered nurse and is designated as a clinical specialist, certified nurse-midwife, or certified nurse practitioner;
(3) A physician assistant licensed under Chapter 4730. of the Revised Code.
(B) The medicaid program shall cover pasteurized human donor milk and human milk fortifiers, in both hospital and home settings, for an infant whose gestationally corrected age is less than twelve months when all of the following apply:
(1) A licensed health professional signs an order stating that human donor milk or human milk fortifiers are medically necessary because the infant meets any of the following criteria:
(a) The infant has a birth weight less than eighteen hundred grams or body weight below healthy levels.
(b) The infant has a gestational age at birth of thirty-four weeks or less.
(c) The infant has any congenital or acquired condition for which the health professional determines that the use of pasteurized human donor milk or human milk fortifiers will support the treatment of the condition and recovery of the infant.
(2) The infant is medically or physically unable to receive maternal breast milk or participate in breast-feeding, or the infant's mother is medically or physically unable to produce breast milk in sufficient quantities or of adequate caloric density, despite lactation support.
(C) The medicaid director may adopt rules in accordance with Chapter 119. of the Revised Code to implement this section.
Last updated October 12, 2023 at 11:41 AM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.09 | Equivalent Coverage for Orally and Intravenously Administered Cancer Medications.

Effective:
January 1, 2015
Latest Legislation:
Senate Bill 99 - 130th General Assembly
(A) Except as provided in division (C) of this section, the medicaid program shall cover prescribed, orally administered cancer medications on at least the same basis that it covers intraveneously administered or injected cancer medications. In implementing this section, the department of medicaid shall not institute cost-sharing requirements under section 5162.20 of the Revised Code for prescribed, orally administered cancer medications that are greater than any cost-sharing requirements instituted under that section for intraveneously administered or injected cancer medications.
(B) Division (A) of this section does not preclude the department from requiring a medicaid recipient to obtain prior authorization before a prescribed, orally administered cancer medication is dispensed to the recipient.
(C) This section shall not be implemented during a fiscal year if the medicaid director determines that this section's implementation would cause the costs of the medicaid program's coverage of prescribed drugs to increase by more than one per cent over such costs for the most recent previous fiscal year for which the amount of such costs is known.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.091 | Coverage for Opioid Analgesics.

Effective:
April 6, 2017
Latest Legislation:
Senate Bill 319 - 131st General Assembly
(A) As used in this section:
(1) "Benzodiazepine" has the same meaning as in section 3719.01 of the Revised Code.
(2) "Chronic pain" has the same meaning as in section 4731.052 of the Revised Code.
(3) "Hospice care program" and "hospice patient" have the same meanings as in section 3712.01 of the Revised Code.
(4) "Opioid analgesic" has the same meaning as in section 3719.01 of the Revised Code.
(5) "Prescriber" has the same meaning as in section 4729.01 of the Revised Code.
(6) "Terminal condition" means an irreversible, incurable, and untreatable condition that caused by disease, illness, or injury and will likely result in death. A terminal condition is one in which there can be no recovery, although there may be periods of remission.
(B)(1) With respect to the medicaid program's coverage of prescribed drugs, the department of medicaid shall apply prior authorization requirements or other utilization review measures as conditions of providing coverage of an opioid analgesic prescribed for the treatment of chronic pain, except when the drug is prescribed under one of the following circumstances:
(a) To an individual who is a hospice patient in a hospice care program;
(b) To an individual who has been diagnosed with a terminal condition but is not a hospice patient in a hospice care program;
(c) To an individual who has cancer or another condition associated with the individual's cancer or history of cancer.
(2) When implementing division (B)(1) of this section, the department shall consider either or both of the following, as applicable to the case in which the opioid analgesic is prescribed:
(a) If the course of treatment with the drug continues for more than ninety days, the requirements of section 4731.052 of the Revised Code;
(b) If the morphine equivalent daily dose for the drug exceeds eighty milligrams or the individual is being treated with a benzodiazepine at the time the opioid analgesic is prescribed, the guidelines established by the governor's cabinet opiate action team and presented in the document titled "Ohio Guidelines for Prescribing Opioids for the Treatment of Chronic, Non-terminal Pain 80 mg of a Morphine Equivalent Daily Dose (MED) 'Trigger Point'" or a successor document, unless the guidelines are no longer in effect at the time the opioid analgesic is prescribed.
(C) If the department measures the efficiency, quality of care, or clinical performance of a prescriber, including through the use of patient satisfaction surveys, it shall not penalize the prescriber, financially or otherwise, for deciding not to prescribe an opioid analgesic.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.092 | Coverage of Remote Ultrasounds and Fetal Nonstress Tests.

Effective:
October 3, 2023
Latest Legislation:
House Bill 33 - 135th General Assembly
(A) Except as provided in division (B) of this section, the medicaid program shall cover remote ultrasound procedures and remote fetal nonstress tests, utilizing established current procedural terminology codes (CPT codes) for those procedures for when the patient is in a residence or other off-site location from the patient's medicaid provider.
(B) The coverage under division (A) of this section applies only under the following circumstances:
(1) The medicaid provider responsible for the procedure uses digital technology that meets both of the following criteria:
(a) The technology is used only to collect medical and other data from a patient and electronically transmit that data securely to a health care provider in a different location for that provider's examination of the data;
(b) The technology has been approved by the United States food and drug administration for remote data acquisition, if required under federal law.
(2) For remote fetal nonstress tests, the CPT code includes a place of service modifier for at home monitoring using remote monitoring solutions that are cleared by the United States food and drug administration for monitoring fetal heart rate, maternal heart rate, and uterine activity.
(C) The department shall adopt rules as necessary to implement this section.
Last updated October 12, 2023 at 11:42 AM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.10 | Coverage of Tobacco Cessation Medications and Services.

Effective:
September 18, 2020
Latest Legislation:
House Bill 11 - 133rd General Assembly
(A) The medicaid program shall cover both of the following, subject to division (C) of this section:
(1) All tobacco cessation medications approved by the United States food and drug administration;
(2) All forms of tobacco cessation services recommended by the United States preventive services task force, including individual, group, and telephone counseling and any combination thereof.
(B) The department of medicaid shall not impose any of the following conditions with respect to the coverage required by this section:
(1) Counseling requirements for tobacco cessation medications;
(2) Except as provided in division (B)(4) of this section, limits on the duration of services, including annual or lifetime limits on the number of covered attempts to quit using tobacco;
(3) Cost-sharing requirements under section 5162.20 of the Revised Code;
(4) Prior authorization requirements, step therapy protocols as defined in section 5164.7512 of the Revised Code, or any other utilization management requirements, except that prior authorization may be required for either of the following:
(a) Treatment that exceeds the duration recommended in the United States public health service clinical practice guidelines on treating tobacco use and dependence;
(b) Services associated with more than two attempts to quit using tobacco within a twelve-month period.
(C) The director of health shall adopt rules in accordance with Chapter 119. of the Revised Code that establish standards and procedures for approving the forms of tobacco cessation medications and services that must be covered under this section. The rules shall also establish standards and procedures for updating the approved forms of tobacco cessation medications and services that must be covered under this section when the approved forms are modified by the United States food and drug administration, United States public health service, or United States preventive services task force.
(D) With respect to the coverage required by this section, the department of medicaid shall do both of the following:
(1) Inform medicaid recipients about the coverage;
(2) Market the coverage to Medicaid recipients.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.14 | Medicaid Coverage for Health Care Service Provided by Pharmacist.

Effective:
December 16, 2020
Latest Legislation:
House Bill 203 - 133rd General Assembly
The medicaid program may cover a health care service that a pharmacist provides to a medicaid recipient in accordance with Chapter 4729. of the Revised Code, including any of the following services:
(A) Managing drug therapy under a consult agreement pursuant to section 4729.39 of the Revised Code;
(B) Administering immunizations in accordance with section 4729.41 of the Revised Code;
(C) Administering drugs in accordance with section 4729.45 of the Revised Code.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.15 | Mental Health Services.

Effective:
April 6, 2023
Latest Legislation:
House Bill 281 - 134th General Assembly
(A) As used in this section:
(1) "Community mental health services provider or facility" means a community mental health services provider or facility that has its community mental health services certified by the department of mental health and addiction services under section 5119.36 of the Revised Code or by the department of job and family services under section 5103.03 of the Revised Code.
(2) "Mental health professional" means a person qualified to work with persons with mental illnesses under the standards established by the director of mental health and addiction services pursuant to section 5119.36 of the Revised Code.
(B) The medicaid program may cover the following mental health services when provided by community mental health services providers or facilities:
(1) Outpatient mental health services, including, but not limited to, preventive, diagnostic, therapeutic, rehabilitative, and palliative interventions rendered to individuals in an individual or group setting by a mental health professional in accordance with a plan of treatment appropriately established, monitored, and reviewed;
(2) Partial-hospitalization mental health services rendered by persons directly supervised by a mental health professional;
(3) Unscheduled, emergency mental health services of a kind ordinarily provided to persons in crisis when rendered by persons supervised by a mental health professional;
(4) Assertive community treatment and intensive home-based mental health services.
(C) The department of medicaid shall enter into a separate contract with the department of mental health and addiction services under section 5162.35 of the Revised Code with regard to the mental health services the medicaid program covers pursuant to this section.
Last updated September 29, 2023 at 2:49 PM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.16 | Coverage of One or More State Plan Home and Community-Based Services.

Effective:
September 18, 2020
Latest Legislation:
House Bill 11 - 133rd General Assembly
The medicaid program may cover one or more state plan home and community-based services that the department of medicaid selects for coverage. A medicaid recipient of any age may receive a state plan home and community-based service if the recipient has countable income not exceeding two hundred twenty-five per cent of the federal poverty line, has a medical need for the service, and meets all other eligibility requirements for the service specified in rules adopted under section 5164.02 of the Revised Code. The rules may not require a medicaid recipient to undergo a level of care determination to be eligible for a state plan home and community-based service.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.17 | Medicaid Coverage of Tobacco Cessation Services.

Effective:
September 18, 2020
Latest Legislation:
House Bill 11 - 133rd General Assembly
The medicaid program may cover tobacco cessation services in addition to the services that must be covered under section 5164.10 of the Revised Code or may exclude coverage of additional tobacco cessation services.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.25 | Recipient With Developmental Disability Who Is Eligible for Medicaid Case Management Services.

Effective:
October 12, 2016
Latest Legislation:
House Bill 158 - 131st General Assembly
The departments of developmental disabilities and medicaid may approve, reduce, deny, or terminate a medicaid service included in the individual service plan developed for a medicaid recipient with a developmental disability who is eligible for medicaid case management services. If either department approves, reduces, denies, or terminates a service, that department shall timely notify the medicaid recipient that the recipient may appeal pursuant to section 5160.31 of the Revised Code.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.26 | Healthcheck Component.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The department of medicaid shall establish a combination of written and oral methods designed to provide information about healthcheck to all persons eligible for the program or their parents or guardians. The department shall ensure that its methods of providing information are effective.
Each entity that distributes or accepts applications for medicaid shall prominently display a notice that complies with the methods of providing information about healthcheck established under this section.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.29 | Revised Medicaid Provider Enrollment System.

Effective:
September 29, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
Not later than December 31, 2018, the department of medicaid shall develop and implement revisions to the system by which persons and government entities become and remain medicaid providers so that there is a single system of records for the system and the persons and government entities do not have to submit duplicate data to the state to become or remain medicaid providers for any component or aspect of a component of the medicaid program, including a component or aspect of a component administered by another state agency or political subdivision pursuant to a contract entered into under section 5162.35 of the Revised Code. The departments of aging, developmental disabilities, and mental health and addiction services shall participate in the development of the revisions and shall utilize the revised system.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.291 | Provider Credentialing Committee.

Effective:
March 23, 2022
Latest Legislation:
House Bill 122 - 134th General Assembly
The department of medicaid shall establish a credentialing program that includes a credentialing committee to review the competence, professional conduct, and quality of care provided by medicaid providers.
Any activities performed by the credentialing committee shall be considered activities of a peer review committee of a health care entity and shall be subject to sections 2305.25 to 2305.253 of the Revised Code.
The medicaid director may adopt rules under section 5164.02 of the Revised Code as necessary to implement this section. Any rules adopted shall be consistent with the requirements that apply to medicare advantage organizations under 42 C.F.R. 422.204.
Last updated January 27, 2022 at 3:52 PM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.30 | Provider Agreement With Department Required.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
No person or government entity may participate in the medicaid program as a medicaid provider without a valid provider agreement with the department of medicaid.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.301 | Medicaid Provider Agreements for Physician Assistants.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) As used in this section, "group practice" has the same meaning as in section 4731.65 of the Revised Code.
(B) The department of medicaid shall establish a process by which a physician assistant may enter into a provider agreement.
(C)(1) Subject to division (C)(2) of this section, a claim for medicaid payment for a medicaid service provided by a physician assistant to a medicaid recipient may be submitted by the physician assistant who provided the service or the physician, group practice, clinic, or other health care facility that employs the physician assistant.
(2) A claim for medicaid payment may be submitted by the physician assistant who provided the service only if the physician assistant has a valid provider agreement. When submitting the claim, the physician assistant shall use only the medicaid provider number the department has assigned to the physician assistant.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.31 | Funding for Implementing the Provider Screening Requirements.

Effective:
September 29, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
(A) For the purpose of raising funds necessary to pay the expenses of implementing the provider screening requirements of subpart E of 42 C.F.R. Part 455 and except as provided in division (B) of this section, the department of medicaid shall collect an application fee from a medicaid provider before doing any of the following:
(1) Entering into a provider agreement with a medicaid provider that seeks initial enrollment as a provider;
(2) Entering into a provider agreement with a former medicaid provider that seeks re-enrollment as a provider;
(3) Revalidating a medicaid provider's continued enrollment as a provider.
(B) The department is not to collect an application fee from a medicaid provider that is exempt from paying the fee under 42 C.F.R. 455.460(a).
(C) The application fees shall be deposited into the health care/medicaid support and recoveries fund created under section 5162.52 of the Revised Code. Application fees are nonrefundable when collected in accordance with 42 C.F.R. 455.460(a).
(D) The medicaid director shall adopt rules under section 5164.02 of the Revised Code as necessary to implement this section, including a rule establishing the amount of the application fee to be collected under this section. The amount of the application fee shall not be set at an amount that is more than necessary to pay for the expenses of implementing the provider screening requirements.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.32 | Expiration of Medicaid Provider Agreements.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) Each medicaid provider agreement shall expire not later than five years from its effective date. If a provider agreement entered into before the effective date of this amendment does not have a time limit, the department of medicaid shall convert the agreement to a provider agreement with a time limit.
(B) The medicaid director shall adopt rules under section 5164.02 of the Revised Code as necessary to implement this section. The rules shall be consistent with subpart E of 42 C.F.R. Part 455 and include a process for revalidating medicaid providers' continued enrollments as providers. All of the following apply to the revalidation process:
(1) The department shall refuse to revalidate a provider's provider agreement when the provider fails to file a complete application for revalidation within the time and in the manner required under the revalidation process.
(2) If a provider files a complete application for revalidation within the time and in the manner required under the revalidation process, but the provider agreement expires before the department acts on the application or before the effective date of the department's decision on the application, the provider, subject to division (B)(3) of this section, may continue operating under the terms of the expired provider agreement until the effective date of the department's decision.
(3) If a provider continues operating under the terms of an expired provider agreement pursuant to division (B)(2) of this section and the department denies the provider's application for revalidation, medicaid payments shall not be made for services or items the provider provides during the period beginning on the date the provider agreement expired and ending on the effective date of a subsequent provider agreement, if any, the department enters into with the provider.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.33 | Denying, Terminating, and Suspending Provider Agreements.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) The medicaid director may do the following for any reason permitted or required by federal law and when the director determines that the action is in the best interests of medicaid recipients or the state:
(1) Deny, refuse to revalidate, suspend, or terminate a provider agreement;
(2) Exclude an individual, provider of services or goods, or other entity from participation in the medicaid program.
(B) No individual, provider, or entity excluded from participation in the medicaid program under this section shall do any of the following:
(1) Own, or provide services to, any other medicaid provider or risk contractor;
(2) Arrange for, render, or order services for medicaid recipients during the period of exclusion;
(3) During the period of exclusion, receive direct payments under the medicaid program or indirect payments of medicaid funds in the form of salary, shared fees, contracts, kickbacks, or rebates from or through any other medicaid provider or risk contractor.
(C) An individual, provider, or entity excluded from participation in the medicaid program under this section may request a reconsideration of the exclusion. The director shall adopt rules under section 5164.02 of the Revised Code governing the process for requesting a reconsideration.
(D) Nothing in this section limits the applicability of section 5164.38 of the Revised Code to a medicaid provider.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.37 | Suspension of Provider Agreement Without Notice.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
(A) The department of medicaid may suspend a medicaid provider's provider agreement without prior notice if the department has evidence that the provider presents a danger of immediate and serious harm to the health, safety, or welfare of medicaid recipients. The department also shall suspend all medicaid payments to the medicaid provider for services rendered, regardless of the date that the services were rendered, when the department suspends the provider agreement under this section.
(B) If the department suspends a medicaid provider's provider agreement under this section, the department shall do both of the following:
(1) Not later than five days after suspending the provider agreement, notify the medicaid provider of the suspension;
(2) Not later than ten business days after suspending the provider agreement, notify the medicaid provider that the department intends to terminate the provider agreement.
(C) The notice that the department provides to a medicaid provider under division (B)(2) of this section shall include the allegation that the provider presents a danger of immediate and serious harm to the health, safety, or welfare of medicaid recipients. It may also include other grounds for terminating the provider agreement. Section 5164.38 of the Revised Code applies to the termination of the provider agreement.
(D) The suspension of a medicaid provider's provider agreement and medicaid payments shall cease at the earliest of the following:
(1) The department's failure to provide a notice required by division (B) of this section by the time specified in that division;
(2) The department rescinds its notice to terminate the provider agreement.
(3) The department issues an order regarding the termination of the provider agreement pursuant to an adjudication conducted in accordance with Chapter 119. of the Revised Code.
(E) This section does not limit the department's authority to suspend or terminate a provider agreement or medicaid payments to a medicaid provider under any other provision of the Revised Code.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.39 | Hearing Not Required Unless Timely Requested.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
In any action taken by the department of medicaid under section 5164.38 or 5164.57 of the Revised Code or any other state statute governing the medicaid program that requires the department to give notice of an opportunity for a hearing in accordance with Chapter 119. of the Revised Code, if the department gives notice of the opportunity for a hearing but the medicaid provider or other entity subject to the notice does not request a hearing or timely request a hearing in accordance with section 119.07 of the Revised Code, the department is not required to hold a hearing. The medicaid director may proceed by issuing a final adjudication order in accordance with Chapter 119. of the Revised Code.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.44 | Employee Status of Independent Provider.

Effective:
March 23, 2016
Latest Legislation:
House Bill 56 - 131st General Assembly
(A) As used in this section:
(1) "Aide services" means all of the following:
(a) Home health aide services covered by the medicaid program as part of the home health services benefit pursuant to 42 C.F.R. 440.70(b)(2);
(b) Home care attendant services covered by a participating medicaid waiver component, as defined in section 5166.30 of the Revised Code;
(c) Any of the following covered by a home and community-based services medicaid waiver component:
(i) Personal care aide services;
(ii) Homemaker/personal care services;
(iii) Community inclusion services.
(2) "Independent provider" means an individual who personally provides aide services or nursing services under the medicaid program and is not employed by, under contract with, or affiliated with another entity that provides the services.
(3) "Nursing services" means all of the following:
(a) Nursing services covered by the medicaid program as part of the home health services benefit pursuant to 42 C.F.R. 440.70(b)(1);
(b) Private duty nursing services, as defined in 42 C.F.R. 440.80, covered by the medicaid program;
(c) Nursing services covered by a home and community-based services medicaid waiver component.
(B) Notwithstanding any provision of the Revised Code to the contrary, an independent provider is not an employee of the state, or any political subdivision of the state, for any purpose under state law due to being an independent provider or any actions taken to become or remain an independent provider.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.46 | Electronic Claims Submission Process; Electronic Fund Transfers.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) As used in this section, "electronic claims submission process" means any of the following:
(1) Electronic interchange of data;
(2) Direct entry of data through an internet-based mechanism implemented by the department of medicaid;
(3) Any other process for the electronic submission of claims that is specified in rules adopted under section 5162.02 of the Revised Code.
(B) Not later than January 1, 2013, and except as provided in division (C) of this section, each medicaid provider shall do both of the following:
(1) Use only an electronic claims submission process to submit to the department of medicaid claims for medicaid payment for medicaid services provided to medicaid recipients;
(2) Arrange to receive medicaid payment from the department by means of electronic funds transfer.
(C) Division (B) of this section does not apply to any of the following:
(1) A nursing facility;
(2) An ICF/IID;
(3) A medicaid managed care organization;
(4) Any other medicaid provider or type of medicaid provider designated in rules adopted under section 5162.02 of the Revised Code.
(D) The department shall not process a medicaid claim submitted on or after January 1, 2013, unless the claim is submitted through an electronic claims submission process in accordance with this section.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.47 | Contracting for Review and Analysis, Quality Assurance and Quality Review.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) As used in this section, "OCHSPS" means the private, not-for-profit corporation known as the Ohio children's hospital solutions for patient safety, which was formed for the purpose of improving pediatric patient care in this state, which performs functions that are included within the functions of a peer review committee as defined in section 2305.25 of the Revised Code, and which consists of all of the following members: Akron children's hospital, Cincinnati children's hospital medical center, Cleveland clinic children's hospital, Dayton children's medical center, mercy children's hospital, nationwide children's hospital, rainbow babies & children's hospital, and Toledo children's hospital.
(B) If, as authorized by section 5160.10 of the Revised Code, the medicaid director chooses to contract with a person to perform either or both of the following services, the director may contract with any qualified person, including OCHSPS, to perform the service or services on behalf of the department of medicaid:
(1) Review and analyze claims for medicaid services provided to children in accordance with all state and federal laws governing the confidentiality of patient-identifying information;
(2) Perform quality assurance and quality review functions, other than those described in division (B)(1) of this section, related to medicaid services provided to children.
The functions specified in division (B)(2) of this section may include those recommended by the best evidence for advancing child health in Ohio now (BEACON) council.
(C) If the director enters into a contract with OCHSPS for OCHSPS to perform either or both of the services described in division (B) of this section, OCHSPS shall, only for purposes of section 5160.12 of the Revised Code, be considered a public entity and the director shall seek federal financial participation for costs incurred by OCHSPS in performing the service or services.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.471 | Summary Data Regarding Perinatal Services.

Effective:
April 6, 2017
Latest Legislation:
Senate Bill 332 - 131st General Assembly
Not less than once each year and in accordance with all state and federal laws governing the confidentiality of patient-identifying information, the department of medicaid shall make summary data regarding perinatal services available on request to local organizations concerned with infant mortality reduction initiatives and recipients of grants administered by the division of family and community health services in the department of health.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.48 | Medicaid Payments Made to Organization on Behalf of Providers.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The medicaid director may implement a system under which medicaid payments for medicaid services are made to an organization on behalf of medicaid providers. The system may not provide for an organization to receive an amount that exceeds, in aggregate, the amount the medicaid program would have paid directly to medicaid providers if not for this section.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.55 | Final Fiscal Audits.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The department of medicaid may conduct final fiscal audits of medicaid providers in accordance with the applicable requirements set forth in federal laws and regulations and determine any amounts the provider may owe the state. When conducting final fiscal audits, the department shall consider generally accepted auditing standards, which include the use of statistical sampling.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.56 | Lien for Amount Owed by Provider.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
Under the medicaid program, any amount determined to be owed the state by a final fiscal audit conducted pursuant to section 5164.55 of the Revised Code, upon the issuance of an adjudication order pursuant to Chapter 119. of the Revised Code that contains a finding that there is a preponderance of the evidence that a medicaid provider will liquidate assets or file bankruptcy in order to prevent payment of the amount determined to be owed the state, becomes a lien upon the real and personal property of the provider. Upon failure of the provider to pay the amount to the state, the medicaid director shall file notice of the lien, for which there shall be no charge, in the office of the county recorder of the county in which it is ascertained that the provider owns real or personal property. The director shall notify the provider by mail of the lien, but absence of proof that the notice was sent does not affect the validity of the lien. The lien is not valid as against the claim of any mortgagee, pledgee, purchaser, judgment creditor, or other lienholder of record at the time the notice is filed.
If the provider acquires real or personal property after notice of the lien is filed, the lien shall not be valid as against the claim of any mortgagee, pledgee, subsequent bona fide purchaser for value, judgment creditor, or other lienholder of record to such after-acquired property unless the notice of lien is refiled after the property is acquired by the provider and before the competing lien attaches to the after-acquired property or before the conveyance to the subsequent bona fide purchaser for value.
When the amount has been paid, the provider may record with the recorder notice of the payment. For recording such notice of payment, the recorder shall charge and receive from the provider a base fee of one dollar for services and a housing trust fund fee of one dollar pursuant to section 317.36 of the Revised Code.
In the event of a distribution of the provider's assets pursuant to an order of any court under the law of this state including any receivership, assignment for benefit of creditors, adjudicated insolvency, or similar proceedings, amounts then or thereafter due the state under the medicaid program have the same priority as provided by law for the payment of taxes due the state and shall be paid out of the receivership trust fund or other such trust fund in the same manner as provided for claims for unpaid taxes due the state.
If the attorney general finds after investigation that any amount due the state under the medicaid program is uncollectable, in whole or in part, the attorney general shall recommend to the director the cancellation of all or part of the claim. The director may thereupon effect the cancellation.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.58 | Agency Action to Recover Overpayment to Provider.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) If a state agency that enters into a contract with the department of medicaid under section 5162.35 of the Revised Code identifies that a medicaid overpayment has been made to a medicaid provider, the state agency may commence actions to recover the overpayment on behalf of the department.
(B) In recovering an overpayment pursuant to this section, a state agency shall comply with the following procedures:
(1) The state agency shall attempt to recover the overpayment by notifying the medicaid provider of the overpayment and requesting voluntary repayment. Not later than five business days after notifying the medicaid provider, the state agency shall notify the department in writing of the overpayment. The state agency may negotiate a settlement of the overpayment and notify the department of the settlement. A settlement negotiated by the state agency is not valid and shall not be implemented until the department has given its written approval of the settlement.
(2) If the state agency is unable to obtain voluntary repayment of an overpayment, the agency shall give the medicaid provider notice of an opportunity for a hearing in accordance with Chapter 119. of the Revised Code. If the medicaid provider timely requests a hearing in accordance with section 119.07 of the Revised Code, the state agency shall conduct the hearing to determine the legal and factual validity of the overpayment. On completion of the hearing, the state agency shall submit its hearing officer's report and recommendation and the complete record of proceedings, including all transcripts, to the medicaid director for final adjudication. The director may issue a final adjudication order in accordance with Chapter 119. of the Revised Code. The state agency shall pay any attorney's fees imposed under section 119.092 of the Revised Code. The department of medicaid shall pay any attorney's fees imposed under section 2335.39 of the Revised Code.
(C) In any action taken by a state agency under this section that requires the agency to give notice of an opportunity for a hearing in accordance with Chapter 119. of the Revised Code, if the agency gives notice of the opportunity for a hearing but the medicaid provider subject to the notice does not request a hearing or timely request a hearing in accordance with section 119.07 of the Revised Code, the agency is not required to hold a hearing. The agency may request that the medicaid director issue a final adjudication order in accordance with Chapter 119. of the Revised Code.
(D) This section does not preclude the department of medicaid from adjudicating a final fiscal audit under section 5164.38 of the Revised Code, recovering overpayments under section 5164.57 of the Revised Code, or making findings or taking other actions authorized by state statutes governing the medicaid program.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.59 | Deduction of Incorrect Payments.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The department of medicaid may deduct from medicaid payments for medicaid services rendered by a medicaid provider any amounts the provider owes the state as the result of incorrect medicaid payments the department has made to the provider.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.60 | Interest on Medicaid Provider Excess Payments.

Effective:
October 3, 2023
Latest Legislation:
House Bill 33 - 135th General Assembly
Any medicaid provider who, without intent, obtains payments under the medicaid program in excess of the amount to which the provider is entitled is liable for payment of interest on the amount of the excess payments for a period determined by the department, but not to exceed the period from the date on which payment was made to the date on which repayment is made to the state. The interest shall be paid at the average bank prime rate in effect on the first day of the calendar quarter during which the provider receives notice of the excess payment. The department of medicaid shall determine the average bank prime rate using statistical release H.15, "selected interest rates," a weekly publication of the federal reserve board, or any successor publication. If statistical release H.15, or its successor, ceases to contain the bank prime rate information or ceases to be published, the department shall request a written statement of the average bank prime rate from the federal reserve bank of Cleveland or the federal reserve board.
Last updated October 5, 2023 at 3:23 PM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.61 | Scope of Available Remedies for Recovery of Excess Payments.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The authority, under state and federal law, of the department of medicaid or a county department of job and family services to recover excess medicaid payments made to a medicaid provider is not limited by the availability of remedies under sections 5162.21 and 5162.23 of the Revised Code for recovering benefits paid on behalf of medicaid recipients.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.70 | Limitations on Medicaid Payments for Services.

Effective:
September 29, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
Except as otherwise required by federal statute or regulation, no medicaid payment for any medicaid service provided by a hospital, nursing facility, or ICF/IID shall exceed the limits established under Subpart C of 42 C.F.R. Part 447.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.71 | Payments for Freestanding Medical Laboratory Charges.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
Medicaid payments for freestanding medical laboratory charges shall not exceed the customary and usual fee for laboratory profiles.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.72 | Limitations on Payments for Inpatient Hospital Care.

Effective:
October 3, 2023
Latest Legislation:
House Bill 33 - 135th General Assembly
The number of days of inpatient hospital care for which a medicaid payment is made on behalf of a medicaid recipient to a hospital that is not paid under a diagnostic-related-group prospective payment system shall not exceed thirty days during a period beginning on the day of the recipient's admission to the hospital and ending sixty days after the termination of that hospital stay, except that the department of medicaid may make exceptions to this limitation. The limitation does not apply to children and youth participating in the program for children and youth with special health care needs established under section 3701.023 of the Revised Code.
Last updated October 5, 2023 at 3:23 PM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.721 | Claims by Freestanding Birthing Centers.

Effective:
April 6, 2017
Latest Legislation:
Senate Bill 332 - 131st General Assembly
A hospital or freestanding birthing center that is a medicaid provider may submit to the department of medicaid or the department's fiscal agent a medicaid claim that is both of the following:
(A) For a long-acting reversible contraceptive device that is covered by medicaid and provided to a medicaid recipient during the period after the recipient gives birth in the hospital or center and before the recipient is discharged from that location ;
(B) Separate from another medicaid claim for other inpatient care the hospital or center provides to the medicaid recipient.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5164 | Medicaid State Plan Services › Section 5164.73 | Division of Payments Between Physician or Podiatrist and Nurse.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The division of any medicaid payment between a collaborating physician or podiatrist and a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner for services performed by the nurse shall be determined and agreed on by the nurse and collaborating physician or podiatrist. In no case shall the medicaid payment exceed the medicaid payment that the physician or podiatrist would have received had the physician or podiatrist provided the entire service.