reglab/statecodes huggingface dataset:
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5166 | Federal Medicaid Waiver Programs › Section 5166.404 | Points Award System.

Effective:
September 29, 2015
Latest Legislation:
House Bill 64 - 131st General Assembly
(A) The medicaid director shall establish a system under which points are awarded in accordance with this section to healthy Ohio program debit swipe cards. One dollar of medicaid funds shall be deposited into a healthy Ohio program participant's buckeye account for each point awarded to the participant under this section.
(B) The director shall provide a one-time award of twenty points to a healthy Ohio program participant who provides for the participant's contributions under division (C) of section 5166.402 of the Revised Code to be made by electronic funds transfers from the participant's checking or savings account. Twenty points shall be deducted from the participant's card if the participant terminates the electronic funds transfers.
(C) The director may award up to two hundred points annually to a healthy Ohio program participant who achieves health care goals. The points shall be awarded in accordance with the rules authorized by section 5166.409 of the Revised Code. A participant shall not be awarded more than two hundred points per year under this division regardless of the number of health care goals the participant achieves that year.
(D) Up to one hundred points may be awarded annually to a healthy Ohio program participant by one or more primary care physicians who verify that the participant has satisfied health care benchmarks set by the physicians. A participant shall not be awarded more than one hundred points per year under this division regardless of how many primary care physicians award points to the participant that year and the number of points the primary care physicians award the participant that year.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5166 | Federal Medicaid Waiver Programs › Section 5166.405 | Cessation of Participation.

Effective:
September 29, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
(A) A healthy Ohio program participant's participation in the program shall cease if any of the following applies:
(1) Unless the participant is pregnant, a monthly installment payment to the participant's buckeye account is sixty days late.
(2) The participant fails to submit documentation needed for a redetermination of the participant's eligibility for medicaid before the sixty-first day after the documentation is requested.
(3) The participant becomes eligible for medicaid on a basis other than being included in the category identified by the department of medicaid as covered families and children or being included in the expansion eligibility group.
(4) The participant becomes a ward of the state.
(5) The participant ceases to be eligible for medicaid.
(6) The participant exhausts the annual or lifetime payout limit specified in division (D) of section 5166.401 of the Revised Code.
(7) The participant requests that the participant's participation be terminated.
(B) A healthy Ohio program participant who ceases to participate in the program under division (A)(1) or (2) of this section may not resume participation until the former participant pays the full amount of the monthly installment payment or submits the documentation needed for the former participant's medicaid eligibility redetermination. The former participant shall not be transferred to the fee-for-service component of medicaid or the care management system as a result of ceasing to participate in the healthy Ohio program under division (A)(1) or (2) of this section.
(C) Except as provided in section 5166.407 of the Revised Code, a healthy Ohio program participant who ceases to participate in the program shall be provided the contributions that are in the participant's buckeye account at the time the participant ceases participation.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5166 | Federal Medicaid Waiver Programs › Section 5166.406 | Exhaustion of Payout Limits.

Effective:
September 29, 2015
Latest Legislation:
House Bill 64 - 131st General Assembly
If a healthy Ohio program participant exhausts the annual or lifetime payout limits specified in division (D) of section 5166.401 of the Revised Code, the participant shall be transferred to the fee-for-service component of medicaid or the care management system. A participant who exhausts the annual payout limit for a year shall resume participation in the healthy Ohio program at the beginning of the immediately following year if division (B) of section 5166.40 of the Revised Code continues to apply to the participant.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5166 | Federal Medicaid Waiver Programs › Section 5166.407 | Disqualification for Medicaid; Disposition of Remainder in Buckeye Account.

Effective:
September 29, 2015
Latest Legislation:
House Bill 64 - 131st General Assembly
(A) If a healthy Ohio program participant ceases to qualify for medicaid due to increased family countable income and purchases a health insurance policy or obtains health care coverage under an eligible employer-sponsored health plan, the amount remaining in the former participant's buckeye account shall be transferred to an account to be known as a bridge account. The amount so transferred may be used only to pay for the following:
(1) If the former participant has purchased a health insurance policy, the former participant's costs in purchasing the policy and paying for the former participant's out-of-pocket expenses under the policy for health care services and prescription drugs covered by the policy;
(2) If the former participant has obtained health care coverage under an eligible employer-sponsored health plan, the former participant's out-of-pocket expenses under the plan for health care services and prescription drugs covered by the plan.
(B) Only the amount remaining in a former healthy Ohio program participant's buckeye account at the time the former participant ceased to participate in the healthy Ohio program shall be deposited into the bridge account. The bridge account shall be closed once the amount transferred to it under division (A) of this section is exhausted.
(C) The medicaid director shall notify a former healthy Ohio program participant when a bridge account is established for the former participant under this section.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5166 | Federal Medicaid Waiver Programs › Section 5166.408 | Referral to Workforce Development Agency.

Effective:
September 29, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
Each county department of job and family services shall offer to refer to a local board each healthy Ohio program participant who resides in the county served by the county department and is either unemployed or employed for less than an average of twenty hours per week. The referral shall include information about the workforce development activities available from the local board. A participant may refuse to accept the referral and to participate in the workforce development activities without any affect on the participant's eligibility for, or participation in, the healthy Ohio program.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5166 | Federal Medicaid Waiver Programs › Section 5166.409 | Rules.

Effective:
September 29, 2015
Latest Legislation:
House Bill 64 - 131st General Assembly
The medicaid director shall adopt rules under section 5166.02 of the Revised Code to do all of the following:
(A) For the purpose of division (F)(1)(a) of section 5166.402 of the Revised Code, establish requirements regarding preventative health services for healthy Ohio program participants. The requirements may differ for participants of different ages and genders.
(B) For the purpose of division (G)(2) of section 5166.402 of the Revised Code, authorize additional uses of a buckeye account and establish the means for using the account for those purposes.
(C) For the purpose of division (A)(3) of section 5166.403 of the Revised Code, establish requirements for the use of a healthy Ohio program debit swipe card to pay for the costs of medically necessary health care services not covered by the health plan in which a healthy Ohio program participant enrolls.
(D) For the purpose of division (C) of section 5166.404 of the Revised Code, establish a system under which the director may award points to healthy Ohio program participants who achieve health care goals. The rules shall specify the goals that qualify for points and the number of points each goal is worth. The number of points may vary for different goals.
(E) For the purpose of section 5166.407 of the Revised Code, establish procedures and requirements for the transfer of the amounts remaining in former healthy Ohio program participants' buckeye accounts to bridge accounts.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5166 | Federal Medicaid Waiver Programs › Section 5166.45 | Medicaid Enrollment for Chidren Through Age Three.

Effective:
October 3, 2023
Latest Legislation:
House Bill 33 - 135th General Assembly
(A) As used in this section, "medical assistance program" and "refugee medical assistance program" have the same meanings as in section 5160.01 of the Revised Code.
(B) The medicaid director shall establish a medicaid waiver component to provide continuous medicaid enrollment for children from birth through three years of age. A child who is determined eligible for medical assistance under Title XIX of the "Social Security Act" or child health assistance under Title XXI of the "Social Security Act" shall remain eligible for those benefits until the earlier of:
(1) The end of a period, not to exceed forty-eight months, following the determination;
(2) The date when the individual exceeds four years of age.
(C) The waiver component described in division (B) of this section does not apply to a child who is eligible for a medical assistance program on the basis of being any of the following:
(1) Deemed presumptively eligible for medicaid pursuant to section 5163.101 of the Revised Code;
(2) Eligible for alien emergency medical assistance, as specified in section 1903(v)(2) of the "Social Security Act," 42 U.S.C. 1396b(v)(2);
(3) Eligible for the refugee medical assistance program administered pursuant to section 5160.50 of the Revised Code.
Last updated October 6, 2023 at 5:11 PM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.02 | Rules.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The medicaid director shall adopt rules as necessary to implement this chapter. The rules shall be adopted in accordance with Chapter 119. of the Revised Code.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.03 | Care Management System.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
As part of the medicaid program, the department of medicaid shall establish a care management system. The department shall implement the system in some or all counties.
The department shall designate the medicaid recipients who are required or permitted to participate in the care management system. Those who shall be required to participate in the system include medicaid recipients who receive cognitive behavioral therapy as described in division (A)(2) of section 5167.16 of the Revised Code. Except as provided in section 5166.406 of the Revised Code, no medicaid recipient participating in the healthy Ohio program established under section 5166.40 of the Revised Code shall participate in the system.
The general assembly's authorization through the enactment of legislation is needed before home and community-based services available under a medicaid waiver component or nursing facility services are included in the care management system, except that ICDS participants may be required or permitted to obtain such services under the system. Medicaid recipients who receive such services may be designated for voluntary or mandatory participation in the system in order to receive other health care services included in the system.
The department may require or permit participants in the care management system to do either or both of the following:
(A) Obtain health care services from providers designated by the department;
(B) Enroll in a medicaid MCO plan.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.04 | Inclusion of Alcohol, Drug Addiction, and Mental Health Services in Care Management System.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
The department of medicaid shall include alcohol, drug addiction, and mental health services covered by medicaid in the care management system.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.05 | Inclusion of Prescribed Drugs in Care Management System.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
The department of medicaid may include prescribed drugs covered by the medicaid program in the care management system.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.051 | Coverage of Services Provided by Pharmacist.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
If the medicaid program covers the pharmacist services described in section 5164.14 of the Revised Code, the department of medicaid may include the services in the care management system.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.10 | Authority to Contract With Managed Care Orgainizations.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
The department of medicaid may enter into contracts with managed care organizations under which the organizations are authorized to provide, or arrange for the provision of, health care services to medicaid recipients who are required or permitted to participate in the care management system.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.101 | Basis of Hospital Inpatient Capital Payment Portion of Payment to Medicaid Managed Care Organization.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
(A) Subject to division (B) of this section, the department of medicaid or its actuary shall base the hospital inpatient capital payment portion of the payment made to a medicaid managed care organization on data for services provided to all of the organization's enrollees, as reported by hospitals on relevant cost reports submitted pursuant to rules adopted under section 5167.02 of the Revised Code.
(B) The hospital inpatient capital payment portion of the payment made to medicaid managed care organizations shall not exceed any maximum rate established in rules adopted under section 5167.02 of the Revised Code.
If a maximum rate is established, a medicaid managed care organization shall not compensate hospitals for inpatient capital costs in an amount that exceeds that rate.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.103 | Performance Metrics; Publication.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
In addition to the managed care performance payment program created under section 5167.30 of the Revised Code, the department of medicaid shall establish performance metrics that will be used to evaluate and compare how medicaid managed care organizations perform under the contracts entered into under section 5167.10 of the Revised Code. The performance metrics may include financial incentives and penalties.
The department shall make available on its internet web site the metrics the department uses to determine how well medicaid managed care organizations perform. The department shall update its internet web site each quarter to reflect any changes it makes to the metrics.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.11 | Managed Care Organization Contract to Provide Grievance Process.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
Each medicaid managed care organization shall provide a grievance process for the organization's enrollees in accordance with 42 C.F.R. 438, subpart F.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.12 | Requirements When Prescribed Drugs Are Included in Care Management System.

Effective:
October 3, 2023
Latest Legislation:
House Bill 33 - 135th General Assembly
If prescribed drugs are included in the care management system:
(A) Medicaid MCO plans may include strategies for the management of drug utilization, but any such strategies are subject to the limitations and requirements of this section and the approval of the department of medicaid.
(B) A medicaid MCO plan shall not impose a prior authorization requirement in the case of a drug to which all of the following apply:
(1) The drug is an antidepressant or antipsychotic.
(2) The drug is administered or dispensed in a standard tablet or capsule form, except that in the case of an antipsychotic, the drug also may be administered or dispensed in a long-acting injectable form.
(3) The drug is prescribed by any of the following:
(a) A physician who has registered the physician's psychiatric specialty with the department;
(b) A psychiatrist who is practicing at a location on behalf of a community mental health services provider whose mental health services are certified by the department of mental health and addiction services under section 5119.36 of the Revised Code;
(c) A certified nurse practitioner, as defined in section 4723.01 of the Revised Code, who is certified in psychiatric mental health by a national certifying organization approved by the board of nursing under section 4723.46 of the Revised Code;
(d) A clinical nurse specialist, as defined in section 4723.01 of the Revised Code, who is certified in psychiatric mental health by a national certifying organization approved by the board of nursing under section 4723.46 of the Revised Code.
(4) The drug is prescribed for a use that is indicated on the drug's labeling, as approved by the federal food and drug administration.
(C) The department shall authorize a medicaid MCO plan to include a pharmacy utilization management program under which prior authorization through the program is established as a condition of obtaining a controlled substance pursuant to a prescription.
(D) Each medicaid managed care organization and medicaid MCO plan shall comply with sections 5164.091, 5164.10, 5164.7511, 5164.7512, and 5164.7514 of the Revised Code as if the organization were the department and the plan were the medicaid program.
Last updated October 6, 2023 at 10:44 AM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.122 | Disclosure of Sources of Payment.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
(A) The state pharmacy benefit manager shall, on request from the department of medicaid, disclose to the department all sources of payment it receives for prescribed drugs, including any financial benefits such as drug rebates, discounts, credits, clawbacks, fees, grants, chargebacks, reimbursements, or other payments related to services provided for the medicaid managed care organization.
(B) Each medicaid managed care organization shall disclose to the department of medicaid in the format specified by the department the organization's administrative costs associated with providing pharmacy services under the care management system.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.123 | Medicaid Mco Contracts With 340b Program Participants.

Effective:
April 12, 2021
Latest Legislation:
Senate Bill 263 - 133rd General Assembly
(A) No contract between a medicaid managed care organization, including a third-party administrator, and a 340B covered entity shall contain any of the following provisions:
(1) A payment rate for a prescribed drug that is less than the national average drug acquisition cost rate for that drug as determined by the United States centers for medicare and medicaid services, measured at the time the drug is administered or dispensed, or, if no such rate is available at that time, a reimbursement rate that is less than the wholesale acquisition cost of the drug, as defined in 42 U.S.C. 1395w-3a(c)(6)(B);
(2) A fee that is not imposed on a health care provider that is not a 340B covered entity;
(3) A fee amount that exceeds the amount for a health care provider that is not a 340B covered entity.
(B) The organization, or its contracted third-party administrators, shall not discriminate against a 340B covered entity in a manner that prevents or interferes with a medicaid recipient's choice to receive a prescription drug from a 340B covered entity or its contracted pharmacies.
(C) Any provision of a contract entered into between the organization and a 340B covered entity that is contrary to division (A) of this section is unenforceable and shall be replaced with the dispensing fee or payment rate that applies for health care providers that are not 340B covered entities.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.13 | Implementation of Coordinated Services Program for Enrollees Who Abuse Prescribed Drugs.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
Each medicaid managed care organization shall implement a coordinated services program for the organization's enrollees who are found to have obtained prescribed drugs under the medicaid program at a frequency or in an amount that is not medically necessary. The program shall be implemented in a manner that is consistent with section 1915(a)(2) of the "Social Security Act," 42 U.S.C. 1396n(a)(2), and 42 C.F.R. 431.54(e).
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.14 | Data Security Agreements for Managed Care Organization's Use of Drug Database.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
Each medicaid managed care organization shall enter into a data security agreement with the state board of pharmacy governing the managed care organization's use of the board's drug database established and maintained under section 4729.75 of the Revised Code.
This section does not apply if the board no longer maintains the drug database.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.15 | Chiropractic Services.

Effective:
June 13, 2022
Latest Legislation:
House Bill 136 - 134th General Assembly
When contracting under section 5167.10 of the Revised Code with a medicaid managed care organization, the department of medicaid shall require the organization to comply with section 5164.061 of the Revised Code as if the organization were the department.
This section does not limit the authority of a medicaid managed care organization to implement measures designed to improve quality and reduce costs.
Last updated March 22, 2022 at 2:04 PM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.16 | Home Visits and Cognitive Behavioral Therapy.

Effective:
September 30, 2021
Latest Legislation:
House Bill 110 - 134th General Assembly
(A) As used in this section:
(1) "Help me grow program" means the program established by the department of health pursuant to section 3701.61 of the Revised Code.
(2) "Targeted case management" has the same meaning as in 42 C.F.R. 440.169(b).
(B) A medicaid managed care organization shall provide to a medicaid recipient who meets the criteria in division (C) of this section, or arrange for such recipient to receive, both of the following types of services:
(1) Home visits, which shall include depression screenings, for which federal financial participation is available under the targeted case management benefit;
(2) Cognitive behavioral therapy, provided by a community mental health services provider, that is determined to be medically necessary through a depression screening conducted as part of a home visit.
(C) A medicaid recipient qualifies to receive the services specified in division (B) of this section if the medicaid recipient is enrolled in the help me grow program, enrolled in the medicaid managed care organization providing or arranging for the services, and is either pregnant or the birth mother of a child under five years of age.
(D) If requested by a medicaid recipient eligible for the cognitive behavioral therapy covered under division (B)(2) of this section, the therapy shall be provided in the recipient's home. The medicaid managed care organization shall inform the medicaid recipient of the right to make the request and how to make it.
Last updated September 29, 2023 at 2:54 PM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.17 | Enhanced Care Management Services for Pregnant Women and Women Capable of Becoming Pregnant.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
Each medicaid managed care organization shall provide enhanced care management services for pregnant women and women capable of becoming pregnant in the communities specified in rules adopted under section 3701.142 of the Revised Code. The services shall be provided in a manner intended to decrease the incidence of prematurity, low birth weight, and infant mortality, as well as improve the overall health status of women capable of becoming pregnant for the purpose of ensuring optimal future birth outcomes.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.171 | Uniform Prior Approval Form for Progesterone.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
Each medicaid managed care organization shall, if the organization requires practitioners to obtain prior approval before administering progesterone to the organization's enrollees who are pregnant, use a uniform prior approval form for progesterone that is not more than one page.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.18 | Identification of Fraud, Waste, and Abuse.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
Each medicaid managed care organization shall comply with federal and state efforts to identify fraud, waste, and abuse in the medicaid program.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.20 | Reference by Managed Care Organization to Noncontracting Participant.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
(A) Except as provided in division (B) of this section, when a medicaid managed care organization refers an enrollee to receive services, other than emergency services provided on or after January 1, 2007, at a hospital that participates in the medicaid program but is not under contract with the organization, the hospital shall provide the service for which the referral was made and shall accept from the organization, as payment in full, the amount derived from the payment rate used by the department of medicaid to pay other hospitals of the same type for providing the same service to a medicaid recipient who is not enrolled in a medicaid MCO plan.
(B) A hospital is not subject to division (A) of this section if all of the following are the case:
(1) The hospital is located in a county in which participants in the care management system are required before January 1, 2006, to be enrolled in a medicaid MCO plan;
(2) The hospital has entered into a contract before January 1, 2006, with at least one health insuring corporation serving the participants specified in division (B)(1) of this section;
(3) The hospital remains under contract with at least one health insuring corporation serving participants in the care management system who are required to be enrolled in a medicaid MCO plan.
(C) The medicaid director shall adopt rules under section 5167.02 of the Revised Code specifying the circumstances under which a medicaid managed care organization is permitted to refer an enrollee to a hospital that is not under contract with the organization.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.201 | Payment of Nonsystem Provider for Emergency Services.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
When a medicaid managed care organization's enrollee receives emergency services on or after January 1, 2007, from a provider that is not under contract with the organization, the provider shall accept from the organization, as payment in full, not more than the amounts (less any payments for indirect costs of medical education and direct costs of graduate medical education) that the provider could collect if the enrollee received medicaid other than through enrollment in a medicaid MCO plan.
An agreement entered into by an enrollee, an enrollee's parent, or an enrollee's legal guardian that requires payment for emergency services in violation of this section is void and unenforceable.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.21 | Payments to Skilled Nursing Facility.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) As used in this section:
(1) "Covered skilled nursing facility services" has the same meaning as in the "Social Security Act," section 1888(e)(2)(A), 42 U.S.C. 1395yy(e)(2)(A).
(2) "Current medicare fee-for-service rate" means the fee-for-service rate in effect for a covered skilled nursing facility service under medicare at the time the service is provided.
(3) "Skilled nursing facility" has the same meaning as in the "Social Security Act," section 1819(a), 42 U.S.C. 1395i-3(a).
(B) Except as provided in division (C) of this section, a medicaid managed care organization shall pay a skilled nursing facility at least the current medicare fee-for-service rate, without deduction for any coinsurance, for covered skilled nursing facility services that the skilled nursing facility provides to a dual eligible individual if the medicaid managed care organization is responsible for the payment under the terms of a contract that the medicaid managed care organization, medicaid director, and United States secretary of health and human services jointly enter into under the integrated care delivery system authorized by section 5164.91 of the Revised Code.
(C) A medicaid managed care organization is required to pay the rate specified in division (B) of this section for covered skilled nursing facility services only if all of the following apply:
(1) The United States secretary agrees to the payment rate as part of the contract that the medicaid managed care organization, medicaid director, and United States secretary jointly enter into under the integrated care delivery system;
(2) The medicaid managed care organization receives a federal capitation payment that is an actuarially sufficient amount for the costs that the medicaid managed care organization incurs in paying the rate;
(3) No state funds are used for any part of the costs that the medicaid managed care organization incurs in paying the rate;
(4) The integrated care delivery system provides for dual eligible individuals to receive the covered skilled nursing facility services as part of the system.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.22 | Recoupment of Overpayment.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
When a medicaid managed care organization seeks to recoup an overpayment made to a provider, it shall provide the provider all of the details of the recoupment, including all of the following information:
(A) The name, address, and medicaid identification number of the enrollee to whom the services were provided;
(B) The date or dates that the services were provided;
(C) The reason for the recoupment;
(D) The method by which the provider may contest the proposed recoupment.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.221 | Assessment of Recoupment Efforts.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
The department of medicaid shall assess the efforts of medicaid managed care organizations to recoup overpayments made to providers who are network providers and providers who are not network providers. The assessments shall examine the amount of time recoupment efforts take starting from the time providers receive final payment and ending when the recoupment effort is completed. Each medicaid managed care organization shall submit to the department information regarding such recoupment efforts that the department needs to perform the assessments. The department shall specify what information is so needed. Following the assessments, the department shall include in the contracts entered into with medicaid managed care organizations under section 5167.10 of the Revised Code terms the department determines are reasonable to establish limits on such recoupment efforts. The terms shall include exceptions for cases of fraud and other types of deception.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.241 | State Pharmacy Benefit Manager Contract; Payment Arrangements.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
(A)(1) Medicaid managed care organizations shall use the state pharmacy benefit manager selected under section 5167.24 of the Revised Code pursuant to the terms of the master contract entered into under that section.
All payment arrangements between the department of medicaid, medicaid managed care organizations, and the state pharmacy benefit manager shall comply with state and federal statutes, regulations adopted by the centers for medicare and medicaid services, and any other agreement between the department and the centers for medicare and medicaid services. The director may change a payment arrangement in order to comply with state and federal statutes, regulations adopted by the centers for medicare and medicaid services, or any other agreement between the department and the centers for medicare and medicaid services.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.243 | Quarterly Reports.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
(A) The state pharmacy benefit manager shall provide to the medicaid director a written quarterly report containing the following information from the immediately preceding quarter:
(1) The prices that the state pharmacy benefit manager negotiated for prescribed drugs under the care management system. The price must include any rebates the state pharmacy benefit manager received from the drug manufacturer;
(2) The prices the state pharmacy benefit manager paid to pharmacies for prescribed drugs;
(3) Any rebate amounts the state pharmacy benefit manager passed on to individual pharmacies;
(4) The percentage of savings in drug prices that are passed on to participants in the care management system;
(5) The information described in division (C) of section 5167.24 of the Revised Code;
(6) Any other information required by the director.
(B) The director may ask the state pharmacy benefit manager to provide additional information as necessary and shall collect other clinical data from the state pharmacy benefit manager as the director sees fit.
(C) At the time of contract execution, renewal, or modification, the department shall modify the reporting requirements under its medicaid managed care organization contracts as necessary to meet the requirements of this section.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.244 | Violations; Penalty.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
No person shall violate the terms of the master state pharmacy benefit manager contract under section 5167.24 of the Revised Code or section 5167.241 of the Revised Code. Whoever violates those sections is subject to a civil penalty in an amount to be determined by the medicaid director.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.245 | Appeals Process.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
The medicaid director shall establish an appeals process by which pharmacies may appeal to the department of medicaid any disputes relating to the maximum allowable cost set by the state pharmacy benefit manager for a prescribed drug. All pharmacies participating in the care management system shall use the appeals process to resolve any disputes relating to the maximum allowable cost set by the state pharmacy benefit manager.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.26 | Records for Determining Costs.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
For the purpose of determining the amount the department of medicaid pays hospitals under section 5168.09 of the Revised Code and the amount of disproportionate share hospital payments paid by the medicare program pursuant to section 1915 of the "Social Security Act," 42 U.S.C. 1396n, a medicaid managed care organization shall keep detailed records for each hospital with which it contracts, including records regarding the cost to the hospital of providing hospital services for the organization, payments made by the organization to the hospital for the services, utilization of hospital services by the organization's enrollees, and other utilization data required by the department.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.30 | Managed Care Performance Payment Program.

Effective:
September 29, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
(A)(1) The department of medicaid shall establish a managed care performance payment program. Under the program, the department may provide payments to medicaid managed care organizations that meet performance standards established by the department.
(2) In establishing performance standards, the department may consult any of the following:
(a) Any quality measurements developed under the pediatric quality measures program established pursuant to the "Social Security Act," section 1139A, 42 U.S.C. 1320b-9a;
(b) Any core set of adult health quality measures for medicaid eligible adults used for purposes of the "Social Security Act," section 1139A, 42 U.S.C. 1320b-9b, and any adult health quality used for purposes of the medicaid quality measurement program when the program is established under that section of the "Social Security Act";
(c) The most recent healthcare effectiveness data and information set and quality measurement tool established by the national committee for quality assurance.
(3) The standards that must be met to receive the payments may be specified in the contract the department enters into with a medicaid managed care organization.
(4) If a medicaid managed care organization meets the performance standards established by the department, the department shall make one or more performance payments to the organization. The amount of each performance payment, the number of payments, and the schedule for making the payments shall be established by the department. The payments shall be discontinued if the department determines that the organization no longer meets the performance standards. The department shall not make or discontinue payments based on any performance standard that has been in effect as part of the organization's contract for less than six months.
(B) For purposes of the program, the department shall establish an amount that is to be withheld each time a premium payment is made to a medicaid managed care organization. The amount shall be established as a percentage of each premium payment. The percentage shall be the same for all medicaid managed care organizations. The sum of all withholdings under this division shall not exceed five per cent of the total of all premium payments made to all medicaid managed care organizations.
Each medicaid managed care organization shall agree to the withholding as a condition of receiving or maintaining its provider agreement with the department.
When the amount is established and each time the amount is modified thereafter, the department shall certify the amount to the director of budget and management and begin withholding the amount from each premium the department pays to a medicaid managed care organization.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.31 | Financial Incentive Awards.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The department of medicaid may provide financial incentive awards to medicaid managed care organizations that meet or exceed performance standards specified in provider agreements or rules adopted by the medicaid director under section 5167.02 of the Revised Code. The department may specify in a contract with a medicaid managed care organization the amounts of financial incentive awards, methodology for distributing awards, types of awards, and standards for administration by the department.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.32 | Improving Integrity of Care Management System.

Effective:
September 29, 2015
Latest Legislation:
House Bill 64 - 131st General Assembly
Not later than July 1, 2016, the department of medicaid shall implement strategies to improve the integrity of the care management system, including strategies to do both of the following:
(A) Increase the department's oversight of medicaid managed care organizations;
(B) Provide incentives for identifying fraud, waste, and abuse in the care management system.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.33 | Strategies Regarding Payment to Providers.

Effective:
September 29, 2015
Latest Legislation:
House Bill 64 - 131st General Assembly
(A) Not later than July 1, 2018, each medicaid managed care organization shall implement strategies that base payments to providers on the value received from the providers' services, including their success in reducing waste in the provision of the services. Not later than July 1, 2020, each medicaid managed care organization shall ensure that at least fifty per cent of the aggregate net payments it makes to providers are based on the value received from the providers' services.
The department of medicaid may measure a medicaid managed care organization's compliance with this section based on the actions of the organization, the providers in the organization's provider panel, the organization's subcontractors, or any combination of the organization, providers, and subcontractors.
(B) The medicaid director shall adopt rules under section 5167.02 of the Revised Code as necessary to implement this section, including rules that specify how all of the following are to be determined:
(1) The value received from a provider's services;
(2) A provider's success in reducing waste in the provision of services;
(3) The percentage of a medicaid managed care organization's aggregate net payments to providers that are based on the value received from the providers' services.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.34 | Immunity From Liability.

Effective:
September 29, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
A medicaid managed care organization, its officers, employees, or other persons associated with the managed care organization are not liable in a civil action for damages or other relief for furnishing information to the department of medicaid regarding potential fraud, waste, or abuse in the medicaid program.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.40 | Appointment of Temporary Manager.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The department of medicaid shall appoint a temporary manager for a medicaid managed care organization if the department determines that the medicaid managed care organization has repeatedly failed to meet substantive requirements specified in the "Social Security Act," sections 1903(m) and 1932, 42 U.S.C. 1396b(m) and 1396u-2; or 42 C.F.R. 438 Part I. The appointment of a temporary manager does not preclude the department from imposing other sanctions available to the department against the medicaid managed care organization.
The medicaid managed care organization shall pay all costs of having the temporary manager perform the temporary manager's duties, including all costs the temporary manager incurs in performing those duties. If the temporary manager incurs costs or liabilities on behalf of the medicaid managed care organization, the medicaid managed care organization shall pay those costs and be responsible for those liabilities.
The appointment of a temporary manager is not subject to Chapter 119. of the Revised Code, but the managed care organization may request a reconsideration of the appointment. Reconsiderations shall be requested and conducted in accordance with rules the medicaid director shall adopt under section 5167.02 of the Revised Code.
The appointment of a temporary manager does not cause the medicaid managed care organization to lose the right to appeal, in accordance with Chapter 119. of the Revised Code, any proposed termination or any decision not to revalidate the medicaid managed care organization's provider agreement or the right to initiate the sale of the medicaid managed care organization or its assets.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.41 | Disenrolling Some or All Medicaid Recipients From Mco Plan Offered by a Managed Care Organization.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
The department of medicaid may disenroll some or all medicaid recipients from a medicaid MCO plan offered by a medicaid managed care organization if the department proposes to terminate or not to renew the contract entered into under section 5167.10 of the Revised Code and determines that the recipients' access to medically necessary services is jeopardized by the proposal to terminate or not to renew the contract. The disenrollment is not subject to Chapter 119. of the Revised Code, but the medicaid managed care organization may request a reconsideration of the disenrollment. Reconsiderations shall be requested and conducted in accordance with rules the medicaid director shall adopt under section 5167.02 of the Revised Code. The request for, or conduct of, a reconsideration regarding a proposed disenrollment shall not delay the disenrollment.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5167 | Medicaid Managed Care › Section 5167.45 | Information About Medicaid Recipients' Races, Ethnicities, and Primary Languages.

Effective:
April 6, 2017
Latest Legislation:
Senate Bill 332 - 131st General Assembly
The department of medicaid shall include information about medicaid recipients' races, ethnicities, and primary languages in data the department shares with medicaid managed care organizations. Medicaid managed care organizations shall include this information in the data the organizations share with providers.