Chapter 5160: MEDICAL ASSISTANCE PROGRAMS

5160.01 Defintions.

As used in this chapter:

(A) "Dual eligible individual" has the same meaning as in the "Social Security Act," section 1915(h)(2)(B), 42 U.S.C. 1396n(h)(2)(B). A dual eligible individual is a medicare-medicaid enrollee (MME).

(B) "Exchange" has the same meaning as in 45 C.F.R. 155.20.

(C) "Federal financial participation" means the federal government's share of expenditures made by an entity in implementing a medical assistance program.

(D) "Medical assistance program" means all of the following:

(1) The medicaid program;

(2) The children's health insurance program;

(3) The refugee medical assistance program;

(4) Any other program that provides medical assistance and state statutes authorize the department of medicaid to administer.

(E) "Medical assistance recipient" means a recipient of a medical assistance program. To the extent appropriate in the context, "medical assistance recipient" includes an individual applying for a medical assistance program, a former medical assistance recipient, or both.

(F) "Medicaid managed care organization" has the same meaning as in section 5167.01 of the Revised Code.

(G) "Refugee medical assistance program" means the program that the department of medicaid administers pursuant to section 5160.50 of the Revised Code.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.011 References to department or director of other agencies.

References to the department or director of public welfare, department or director of human services, department or director of job and family services, office of medical assistance, or medical assistance director in any statute, rule, contract, grant, or other document is deemed to refer to the department of medicaid or medicaid director, as the case may be, to the extent the reference is about a duty or authority of the department of medicaid or medicaid director regarding a medical assistance program.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.02 Rules.

The medicaid director shall adopt rules as necessary to implement this chapter.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.021 Adoption of rules.

(A) When the medicaid director is authorized by a statute to adopt a rule, the director shall adopt the rule in accordance with the following:

(1) Chapter 119. of the Revised Code if either of the following applies:

(a) The statute authorizing the rule requires that the rule be adopted in accordance with Chapter 119. of the Revised Code.

(b) Unless division (A)(2)(b) of this section applies, the statute authorizing the rule does not specify the procedure for the rule's adoption.

(2) Section 111.15 of the Revised Code, excluding divisions (D) and (E) of that section, if either of the following applies:

(a) The statute authorizing the rule requires that the rule be adopted in accordance with section 111.15 of the Revised Code and, by the terms of division (D) of that section, division (D) of that section does not apply to the rule.

(b) The statute authorizing the rule does not specify the procedure for the rule's adoption and the rule concerns the day-to-day staff procedures and operations of the department of medicaid or financial and operational matters between the department and a person or government entity receiving a grant from the department.

(3) Section 111.15 of the Revised Code, including divisions (D) and (E) of that section, if the statute authorizing the rule requires that the rule be adopted in accordance with that section and the rule is not exempt from the application of division (D) of that section.

(B) Except as otherwise required by a statute, the adoption of a rule in accordance with Chapter 119. of the Revised Code does not make the department of medicaid subject to the notice, hearing, or other requirements of sections 119.06 to 119.13 of the Revised Code.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.03 Authority of medicaid director.

The medicaid director is the executive head of the department of medicaid. All duties conferred on the department by law or order of the director are under the director's control and shall be performed in accordance with rules the director adopts.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.04 Assistant director; powers and duties.

The medicaid director shall appoint one assistant director for the department of medicaid. The assistant director shall exercise powers, and perform duties, as ordered by the medicaid director. The assistant director shall act as the medicaid director in the medicaid director's absence or disability and when the position of medicaid director is vacant.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.05 Appointment of employees.

The medicaid director may appoint such employees as are necessary for the efficient operation of the department of medicaid. The director may prescribe the title and duties of the employees.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.051 Filling positions with peculiar and exceptional qualifications.

If the medicaid director determines that a position with the department of medicaid can best be filled in accordance with division (A)(2) of section 124.30 of the Revised Code or without regard to a residency requirement established by a rule adopted by the director of administrative services, the medicaid director shall provide the director of administrative services certification of the determination.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.052 Procedures and formats for section 109.5721 notices.

The department of medicaid shall collaborate with the superintendent of the bureau of criminal identification and investigation to develop procedures and formats necessary to produce the notices described in division (C) of section 109.5721 of the Revised Code in a format that is acceptable for use by the department. The medicaid director may adopt rules under section 5160.02 of the Revised Code necessary for such collaboration. Any such rules shall be adopted in accordance with section 111.15 of the Revised Code as if they were internal management rules.

The medicaid director may adopt rules under section 5160.02 of the Revised Code necessary for utilizing the information received pursuant to section 109.5721 of the Revised Code. The rules shall be adopted in accordance with Chapter 119. of the Revised Code.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.06 Fidelity bonds.

The medicaid director may require any of the employees of the department of medicaid who may be charged with custody or control of any public money or property or who is required to give bond, to give a bond, properly conditioned, in a sum to be fixed by the director which when approved by the director, shall be filed in the office of the secretary of state. The cost of such bonds, when approved by the director, shall be paid from funds available for the department. The bonds required or authorized by this section may, in the discretion of the director, be individual, schedule, or blanket bonds.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.10 Expending funds.

The medicaid director may expend funds appropriated or available to the department of medicaid from persons and government entities. For purposes of this section, the director may enter into contracts or agreements with persons and government entities and make grants to persons and government entities. To the extent permitted by federal law, the director may advance funds to a grantee when necessary for the grantee to perform duties under the grant as specified by the director.

The director may adopt rules under section 5160.02 of the Revised Code as necessary to define terms and adopt procedures and other provisions necessary to implement this section.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.11 State health care grants fund.

The state health care grants fund is hereby created in the state treasury. Money the department of medicaid receives from private foundations in support of pilot projects that promote exemplary programs that enhance programs the department administers shall be credited to the fund. The department may expend the money on such projects, may use the money, to the extent allowable, to match federal financial participation in support of such projects, and shall comply with requirements the foundations have stipulated in their agreements with the department as to the purposes for which the money may be expended.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.12 Seeking federal financial participation for costs incurred by entity implementing program administered by department.

(A) As used in this section, "entity" includes an agency, board, commission, or department of the state or a political subdivision of the state; a private, nonprofit entity; a school district; a private school; or a public or private institution of higher education.

(B) This section does not apply to contracts entered into under section 5162.32 or 5162.35 of the Revised Code.

(C) At the request of any public entity having authority to implement a program administered by the department of medicaid or any private entity under contract with a public entity to implement a program administered by the department, the department may seek to obtain federal financial participation for costs incurred by the entity. Federal financial participation may be sought from programs operated pursuant to Title XIX of the "Social Security Act," 42 U.S.C. 1396, et seq., and any other statute or regulation under which federal financial participation may be available, except that federal financial participation may be sought only for expenditures made with funds for which federal financial participation is available under federal law.

(D) All funds collected by the department pursuant to division (C) of this section shall be distributed to the entities that incurred the costs.

(E) In distributing federal financial participation pursuant to this section, the department may either enter into an agreement with the entity that is to receive the funds or distribute the funds in accordance with rules authorized by division (H) of this section. If the department decides to enter into an agreement to distribute the funds, the agreement may include terms that do any of the following:

(1) Provide for the whole or partial reimbursement of any cost incurred by the entity in implementing the program;

(2) In the event that federal financial participation is disallowed or otherwise unavailable for any expenditure, require the department or the entity, whichever party caused the disallowance or unavailability of federal financial participation, to assume responsibility for the expenditures;

(3) Require the entity to certify to the department the availability of sufficient unencumbered funds to match the federal financial participation the entity receives under this section;

(4) Establish the length of the agreement, which may be for a fixed or a continuing period of time;

(5) Establish any other requirements determined by the department to be necessary for the efficient administration of the agreement.

(F) An entity that receives federal financial participation pursuant to this section for a program aiding children and their families shall establish a process for collaborative planning with the department for the use of the funds to improve and expand the program.

(G) Federal financial participation received pursuant to this section shall not be included in any calculation made under section 5101.16 or 5101.161 of the Revised Code.

(H) The medicaid director may adopt rules under section 5160.02 of the Revised Code as necessary to implement this section, including rules for the distribution of federal financial participation pursuant to this section. The rules shall be adopted in accordance with Chapter 119. of the Revised Code.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.13 Maximizing receipt of federal revenue.

The department of medicaid may enter into contracts with private entities to maximize federal revenue without the expenditure of state money. In selecting private entities with which to contract, the department shall engage in a request for proposals process. The department, subject to the approval of the controlling board, may also directly enter into contracts with public entities providing revenue maximization services.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.16 Appointment of agents.

The department of medicaid may appoint and commission any competent person to serve as a special agent, investigator, or representative to perform a designated duty for and on behalf of the department. Specific credentials shall be given by the department to each person so designated, and each credential shall state the following:

(A) The person's name;

(B) The agency with which the person is connected;

(C) The purpose of the appointment;

(D) The date the appointment expires, if appropriate;

(E) Such information as the department considers proper.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.20 Audits and investigations; authority of department.

(A) The department of medicaid may conduct any audits or investigations that are necessary in the performance of the department's duties, and to that end, the department has the same power as a judge of a county court to administer oaths and to enforce the attendance and testimony of witnesses and the production of books or papers.

The department shall keep a record of the department's audits and investigations stating the time, place, charges, or subject; witnesses summoned and examined; and the department's conclusions.

Witnesses shall be paid the fees and mileage provided for under section 119.094 of the Revised Code.

(B) Any judge of any division of the court of common pleas, on application of the department, may compel the attendance of witnesses, the production of books or papers, and the giving of testimony before the department, by a judgment for contempt or otherwise, in the same manner as in cases before those courts.

(C) Until an audit report is formally released by the department, the audit report or any working paper or other document or record prepared by the department and related to the audit that is the subject of the audit report is not a public record under section 149.43 of the Revised Code.

(D) The medicaid director may adopt rules under section 5160.02 of the Revised Code as necessary to implement this section. The rules shall be adopted in accordance with section 111.15 of the Revised Code as if they were internal management rules.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.21 Audit of medical assistance recipient.

On the request of the medicaid director, the auditor of state may conduct an audit of any medical assistance recipient. If the auditor decides to conduct an audit under this section, the auditor shall enter into an interagency agreement with the department of medicaid that specifies that the auditor agrees to comply with section 5160.45 of the Revised Code with respect to any information the auditor receives pursuant to the audit.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.22 Examination of records regarding medical assistance programs.

(A) The auditor of state and attorney general, or their designees, may examine any records, whether in computer or printed format, in the possession of the medicaid director or any county director of job and family services, regarding medical assistance programs. The auditor of state and attorney general shall do both of the following regarding the records:

(1) Provide safeguards that restrict access to the records to purposes directly connected with an audit or investigation, prosecution, or criminal or civil proceeding conducted in connection with the administration of the programs;

(2) Comply, and ensure that their designees comply, with section 5160.45 of the Revised Code and rules of the medicaid director restricting the disclosure of information regarding medical assistance recipients.

(B) Any person who fails to comply with the restriction specified in division (A) of this section is disqualified from acting as an agent or employee or in any other capacity under appointment or employment of any state board, commission, or agency.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.23 Audit costs.

The auditor of state is responsible for the costs the auditor incurs in carrying out the auditor's duties under sections 5160.21 and 5160.22 of the Revised Code.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.30 Administrative activities for medical assistance programs.

(A) Except as provided in divisions (B) and (C) of this section, the department of medicaid may accept applications, determine eligibility, redetermine eligibility, and perform related administrative activities for medical assistance programs.

(B) The department may enter into agreements with one or more agencies of the federal government, the state, other states, and local governments of this or other states to accept applications, determine eligibility, redetermine eligibility, and perform related administrative activities on behalf of the department with respect to medical assistance programs.

(C) If federal law requires a face-to-face interview to complete an eligibility determination for a medical assistance program, the department shall not conduct the face-to-face interview.

(D) Subject to division (C) of this section, if the department elects to accept applications, determine eligibility, redetermine eligibility, and perform related administrative activities for a medical assistance program, both of the following apply:

(1) An individual may apply for the medical assistance program to the department or an agency authorized by an agreement entered into under division (B) of this section to accept the individual's application;

(2) The department is subject to federal statutes and regulations and state statutes and rules that require, permit, or prohibit an action regarding accepting applications, determining or redetermining eligibility, and performing related administrative activities for the medical assistance program.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.31 Appeals regarding determination of eligiblity for medical assistance program.

(A) A medical assistance recipient may appeal a decision regarding the recipient's eligibility for a medical assistance program or services available to the recipient under a medical assistance program.

(B) Regarding appeals authorized by this section, the department of medicaid shall do one or more of the following:

(1) Administer an appeals process similar to the appeals process established under section 5101.35 of the Revised Code;

(2) Contract with the department of job and family services pursuant to section 5162.35 of the Revised Code to provide for the department of job and family services to hear the appeals in accordance with section 5101.35 of the Revised Code;

(3) Delegate authority to hear appeals to an exchange or exchange appeals entity.

(C) If a medical assistance recipient files an appeal as authorized by this section, the department of medicaid may do either or both of the following:

(1) Take corrective action regarding the matter being appealed before a hearing decision regarding the matter is issued;

(2) If a hearing decision, administrative appeal decision, or court ruling is against the recipient, take action in favor of the recipient despite the contrary decision or ruling, unless, in the case of a court's ruling, the ruling prohibits the department from taking the action.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.35 [Renumbered from 5101.571] Recovery of medical support definitions.

As used in sections 5160.35 to 5160.43 of the Revised Code:

(A) "Information" means all of the following:

(1) An individual's name, address, date of birth, and social security number;

(2) The group or plan number, or other identifier, assigned by a third party to a policy held by an individual or a plan in which the individual participates and the nature of the coverage;

(3) Any other data the medicaid director specifies in rules authorized by section 5160.43 of the Revised Code.

(B)

"Medical support" means support specified as support for the purpose of medical care by order of a court or administrative agency.

(C)

(1) Subject to division (C)(2) of this section, and except as provided in division (C)(3) of this section, "third party" means all of the following:

(a) A person authorized to engage in the business of sickness and accident insurance under Title XXXIX of the Revised Code;

(b) A person or governmental entity providing coverage for medical services or items to individuals on a self-insurance basis;

(c) A health insuring corporation as defined in section 1751.01 of the Revised Code;

(d) A group health plan as defined in 29 U.S.C. 1167;

(e) A service benefit plan as referenced in 42 U.S.C. 1396a(a)(25);

(f) A managed care organization;

(g) A pharmacy benefit manager;

(h) A third party administrator;

(i) Any other person or governmental entity that is, by law, contract, or agreement, responsible for the payment or processing of a claim for a medical item or service for a medical assistance recipient .

(2) Except when otherwise provided by the "Social Security Act," section 1862(b), 42 U.S.C. 1395y(b), a person or governmental entity listed in division (C)(1) of this section is a third party even if the person or governmental entity limits or excludes payments for a medical item or service in the case of a public assistance recipient.

(3) "Third party" does not include the program for medically handicapped children established under section 3701.023 of the Revised Code.

Renumbered from § 5101.571 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 10/1/2011.

Amended by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 10/16/2009.

Effective Date: 06-30-1994; 2007 HB119 09-29-2007; 2008 HB562 09-22-2008

5160.37 [Renumbered from 5101.58] Right of recovery for cost of medical assistance.

(A) A medical assistance recipient's enrollment in a medical assistance program gives an automatic right of recovery to the department of medicaid and a county department of job and family services against the liability of a third party for the cost of medical assistance paid on behalf of the recipient . When an action or claim is brought against a third party by a medical assistance recipient , any payment, settlement or compromise of the action or claim, or any court award or judgment, is subject to the recovery right of the department of medicaid or county department . Except in the case of a medical assistance recipient who receives medical assistance through a medicaid managed care organization, the department's or county department's claim shall not exceed the amount of medical assistance paid by the department or county department on behalf of the recipient . A payment, settlement, compromise, judgment, or award that excludes the cost of medical assistance paid for by the department or county department shall not preclude a department from enforcing its rights under this section.

(B) In the case of a medical assistance recipient who receives medical assistance through a medicaid managed care organization, the amount of the department's or county department's claim shall be the amount the medicaid managed care organization pays for medical assistance rendered to the recipient , even if that amount is more than the amount the department or county department pays to the medicaid managed care organization for the recipient's medical assistance.

(C) A medical assistance recipient , and the recipient's attorney, if any, shall cooperate with the departments. In furtherance of this requirement, the medical assistance recipient , or the recipient's attorney, if any, shall, not later than thirty days after initiating informal recovery activity or filing a legal recovery action against a third party, provide written notice of the activity or action to the department of medicaid or county department if it has paid for medical assistance under a medical assistance program.

(D) The written notice that must be given under division (C) of this section shall disclose the identity and address of any third party against whom the medical assistance recipient has or may have a right of recovery.

(E) No settlement, compromise, judgment, or award or any recovery in any action or claim by a medical assistance recipient where the department or county department has a right of recovery shall be made final without first giving the department or county department written notice as described in division (C) of this section and a reasonable opportunity to perfect its rights of recovery. If the department or county department is not given the appropriate written notice, the medical assistance recipient and, if there is one, the recipient's attorney, are liable to reimburse the department or county department for the recovery received to the extent of medical assistance payments made by the department or county department.

(F) The department or county department shall be permitted to enforce its recovery rights against the third party even though it accepted prior payments in discharge of its rights under this section if, at the time the department or county department received such payments, it was not aware that additional medical expenses had been incurred but had not yet been paid by the department or county department. The third party becomes liable to the department or county department as soon as the third party is notified in writing of the valid claims for recovery under this section.

(G)

(1) Subject to division (G)(2) of this section, the right of recovery of the department or county department does not apply to that portion of any judgment, award, settlement, or compromise of a claim, to the extent of attorneys' fees, costs, or other expenses incurred by a medical assistance recipient in securing the judgment, award, settlement, or compromise, or to the extent of medical, surgical, and hospital expenses paid by such recipient from the recipient's own resources.

(2) Reasonable attorneys' fees, not to exceed one-third of the total judgment, award, settlement, or compromise, plus costs and other expenses incurred by the medical assistance recipient in securing the judgment, award, settlement, or compromise, shall first be deducted from the total judgment, award, settlement, or compromise. After fees, costs, and other expenses are deducted from the total judgment, award, settlement, or compromise, the department of medicaid or county department shall receive no less than one-half of the remaining amount, or the actual amount of medical assistance paid, whichever is less.

(H) A right of recovery created by this section may be enforced separately or jointly by the department of medicaid or county department . To enforce its recovery rights, the department or county department may do any of the following:

(1) Intervene or join in any action or proceeding brought by the medical assistance recipient or on the recipient's behalf against any third party who may be liable for the cost of medical assistance paid;

(2) Institute and pursue legal proceedings against any third party who may be liable for the cost of medical assistance paid;

(3) Initiate legal proceedings in conjunction with any injured, diseased, or disabled medical assistance recipient or the recipient's attorney or representative.

(I) A medical assistance recipient shall not assess attorney fees, costs, or other expenses against the department of medicaid or a county department when the department or county department enforces its right of recovery created by this section.

(J) The right of recovery given to the department under this section includes payments made by a third party under contract with a person having a duty to support.

(K) [Effective 1/1/2014] The department of medicaid may assign to a medical assistance provider the right of recovery given to the department under this section with respect to any claim for which the department has notified the provider that the department intends to recoup the department's prior payment for the claim.

Renumbered from § 5101.58 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013 and 1/1/2014.

Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 10/1/2011.

Amended by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 10/16/2009.

Effective Date: 06-26-2003; 2007 HB119 09-29-2007; 2008 HB562 09-22-2008

5160.371 Disclosure of third-party payer information.

In addition to the requirement of division (C) of section 5160.37 of the Revised Code to cooperate with the department of medicaid and county department of job and family services, a medical assistance recipient and the recipient's attorney, if any, shall cooperate with each medical provider of the recipient. Cooperation with a medical provider shall consist of disclosing to the provider all information the recipient and attorney, if any, possess that would assist the provider in determining each third party that is responsible for the payment or processing of a claim for medical assistance provided to the recipient. If disclosure is not made in accordance with this section, the recipient and the recipient's attorney, if any, are liable to reimburse the department or county department for the amount that would have been paid by a third party had the third party been disclosed to the provider by the recipient or the recipient's attorney.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.38 [Renumbered from 5101.59] Assignment of rights to department.

(A) The application for, or enrollment in, a medical assistance program constitutes an automatic assignment of rights specified in division (B) of this section to the department of medicaid. This assignment includes the rights of the medical assistance recipient and also the rights of any other member of the assistance group for whom the recipient can legally make an assignment.

(B) Pursuant to this section, a medical assistance recipient assigns to the department any rights to medical support available to the recipient or other members of the recipient's assistance group under an order of a court or administrative agency, and any rights to payments by a liable third party for the cost of medical assistance paid on behalf of the recipient or other members of the assistance group. The recipient shall cooperate with the department in obtaining such payments.

Medicare benefits shall not be assigned pursuant to this section. Benefits assigned to the department by operation of this section are directly reimbursable to the department by liable third parties.

(C) Refusal by a medical assistance recipient to cooperate in obtaining medical assistance paid for self or any other member of the recipient's assistance group renders the recipient ineligible for a medical assistance program, unless cooperation is waived by the department. Eligibility shall continue for any individual who cannot legally assign the individual's own rights and who would have been eligible for a medical assistance program but for the refusal to assign the individual's rights or to cooperate as required by this section by another person legally able to assign the individual's rights.

(D) If a medical assistance recipient or any member of the recipient's assistance group becomes ineligible for a medical assistance program, the department shall restore to the recipient or assistance group member any future rights to benefits assigned under this section.

Renumbered from § 5101.59 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 06-26-2003; 2007 HB119 09-29-2007

5160.39 [Renumbered from 5101.572] Third-party cooperation regarding liability information.

(A) A third party shall cooperate with the department of medicaid in identifying individuals for the purpose of establishing third party liability regarding medical assistance programs.

(B) In furtherance of the requirement in division (A) of this section and to allow the department to determine any period that the individual or the individual's spouse or dependent may have been covered by the third party and the nature of the coverage, a third party shall provide, as the department so chooses, information or access to information, or both, in the third party's electronic data system on the department's request and in accordance with division (C) of this section.

(C)

(1) If the department chooses to receive information directly, the third party shall provide the information under all of the following circumstances:

(a) In a medium, format, and manner prescribed in rules authorized by section 5160.43 of the Revised Code;

(b) Free of charge;

(c) Not later than the end of the thirtieth day after the department makes its request, unless a different time is agreed to by the director in writing.

(2) If the department chooses to receive access to information, the third party shall provide access by a method prescribed in rules authorized by section 5160.43 of the Revised Code. In facilitating access, the department may enter into a trading partner agreement with the third party to permit the exchange of information via "ASC X 12N 270/271 Health Care Eligibility Benefit Inquiry and Response" transactions.

(D) All of the following apply with respect to information provided by a third party to the department under this section:

(1) The information is confidential and not a public record under section 149.43 of the Revised Code.

(2) The release of information to the department is not to be considered a violation of any right of confidentiality or contract that the third party may have with covered persons including, but not limited to, contractees, beneficiaries, heirs, assignees, and subscribers.

(3) The third party is immune from any liability that it may otherwise incur through its release of information to the department.

The department shall limit its use of information gained from third parties to purposes directly connected with the administration of the medicaid program and the child support program authorized by Title IV-D of the "Social Security Act ," 42 U.S.C. 651 et seq.

(E) No third party shall disclose to other parties or make use of any information regarding medical assistance recipients that it obtains from the department, except in the manner provided in rules authorized by section 5160.43 of the Revised Code.

Renumbered from § 5101.572 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 07-01-2000; 2007 HB119 09-29-2007; 2008 HB562 09-22-2008

5160.40 [Renumbered from 5101.573] Third-party duties; medicaid managed care organizations.

(A) Subject to divisions (B) and (C) of this section, a third party shall do all of the following:

(1) Accept the department of medicaid's right of recovery under section 5160.37 of the Revised Code and the assignment of rights to the department that are described in section 5160.38 of the Revised Code;

(2) Respond to an inquiry by the department regarding a claim for payment of a medical item or service that was submitted to the third party not later than six years after the date of the provision of such medical item or service;

(3) Not charge a fee to do either of the following for a claim described in division (A)(2) of this section:

(a) Determine whether the claim should be paid;

(b) Process the claim.

(4) Pay a claim described in division (A)(2) of this section;

(5) Not deny a claim submitted by the department solely on the basis of the date of submission of the claim, type or format of the claim form, or a failure by the medical assistance recipient who is the subject of the claim to present proper documentation of coverage at the time of service, if both of the following have occurred:

(a) The claim was submitted by the department not later than six years after the date of the provision of the medical item or service.

(b) An action by the department to enforce its right of recovery under section 5160.37 of the Revised Code on the claim was commenced not later than six years after the department's submission of the claim.

(6) Consider the department's payment of a claim for a medical item or service to be the equivalent of the medical assistance recipient having obtained prior authorization for the item or service from the third party;

(7) Not deny a claim described in division (A)(6) of this section that is submitted by the department solely on the basis of the medical assistance recipient's failure to obtain prior authorization for the medical item or service.

(B) For purposes of the requirements in division (A) of this section, a third party shall treat a medicaid managed care organization as the department for a claim

if the individual who is the subject of the claim received a medical item or service through a medicaid managed care organization

and the department has assigned its right of recovery for the claim to the medicaid managed care organization.

(C) [Effective 1/1/2014]If the department of medicaid, as permitted by division (K) of section 5160.37 of the Revised Code, assigns to a medical assistance provider the department's right of recovery for a claim for which it has notified the provider that it intends to recoup its prior payment for a claim, a third party shall treat the provider as the department and shall pay the provider the greater of the following:

(1) The amount the department intends to recoup from the provider for the claim.

(2) If the third party and the provider have an agreement that requires the third party to pay the provider at the time the provider presents the claim to the third party, the amount that is to be paid under that agreement.

(D) The time limitations associated with the requirements in divisions (A)(2) and (5) of this section apply only to submissions of claims to, and payments of claims by, a health insurer to which the "Social Security Act," section 1902(a)(25)(I), 42 U.S.C. 1396a(a)(25)(I), applies.

Renumbered from § 5101.573 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013 and 1/1/2014.

Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.

Amended by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 10/16/2009.

Effective Date: 2007 HB119 09-29-2007

5160.41 [Renumbered from 5101.574] Excluded considerations for third-party medical assistance.

No third party shall consider whether an individual is eligible for or enrolled in a medical assistance program when either of the following applies:

(A) The individual seeks to obtain a policy or enroll in a plan or program operated or administered by the third party;

(B) The individual, or a person or governmental entity on the individual's behalf, seeks payment for a medical item or service provided to the individual.

Renumbered from § 5101.574 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 2007 HB119 09-29-2007

5160.42 [Renumbered from 5101.575] Sanctions against third parties for violations.

(A) If a third party violates section 5160.39, 5160.40, or 5160.41 of the Revised Code, a governmental entity that is responsible for issuing a license, certificate of authority, registration, or approval that authorizes the third party to do business in this state may impose a fine against the third party or deny, revoke, or terminate the third party's license, certificate, registration, or approval to do business in this state. The governmental entity shall determine which sanction is to be imposed. All actions to impose the sanction shall be taken in accordance with Chapter 119. of the Revised Code.

(B) In addition to the sanctions that may be imposed under division (A) of this section for a violation of section 5160.39, 5160.40, or 5160.41 of the Revised Code, the attorney general may petition a court of common pleas to enjoin the violation.

Renumbered from § 5101.575 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 2007 HB119 09-29-2007

5160.43 [Renumbered from 5101.591] Adoption of rules regarding recovery of costs.

(A) The medicaid director may adopt rules under section 5160.02 of the Revised Code to implement sections 5160.35 to 5160.43 of the Revised Code, including rules that specify what constitutes cooperating with efforts to obtain support or payments, or medical assistance payments, and when cooperation may be waived.

(B) The department shall adopt rules under section 5160.02 of the Revised Code to do all of the following:

(1) For purposes of the definition of "information" in division (A) of section 5160.35 of the Revised Code, any data other than the data specified in that division that should be included in the definition.

(2) For purposes of division (C)(1)(a) of section 5160.39 of the Revised Code, the medium, format, and manner in which a third party must provide information to the department.

(3) For purposes of division (C)(2) of section 5160.39 of the Revised Code, the method by which a third party must provide the department with access to information.

(C) Rules authorized by division (A) of this section may be adopted in accordance with section 111.15 of the Revised Code. Rules authorized by division (B) of this section shall be adopted in accordance with Chapter 119. of the Revised Code.

Renumbered from § 5101.591 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 2007 HB119 09-29-2007

5160.45 [Renumbered from 5101.271] Disclosure of medical assistance information.

(A) As used in sections 5160.45 to 5160.481 of the Revised Code, "information" means all of the following:

(1) Records, as defined in section 149.011 of the Revised Code;

(2) Any other documents in any format;

(3) Data derived from records and documents that are generated, acquired, or maintained by the department of medicaid, a county department of job and family services, or an entity performing duties on behalf of the department or a county department.

(B) Except as permitted by this section, section 5160.47, or rules authorized by section 5160.48 or 5160.481 of the Revised Code, or when required by federal law, no person or government entity shall use or disclose information regarding a medical assistance recipient for any purpose not directly connected with the administration of a medical assistance program.

(C) Both of the following shall be considered to be purposes directly connected with the administration of a medical assistance program:

(1) Treatment, payment, or other operations or activities authorized by 42 C.F.R. Chapter IV;

(2) Any administrative function or duty the department of medicaid performs alone or jointly with a federal government entity, another state government entity, or a local government entity implementing a provision of federal law.

(D) The department or a county department of job and family services may disclose information regarding a medical assistance recipient to any of the following:

(1) The recipient or the recipient's authorized representative;

(2) The recipient's legal guardian in accordance with division (C) of section 2111.13 of the Revised Code;

(3) The attorney of the recipient, if the department or county department has obtained authorization from the recipient or the recipient's authorized representative or legal guardian that meets all requirements of the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. 1320d et seq., regulations promulgated by the United States department of health and human services to implement the act, section 5160.46 of the Revised Code, and any rules authorized by section 5160.48 of the Revised Code;

(4) A health information or health records management entity that has executed with the department a business associate agreement required by 45 C.F.R 164.502(e)(2) and has been authorized by the recipient or the recipient's authorized representative or legal guardian to receive the recipient's electronic health records in accordance with rules authorized by section 5160.48 of the Revised Code;

(5) A court if pursuant to a written order of the court.

(E) The department may receive from county departments of job and family services information regarding any medical assistance recipient for purposes of training and verifying the accuracy of eligibility determinations for a medical assistance program. The department may assemble information received under this division into a report if the report is in a form specified by the department. Information received and assembled into a report under this division shall remain confidential and not be subject to disclosure pursuant to section 149.43 or 1347.08 of the Revised Code.

(F) The department shall notify courts in this state regarding its authority, under division (D)(5) of this section, to disclose information regarding a medical assistance recipient pursuant to a written court order.

Renumbered from § 5101.271 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Added by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.

5160.46 Authorization form.

(A) For the purposes of section 5160.45 of the Revised Code, an authorization shall be made on a form that uses language understandable to the average person and contains all of the following:

(1) A description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion;

(2) The name or other specific identification of the person or class of persons authorized to make the requested use or disclosure;

(3) The name or other specific identification of the person or government entity to which the information may be released;

(4) A description of each purpose of the requested use or disclosure of the information;

(5) The date on which the authorization expires or an event related either to the individual who is the subject of the request or to the purposes of the requested use or disclosure, the occurrence of which will cause the authorization to expire;

(6) A statement that the information used or disclosed pursuant to the authorization may be disclosed by the recipient of the information and may no longer be protected from disclosure;

(7) The signature of the individual or the individual's authorized representative and the date on which the authorization was signed;

(8) If signed by an authorized representative, a description of the representative's authority to act for the individual;

(9) A statement of the individual or authorized representative's right to prospectively revoke the written authorization in writing, along with either of the following:

(a) A description of how the individual or authorized representative may revoke the authorization;

(b) If the department of medicaid has established a privacy notice that contains a description of how the individual or authorized representative may revoke the authorization, a reference to the privacy notice.

(10) A statement that treatment, payment, enrollment, or eligibility for a medical assistance program cannot be conditioned on signing the authorization unless the authorization is necessary for determining eligibility for the program.

(B) An authorization for the release of information regarding a medical assistance recipient to the recipient's attorney under division (D)(3) of section 5160.45 of the Revised Code may include a provision specifically authorizing the release of the recipient's electronic health records, if any, in accordance with rules authorized by section 5160.48 or 5160.481 of the Revised Code.

(C) When an individual requests information pursuant to section 5160.45 of the Revised Code regarding the individual's enrollment in a medical assistance program and does not wish to provide a statement of purpose, the statement "at request of the individual" is a sufficient description for purposes of division (A)(4) of this section.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.47 Membership in the public assistance reporting information system.

The department of medicaid shall enter into any necessary agreements with the United States department of health and human services and neighboring states to join and participate as an active member in the public assistance reporting information system. The department may disclose information regarding a medical assistance recipient to the extent necessary to participate as an active member in the system.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.48 Rules for conditions and procedures for the release of information.

(A) The medicaid director shall adopt rules under section 5160.02 of the Revised Code implementing sections 5160.45 to 5160.481 of the Revised Code and governing the custody, use, disclosure, and preservation of the information generated or received by the department of medicaid, county departments of job and family services, other state and county entities, contractors, grantees, private entities, or officials participating in the administration of medical assistance programs. The rules shall be adopted in accordance with Chapter 119. of the Revised Code. The rules may define who is an "authorized representative" for purposes of sections 5160.45 and 5160.46 of the Revised Code. The rules shall specify conditions and procedures for the release of information, which may include both of the following:

(1) Permitting a provider of a service under a medical assistance program limited access to information that is essential for the provider to render the service or to bill for the service rendered;

(2) Permitting a contractor, grantee, or other state or county entity limited access to information that is essential for the contractor, grantee, or entity to perform administrative or other duties on behalf of the department or a county department.

(B) The department of aging, when investigating a complaint under section 173.20 of the Revised Code, shall be granted any limited access permitted in the rules authorized by division (A)(1) of this section.

A contractor, grantee, or entity given access to information pursuant to the rules authorized by division (A)(2) of this section is bound by the director's rules. Disclosure of the information by the contractor, grantee, or entity in a manner not authorized by the rules is a violation of section 5160.45 of the Revised Code.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.481 Adoption of rules by other agencies.

Whenever names, addresses, or other information relating to medical assistance recipients is held by any agency other than the department of medicaid or a county department of job and family services, that other agency shall adopt rules consistent with sections 5160.45 to 5160.481 of the Revised Code to prevent the publication or disclosure of names, lists, or other information concerning those recipients.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.50 Refugee medical assistance program.

The department of medicaid shall administer the refugee medical assistance program authorized by the "Immigration and Nationality Act," section 412(e), 8 U.S.C. 1522(e).

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.52 Authority to enter into interstate compacts for provision of medical assistance to children.

The medicaid director may provide for the department of medicaid to develop, participate in the development of, negotiate, and enter into one or more interstate compacts on behalf of this state with agencies of any other states, for the provision of medical assistance to children in relation to whom all of the following apply:

(A) They have special needs.

(B) This state or another state that is a party to the interstate compact is providing adoption assistance on their behalf.

(C) They move into this state from another state or move out of this state to another state.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5160.99 Penalty for unlawful disclosure of information.

Whoever violates division (B) of section 5160.45 of the Revised Code is guilty of a misdemeanor of the first degree.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.