Chapter 5164 | Medicaid State Plan Services

Section 5164.01 | Definitions.

• Effective: October 17, 2019
• Latest Legislation: House Bill 166 - 133rd General Assembly

As used in this chapter:

(A) "Adjudication" has the same meaning as in section 119.01 of the Revised Code.

(B) "Behavioral health redesign" means revisions to the medicaid program's coverage of community behavioral health services beginning July 1, 2017, including revisions that update medicaid billing codes and payment rates for community behavioral health services.

(C) "Clean claim" has the same meaning as in 42 C.F.R. 447.45(b).

(D) "Community behavioral health services" means both of the following:

(1) Alcohol and drug addiction services provided by a community addiction services provider, as defined in section 5119.01 of the Revised Code;

(2) Mental health services provided by a community mental health services provider, as defined in section 5119.01 of the Revised Code.

(E) "Early and periodic screening, diagnostic, and treatment services" has the same meaning as in the "Social Security Act," section 1905(r), 42 U.S.C. 1396d(r).

(F) "Federal financial participation" has the same meaning as in section 5160.01 of the Revised Code.

(G) "Federal poverty line" has the same meaning as in section 5162.01 of the Revised Code.

(H) "Healthcheck" means the component of the medicaid program that provides early and periodic screening, diagnostic, and treatment services.

(I) "Home and community-based services medicaid waiver component" has the same meaning as in section 5166.01 of the Revised Code.

(J) "Hospital" has the same meaning as in section 3727.01 of the Revised Code.

(K) "ICDS participant" means a dual eligible individual who participates in the integrated care delivery system.

(L) "ICF/IID" has the same meaning as in section 5124.01 of the Revised Code.

(M) "Integrated care delivery system" and "ICDS" mean the demonstration project authorized by section 5164.91 of the Revised Code.

(N) "Mandatory services" means the health care services and items that must be covered by the medicaid state plan as a condition of the state receiving federal financial participation for the medicaid program.

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

(P) "Medicaid provider" means a person or government entity with a valid provider agreement to provide medicaid services to medicaid recipients. To the extent appropriate in the context, "medicaid provider" includes a person or government entity applying for a provider agreement, a former medicaid provider, or both.

(Q) "Medicaid services" means either or both of the following:

(1) Mandatory services;

(2) Optional services that the medicaid program covers.

(R) "Nursing facility" has the same meaning as in section 5165.01 of the Revised Code.

(S) "Optional services" means the health care services and items that may be covered by the medicaid state plan or a federal medicaid waiver and for which the medicaid program receives federal financial participation.

(T) "Prescribed drug" has the same meaning as in 42 C.F.R. 440.120.

(U) "Provider agreement" means an agreement to which all of the following apply:

(1) It is between a medicaid provider and the department of medicaid;

(2) It provides for the medicaid provider to provide medicaid services to medicaid recipients;

(3) It complies with 42 C.F.R. 431.107(b).

(V) "State plan home and community-based services" means home and community-based services that, as authorized by section 1915(i) of the "Social Security Act," 42 U.S.C. 1396n(i), may be covered by the medicaid program pursuant to an amendment to the medicaid state plan.

(W) "Terminal distributor of dangerous drugs" has the same meaning as in section 4729.01 of the Revised Code.

Section 5164.02 | Rules to implement chapter.

• Effective: September 29, 2017
• Latest Legislation: House Bill 49 - 132nd General Assembly

(A) 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.

(B) The rules shall establish all of the following:

(1) The amount, duration, and scope of the medicaid services covered by the medicaid program;

(2) The medicaid payment rate for each medicaid service or, in lieu of the rate, the method by which the rate is to be determined for each medicaid service;

(3) Procedures for enforcing the rules adopted under this section that provide due process protections, including procedures for corrective action plans for, and imposing financial and administrative sanctions on, persons and government entities that violate the rules.

(C) The rules may be different for different medicaid services.

(D) The medicaid director is not required to adopt a rule establishing the medicaid payment rate for a medicaid service if the director adopts a rule establishing the method by which the rate is to be determined for the medicaid service and makes the rate available on the internet web site maintained by the department of medicaid.

Section 5164.03 | Mandatory and optional services.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) The medicaid program shall cover all mandatory services.

(B) The medicaid program shall cover all of the optional services that state statutes require the medicaid program to cover.

(C) The medicaid program may cover any of the optional services to which either of the following applies:

(1) State statutes expressly permit the medicaid program to cover the optional service;

(2) State statutes do not address whether the medicaid program may cover the optional service.

(D) The medicaid program shall not cover any optional services that state statutes prohibit the medicaid program from covering.

Section 5164.06 | Medicaid coverage of occupational therapy services.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The medicaid program shall cover occupational therapy services provided by an occupational therapist licensed under section 4755.08 of the Revised Code. Coverage shall not be limited to services provided in a hospital or nursing facility. Any licensed occupational therapist may enter into a provider agreement with the department of medicaid to provide occupational therapy services under the medicaid program.

Section 5164.061 | Chiropractic services.

• Effective: June 13, 2022
• Latest Legislation: House Bill 136 - 134th General Assembly

(A) As used in this section:

(1) "Prescriber" has the same meaning as in section 4729.01 of the Revised Code, but does not include a dentist, optometrist, or veterinarian.

(2) "Prior authorization requirement" means any practice in which coverage of a health care service, device, or drug is dependent upon a recipient or health care practitioner obtaining approval from the medicaid program prior to the service, device, or drug being performed, received, or prescribed, as applicable.

(B)(1) The medicaid program shall cover evaluation and management services provided by a chiropractor if the chiropractor is licensed to practice chiropractic under Chapter 4734. of the Revised Code.

(2) The medicaid director may adopt rules under section 5164.02 of the Revised Code to cover other services provided by a chiropractor under the medicaid program.

(3) With respect to the coverage described in this section, all of the following apply:

(a) A chiropractor may provide covered services in any location, including a hospital or nursing facility.

(b) The medicaid program shall not impose a prior authorization requirement on covered services.

(c) The medicaid program shall not make coverage contingent upon the medicaid recipient first receiving a referral, prescription, or treatment from a prescriber.

(C) If a service described in this section could be provided by either a chiropractor licensed under Chapter 4734. of the Revised Code or a licensed health professional other than a chiropractor, the medicaid program shall pay the chiropractor the same amount for the service that it pays the licensed health professional.

Last updated March 22, 2022 at 2:03 PM

Section 5164.07 | Coverage of inpatient care and follow-up care for a mother and her newborn.

• Effective: April 6, 2017
• Latest Legislation: House Bill 216 - 131st General Assembly

(A) The medicaid program shall include coverage of inpatient care and follow-up care for a mother and her newborn as follows:

(1) The medicaid program shall cover a minimum of forty-eight hours of inpatient care following a normal vaginal delivery and a minimum of ninety-six hours of inpatient care following a cesarean delivery. Services covered as inpatient care shall include medical, educational, and any other services that are consistent with the inpatient care recommended in the protocols and guidelines developed by national organizations that represent pediatric, obstetric, and nursing professionals.

(2) The medicaid program shall cover a physician-directed source of follow-up care or a source of follow-up care directed by an advanced practice registered nurse. Services covered as follow-up care shall include physical assessment of the mother and newborn, parent education, assistance and training in breast or bottle feeding, assessment of the home support system, performance of any medically necessary and appropriate clinical tests, and any other services that are consistent with the follow-up care recommended in the protocols and guidelines developed by national organizations that represent pediatric, obstetric, and nursing professionals. The coverage shall apply to services provided in a medical setting or through home health care visits. The coverage shall apply to a home health care visit only if the health care professional who conducts the visit is knowledgeable and experienced in maternity and newborn care.

When a decision is made in accordance with division (B) of this section to discharge a mother or newborn prior to the expiration of the applicable number of hours of inpatient care required to be covered, the coverage of follow-up care shall apply to all follow-up care that is provided within forty-eight hours after discharge. When a mother or newborn receives at least the number of hours of inpatient care required to be covered, the coverage of follow-up care shall apply to follow-up care that is determined to be medically necessary by the health care professionals responsible for discharging the mother or newborn.

(B) Any decision to shorten the length of inpatient stay to less than that specified under division (A)(1) of this section shall be made by the physician attending the mother or newborn, except that if a certified nurse-midwife is attending the mother in collaboration with a physician, the decision may be made by the certified nurse-midwife. Decisions regarding early discharge shall be made only after conferring with the mother or a person responsible for the mother or newborn. For purposes of this division, a person responsible for the mother or newborn may include a parent, guardian, or any other person with authority to make medical decisions for the mother or newborn.

(C) The department of medicaid, in administering the medicaid program, may not do either of the following:

(1) Terminate the provider agreement of a health care professional or health care facility solely for making recommendations for inpatient or follow-up care for a particular mother or newborn that are consistent with the care required to be covered by this section;

(2) Establish or offer monetary or other financial incentives for the purpose of encouraging a person to decline the inpatient or follow-up care required to be covered by this section.

(D) This section does not do any of the following:

(1) Require the medicaid program to cover inpatient or follow-up care that is not received in accordance with the program's terms pertaining to the health care professionals and facilities from which a medicaid recipient is authorized to receive health care services.

(2) Require a mother or newborn to stay in a hospital or other inpatient setting for a fixed period of time following delivery;

(3) Require a child to be delivered in a hospital or other inpatient setting;

(4) Authorize a certified nurse-midwife to practice beyond the authority to practice nurse-midwifery in accordance with Chapter 4723. of the Revised Code;

(5) Establish minimum standards of medical diagnosis, care, or treatment for inpatient or follow-up care for a mother or newborn. A deviation from the care required to be covered under this section shall not, on the basis of this section, give rise to a medical claim or derivative medical claim, as those terms are defined in section 2305.113 of the Revised Code.

Section 5164.071 | Doula program.

• Effective: April 30, 2024
• Latest Legislation: House Bill 101 - 135th General Assembly

(A) As used in this section, "doula" has the same meaning as in section 4723.89 of the Revised Code.

(B) The medicaid program shall cover doula services that are provided by a doula if the doula has a valid provider agreement and is certified under section 4723.89 of the Revised Code. Medicaid payments for doula services shall be determined on the basis of each pregnancy, regardless of whether multiple births occur as a result of that pregnancy.

(C) Any provider outcome measurements or incentives the department of medicaid implements for the medicaid coverage of doula services shall be consistent with this state's medicare-medicaid plan quality withhold provider or managed care plan methodology and benchmarks.

(D) The medicaid director shall adopt rules under section 5164.02 of the Revised Code to implement this section.

Last updated February 12, 2024 at 9:13 AM

Section 5164.072 | Coverage of donor breast milk and fortifiers.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) As used in this section, "licensed health professional" means the following:

(1) A physician authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery;

(2) An advanced practice registered nurse who holds a current, valid license issued under Chapter 4723. of the Revised Code that authorizes the practice of nursing as an advanced practice registered nurse and is designated as a clinical specialist, certified nurse-midwife, or certified nurse practitioner;

(3) A physician assistant licensed under Chapter 4730. of the Revised Code.

(B) The medicaid program shall cover pasteurized human donor milk and human milk fortifiers, in both hospital and home settings, for an infant whose gestationally corrected age is less than twelve months when all of the following apply:

(1) A licensed health professional signs an order stating that human donor milk or human milk fortifiers are medically necessary because the infant meets any of the following criteria:

(a) The infant has a birth weight less than eighteen hundred grams or body weight below healthy levels.

(b) The infant has a gestational age at birth of thirty-four weeks or less.

(c) The infant has any congenital or acquired condition for which the health professional determines that the use of pasteurized human donor milk or human milk fortifiers will support the treatment of the condition and recovery of the infant.

(2) The infant is medically or physically unable to receive maternal breast milk or participate in breast-feeding, or the infant's mother is medically or physically unable to produce breast milk in sufficient quantities or of adequate caloric density, despite lactation support.

(C) The medicaid director may adopt rules in accordance with Chapter 119. of the Revised Code to implement this section.

Last updated October 12, 2023 at 11:41 AM

Section 5164.08 | Breast cancer and cervical cancer screening.

• Effective: September 23, 2022
• Latest Legislation: House Bill 371 - 134th General Assembly

(A) As used in this section:

(1) "Screening mammography" means a radiologic examination utilized to detect unsuspected breast cancer at an early stage in asymptomatic women and includes the x-ray examination of the breast using equipment that is dedicated specifically for mammography, including the x-ray tube, filter, compression device, screens, film, and cassettes, and that has an average radiation exposure delivery of less than one rad mid-breast. "Screening mammography" includes digital breast tomosynthesis. "Screening mammography" includes two views for each breast. The term also includes the professional interpretation of the film.

"Screening mammography" does not include diagnostic mammography.

(2) "Supplemental breast cancer screening" means any additional screening method deemed medically necessary by a treating health care provider for proper breast cancer screening in accordance with applicable American college of radiology guidelines, including magnetic resonance imaging, ultrasound, or molecular breast imaging.

(B) The medicaid program shall cover all of the following:

(1) To detect the presence of breast cancer in adult women, screening mammography;

(2) To detect the presence of breast cancer in adult women meeting any of the conditions described in division (C)(2) of this section, supplemental breast cancer screening;

(3) To detect the presence of cervical cancer, cytologic screening.

(C)(1) The medicaid program's coverage pursuant to division (B)(1) of this section shall cover expenses for one screening mammography every year, including digital breast tomosynthesis.

(2) The medicaid program's coverage pursuant to division (B)(2) of this section shall cover expenses for supplemental breast cancer screening for an adult woman who meets any of the following conditions:

(a) The woman's screening mammography demonstrates, based on the breast imaging reporting and data system established by the American college of radiology, that the woman has dense breast tissue;

(b) The woman is at an increased risk of breast cancer due to family history, prior personal history of breast cancer, ancestry, genetic predisposition, or other reasons as determined by the woman's health care provider.

(D) The medicaid program's coverage of screening mammographies pursuant to division (B)(1) or (2) of this section shall be provided only for screening mammographies or supplemental breast cancer screenings that are performed in a facility or mobile mammography screening unit that is accredited under the American college of radiology mammography accreditation program or in a hospital as defined in section 3727.01 of the Revised Code.

(E) The medicaid program's coverage of cytologic screenings pursuant to division (B)(3) of this section shall be provided only for cytologic screenings that are processed and interpreted in a laboratory certified by the college of American pathologists or in a hospital as defined in section 3727.01 of the Revised Code.

Last updated October 31, 2022 at 5:19 PM

Section 5164.09 | Equivalent coverage for orally and intravenously administered cancer medications.

• Effective: January 1, 2015
• Latest Legislation: Senate Bill 99 - 130th General Assembly

(A) Except as provided in division (C) of this section, the medicaid program shall cover prescribed, orally administered cancer medications on at least the same basis that it covers intraveneously administered or injected cancer medications. In implementing this section, the department of medicaid shall not institute cost-sharing requirements under section 5162.20 of the Revised Code for prescribed, orally administered cancer medications that are greater than any cost-sharing requirements instituted under that section for intraveneously administered or injected cancer medications.

(B) Division (A) of this section does not preclude the department from requiring a medicaid recipient to obtain prior authorization before a prescribed, orally administered cancer medication is dispensed to the recipient.

(C) This section shall not be implemented during a fiscal year if the medicaid director determines that this section's implementation would cause the costs of the medicaid program's coverage of prescribed drugs to increase by more than one per cent over such costs for the most recent previous fiscal year for which the amount of such costs is known.

Section 5164.091 | Coverage for opioid analgesics.

• Effective: April 6, 2017
• Latest Legislation: Senate Bill 319 - 131st General Assembly

(A) As used in this section:

(1) "Benzodiazepine" has the same meaning as in section 3719.01 of the Revised Code.

(2) "Chronic pain" has the same meaning as in section 4731.052 of the Revised Code.

(3) "Hospice care program" and "hospice patient" have the same meanings as in section 3712.01 of the Revised Code.

(4) "Opioid analgesic" has the same meaning as in section 3719.01 of the Revised Code.

(5) "Prescriber" has the same meaning as in section 4729.01 of the Revised Code.

(6) "Terminal condition" means an irreversible, incurable, and untreatable condition that caused by disease, illness, or injury and will likely result in death. A terminal condition is one in which there can be no recovery, although there may be periods of remission.

(B)(1) With respect to the medicaid program's coverage of prescribed drugs, the department of medicaid shall apply prior authorization requirements or other utilization review measures as conditions of providing coverage of an opioid analgesic prescribed for the treatment of chronic pain, except when the drug is prescribed under one of the following circumstances:

(a) To an individual who is a hospice patient in a hospice care program;

(b) To an individual who has been diagnosed with a terminal condition but is not a hospice patient in a hospice care program;

(c) To an individual who has cancer or another condition associated with the individual's cancer or history of cancer.

(2) When implementing division (B)(1) of this section, the department shall consider either or both of the following, as applicable to the case in which the opioid analgesic is prescribed:

(a) If the course of treatment with the drug continues for more than ninety days, the requirements of section 4731.052 of the Revised Code;

(b) If the morphine equivalent daily dose for the drug exceeds eighty milligrams or the individual is being treated with a benzodiazepine at the time the opioid analgesic is prescribed, the guidelines established by the governor's cabinet opiate action team and presented in the document titled "Ohio Guidelines for Prescribing Opioids for the Treatment of Chronic, Non-terminal Pain 80 mg of a Morphine Equivalent Daily Dose (MED) 'Trigger Point'" or a successor document, unless the guidelines are no longer in effect at the time the opioid analgesic is prescribed.

(C) If the department measures the efficiency, quality of care, or clinical performance of a prescriber, including through the use of patient satisfaction surveys, it shall not penalize the prescriber, financially or otherwise, for deciding not to prescribe an opioid analgesic.

Section 5164.092 | Coverage of remote ultrasounds and fetal nonstress tests.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) Except as provided in division (B) of this section, the medicaid program shall cover remote ultrasound procedures and remote fetal nonstress tests, utilizing established current procedural terminology codes (CPT codes) for those procedures for when the patient is in a residence or other off-site location from the patient's medicaid provider.

(B) The coverage under division (A) of this section applies only under the following circumstances:

(1) The medicaid provider responsible for the procedure uses digital technology that meets both of the following criteria:

(a) The technology is used only to collect medical and other data from a patient and electronically transmit that data securely to a health care provider in a different location for that provider's examination of the data;

(b) The technology has been approved by the United States food and drug administration for remote data acquisition, if required under federal law.

(2) For remote fetal nonstress tests, the CPT code includes a place of service modifier for at home monitoring using remote monitoring solutions that are cleared by the United States food and drug administration for monitoring fetal heart rate, maternal heart rate, and uterine activity.

(C) The department shall adopt rules as necessary to implement this section.

Last updated October 12, 2023 at 11:42 AM

Section 5164.10 | Coverage of tobacco cessation medications and services.

• Effective: September 18, 2020
• Latest Legislation: House Bill 11 - 133rd General Assembly

(A) The medicaid program shall cover both of the following, subject to division (C) of this section:

(1) All tobacco cessation medications approved by the United States food and drug administration;

(2) All forms of tobacco cessation services recommended by the United States preventive services task force, including individual, group, and telephone counseling and any combination thereof.

(B) The department of medicaid shall not impose any of the following conditions with respect to the coverage required by this section:

(1) Counseling requirements for tobacco cessation medications;

(2) Except as provided in division (B)(4) of this section, limits on the duration of services, including annual or lifetime limits on the number of covered attempts to quit using tobacco;

(3) Cost-sharing requirements under section 5162.20 of the Revised Code;

(4) Prior authorization requirements, step therapy protocols as defined in section 5164.7512 of the Revised Code, or any other utilization management requirements, except that prior authorization may be required for either of the following:

(a) Treatment that exceeds the duration recommended in the United States public health service clinical practice guidelines on treating tobacco use and dependence;

(b) Services associated with more than two attempts to quit using tobacco within a twelve-month period.

(C) The director of health shall adopt rules in accordance with Chapter 119. of the Revised Code that establish standards and procedures for approving the forms of tobacco cessation medications and services that must be covered under this section. The rules shall also establish standards and procedures for updating the approved forms of tobacco cessation medications and services that must be covered under this section when the approved forms are modified by the United States food and drug administration, United States public health service, or United States preventive services task force.

(D) With respect to the coverage required by this section, the department of medicaid shall do both of the following:

(1) Inform medicaid recipients about the coverage;

(2) Market the coverage to Medicaid recipients.

Section 5164.14 | Medicaid coverage for health care service provided by pharmacist.

• Effective: December 16, 2020
• Latest Legislation: House Bill 203 - 133rd General Assembly

The medicaid program may cover a health care service that a pharmacist provides to a medicaid recipient in accordance with Chapter 4729. of the Revised Code, including any of the following services:

(A) Managing drug therapy under a consult agreement pursuant to section 4729.39 of the Revised Code;

(B) Administering immunizations in accordance with section 4729.41 of the Revised Code;

(C) Administering drugs in accordance with section 4729.45 of the Revised Code.

Section 5164.15 | Mental health services.

• Effective: April 6, 2023
• Latest Legislation: House Bill 281 - 134th General Assembly

(A) As used in this section:

(1) "Community mental health services provider or facility" means a community mental health services provider or facility that has its community mental health services certified by the department of mental health and addiction services under section 5119.36 of the Revised Code or by the department of job and family services under section 5103.03 of the Revised Code.

(2) "Mental health professional" means a person qualified to work with persons with mental illnesses under the standards established by the director of mental health and addiction services pursuant to section 5119.36 of the Revised Code.

(B) The medicaid program may cover the following mental health services when provided by community mental health services providers or facilities:

(1) Outpatient mental health services, including, but not limited to, preventive, diagnostic, therapeutic, rehabilitative, and palliative interventions rendered to individuals in an individual or group setting by a mental health professional in accordance with a plan of treatment appropriately established, monitored, and reviewed;

(2) Partial-hospitalization mental health services rendered by persons directly supervised by a mental health professional;

(3) Unscheduled, emergency mental health services of a kind ordinarily provided to persons in crisis when rendered by persons supervised by a mental health professional;

(4) Assertive community treatment and intensive home-based mental health services.

(C) The department of medicaid shall enter into a separate contract with the department of mental health and addiction services under section 5162.35 of the Revised Code with regard to the mental health services the medicaid program covers pursuant to this section.

Last updated September 29, 2023 at 2:49 PM

Section 5164.16 | Coverage of one or more state plan home and community-based services.

• Effective: September 18, 2020
• Latest Legislation: House Bill 11 - 133rd General Assembly

The medicaid program may cover one or more state plan home and community-based services that the department of medicaid selects for coverage. A medicaid recipient of any age may receive a state plan home and community-based service if the recipient has countable income not exceeding two hundred twenty-five per cent of the federal poverty line, has a medical need for the service, and meets all other eligibility requirements for the service specified in rules adopted under section 5164.02 of the Revised Code. The rules may not require a medicaid recipient to undergo a level of care determination to be eligible for a state plan home and community-based service.

Section 5164.17 | Medicaid coverage of tobacco cessation services.

• Effective: September 18, 2020
• Latest Legislation: House Bill 11 - 133rd General Assembly

The medicaid program may cover tobacco cessation services in addition to the services that must be covered under section 5164.10 of the Revised Code or may exclude coverage of additional tobacco cessation services.

Section 5164.20 | Medicaid not to cover drugs for erectile dysfunction.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The medicaid program shall not cover prescribed drugs for treatment of erectile dysfunction.

Section 5164.25 | Recipient with developmental disability who is eligible for medicaid case management services.

• Effective: October 12, 2016
• Latest Legislation: House Bill 158 - 131st General Assembly

The departments of developmental disabilities and medicaid may approve, reduce, deny, or terminate a medicaid service included in the individual service plan developed for a medicaid recipient with a developmental disability who is eligible for medicaid case management services. If either department approves, reduces, denies, or terminates a service, that department shall timely notify the medicaid recipient that the recipient may appeal pursuant to section 5160.31 of the Revised Code.

Section 5164.26 | Healthcheck component.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The department of medicaid shall establish a combination of written and oral methods designed to provide information about healthcheck to all persons eligible for the program or their parents or guardians. The department shall ensure that its methods of providing information are effective.

Each entity that distributes or accepts applications for medicaid shall prominently display a notice that complies with the methods of providing information about healthcheck established under this section.

Section 5164.29 | Revised Medicaid provider enrollment system.

• Effective: September 29, 2017
• Latest Legislation: House Bill 49 - 132nd General Assembly

Not later than December 31, 2018, the department of medicaid shall develop and implement revisions to the system by which persons and government entities become and remain medicaid providers so that there is a single system of records for the system and the persons and government entities do not have to submit duplicate data to the state to become or remain medicaid providers for any component or aspect of a component of the medicaid program, including a component or aspect of a component administered by another state agency or political subdivision pursuant to a contract entered into under section 5162.35 of the Revised Code. The departments of aging, developmental disabilities, and mental health and addiction services shall participate in the development of the revisions and shall utilize the revised system.

Section 5164.291 | Provider credentialing committee.

• Effective: March 23, 2022
• Latest Legislation: House Bill 122 - 134th General Assembly

The department of medicaid shall establish a credentialing program that includes a credentialing committee to review the competence, professional conduct, and quality of care provided by medicaid providers.

Any activities performed by the credentialing committee shall be considered activities of a peer review committee of a health care entity and shall be subject to sections 2305.25 to 2305.253 of the Revised Code.

The medicaid director may adopt rules under section 5164.02 of the Revised Code as necessary to implement this section. Any rules adopted shall be consistent with the requirements that apply to medicare advantage organizations under 42 C.F.R. 422.204.

Last updated January 27, 2022 at 3:52 PM

Section 5164.30 | Provider agreement with department required.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

No person or government entity may participate in the medicaid program as a medicaid provider without a valid provider agreement with the department of medicaid.

Section 5164.301 | Medicaid provider agreements for physician assistants.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) As used in this section, "group practice" has the same meaning as in section 4731.65 of the Revised Code.

(B) The department of medicaid shall establish a process by which a physician assistant may enter into a provider agreement.

(C)(1) Subject to division (C)(2) of this section, a claim for medicaid payment for a medicaid service provided by a physician assistant to a medicaid recipient may be submitted by the physician assistant who provided the service or the physician, group practice, clinic, or other health care facility that employs the physician assistant.

(2) A claim for medicaid payment may be submitted by the physician assistant who provided the service only if the physician assistant has a valid provider agreement. When submitting the claim, the physician assistant shall use only the medicaid provider number the department has assigned to the physician assistant.

Section 5164.31 | Funding for implementing the provider screening requirements.

• Effective: September 29, 2017
• Latest Legislation: House Bill 49 - 132nd General Assembly

(A) For the purpose of raising funds necessary to pay the expenses of implementing the provider screening requirements of subpart E of 42 C.F.R. Part 455 and except as provided in division (B) of this section, the department of medicaid shall collect an application fee from a medicaid provider before doing any of the following:

(1) Entering into a provider agreement with a medicaid provider that seeks initial enrollment as a provider;

(2) Entering into a provider agreement with a former medicaid provider that seeks re-enrollment as a provider;

(3) Revalidating a medicaid provider's continued enrollment as a provider.

(B) The department is not to collect an application fee from a medicaid provider that is exempt from paying the fee under 42 C.F.R. 455.460(a).

(C) The application fees shall be deposited into the health care/medicaid support and recoveries fund created under section 5162.52 of the Revised Code. Application fees are nonrefundable when collected in accordance with 42 C.F.R. 455.460(a).

(D) The medicaid director shall adopt rules under section 5164.02 of the Revised Code as necessary to implement this section, including a rule establishing the amount of the application fee to be collected under this section. The amount of the application fee shall not be set at an amount that is more than necessary to pay for the expenses of implementing the provider screening requirements.

Section 5164.32 | Expiration of medicaid provider agreements.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) Each medicaid provider agreement shall expire not later than five years from its effective date. If a provider agreement entered into before the effective date of this amendment does not have a time limit, the department of medicaid shall convert the agreement to a provider agreement with a time limit.

(B) The medicaid director shall adopt rules under section 5164.02 of the Revised Code as necessary to implement this section. The rules shall be consistent with subpart E of 42 C.F.R. Part 455 and include a process for revalidating medicaid providers' continued enrollments as providers. All of the following apply to the revalidation process:

(1) The department shall refuse to revalidate a provider's provider agreement when the provider fails to file a complete application for revalidation within the time and in the manner required under the revalidation process.

(2) If a provider files a complete application for revalidation within the time and in the manner required under the revalidation process, but the provider agreement expires before the department acts on the application or before the effective date of the department's decision on the application, the provider, subject to division (B)(3) of this section, may continue operating under the terms of the expired provider agreement until the effective date of the department's decision.

(3) If a provider continues operating under the terms of an expired provider agreement pursuant to division (B)(2) of this section and the department denies the provider's application for revalidation, medicaid payments shall not be made for services or items the provider provides during the period beginning on the date the provider agreement expired and ending on the effective date of a subsequent provider agreement, if any, the department enters into with the provider.

Section 5164.33 | Denying, terminating, and suspending provider agreements.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) The medicaid director may do the following for any reason permitted or required by federal law and when the director determines that the action is in the best interests of medicaid recipients or the state:

(1) Deny, refuse to revalidate, suspend, or terminate a provider agreement;

(2) Exclude an individual, provider of services or goods, or other entity from participation in the medicaid program.

(B) No individual, provider, or entity excluded from participation in the medicaid program under this section shall do any of the following:

(1) Own, or provide services to, any other medicaid provider or risk contractor;

(2) Arrange for, render, or order services for medicaid recipients during the period of exclusion;

(3) During the period of exclusion, receive direct payments under the medicaid program or indirect payments of medicaid funds in the form of salary, shared fees, contracts, kickbacks, or rebates from or through any other medicaid provider or risk contractor.

(C) An individual, provider, or entity excluded from participation in the medicaid program under this section may request a reconsideration of the exclusion. The director shall adopt rules under section 5164.02 of the Revised Code governing the process for requesting a reconsideration.

(D) Nothing in this section limits the applicability of section 5164.38 of the Revised Code to a medicaid provider.

Section 5164.34 | Criminal records check of provider personnel, owners and officers.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) As used in this section:

(1) "Criminal records check" has the same meaning as in section 109.572 of the Revised Code.

(2) "Disqualifying offense" means any of the offenses listed or described in divisions (A)(3)(a) to (e) of section 109.572 of the Revised Code.

(3) "Owner" means a person who has an ownership interest in a medicaid provider in an amount designated in rules authorized by this section.

(4) "Person subject to the criminal records check requirement" means the following:

(a) A medicaid provider who is notified under division (E)(1) of this section that the provider is subject to a criminal records check;

(b) An owner or prospective owner, officer or prospective officer, or board member or prospective board member of a medicaid provider if, pursuant to division (E)(1)(a) of this section, the owner or prospective owner, officer or prospective officer, or board member or prospective board member is specified in information given to the provider under division (E)(1) of this section;

(c) An employee or prospective employee of a medicaid provider if both of the following apply:

(i) The employee or prospective employee is specified, pursuant to division (E)(1)(b) of this section, in information given to the provider under division (E)(1) of this section.

(ii) The provider is not prohibited by division (D)(3)(b) of this section from employing the employee or prospective employee.

(5) "Responsible entity" means the following:

(a) With respect to a criminal records check required under this section for a medicaid provider, the department of medicaid or the department's designee;

(b) With respect to a criminal records check required under this section for an owner or prospective owner, officer or prospective officer, board member or prospective board member, or employee or prospective employee of a medicaid provider, the provider.

(B) This section does not apply to any of the following:

(1) An individual who is subject to a criminal records check under section 3712.09, 3721.121, 5123.081, or 5123.169 of the Revised Code;

(2) An individual who is subject to a database review or criminal records check under section 173.38, 173.381, 3740.11, or 5164.342 of the Revised Code;

(3) An individual who is an applicant or independent provider, both as defined in section 5164.341 of the Revised Code.

(C) The department of medicaid may do any of the following:

(1) Require that any medicaid provider submit to a criminal records check as a condition of obtaining or maintaining a provider agreement;

(2) Require that any medicaid provider require an owner or prospective owner, officer or prospective officer, or board member or prospective board member of the provider submit to a criminal records check as a condition of being an owner, officer, or board member of the provider;

(3) Require that any medicaid provider do the following:

(a) If so required by rules authorized by this section, determine pursuant to a database review conducted under division (F)(1)(a) of this section whether any employee or prospective employee of the provider is included in a database;

(b) Unless the provider is prohibited by division (D)(3)(b) of this section from employing the employee or prospective employee, require the employee or prospective employee to submit to a criminal records check as a condition of being an employee of the provider.

(D)(1) The department or the department's designee shall deny or terminate a medicaid provider's provider agreement if the provider is a person subject to the criminal records check requirement and either of the following applies:

(a) The provider fails to obtain the criminal records check after being given the information specified in division (G)(1) of this section.

(b) Except as provided in rules authorized by this section, the provider is found by the criminal records check to have been convicted of or have pleaded guilty to a disqualifying offense, regardless of the date of the conviction or the date of entry of the guilty plea.

(2) No medicaid provider shall permit a person to be an owner, officer, or board member of the provider if the person is a person subject to the criminal records check requirement and either of the following applies:

(a) The person fails to obtain the criminal records check after being given the information specified in division (G)(1) of this section.

(b) Except as provided in rules authorized by this section, the person is found by the criminal records check to have been convicted of or have pleaded guilty to a disqualifying offense, regardless of the date of the conviction or the date of entry of the guilty plea.

(3) Except as provided in division (I) of this section, no medicaid provider shall employ a person if any of the following apply:

(a) The person has been excluded from being a medicaid provider, a medicare provider, or provider for any other federal health care program.

(b) If the person is subject to a database review conducted under division (F)(1)(a) of this section, the person is found by the database review to be included in a database and the rules authorized by this section regarding the database review prohibit the provider from employing a person included in the database.

(c) If the person is a person subject to the criminal records check requirement, either of the following applies:

(i) The person fails to obtain the criminal records check after being given the information specified in division (G)(1) of this section.

(ii) Except as provided in rules authorized by this section, the person is found by the criminal records check to have been convicted of or have pleaded guilty to a disqualifying offense, regardless of the date of the conviction or the date of entry of the guilty plea.

(E)(1) The department or the department's designee shall inform each medicaid provider whether the provider is subject to a criminal records check. For providers with valid provider agreements, the information shall be given at times designated in rules authorized by this section. For providers applying to be medicaid providers, the information shall be given at the time of initial application. When the information is given, the department or the department's designee shall specify the following:

(a) Which of the provider's owners or prospective owners, officers or prospective officers, or board members or prospective board members are subject to a criminal records check;

(b) Which of the provider's employees or prospective employees are subject to division (C)(3) of this section.

(2) At times designated in rules authorized by this section, a medicaid provider that is a person subject to the criminal records check requirement shall do the following:

(a) Inform each person specified under division (E)(1)(a) of this section that the person is required to submit to a criminal records check as a condition of being an owner, officer, or board member of the provider;

(b) Inform each person specified under division (E)(1)(b) of this section that the person is subject to division (C)(3) of this section.

(F)(1) If a medicaid provider is a person subject to the criminal records check requirement, the department or the department's designee shall require the conduct of a criminal records check by the superintendent of the bureau of criminal identification and investigation. A medicaid provider shall require the conduct of a criminal records check by the superintendent with respect to each of the persons specified under division (E)(1)(a) of this section. With respect to each employee and prospective employee specified under division (E)(1)(b) of this section, a medicaid provider shall do the following:

(a) If rules authorized by this section require the provider to conduct a database review to determine whether the employee or prospective employee is included in a database, conduct the database review in accordance with the rules;

(b) Unless the provider is prohibited by division (D)(3)(b) of this section from employing the employee or prospective employee, require the conduct of a criminal records check of the employee or prospective employee by the superintendent.

(2) If a person subject to the criminal records check requirement does not present proof of having been a resident of this state for the five-year period immediately prior to the date the criminal records check is requested or provide evidence that within that five-year period the superintendent has requested information about the person from the federal bureau of investigation in a criminal records check, the responsible entity shall require the person to request that the superintendent obtain information from the federal bureau of investigation as part of the criminal records check of the person. Even if the person presents proof of having been a resident of this state for the five-year period, the responsible entity may require that the person request that the superintendent obtain information from the federal bureau of investigation and include it in the criminal records check of the person.

(G) Criminal records checks required by this section shall be obtained as follows:

(1) The responsible entity shall provide each person subject to the criminal records check requirement information about accessing and completing the form prescribed pursuant to division (C)(1) of section 109.572 of the Revised Code and the standard impression sheet prescribed pursuant to division (C)(2) of that section.

(2) The person subject to the criminal records check requirement shall submit the required form and one complete set of the person's fingerprint impressions directly to the superintendent for purposes of conducting the criminal records check using the applicable methods prescribed by division (C) of section 109.572 of the Revised Code. The person shall pay all fees associated with obtaining the criminal records check.

(3) The superintendent shall conduct the criminal records check in accordance with section 109.572 of the Revised Code. The person subject to the criminal records check requirement shall instruct the superintendent to submit the report of the criminal records check directly to the responsible entity. If the department or the department's designee is not the responsible entity, the department or designee may require the responsible entity to submit the report to the department or designee.

(H)(1) A medicaid provider may employ conditionally a person for whom a criminal records check is required by this section prior to obtaining the results of the criminal records check if both of the following apply:

(a) The provider is not prohibited by division (D)(3)(b) of this section from employing the person.

(b) The person submits a request for the criminal records check not later than five business days after the person begins conditional employment.

(2) Except as provided in division (I) of this section, a medicaid provider that employs a person conditionally under division (H)(1) of this section shall terminate the person's employment if either of the following apply:

(a) The results of the criminal records check request are not obtained within the period ending sixty days after the date the request is made.

(b) Regardless of when the results of the criminal records check are obtained, the results indicate that the person has been convicted of or has pleaded guilty to a disqualifying offense, unless circumstances specified in rules authorized by this section exist that permit the provider to employ the person and the provider chooses to employ the person.

(I) As used in this division, "behavioral health services" means alcohol and drug addiction services, mental health services, or both.

A medicaid provider of behavioral health services may choose to employ a person who the provider would be prohibited by division (D)(3) of this section from employing or would be required by division (H)(2) of this section to terminate the person's employment if both of the following apply:

(1) The person holds a valid health professional license issued under the Revised Code granting the person authority to provide behavioral health services, holds a valid peer recovery supporter certificate issued pursuant to rules adopted by the department of mental health and addiction services, or is in the process of obtaining such a license or certificate.

(2) The provider does not submit any medicaid claims for any services the person provides.

(J) The report of a criminal records check conducted pursuant to this section is not a public record for the purposes of section 149.43 of the Revised Code and shall not be made available to any person other than the following:

(1) The person who is the subject of the criminal records check or the person's representative;

(2) The medicaid director and the staff of the department who are involved in the administration of the medicaid program;

(3) The department's designee;

(4) The medicaid provider who required the person who is the subject of the criminal records check to submit to the criminal records check;

(5) An individual receiving or deciding whether to receive, from the subject of the criminal records check, home and community-based services available under the medicaid state plan;

(6) A court, hearing officer, or other necessary individual involved in a case or administrative hearing dealing with any of the following:

(a) The denial, suspension, or termination of a provider agreement;

(b) A person's denial of employment, termination of employment, or employment or unemployment benefits;

(c) A civil or criminal action regarding the medicaid program.

With respect to an administrative hearing dealing with the denial, suspension, or termination of a provider agreement, the report of a criminal records check may be introduced as evidence at the hearing and if admitted, becomes part of the hearing record. Any such report shall be admitted only under seal and shall maintain its status as not a public record.

(K) The medicaid director may adopt rules under section 5164.02 of the Revised Code to implement this section. If the director adopts such rules, the rules shall designate the times at which a criminal records check must be conducted under this section. The rules may do any of the following:

(1) Designate the categories of persons who are subject to a criminal records check under this section;

(2) Specify circumstances under which the department or the department's designee may continue a provider agreement or issue a provider agreement when the medicaid provider is found by a criminal records check to have been convicted of or pleaded guilty to a disqualifying offense;

(3) Specify circumstances under which a medicaid provider may permit a person to be an employee, owner, officer, or board member of the provider when the person is found by a criminal records check conducted pursuant to this section to have been convicted of or have pleaded guilty to a disqualifying offense;

(4) Specify all of the following:

(a) The circumstances under which a database review must be conducted under division (F)(1)(a) of this section to determine whether an employee or prospective employee of a medicaid provider is included in a database;

(b) The procedures for conducting the database review;

(c) The databases that are to be checked;

(d) The circumstances under which, except as provided in division (I) of this section, a medicaid provider is prohibited from employing a person who is found by the database review to be included in a database.

Last updated October 10, 2023 at 11:24 AM

Section 5164.341 | Criminal records check by independent provider.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) As used in this section:

"Anniversary date" means the effective date of the provider agreement relating to the independent provider.

"Applicant" means a person who has applied for a provider agreement to provide home and community-based services as an independent provider under a home and community-based medicaid waiver component administered by the department of medicaid.

"Criminal records check" has the same meaning as in section 109.572 of the Revised Code.

"Disqualifying offense" means any of the offenses listed or described in divisions (A)(3)(a) to (e) of section 109.572 of the Revised Code.

"Independent provider" means a person who has a provider agreement to provide home and community-based services as an independent provider in a home and community-based services medicaid waiver component administered by the department of medicaid. "Independent provider" does not include a person who is employed by an individual enrolled in a participant-directed waiver administered by the department of medicaid.

(B) The department of medicaid or the department's designee shall deny an applicant's application for a provider agreement and shall terminate an independent provider's provider agreement if either of the following applies:

(1) After the applicant or independent provider is given the information and notification required by divisions (D)(2)(a) and (b) of this section, the applicant or independent provider fails to do either of the following:

(a) Access, complete, or forward to the superintendent of the bureau of criminal identification and investigation the form prescribed pursuant to division (C)(1) of section 109.572 of the Revised Code or the standard impression sheet prescribed pursuant to division (C)(2) of that section;

(b) Instruct the superintendent to submit the completed report of the criminal records check required by this section directly to the department or the department's designee.

(2) Except as provided in rules authorized by this section, the applicant or independent provider is found by either of the following to have been convicted of or have pleaded guilty to a disqualifying offense, regardless of the date of the conviction or the date of entry of the guilty plea:

(a) A criminal records check required by this section;

(b) In the case of an independent provider, a notice provided by the bureau of criminal identification and investigation under division (D) of section 109.5721 of the Revised Code.

(C)(1) The department or the department's designee shall inform each applicant, at the time of initial application for a provider agreement, that the applicant is required to provide a set of the applicant's fingerprint impressions and that a criminal records check is required to be conducted as a condition of the department's approving the application.

(2) Unless the department elects to receive notices about independent providers from the bureau of criminal identification and investigation pursuant to division (D) of section 109.5721 of the Revised Code, the department or the department's designee shall inform each independent provider on or before the time of the anniversary date of the provider agreement that the independent provider is required to provide a set of the independent provider's fingerprint impressions and that a criminal records check is required to be conducted.

(D)(1) The department or the department's designee shall require an applicant to complete a criminal records check prior to entering into a provider agreement with the applicant. The department or the department's designee shall require an independent provider to complete a criminal records check at least annually unless the department elects to receive notices about independent providers from the bureau of criminal identification and investigation pursuant to division (D) of section 109.5721 of the Revised Code. If an applicant or independent provider for whom a criminal records check is required by this section does not present proof of having been a resident of this state for the five-year period immediately prior to the date the criminal records check is requested or provide evidence that within that five-year period the superintendent of the bureau of criminal identification and investigation has requested information about the applicant or independent provider from the federal bureau of investigation in a criminal records check, the department or the department's designee shall request that the applicant or independent provider obtain through the superintendent a criminal records request from the federal bureau of investigation as part of the criminal records check of the applicant or independent provider. Even if an applicant or independent provider for whom a criminal records check request is required by this section presents proof of having been a resident of this state for the five-year period, the department or the department's designee may request that the applicant or independent provider obtain information through the superintendent from the federal bureau of investigation in the criminal records check.

(2) The department or the department's designee shall provide the following to each applicant and independent provider for whom a criminal records check is required by this section:

(a) Information about accessing, completing, and forwarding to the superintendent of the bureau of criminal identification and investigation the form prescribed pursuant to division (C)(1) of section 109.572 of the Revised Code and the standard impression sheet prescribed pursuant to division (C)(2) of that section;

(b) Written notification that the applicant or independent provider is to instruct the superintendent to submit the completed report of the criminal records check directly to the department or the department's designee.

(3) Each applicant and independent provider for whom a criminal records check is required by this section shall pay to the bureau of criminal identification and investigation the fee prescribed pursuant to division (C)(3) of section 109.572 of the Revised Code for the criminal records check conducted of the applicant or independent provider.

(E) Neither the report of any criminal records check conducted by the bureau of criminal identification and investigation in accordance with section 109.572 of the Revised Code and pursuant to a request made under this section nor a notice provided by the bureau under division (D) of section 109.5721 of the Revised Code is a public record for the purposes of section 149.43 of the Revised Code. Such a report or notice shall not be made available to any person other than the following:

(1) The person who is the subject of the criminal records check or the person's representative;

(2) The medicaid director and the staff of the department who are involved in the administration of the medicaid program;

(3) The department's designee;

(4) An individual receiving or deciding whether to receive home and community-based services from the person who is the subject of the criminal records check or notice from the bureau;

(5) A court, hearing officer, or other necessary individual involved in a case or administrative hearing dealing with either of the following:

(a) A denial, suspension, or termination of a provider agreement, including when related to the criminal records check or notice from the bureau;

(b) A civil or criminal action regarding the medicaid program.

With respect to an administrative hearing dealing with the denial, suspension, or termination of a provider agreement, the report of a criminal records check may be introduced as evidence at the hearing and if admitted, becomes part of the hearing record. Any such report shall be admitted only under seal and shall maintain its status as not a public record.

(F) The medicaid director shall adopt rules under section 5164.02 of the Revised Code to implement this section. The rules shall specify circumstances under which the department or the department's designee may either approve an applicant's application or allow an independent provider to maintain an existing provider agreement even though the applicant or independent provider is found by either of the following to have been convicted of or have pleaded guilty to a disqualifying offense:

(1) A criminal records check required by this section;

(2) In the case of an independent provider, a notice provided by the bureau of criminal identification and investigation under division (D) of section 109.5721 of the Revised Code.

Last updated October 10, 2023 at 11:26 AM

Section 5164.342 | Criminal records checks by waiver agencies.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) As used in this section:

"Applicant" means a person who is under final consideration for employment with a waiver agency in a full-time, part-time, or temporary position that involves providing home and community-based services.

"Community-based long-term care provider" means a provider as defined in section 173.39 of the Revised Code.

"Community-based long-term care subcontractor" means a subcontractor as defined in section 173.38 of the Revised Code.

"Criminal records check" has the same meaning as in section 109.572 of the Revised Code.

"Disqualifying offense" means any of the offenses listed or described in divisions (A)(3)(a) to (e) of section 109.572 of the Revised Code.

"Employee" means a person employed by a waiver agency in a full-time, part-time, or temporary position that involves providing home and community-based services.

"Waiver agency" means a person or government entity that provides home and community-based services under a home and community-based services medicaid waiver component administered by the department of medicaid, other than such a person or government entity that is certified under the medicare program. "Waiver agency" does not mean an independent provider as defined in section 5164.341 of the Revised Code.

(B) This section does not apply to any individual who is subject to a database review or criminal records check under section 3740.11 of the Revised Code. If a waiver agency also is a community-based long-term care provider or community-based long-term care subcontractor, the waiver agency may provide for any of its applicants and employees who are not subject to database reviews and criminal records checks under section 173.38 of the Revised Code to undergo database reviews and criminal records checks in accordance with that section rather than this section.

(C) No waiver agency shall employ an applicant or continue to employ an employee in a position that involves providing home and community-based services if any of the following apply:

(1) A review of the databases listed in division (E) of this section reveals any of the following:

(a) That the applicant or employee is included in one or more of the databases listed in divisions (E)(1) to (5) of this section;

(b) That there is in the state nurse aide registry established under section 3721.32 of the Revised Code a statement detailing findings by the director of health that the applicant or employee abused, neglected, or exploited a long-term care facility or residential care facility resident or misappropriated property of such a resident;

(c) That the applicant or employee is included in one or more of the databases, if any, specified in rules authorized by this section and the rules prohibit the waiver agency from employing an applicant or continuing to employ an employee included in such a database in a position that involves providing home and community-based services.

(2) After the applicant or employee is given the information and notification required by divisions (F)(2)(a) and (b) of this section, the applicant or employee fails to do either of the following:

(a) Access, complete, or forward to the superintendent of the bureau of criminal identification and investigation the form prescribed to division (C)(1) of section 109.572 of the Revised Code or the standard impression sheet prescribed pursuant to division (C)(2) of that section;

(b) Instruct the superintendent to submit the completed report of the criminal records check required by this section directly to the chief administrator of the waiver agency.

(3) Except as provided in rules authorized by this section, the applicant or employee is found by a criminal records check required by this section to have been convicted of or have pleaded guilty to a disqualifying offense, regardless of the date of the conviction or date of entry of the guilty plea.

(D) At the time of each applicant's initial application for employment in a position that involves providing home and community-based services, the chief administrator of a waiver agency shall inform the applicant of both of the following:

(1) That a review of the databases listed in division (E) of this section will be conducted to determine whether the waiver agency is prohibited by division (C)(1) of this section from employing the applicant in the position;

(2) That, unless the database review reveals that the applicant may not be employed in the position, a criminal records check of the applicant will be conducted and the applicant is required to provide a set of the applicant's fingerprint impressions as part of the criminal records check.

(E) As a condition of employing any applicant in a position that involves providing home and community-based services, the chief administrator of a waiver agency shall conduct a database review of the applicant in accordance with rules authorized by this section. If rules authorized by this section so require, the chief administrator of a waiver agency shall conduct a database review of an employee in accordance with the rules as a condition of continuing to employ the employee in a position that involves providing home and community-based services. A database review shall determine whether the applicant or employee is included in any of the following:

(1) The excluded parties list system that is maintained by the United States general services administration pursuant to subpart 9.4 of the federal acquisition regulation and available at the federal web site known as the system for award management;

(2) The list of excluded individuals and entities maintained by the office of inspector general in the United States department of health and human services pursuant to the "Social Security Act," sections 1128 and 1156, 42 U.S.C. 1320a-7 and 1320c-5;

(3) The registry of developmental disabilities employees established under section 5123.52 of the Revised Code;

(4) The internet-based sex offender and child-victim offender database established under division (A)(11) of section 2950.13 of the Revised Code;

(5) The internet-based database of inmates established under section 5120.66 of the Revised Code;

(6) The state nurse aide registry established under section 3721.32 of the Revised Code;

(7) Any other database, if any, specified in rules authorized by this section.

(F)(1) As a condition of employing any applicant in a position that involves providing home and community-based services, the chief administrator of a waiver agency shall require the applicant to request that the superintendent of the bureau of criminal identification and investigation conduct a criminal records check of the applicant. If rules authorized by this section so require, the chief administrator of a waiver agency shall require an employee to request that the superintendent conduct a criminal records check of the employee at times specified in the rules as a condition of continuing to employ the employee in a position that involves providing home and community-based services. However, a criminal records check is not required for an applicant or employee if the waiver agency is prohibited by division (C)(1) of this section from employing the applicant or continuing to employ the employee in a position that involves providing home and community-based services. If an applicant or employee for whom a criminal records check request is required by this section does not present proof of having been a resident of this state for the five-year period immediately prior to the date the criminal records check is requested or provide evidence that within that five-year period the superintendent has requested information about the applicant or employee from the federal bureau of investigation in a criminal records check, the chief administrator shall require the applicant or employee to request that the superintendent obtain information from the federal bureau of investigation as part of the criminal records check. Even if an applicant or employee for whom a criminal records check request is required by this section presents proof of having been a resident of this state for the five-year period, the chief administrator may require the applicant or employee to request that the superintendent include information from the federal bureau of investigation in the criminal records check.

(2) The chief administrator shall provide the following to each applicant and employee for whom a criminal records check is required by this section:

(a) Information about accessing, completing, and forwarding to the superintendent of the bureau of criminal identification and investigation the form prescribed pursuant to division (C)(1) of section 109.572 of the Revised Code and the standard impression sheet prescribed pursuant to division (C)(2) of that section;

(b) Written notification that the applicant or employee is to instruct the superintendent to submit the completed report of the criminal records check directly to the chief administrator.

(3) A waiver agency shall pay to the bureau of criminal identification and investigation the fee prescribed pursuant to division (C)(3) of section 109.572 of the Revised Code for any criminal records check required by this section. However, a waiver agency may require an applicant to pay to the bureau the fee for a criminal records check of the applicant. If the waiver agency pays the fee for an applicant, it may charge the applicant a fee not exceeding the amount the waiver agency pays to the bureau under this section if the waiver agency notifies the applicant at the time of initial application for employment of the amount of the fee and that, unless the fee is paid, the applicant will not be considered for employment.

(G)(1) A waiver agency may employ conditionally an applicant for whom a criminal records check is required by this section prior to obtaining the results of the criminal records check if both of the following apply:

(a) The waiver agency is not prohibited by division (C)(1) of this section from employing the applicant in a position that involves providing home and community-based services.

(b) The chief administrator of the waiver agency requires the applicant to request a criminal records check regarding the applicant in accordance with division (F)(1) of this section not later than five business days after the applicant begins conditional employment.

(2) A waiver agency that employs an applicant conditionally under division (G)(1) of this section shall terminate the applicant's employment if the results of the criminal records check, other than the results of any request for information from the federal bureau of investigation, are not obtained within the period ending sixty days after the date the request for the criminal records check is made. Regardless of when the results of the criminal records check are obtained, if the results indicate that the applicant has been convicted of or has pleaded guilty to a disqualifying offense, the waiver agency shall terminate the applicant's employment unless circumstances specified in rules authorized by this section exist that permit the waiver agency to employ the applicant and the waiver agency chooses to employ the applicant.

(H) The report of any criminal records check conducted pursuant to a request made under this section is not a public record for the purposes of section 149.43 of the Revised Code and shall not be made available to any person other than the following:

(1) The applicant or employee who is the subject of the criminal records check or the representative of the applicant or employee;

(2) The chief administrator of the waiver agency that requires the applicant or employee to request the criminal records check or the administrator's representative;

(3) The medicaid director and the staff of the department who are involved in the administration of the medicaid program;

(4) The director of aging or the director's designee if the waiver agency also is a community-based long-term care provider or community-based long-term care subcontractor;

(5) An individual receiving or deciding whether to receive home and community-based services from the subject of the criminal records check;

(6) A court, hearing officer, or other necessary individual involved in a case or administrative hearing dealing with any of the following:

(a) A denial of employment of the applicant or employee;

(b) Employment or unemployment benefits of the applicant or employee;

(c) A civil or criminal action regarding the medicaid program;

(d) A denial, suspension, or termination of a provider agreement.

With respect to an administrative hearing dealing with a denial, suspension, or termination of a provider agreement, the report of a criminal records check may be introduced as evidence at the hearing and if admitted, becomes part of the hearing record. Any such report shall be admitted only under seal and shall maintain its status as not a public record.

(I) The medicaid director shall adopt rules under section 5164.02 of the Revised Code to implement this section.

(1) The rules may do the following:

(a) Require employees to undergo database reviews and criminal records checks under this section;

(b) If the rules require employees to undergo database reviews and criminal records checks under this section, exempt one or more classes of employees from the requirements;

(c) For the purpose of division (E)(7) of this section, specify other databases that are to be checked as part of a database review conducted under this section.

(2) The rules shall specify all of the following:

(a) The procedures for conducting a database review under this section;

(b) If the rules require employees to undergo database reviews and criminal records checks under this section, the times at which the database reviews and criminal records checks are to be conducted;

(c) If the rules specify other databases to be checked as part of a database review, the circumstances under which a waiver agency is prohibited from employing an applicant or continuing to employ an employee who is found by the database review to be included in one or more of those databases;

(d) The circumstances under which a waiver agency may employ an applicant or employee who is found by a criminal records check required by this section to have been convicted of or have pleaded guilty to a disqualifying offense.

(J) The amendments made by H.B. 487 of the 129th general assembly to this section do not preclude the department of medicaid from taking action against a person for failure to comply with former division (H) of this section as that division existed on the day preceding January 1, 2013.

Last updated October 10, 2023 at 11:29 AM

Section 5164.35 | Provider offenses.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) As used in this section, "owner" means any person having at least five per cent ownership in a medicaid provider.

(B)(1) No medicaid provider shall do any of the following:

(a) By deception, obtain or attempt to obtain payments under the medicaid program to which the provider is not entitled pursuant to the provider's provider agreement, or the rules of the federal government or the medicaid director relating to the program;

(b) Willfully receive payments to which the provider is not entitled;

(c) Willfully receive payments in a greater amount than that to which the provider is entitled;

(d) Falsify any report or document required by state or federal law, rule, or provider agreement relating to medicaid payments.

(2) A medicaid provider engages in "deception" for the purpose of this section when the provider, acting with actual knowledge of the representation or information involved, acting in deliberate ignorance of the truth or falsity of the representation or information involved, or acting in reckless disregard of the truth or falsity of the representation or information involved, deceives another or causes another to be deceived by any false or misleading representation, by withholding information, by preventing another from acquiring information, or by any other conduct, act, or omission that creates, confirms, or perpetuates a false impression in another, including a false impression as to law, value, state of mind, or other objective or subjective fact. No proof of specific intent to defraud is required to show, for purposes of this section, that a medicaid provider has engaged in deception.

(C) Any medicaid provider who violates division (B) of this section shall be liable, in addition to any other penalties provided by law, for all of the following civil penalties:

(1) Payment of interest on the amount of the excess payments at the maximum interest rate allowable for real estate mortgages under section 1343.01 of the Revised Code on the date the payment was made to the provider for a period determined by the department, not to exceed the period from the date upon which payment was made, to the date upon which repayment is made to the state;

(2) Payment of an amount equal to three times the amount of any excess payments;

(3) Payment of a sum of not less than five thousand dollars and not more than ten thousand dollars for each deceptive claim or falsification;

(4) All reasonable expenses which the court determines have been necessarily incurred by the state in the enforcement of this section.

(D) In addition to the civil penalties provided in division (C) of this section, the medicaid director, upon the conviction of, or the entry of a judgment in either a criminal or civil action against, a medicaid provider or its owner, officer, authorized agent, associate, manager, or employee in an action brought pursuant to section 109.85 of the Revised Code, shall terminate the provider's provider agreement and stop payment to the provider for medicaid services rendered from the date of conviction or entry of judgment. No such medicaid provider, owner, officer, authorized agent, associate, manager, or employee shall own or provide medicaid services on behalf of any other medicaid provider or risk contractor or arrange for, render, or order medicaid services for medicaid recipients, nor shall such provider, owner, officer, authorized agent, associate, manager, or employee receive direct payments under the medicaid program or indirect payments of medicaid funds in the form of salary, shared fees, contracts, kickbacks, or rebates from or through any other medicaid provider or risk contractor. The provider agreement shall not be terminated, and payment shall not be terminated, if the medicaid provider or owner can demonstrate that the provider or owner did not directly or indirectly sanction the action of its authorized agent, associate, manager, or employee that resulted in the conviction or entry of a judgment in a criminal or civil action brought pursuant to section 109.85 of the Revised Code. Nothing in this division prohibits any owner, officer, authorized agent, associate, manager, or employee of a medicaid provider from entering into a provider agreement if the person can demonstrate that the person had no knowledge of an action of the medicaid provider the person was formerly associated with that resulted in the conviction or entry of a judgment in a criminal or civil action brought pursuant to section 109.85 of the Revised Code.

Nursing facility and ICF/IID providers whose provider agreements are terminated pursuant to this section may continue to receive medicaid payments for up to thirty days after the effective date of the termination if the provider makes reasonable efforts to transfer medicaid recipients to another facility or to alternate care and if federal financial participation is provided for the payments.

(E) The attorney general on behalf of the state may commence proceedings to enforce this section in any court of competent jurisdiction; and the attorney general may settle or compromise any case brought under this section with the approval of the department of medicaid. Notwithstanding any other provision of law providing a shorter period of limitations, the attorney general may commence a proceeding to enforce this section at any time within six years after the conduct in violation of this section terminates.

(F) All moneys collected by the state pursuant to this section shall be deposited in the state treasury to the credit of the general revenue fund.

Last updated October 10, 2023 at 11:31 AM

Section 5164.36 | Credible allegation of fraud or disqualifying indictment; suspension of provider agreement.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) As used in this section:

(1) "Credible allegation of fraud" has the same meaning as in 42 C.F.R. 455.2, except that for purposes of this section any reference in that regulation to the "state" or the "state medicaid agency" means the department of medicaid.

(2) "Disqualifying indictment" means an indictment of a medicaid provider or its officer, authorized agent, associate, manager, employee, or, if the provider is a noninstitutional provider, its owner, if either of the following applies:

(a) The indictment charges the person with committing an act to which both of the following apply:

(i) The act would be a felony or misdemeanor under the laws of this state or the jurisdiction within which the act occurred.

(ii) The act relates to or results from furnishing or billing for medicaid services under the medicaid program or relates to or results from performing management or administrative services relating to furnishing medicaid services under the medicaid program.

(b) The indictment charges the person with committing an act that would constitute a disqualifying offense.

(3) "Disqualifying offense" means any of the offenses listed or described in divisions (A)(3)(a) to (e) of section 109.572 of the Revised Code.

(4) "Noninstitutional medicaid provider" means any person or entity with a provider agreement other than a hospital, nursing facility, or ICF/IID.

(5) "Owner" means any person having at least five per cent ownership in a noninstitutional medicaid provider.

(B)(1) Except as provided in division (C) of this section and in rules authorized by this section, the department of medicaid shall suspend the provider agreement held by a medicaid provider on determining either of the following:

(a) There is a credible allegation of fraud against any of the following for which an investigation is pending under the medicaid program:

(i) The medicaid provider;

(ii) The medicaid provider's owner, officer, authorized agent, associate, manager, or employee.

(b) A disqualifying indictment has been issued against any of the following:

(i) The medicaid provider;

(ii) The medicaid provider's officer, authorized agent, associate, manager, or employee;

(iii) If the medicaid provider is a noninstitutional provider, its owner.

(2) Subject to division (C) of this section, the department shall also suspend all medicaid payments to a medicaid provider for services rendered, regardless of the date that the services are rendered, when the department suspends the provider's provider agreement under this section.

(3) The suspension of a provider agreement shall continue in effect until the latest of the following occurs:

(a) If the suspension is the result of a credible allegation of fraud, the department or a prosecuting authority determines that there is insufficient evidence of fraud by the medicaid provider;

(b) Regardless of whether the suspension is the result of a credible allegation of fraud or a disqualifying indictment, the proceedings in any related criminal case are completed through dismissal of the indictment or through sentencing after conviction or entry of a guilty plea or through finding of not guilty or, if the department commences a process to terminate the suspended provider agreement, the termination process is concluded;

(c) The medicaid provider pays in full all fines and debts due and owing to the department or makes arrangements satisfactory to the department to fulfill those obligations;

(d) A civil action related to a credible allegation of fraud or disqualifying indictment is not pending against the medicaid provider.

(4)(a) When a provider agreement is suspended under this section, none of the following shall take, during the period of the suspension, any of the actions specified in division (B)(4)(b) of this section:

(i) The medicaid provider;

(ii) If the suspension is the result of an action taken by an officer, authorized agent, associate, manager, or employee of the medicaid provider, that person;

(iii) If the medicaid provider is a noninstitutional provider and the suspension is the result of an action taken by the owner of the provider, the owner.

(b) The following are the actions that persons specified in division (B)(4)(a) of this section cannot take during the suspension of a provider agreement:

(i) Own any other medicaid provider or risk contractor;

(ii) Arrange, render, or order services on behalf of any other medicaid provider or risk contractor;

(iii) Arrange or order services for medicaid recipients or render services to medicaid recipients;

(iv) Receive direct payments under the medicaid program or indirect payments of medicaid funds in the form of salary, shared fees, contracts, kickbacks, or rebates from or through any other medicaid provider or risk contractor.

(C) The department shall not suspend a provider agreement or medicaid payments under division (B) of this section if either of the following is the case:

(1) The medicaid provider or, if the provider is a noninstitutional provider, the owner can demonstrate through the submission of written evidence that the provider or owner did not directly or indirectly sanction the action of its authorized agent, associate, manager, or employee that resulted in the credible allegation of fraud or disqualifying indictment.

(2) The medicaid provider or, if the provider is a noninstitutional provider, the owner can demonstrate that good cause exists not to suspend the provider agreement or payments.

With respect to the evidence described in division (C)(1) of this section, the department shall grant, prior to suspension, the provider or owner an opportunity to submit the written evidence to the department.

With respect to a demonstration of good cause described in division (C)(2) of this section, the department shall specify in rules adopted under section 5164.02 of the Revised Code what constitutes good cause and the information, documents, or other evidence that must be submitted to the department as part of the demonstration.

(D) After suspending a provider agreement under division (B) of this section, the department shall send notice of the suspension to the affected medicaid provider or, if the provider is a noninstitutional provider, the owner in accordance with the following time frames:

(1) Not later than five days after the suspension, unless a law enforcement agency makes a written request to temporarily delay the notice;

(2) If a law enforcement agency makes a written request to temporarily delay the notice, not later than thirty days after the suspension occurs subject to the conditions specified in division (E) of this section.

(E) A written request for a temporary delay described in division (D)(2) of this section may be renewed in writing by a law enforcement agency not more than two times except that under no circumstances shall the notice be issued more than ninety days after the suspension occurs.

(F) The notice required by division (D) of this section shall do all of the following:

(1) State that payments are being suspended in accordance with this section and 42 C.F.R. 455.23;

(2) Set forth the general allegations related to the nature of the conduct leading to the suspension, except that it is not necessary to disclose any specific information concerning an ongoing investigation;

(3) State that the suspension continues to be in effect until the latest of the circumstances specified in division (B)(3) of this section occur;

(4) Specify, if applicable, the type or types of medicaid claims or business units of the medicaid provider that are affected by the suspension;

(5) Inform the medicaid provider or owner of the opportunity to submit to the department, not later than thirty days after receiving the notice, a request for reconsideration of the suspension in accordance with division (G) of this section.

(G)(1) Pursuant to the procedure specified in division (G)(2) of this section, a medicaid provider subject to a suspension under this section or, if the provider is a noninstitutional provider, the owner may request a reconsideration of the suspension. The request shall be made not later than thirty days after receipt of a notice required by division (D) of this section. The reconsideration is not subject to an adjudication hearing pursuant to Chapter 119. of the Revised Code.

(2) In requesting a reconsideration, the medicaid provider or owner shall submit written information and documents to the department. The information and documents may pertain to either of the following issues:

(a) Whether the determination to suspend the provider agreement was based on a mistake of fact, other than the validity of an indictment in a related criminal case.

(b) If there has been an indictment in a related criminal case, whether the indictment is a disqualifying indictment.

(H) The department shall review the information and documents submitted in a request made under division (G) of this section for reconsideration of a suspension. After the review, the suspension may be affirmed, reversed, or modified, in whole or in part. The department shall notify the affected provider or owner of the results of the review.

(I) Rules adopted under section 5164.02 of the Revised Code may specify circumstances under which the department would not suspend a provider agreement pursuant to this section.

Last updated October 10, 2023 at 11:43 AM

Section 5164.37 | Suspension of provider agreement without notice.

• Effective: October 17, 2019
• Latest Legislation: House Bill 166 - 133rd General Assembly

(A) The department of medicaid may suspend a medicaid provider's provider agreement without prior notice if the department has evidence that the provider presents a danger of immediate and serious harm to the health, safety, or welfare of medicaid recipients. The department also shall suspend all medicaid payments to the medicaid provider for services rendered, regardless of the date that the services were rendered, when the department suspends the provider agreement under this section.

(B) If the department suspends a medicaid provider's provider agreement under this section, the department shall do both of the following:

(1) Not later than five days after suspending the provider agreement, notify the medicaid provider of the suspension;

(2) Not later than ten business days after suspending the provider agreement, notify the medicaid provider that the department intends to terminate the provider agreement.

(C) The notice that the department provides to a medicaid provider under division (B)(2) of this section shall include the allegation that the provider presents a danger of immediate and serious harm to the health, safety, or welfare of medicaid recipients. It may also include other grounds for terminating the provider agreement. Section 5164.38 of the Revised Code applies to the termination of the provider agreement.

(D) The suspension of a medicaid provider's provider agreement and medicaid payments shall cease at the earliest of the following:

(1) The department's failure to provide a notice required by division (B) of this section by the time specified in that division;

(2) The department rescinds its notice to terminate the provider agreement.

(3) The department issues an order regarding the termination of the provider agreement pursuant to an adjudication conducted in accordance with Chapter 119. of the Revised Code.

(E) This section does not limit the department's authority to suspend or terminate a provider agreement or medicaid payments to a medicaid provider under any other provision of the Revised Code.

Section 5164.38 | Adjudication orders of department.

• Effective: September 29, 2023
• Latest Legislation: Senate Bill 21, House Bill 33 - 135th General Assembly

(A) As used in this section:

(1) "Party" has the same meaning as in division (G) of section 119.01 of the Revised Code.

(2) "Revalidate" means to approve a medicaid provider's continued enrollment as a medicaid provider in accordance with the revalidation process established in rules authorized by section 5164.32 of the Revised Code.

(B) This section does not apply to either of the following:

(1) Any action taken or decision made by the department of medicaid with respect to entering into or refusing to enter into a contract with a managed care organization pursuant to section 5167.10 of the Revised Code;

(2) Any action taken by the department under division (D)(2) of section 5124.60, division (D)(1) or (2) of section 5124.61, or sections 5165.60 to 5165.89 of the Revised Code.

(C) Except as provided in division (E) of this section and section 5164.58 of the Revised Code, the department shall do any of the following by issuing an order pursuant to an adjudication conducted in accordance with Chapter 119. of the Revised Code:

(1) Refuse to enter into a provider agreement with a medicaid provider;

(2) Refuse to revalidate a medicaid provider's provider agreement;

(3) Suspend or terminate a medicaid provider's provider agreement;

(4) Take any action based upon a final fiscal audit of a medicaid provider.

(D) Any party who is adversely affected by the issuance of an adjudication order under division (C) of this section may appeal to the court of common pleas in accordance with section 119.12 of the Revised Code.

(E) The department is not required to comply with division (C)(1), (2), or (3) of this section whenever any of the following occur:

(1) The terms of a provider agreement require the medicaid provider to hold a license, permit, or certificate or maintain a certification issued by an official, board, commission, department, division, bureau, or other agency of state or federal government other than the department of medicaid, and the license, permit, certificate, or certification has been denied, revoked, not renewed, suspended, or otherwise limited.

(2) The terms of a provider agreement require the medicaid provider to hold a license, permit, or certificate or maintain certification issued by an official, board, commission, department, division, bureau, or other agency of state or federal government other than the department of medicaid, and the provider has not obtained the license, permit, certificate, or certification.

(3) The medicaid provider's application for a provider agreement is denied, or the provider's provider agreement is terminated or not revalidated, because of or pursuant to any of the following:

(a) The termination, refusal to renew, or denial of a license, permit, certificate, or certification by an official, board, commission, department, division, bureau, or other agency of this state other than the department of medicaid, notwithstanding the fact that the provider may hold a license, permit, certificate, or certification from an official, board, commission, department, division, bureau, or other agency of another state;

(b) Division (D) or (E) of section 5164.35 of the Revised Code;

(c) The provider's termination, suspension, or exclusion from the medicare program or from another state's medicaid program and, in either case, the termination, suspension, or exclusion is binding on the provider's participation in the medicaid program in this state;

(d) The provider's pleading guilty to or being convicted of a criminal activity materially related to either the medicare or medicaid program;

(e) The provider or its owner, officer, authorized agent, associate, manager, or employee having been convicted of one of the offenses that caused the provider's provider agreement to be suspended pursuant to section 5164.36 of the Revised Code;

(f) The provider's failure to provide the department the national provider identifier assigned the provider by the national provider system pursuant to 45 C.F.R. 162.408.

(4) The medicaid provider's application for a provider agreement is denied, or the provider's provider agreement is terminated or suspended, as a result of action by the United States department of health and human services and that action is binding on the provider's medicaid participation.

(5) The medicaid provider's provider agreement and medicaid payments to the provider are suspended under section 5164.36 or 5164.37 of the Revised Code.

(6) The medicaid provider's application for a provider agreement is denied because the provider's application was not complete;

(7) The medicaid provider's provider agreement is converted under section 5164.32 of the Revised Code from a provider agreement that is not time-limited to a provider agreement that is time-limited.

(8) Unless the medicaid provider is a nursing facility or ICF/IID, the provider's provider agreement is not revalidated pursuant to division (B)(1) of section 5164.32 of the Revised Code.

(9) The medicaid provider's provider agreement is suspended, terminated, or not revalidated because of either of the following:

(a) Any reason authorized or required by one or more of the following: 42 C.F.R. 455.106, 455.23, 455.416, 455.434, or 455.450;

(b) The provider has not billed or otherwise submitted a medicaid claim for two years or longer.

(F) In the case of a medicaid provider described in division (E)(3)(f), (6), (7), or (9)(b) of this section, the department may take its action by sending a notice explaining the action to the provider. The notice shall be sent to the medicaid provider's address on record with the department. The notice may be sent by regular mail.

(G) The department may withhold payments for medicaid services rendered by a medicaid provider during the pendency of proceedings initiated under division (C)(1), (2), or (3) of this section. If the proceedings are initiated under division (C)(4) of this section, the department may withhold payments only to the extent that they equal amounts determined in a final fiscal audit as being due the state. This division does not apply if the department fails to comply with section 119.07 of the Revised Code, requests a continuance of the hearing, or does not issue a decision within thirty days after the hearing is completed. This division does not apply to nursing facilities and ICFs/IID.

Last updated August 7, 2023 at 2:44 PM

Section 5164.39 | Hearing not required unless timely requested.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

In any action taken by the department of medicaid under section 5164.38 or 5164.57 of the Revised Code or any other state statute governing the medicaid program that requires the department to give notice of an opportunity for a hearing in accordance with Chapter 119. of the Revised Code, if the department gives notice of the opportunity for a hearing but the medicaid provider or other entity subject to the notice does not request a hearing or timely request a hearing in accordance with section 119.07 of the Revised Code, the department is not required to hold a hearing. The medicaid director may proceed by issuing a final adjudication order in accordance with Chapter 119. of the Revised Code.

Section 5164.44 | Employee status of independent provider.

• Effective: March 23, 2016
• Latest Legislation: House Bill 56 - 131st General Assembly

(A) As used in this section:

(1) "Aide services" means all of the following:

(a) Home health aide services covered by the medicaid program as part of the home health services benefit pursuant to 42 C.F.R. 440.70(b)(2);

(b) Home care attendant services covered by a participating medicaid waiver component, as defined in section 5166.30 of the Revised Code;

(c) Any of the following covered by a home and community-based services medicaid waiver component:

(i) Personal care aide services;

(ii) Homemaker/personal care services;

(iii) Community inclusion services.

(2) "Independent provider" means an individual who personally provides aide services or nursing services under the medicaid program and is not employed by, under contract with, or affiliated with another entity that provides the services.

(3) "Nursing services" means all of the following:

(a) Nursing services covered by the medicaid program as part of the home health services benefit pursuant to 42 C.F.R. 440.70(b)(1);

(b) Private duty nursing services, as defined in 42 C.F.R. 440.80, covered by the medicaid program;

(c) Nursing services covered by a home and community-based services medicaid waiver component.

(B) Notwithstanding any provision of the Revised Code to the contrary, an independent provider is not an employee of the state, or any political subdivision of the state, for any purpose under state law due to being an independent provider or any actions taken to become or remain an independent provider.

Section 5164.45 | Contracts for examination, processing, and determination of medicaid claims.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) The department of medicaid may contract with any person or persons as a fiscal agent for the examination, processing, and determination of medicaid claims. The contracting party may provide any of the following services, as required by the contract:

(1) Design and operate medicaid management information systems, including the provision of data processing services;

(2) Determine the amounts of payments to be made upon claims for medicaid;

(3) Prepare and furnish to the department lists and computer tapes of such claims for payment;

(4) In addition to audits which may be conducted by the department and by the auditor of state, make audits of providers and the claims of medicaid providers according to the standards set forth in the contract;

(5) Assist medicaid providers in the development of procedures relating to utilization practices, make studies of the effectiveness of such procedures and methods for their improvement, implement and enforce standards of medical policy, and assist in the application of safeguards against unnecessary utilization;

(6) Assist any institution, facility, or agency to qualify as a medicaid provider;

(7) Establish and maintain fiscal records for the medicaid program;

(8) Perform statistical and research studies;

(9) Develop and implement programs for medicaid cost containment;

(10) Perform such other duties as are necessary to carry out the medicaid program.

(B) The department may contract with any person or persons as an insuring agent for the examination, processing, and determination of medicaid claims, as provided in division (A) of this section, and for the payment of medicaid claims through an underwritten program in which the state pays the insuring agent a monthly premium and the insuring agent pays for medicaid services. The person with whom the department contracts, with respect to the awarding, provisions, and performance of such contract, shall not be subject to the provisions of Title XXXIX of the Revised Code or to regulation by the department of insurance, nor to taxation as an insurance company pursuant to section 5725.18 or 5729.03 of the Revised Code. A contract with an insuring agent shall specify the qualifications, including capital and surplus requirements, and other conditions with which the insuring agent must comply.

(C) In entering into a contract under this section, the department, in cooperation with the director of budget and management, shall determine that the contracting party is qualified to perform the required services and shall follow applicable procedures required of the department of administrative services in sections 125.07 to 125.11 of the Revised Code. A contract shall be awarded to the bidder who, with due consideration to the bidder's experience and financial capability, offers the lowest and best bid to the state for control of the costs of the medicaid program consistent with meeting the obligations under that program for fair and equitable treatment of medicaid recipients and medicaid providers. Any arrangement whereby funds are paid to an insuring or fiscal agent for administrative functions under this section shall, for the purposes of section 125.081 of the Revised Code, be deemed to be a contract or purchase by the department of administrative services; however, money to be used by an insuring agent to pay for medicaid services shall not be deemed a contract or purchase within the meaning of such section.

Section 5164.46 | Electronic claims submission process; electronic fund transfers.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) As used in this section, "electronic claims submission process" means any of the following:

(1) Electronic interchange of data;

(2) Direct entry of data through an internet-based mechanism implemented by the department of medicaid;

(3) Any other process for the electronic submission of claims that is specified in rules adopted under section 5162.02 of the Revised Code.

(B) Not later than January 1, 2013, and except as provided in division (C) of this section, each medicaid provider shall do both of the following:

(1) Use only an electronic claims submission process to submit to the department of medicaid claims for medicaid payment for medicaid services provided to medicaid recipients;

(2) Arrange to receive medicaid payment from the department by means of electronic funds transfer.

(C) Division (B) of this section does not apply to any of the following:

(1) A nursing facility;

(2) An ICF/IID;

(3) A medicaid managed care organization;

(4) Any other medicaid provider or type of medicaid provider designated in rules adopted under section 5162.02 of the Revised Code.

(D) The department shall not process a medicaid claim submitted on or after January 1, 2013, unless the claim is submitted through an electronic claims submission process in accordance with this section.

Section 5164.47 | Contracting for review and analysis, quality assurance and quality review.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) As used in this section, "OCHSPS" means the private, not-for-profit corporation known as the Ohio children's hospital solutions for patient safety, which was formed for the purpose of improving pediatric patient care in this state, which performs functions that are included within the functions of a peer review committee as defined in section 2305.25 of the Revised Code, and which consists of all of the following members: Akron children's hospital, Cincinnati children's hospital medical center, Cleveland clinic children's hospital, Dayton children's medical center, mercy children's hospital, nationwide children's hospital, rainbow babies & children's hospital, and Toledo children's hospital.

(B) If, as authorized by section 5160.10 of the Revised Code, the medicaid director chooses to contract with a person to perform either or both of the following services, the director may contract with any qualified person, including OCHSPS, to perform the service or services on behalf of the department of medicaid:

(1) Review and analyze claims for medicaid services provided to children in accordance with all state and federal laws governing the confidentiality of patient-identifying information;

(2) Perform quality assurance and quality review functions, other than those described in division (B)(1) of this section, related to medicaid services provided to children.

The functions specified in division (B)(2) of this section may include those recommended by the best evidence for advancing child health in Ohio now (BEACON) council.

(C) If the director enters into a contract with OCHSPS for OCHSPS to perform either or both of the services described in division (B) of this section, OCHSPS shall, only for purposes of section 5160.12 of the Revised Code, be considered a public entity and the director shall seek federal financial participation for costs incurred by OCHSPS in performing the service or services.

Section 5164.471 | Summary data regarding perinatal services.

• Effective: April 6, 2017
• Latest Legislation: Senate Bill 332 - 131st General Assembly

Not less than once each year and in accordance with all state and federal laws governing the confidentiality of patient-identifying information, the department of medicaid shall make summary data regarding perinatal services available on request to local organizations concerned with infant mortality reduction initiatives and recipients of grants administered by the division of family and community health services in the department of health.

Section 5164.48 | Medicaid payments made to organization on behalf of providers.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The medicaid director may implement a system under which medicaid payments for medicaid services are made to an organization on behalf of medicaid providers. The system may not provide for an organization to receive an amount that exceeds, in aggregate, the amount the medicaid program would have paid directly to medicaid providers if not for this section.

Section 5164.55 | Final fiscal audits.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The department of medicaid may conduct final fiscal audits of medicaid providers in accordance with the applicable requirements set forth in federal laws and regulations and determine any amounts the provider may owe the state. When conducting final fiscal audits, the department shall consider generally accepted auditing standards, which include the use of statistical sampling.

Section 5164.56 | Lien for amount owed by provider.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

Under the medicaid program, any amount determined to be owed the state by a final fiscal audit conducted pursuant to section 5164.55 of the Revised Code, upon the issuance of an adjudication order pursuant to Chapter 119. of the Revised Code that contains a finding that there is a preponderance of the evidence that a medicaid provider will liquidate assets or file bankruptcy in order to prevent payment of the amount determined to be owed the state, becomes a lien upon the real and personal property of the provider. Upon failure of the provider to pay the amount to the state, the medicaid director shall file notice of the lien, for which there shall be no charge, in the office of the county recorder of the county in which it is ascertained that the provider owns real or personal property. The director shall notify the provider by mail of the lien, but absence of proof that the notice was sent does not affect the validity of the lien. The lien is not valid as against the claim of any mortgagee, pledgee, purchaser, judgment creditor, or other lienholder of record at the time the notice is filed.

If the provider acquires real or personal property after notice of the lien is filed, the lien shall not be valid as against the claim of any mortgagee, pledgee, subsequent bona fide purchaser for value, judgment creditor, or other lienholder of record to such after-acquired property unless the notice of lien is refiled after the property is acquired by the provider and before the competing lien attaches to the after-acquired property or before the conveyance to the subsequent bona fide purchaser for value.

When the amount has been paid, the provider may record with the recorder notice of the payment. For recording such notice of payment, the recorder shall charge and receive from the provider a base fee of one dollar for services and a housing trust fund fee of one dollar pursuant to section 317.36 of the Revised Code.

In the event of a distribution of the provider's assets pursuant to an order of any court under the law of this state including any receivership, assignment for benefit of creditors, adjudicated insolvency, or similar proceedings, amounts then or thereafter due the state under the medicaid program have the same priority as provided by law for the payment of taxes due the state and shall be paid out of the receivership trust fund or other such trust fund in the same manner as provided for claims for unpaid taxes due the state.

If the attorney general finds after investigation that any amount due the state under the medicaid program is uncollectable, in whole or in part, the attorney general shall recommend to the director the cancellation of all or part of the claim. The director may thereupon effect the cancellation.

Section 5164.57 | Recovery of medicaid overpayments.

• Effective: September 29, 2015
• Latest Legislation: House Bill 64 - 131st General Assembly

(A)(1) Except as provided in division (A)(2) of this section, the department of medicaid may recover a medicaid payment or portion of a payment made to a medicaid provider to which the provider is not entitled if the department notifies the provider of the overpayment during the five-year period immediately following the end of the state fiscal year in which the overpayment was made.

(2) In the case of a hospital medicaid provider, if the department determines as a result of a medicare or medicaid cost report settlement that the provider received an amount under the medicaid program to which the provider is not entitled, the department may recover the overpayment if the department notifies the provider of the overpayment during the later of the following:

(a) The five-year period immediately following the end of the state fiscal year in which the overpayment was made;

(b) The one-year period immediately following the date the department receives from the United States centers for medicare and medicaid services a completed, audited, medicare cost report for the provider that applies to the state fiscal year in which the overpayment was made.

(B) Among the overpayments that may be recovered under this section are the following:

(1) Payment for a medicaid service, or a day of service, not rendered;

(2) Payment for a day of service at a full per diem rate that should have been paid at a percentage of the full per diem rate;

(3) Payment for a medicaid service, or day of service, that was paid by, or partially paid by, a third party, as defined in section 5160.35 of the Revised Code, and the third party's payment or partial payment was not offset against the amount paid by the medicaid program to reduce or eliminate the amount that was paid by the medicaid program;

(4) Payment when a medicaid recipient's responsibility for payment was understated and resulted in an overpayment to the provider.

(C) The department may recover an overpayment under this section prior to or after any of the following:

(1) Adjudication of a final fiscal audit that section 5164.38 of the Revised Code requires to be conducted in accordance with Chapter 119. of the Revised Code;

(2) Adjudication of a finding under any other provision of state statutes governing the medicaid program or the rules adopted under those statutes;

(3) Expiration of the time to issue a final fiscal audit that section 5164.38 of the Revised Code requires to be conducted in accordance with Chapter 119. of the Revised Code;

(4) Expiration of the time to issue a finding under any other provision of state statutes governing the medicaid program or the rules adopted under those statutes.

(D)(1) Subject to division (D)(2) of this section, the recovery of an overpayment under this section does not preclude the department from subsequently doing the following:

(a) Issuing a final fiscal audit in accordance with Chapter 119. of the Revised Code, as required under section 5164.38 of the Revised Code;

(b) Issuing a finding under any other provision of state statutes governing the medicaid program or the rules adopted under those statutes.

(2) A final fiscal audit or finding issued subsequent to the recovery of an overpayment under this section shall be reduced by the amount of the prior recovery, as appropriate.

(E) Nothing in this section limits the department's authority to recover overpayments pursuant to any other provision of the Revised Code.

Section 5164.58 | Agency action to recover overpayment to provider.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) If a state agency that enters into a contract with the department of medicaid under section 5162.35 of the Revised Code identifies that a medicaid overpayment has been made to a medicaid provider, the state agency may commence actions to recover the overpayment on behalf of the department.

(B) In recovering an overpayment pursuant to this section, a state agency shall comply with the following procedures:

(1) The state agency shall attempt to recover the overpayment by notifying the medicaid provider of the overpayment and requesting voluntary repayment. Not later than five business days after notifying the medicaid provider, the state agency shall notify the department in writing of the overpayment. The state agency may negotiate a settlement of the overpayment and notify the department of the settlement. A settlement negotiated by the state agency is not valid and shall not be implemented until the department has given its written approval of the settlement.

(2) If the state agency is unable to obtain voluntary repayment of an overpayment, the agency shall give the medicaid provider notice of an opportunity for a hearing in accordance with Chapter 119. of the Revised Code. If the medicaid provider timely requests a hearing in accordance with section 119.07 of the Revised Code, the state agency shall conduct the hearing to determine the legal and factual validity of the overpayment. On completion of the hearing, the state agency shall submit its hearing officer's report and recommendation and the complete record of proceedings, including all transcripts, to the medicaid director for final adjudication. The director may issue a final adjudication order in accordance with Chapter 119. of the Revised Code. The state agency shall pay any attorney's fees imposed under section 119.092 of the Revised Code. The department of medicaid shall pay any attorney's fees imposed under section 2335.39 of the Revised Code.

(C) In any action taken by a state agency under this section that requires the agency to give notice of an opportunity for a hearing in accordance with Chapter 119. of the Revised Code, if the agency gives notice of the opportunity for a hearing but the medicaid provider subject to the notice does not request a hearing or timely request a hearing in accordance with section 119.07 of the Revised Code, the agency is not required to hold a hearing. The agency may request that the medicaid director issue a final adjudication order in accordance with Chapter 119. of the Revised Code.

(D) This section does not preclude the department of medicaid from adjudicating a final fiscal audit under section 5164.38 of the Revised Code, recovering overpayments under section 5164.57 of the Revised Code, or making findings or taking other actions authorized by state statutes governing the medicaid program.

Section 5164.59 | Deduction of incorrect payments.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The department of medicaid may deduct from medicaid payments for medicaid services rendered by a medicaid provider any amounts the provider owes the state as the result of incorrect medicaid payments the department has made to the provider.

Section 5164.60 | Interest on Medicaid provider excess payments.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

Any medicaid provider who, without intent, obtains payments under the medicaid program in excess of the amount to which the provider is entitled is liable for payment of interest on the amount of the excess payments for a period determined by the department, but not to exceed the period from the date on which payment was made to the date on which repayment is made to the state. The interest shall be paid at the average bank prime rate in effect on the first day of the calendar quarter during which the provider receives notice of the excess payment. The department of medicaid shall determine the average bank prime rate using statistical release H.15, "selected interest rates," a weekly publication of the federal reserve board, or any successor publication. If statistical release H.15, or its successor, ceases to contain the bank prime rate information or ceases to be published, the department shall request a written statement of the average bank prime rate from the federal reserve bank of Cleveland or the federal reserve board.

Last updated October 5, 2023 at 3:23 PM

Section 5164.61 | Scope of available remedies for recovery of excess payments.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The authority, under state and federal law, of the department of medicaid or a county department of job and family services to recover excess medicaid payments made to a medicaid provider is not limited by the availability of remedies under sections 5162.21 and 5162.23 of the Revised Code for recovering benefits paid on behalf of medicaid recipients.

Section 5164.70 | Limitations on medicaid payments for services.

• Effective: September 29, 2017
• Latest Legislation: House Bill 49 - 132nd General Assembly

Except as otherwise required by federal statute or regulation, no medicaid payment for any medicaid service provided by a hospital, nursing facility, or ICF/IID shall exceed the limits established under Subpart C of 42 C.F.R. Part 447.

Section 5164.71 | Payments for freestanding medical laboratory charges.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

Medicaid payments for freestanding medical laboratory charges shall not exceed the customary and usual fee for laboratory profiles.

Section 5164.72 | Limitations on payments for inpatient hospital care.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

The number of days of inpatient hospital care for which a medicaid payment is made on behalf of a medicaid recipient to a hospital that is not paid under a diagnostic-related-group prospective payment system shall not exceed thirty days during a period beginning on the day of the recipient's admission to the hospital and ending sixty days after the termination of that hospital stay, except that the department of medicaid may make exceptions to this limitation. The limitation does not apply to children and youth participating in the program for children and youth with special health care needs established under section 3701.023 of the Revised Code.

Last updated October 5, 2023 at 3:23 PM

Section 5164.721 | Claims by freestanding birthing centers.

• Effective: April 6, 2017
• Latest Legislation: Senate Bill 332 - 131st General Assembly

A hospital or freestanding birthing center that is a medicaid provider may submit to the department of medicaid or the department's fiscal agent a medicaid claim that is both of the following:

(A) For a long-acting reversible contraceptive device that is covered by medicaid and provided to a medicaid recipient during the period after the recipient gives birth in the hospital or center and before the recipient is discharged from that location ;

(B) Separate from another medicaid claim for other inpatient care the hospital or center provides to the medicaid recipient.

Section 5164.73 | Division of payments between physician or podiatrist and nurse.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The division of any medicaid payment between a collaborating physician or podiatrist and a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner for services performed by the nurse shall be determined and agreed on by the nurse and collaborating physician or podiatrist. In no case shall the medicaid payment exceed the medicaid payment that the physician or podiatrist would have received had the physician or podiatrist provided the entire service.

Section 5164.74 | Reimbursement of graduate medical education costs.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The medicaid director shall adopt rules under section 5164.02 of the Revised Code governing the calculation and payment of, and the allocation of payments for, graduate medical education costs associated with medicaid services rendered to medicaid recipients. Subject to section 5164.741 of the Revised Code, the rules shall provide for payment of graduate medical education costs associated with medicaid services rendered to medicaid recipients, including recipients enrolled in a medicaid managed care organization, that the department of medicaid determines are allowable and reasonable.

Last updated October 6, 2021 at 11:01 AM

Section 5164.741 | Payment for graduate medical education costs to noncontracting hospitals.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) Except as provided in division (B) of this section, the department of medicaid may deny medicaid payment to a hospital for direct graduate medical education costs associated with the delivery of medicaid services to any medicaid recipient if the hospital refuses without good cause to contract with a medicaid managed care organization that serves the area in which the hospital is located.

(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 managed care organization that is a health insuring corporation.

(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 health insuring corporation.

(C) The medicaid director shall specify in the rules adopted under section 5164.02 of the Revised Code what constitutes good cause for a hospital to refuse to contract with a medicaid managed care organization.

Section 5164.75 | Medicaid payment for a drug subject to a federal upper reimbursement limit.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

As used in this section, "federal upper reimbursement limit" means the limit established pursuant to the "Social Security Act," section 1927(e), 42 U.S.C. 1396r-8(e).

The medicaid payment for a drug that is subject to a federal upper reimbursement limit shall not exceed, in the aggregate, the federal upper reimbursement limit for the drug.

Section 5164.751 | State maximum allowable cost program.

• Effective: April 12, 2021
• Latest Legislation: Senate Bill 263 - 133rd General Assembly

(A) As used in this section, "state maximum allowable cost" means the per unit amount the medicaid program pays a terminal distributor of dangerous drugs for a prescribed drug included in the state maximum allowable cost program established under division (B) of this section. "State maximum allowable cost" excludes dispensing fees and copayments, coinsurance, or other cost-sharing charges, if any.

(B) Subject to section 5167.123 of the Revised Code, the medicaid director shall establish a state maximum allowable cost program for purposes of managing medicaid payments to terminal distributors of dangerous drugs for prescribed drugs identified by the director pursuant to this division. The director shall do all of the following with respect to the program:

(1) Identify and create a list of prescribed drugs to be included in the program.

(2) Update the list of prescribed drugs described in division (B)(1) of this section on a weekly basis.

(3) Review the state maximum allowable cost for each prescribed drug included on the list described in division (B)(1) of this section on a weekly basis.

Section 5164.752 | Determining maximum dispensing fee.

• Effective: September 29, 2017
• Latest Legislation: House Bill 49 - 132nd General Assembly

In July of every even-numbered year, the department of medicaid shall initiate a confidential survey of the cost of dispensing drugs incurred by terminal distributors of dangerous drugs in this state. The survey shall be used as the basis for establishing the medicaid program's dispensing fees for terminal distributors in accordance with section 5164.753 of the Revised Code. The survey shall be completed and its results published not later than the last day of November of the year in which it is conducted.

Each terminal distributor that is a provider of drugs under the medicaid program shall participate in the survey. Except as necessary to publish the survey's results, a terminal distributor's responses to the survey are confidential and not a public record under section 149.43 of the Revised Code.

The survey shall be conducted in conformance with the requirements set forth in 42 C.F.R. 447.500 to 447.518. The survey shall include operational data and direct prescription expenses, professional services and personnel costs, and usual and customary overhead expenses of the terminal distributors surveyed. The survey shall compute and report the cost of dispensing by terminal distributors.

Section 5164.753 | Dispensing fee.

• Effective: September 29, 2017
• Latest Legislation: House Bill 49 - 132nd General Assembly

In December of every even-numbered year, the medicaid director shall establish dispensing fees, effective the following July, for terminal distributors of dangerous drugs that are providers of drugs under the medicaid program. In establishing dispensing fees, the director shall take into consideration the results of the survey conducted under section 5164.752 of the Revised Code. The director may establish dispensing fees that vary by terminal distributor, taking into consideration the volume of drugs a terminal distributor dispenses under the medicaid program or any other criteria the director considers relevant.

Section 5164.754 | Agreement for multiple-state drug purchasing program.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) As used in this section, "dangerous drug" and "manufacturer of dangerous drugs" have the same meaning as in section 4729.01 of the Revised Code.

(B) The medicaid director may enter into or administer an agreement or cooperative arrangement with other states to create or join a multiple-state prescription drug purchasing program for the purpose of negotiating with manufacturers of dangerous drugs to receive discounts or rebates for dangerous drugs covered by the medicaid program.

Section 5164.755 | Supplemental drug rebate program.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The medicaid director, in rules adopted under section 5164.02 of the Revised Code, may establish and implement a supplemental drug rebate program under which drug manufacturers may be required to provide the department of medicaid a supplemental rebate as a condition of having the drug manufacturers' drug products covered by the medicaid program without prior approval. The department may receive a supplemental rebate negotiated under the program for a drug dispensed to a medicaid recipient pursuant to a prescription or a drug purchased by a medicaid provider for administration to a medicaid recipient in the provider's primary place of business.

If the director establishes a supplemental drug rebate program, the director shall consult with drug manufacturers regarding the establishment and implementation of the program.

Section 5164.756 | Drug rebate agreement or supplemental drug rebate agreement for medicaid program not subject to public records law.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

Any record, data, pricing information, or other information regarding a drug rebate agreement or a supplemental drug rebate agreement for the medicaid program that the department of medicaid receives from a pharmaceutical manufacturer or creates pursuant to negotiation of the agreement is not a public record under section 149.43 of the Revised Code and shall be treated by the department as confidential information.

Section 5164.757 | E-prescribing applications.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) As used in this section, "licensed health professional authorized to prescribe drugs" has the same meaning as in section 4729.01 of the Revised Code.

(B) The medicaid director may acquire or specify technologies to provide information regarding medicaid recipient eligibility, claims history, and drug coverage to medicaid providers through electronic health record and e-prescribing applications.

If such technologies are acquired or specified, the e-prescribing applications shall enable a medicaid provider who is a licensed health professional authorized to prescribe drugs to use an electronic system to prescribe a drug for a medicaid recipient. The purpose of the electronic system is to eliminate the need for such medicaid providers to issue prescriptions for medicaid recipients by handwriting or telephone. The technologies acquired or specified by the director also shall provide such medicaid providers with an up-to-date, clinically relevant drug information database and a system of electronically monitoring medicaid recipients' medical history, drug regimen compliance, and fraud and abuse.

Section 5164.758 | Adoption of rules for implementation of coordinated services program for medicaid users who abuse prescription drugs.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The medicaid director shall adopt rules under section 5164.02 of the Revised Code to implement a coordinated services program for medicaid recipients 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 the "Social Security Act," section 1915(a)(2), 42 U.S.C. 1396n(a)(2), and 42 C.F.R. 431.54(e).

Section 5164.759 | Outpatient drug use review program.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

In accordance with the "Social Security Act," section 1927(g), 42 U.S.C. 1396r-8(g), the department of medicaid shall establish an outpatient drug use review program to assure that prescriptions obtained by medicaid recipients are appropriate, medically necessary, and unlikely to cause adverse medical results.

Section 5164.7510 | Pharmacy and therapeutics committee.

• Effective: October 17, 2019
• Latest Legislation: House Bill 166 - 133rd General Assembly

(A) There is hereby established the pharmacy and therapeutics committee of the department of medicaid. The committee shall assist the department with developing and maintaining a preferred drug list for the medicaid program.

The committee shall review and recommend to the medicaid director the drugs that should be included on the preferred drug list. The recommendations shall be made based on the evaluation of competent evidence regarding the relative safety, efficacy, and effectiveness of prescribed drugs within a class or classes of prescribed drugs.

(B) The committee shall consist of ten members and shall be appointed by the medicaid director. The director shall seek recommendations for membership from relevant professional organizations. A candidate for membership recommended by a professional organization shall have professional experience working with medicaid recipients.

The membership of the committee shall include:

(1) Three pharmacists licensed under Chapter 4729. of the Revised Code;

(2) Two doctors of medicine and two doctors of osteopathy who hold licenses issued under Chapter 4731. of the Revised Code, one of whom is a family practice physician;

(3) A registered nurse licensed under Chapter 4723. of the Revised Code;

(4) A pharmacologist who has a doctoral degree;

(5) A psychiatrist who holds a license to practice medicine and surgery or osteopathic medicine and surgery issued under Chapter 4731. of the Revised Code and specializes in psychiatry.

(C) The committee shall elect from among its members a chairperson. Five committee members constitute a quorum.

The committee shall establish guidelines necessary for the committee's operation.

The committee may establish one or more subcommittees to investigate and analyze issues consistent with the duties of the committee under this section. The subcommittees may submit proposals regarding the issues to the committee and the committee may adopt, reject, or modify the proposals.

A vote by a majority of a quorum is necessary to make recommendations to the director. In the case of a tie, the chairperson shall decide the outcome.

(D) The director shall act on the committee's recommendations not later than thirty days after the recommendation is posted on the department's web site under division (F) of this section. If the director does not accept a recommendation of the committee, the director shall present the basis for this determination not later than fourteen days after making the determination or at the next scheduled meeting of the committee, whichever is sooner.

(E) An interested party may request, and shall be permitted, to make a presentation or submit written materials to the committee during a committee meeting. The presentation or other materials shall be relevant to an issue under consideration by the committee and any written material, including a transcript of testimony to be given on the day of the meeting, may be submitted to the committee in advance of the meeting.

(F) The department shall post the following on the department's web site:

(1) Guidelines established by the committee under division (C) of this section;

(2) A detailed committee agenda not later than fourteen days prior to the date of a regularly scheduled meeting and not later than seventy-two hours prior to the date of a special meeting called by the committee;

(3) Committee recommendations not later than seven days after the meeting at which the recommendation was approved;

(4) The director's final determination as to the recommendations made by the committee under this section.

Section 5164.7511 | Medication synchronization for medicaid recipients.

• Effective: March 22, 2020
• Latest Legislation: Senate Bill 229 - 132nd General Assembly

(A) As used in this section:

(1) "Cost-sharing" means any cost-sharing requirements instituted for the medicaid program under section 5162.20 of the Revised Code.

(2) "Medication synchronization" means a pharmacy service that synchronizes the filling or refilling of prescriptions in a manner that allows the dispensed drugs to be obtained on the same date each month.

(3) "Prescriber" has the same meaning as in section 4729.01 of the Revised Code.

(B) With respect to coverage of prescribed drugs, the medicaid program shall provide for medication synchronization for a medicaid recipient if all of the following conditions are met:

(1) The recipient elects to participate in medication synchronization.

(2) The recipient, the prescriber, and a pharmacist at a pharmacy participating in the medicaid program agree that medication synchronization is in the best interest of the recipient.

(3) The prescribed drug to be included in the medication synchronization meets the requirements of division (C) of this section.

(C) To be eligible for inclusion in medication synchronization for a medicaid recipient, a prescribed drug must meet all of the following requirements:

(1) Be covered by the medicaid program;

(2) Be prescribed for the treatment and management of a chronic disease or condition and be subject to refills;

(3) Satisfy all relevant prior authorization criteria;

(4) Not have quantity limits, dose optimization criteria, or other requirements that would be violated if synchronized;

(5) Not have special handling or sourcing needs, as determined by the medicaid program, that require a single, designated pharmacy to fill or refill the prescription;

(6) Be formulated so that the quantity or amount dispensed can be effectively divided in order to achieve synchronization;

(7) Not be a schedule II controlled substance, opioid analgesic, or benzodiazepine, as those terms are defined in section 3719.01 of the Revised Code.

(D)(1) To provide for medication synchronization under division (B) of this section, the medicaid program shall authorize coverage of a prescribed drug subject to medication synchronization when the drug is dispensed in a quantity or amount that is less than a thirty-day supply.

(2) The requirement of division (D)(1) of this section applies only once for each prescribed drug subject to medication synchronization for the same medicaid recipient, except when either of the following occurs:

(a) The prescriber changes the dosage or frequency of administration of the prescribed drug subject to medication synchronization.

(b) The prescriber prescribes a different drug.

(E)(1) In providing for medication synchronization under division (B) of this section, the medicaid program shall apply a prorated daily cost-sharing rate for a supply of a prescribed drug subject to medication synchronization that is dispensed at a pharmacy participating in the program.

(2) Division (E)(1) of this section does not require the medicaid program to waive any cost-sharing requirement in its entirety.

(F) In providing for medication synchronization under division (B) of this section, the medicaid program shall not use payment structures that incorporate dispensing fees that are determined by calculating the days' supply of drugs dispensed. Dispensing fees shall be based exclusively on the total number of prescriptions that are filled or refilled.

(G) This section does not require the medicaid program to provide to a pharmacy participating in the program or a pharmacist at a participating pharmacy any monetary or other financial incentive for the purpose of encouraging the pharmacy or pharmacist to recommend medication synchronization to a medicaid recipient.

Section 5164.7512 | Definitions for sections 5164.7512 to 5164.7514.

• Effective: April 5, 2019
• Latest Legislation: Senate Bill 265 - 132nd General Assembly

(A) As used in sections 5164.7512 to 5164.7514 of the Revised Code:

(1) "Clinical practice guidelines" means a systematically developed statement to assist providers and medicaid recipients in making decisions about appropriate health care for specific clinical circumstances and conditions.

(2) "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols, and clinical practice guidelines used by the medicaid program to determine whether or not a health care service or drug is appropriate and consistent with medical or scientific evidence.

(3) "Medical or scientific evidence" has the same meaning as in section 3922.01 of the Revised Code.

(4) "Step therapy exemption" means an overriding of a step therapy protocol in favor of immediate coverage of a medicaid provider's selected prescription drug.

(5) "Step therapy protocol" means a protocol under which it is determined through a specific sequence whether the medicaid program, under either a pharmacy or medical benefit, will pay for a prescribed drug that a medicaid provider, consistent with medical or scientific evidence, prescribes for a medicaid recipient's specified medical condition, including both self-administered and physician-administered drugs.

(6) "Urgent care services" has the same meaning as in section 3922.041 of the Revised Code.

(B) If the department of medicaid utilizes a step therapy protocol for the medicaid program under which it is recommended that prescribed drugs be taken in a specific sequence, the department shall do all of the following:

(1) Implement that step therapy protocol using clinical review criteria that are based on clinical practice guidelines or medical or scientific evidence. The department shall take into account the needs of atypical patient populations and diagnoses when establishing clinical review criteria.

(2) In a manner consistent with section 5164.7514 of the Revised Code, establish and implement a step therapy exemption process under which medicaid recipients and medicaid providers who prescribe prescribed drugs for medicaid recipients may request and receive a step therapy exemption;

(3)(a) Make available, to all medicaid providers, a list of all drugs covered by the medicaid program that are subject to a step therapy protocol;

(b) Along with the information required under division (B) (3)(a) of this section, the department of medicaid shall indicate what information or documentation must be provided to the department for a step therapy exemption request to be considered complete. Such information shall be provided for each drug, if the requirements vary according to the drug or protocol in question.

(c) The list required under division (B)(3)(a) of this section, along with all of the required information or documentation described in division (B)(3)(b) of this section, shall be made available on the department of medicaid's web site or provider portal.

(C) This section shall not be construed as requiring the department to set up a new entity to develop clinical review criteria for step therapy protocols.

Section 5164.7514 | Step therapy exemption process.

• Effective: April 5, 2019
• Latest Legislation: Senate Bill 265 - 132nd General Assembly

(A) All of the following shall apply to the step therapy exemption process established and implemented by the department of medicaid pursuant to division (B)(2) of section 5164.7512 of the Revised Code:

(1) The process shall be clear and convenient.

(2) The process shall be easily accessible on the department's web site.

(3) The process shall require that a medicaid provider initiate a step therapy exemption request on behalf of a medicaid recipient.

(4) The process shall require supporting documentation and rationale be submitted with each request for a step therapy exemption.

(5) The process shall, pursuant to a step therapy exemption request made under division (B)(2) of section 5164.7512 of the Revised Code or an appeal made under division (B)(2) of this section, require the department to grant a step therapy exemption if either of the following applies:

(a) Either of the following apply to the prescribed drug that would otherwise have to be used under the step therapy protocol:

(i) The required prescription drug is contraindicated for that specific medicaid recipient, pursuant to the drug's United States food and drug administration prescribing information.

(ii) The medicaid recipient tried the required prescription drug while enrolled in medicaid or other health care coverage, or another United States food and drug administration approved AB-rated prescription drug, and such prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event.

(b) The medicaid recipient is stable on the prescribed drug selected by the recipient's medicaid provider for the medical condition under consideration, regardless of whether or not the drug was prescribed while the individual in question was a medicaid recipient, or has already gone through a step therapy protocol. However, the department may require a stable medicaid recipient to try a pharmaceutical alternative, per the federal food and drug administration's orange book, purple book, or their successors, prior to providing coverage for the prescribed drug.

(6) On granting a step therapy exemption, the department shall authorize payment for the prescribed drug prescribed by the medicaid recipient's medicaid provider.

(B)(1) From the time a step therapy exemption request is received, the department shall either grant or deny the request within the following time frames:

(a) Forty-eight hours for requests related to urgent care services;

(b) Ten calendar days for all other requests.

(2)(a) If an exemption request is denied, a medicaid provider may appeal the denial on behalf of the medicaid recipient.

(b) From the time a step therapy appeal is received, the department shall either grant or deny the appeal within the following time frames:

(i) Forty-eight hours for appeals related to urgent care services;

(ii) Ten calendar days for all other appeals.

(3) The appeal shall be between the medicaid provider making the appeal and a clinical peer appointed by or contracted by the department or the department's designee.

(4) If the department does not either grant or deny an exemption request or an appeal within the time frames prescribed in division (B)(1) or (2) of this section, then such an exemption request or appeal shall be deemed to be granted.

(C) If an appeal is rejected, the medicaid recipient in question may make a further appeal in accordance with section 5160.31 of the Revised Code.

(D) This section shall not be construed to prevent either of the following:

(1) The department from requiring a medicaid recipient to try any new or existing pharmaceutical alternative, per the federal food and drug administration's orange book, purple book, or their successors, before authorizing a medicaid payment for the prescribed drug;

(2) A medicaid provider from prescribing a prescribed drug that is determined to be consistent with medical or scientific evidence.

Section 5164.7515 | Annual benchmark for prescribed drug spending growth.

• Effective: October 17, 2019
• Latest Legislation: House Bill 166 - 133rd General Assembly

(A) Not later than July 1, 2020, the medicaid director shall establish an annual benchmark for prescribed drug spending growth under the medicaid program. If the director determines that prescribed drug spending in a given year is projected to exceed the benchmark for that year, the director shall identify specific prescribed drugs that significantly contribute to exceeding the benchmark.

(B) For a prescribed drug identified by the director under division (A) of this section, the director shall determine if there is a current supplemental rebate for that drug between the drug's manufacturer and the department or its designee. If there is a current supplemental rebate for the drug, the director may renegotiate the supplemental rebate agreement. If there is not a supplemental rebate for the drug, the director shall evaluate whether to pursue a supplemental rebate agreement for the drug with the drug manufacturer. In making that evaluation, the director may consider any of the following:

(1) The prescribed drug's actual cost to the state;

(2) Whether the drug's manufacturer is providing significant discounts or rebates for other prescribed drugs under the medicaid program;

(3) Any other information the director considers relevant.

(C)(1) If the director determines that a prescribed drug rebate agreement renegotiation is warranted under division (B) of this section, the director shall establish a target rebate amount. In determining the target rebate amount, the director may consider any of the following:

(a) Publicly available information relevant to pricing the prescribed drug;

(b) Information the department has that is relevant to the pricing of the drug;

(c) Information relating to value-based pricing of the drug for medicaid recipients;

(d) The seriousness and prevalence of the conditions for which the drug is prescribed;

(e) The drug's volume of use among medicaid recipients;

(f) The effectiveness of the drug in treating conditions for which it is prescribed or improving a patient's health, quality of life, or overall health outcomes;

(g) The likelihood that use of the drug will reduce the need for other medical care, including hospitalization;

(h) The average wholesale price, wholesale acquisition cost, and retail price of the drug, and the cost of the drug under the medicaid program, not including any rebates received for the drug under the program;

(i) In the case of generic drugs, the number of manufacturers that produce the drug;

(j) Whether there are pharmaceutical equivalents to the drug;

(k) Any other information the director considers relevant.

(2) In negotiating a new rebate agreement under division (B) of this section, the director shall seek to negotiate an amount that is equal to the target rebate amount under division (C)(1) of this section. The director shall not enter into a rebate agreement that is less than sixty per cent of the target rebate amount. If no rebate agreement is established or renegotiated under this section, the director may consider removing the drug from the medicaid program's preferred drug list and imposing a prior authorization requirement on the drug in accordance with section 5160.34 of the Revised Code.

(D) The director shall publish a list of the prescribed drugs it identifies as being responsible for increasing spending above the annual benchmark for prescribed drug spending growth.

Section 5164.76 | Manner of payment for community mental health service providers or facilities and alcohol and drug addiction services.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) In rules adopted under section 5164.02 of the Revised Code, the medicaid director shall modify the manner or establish a new manner in which the following are paid under medicaid:

(1) Community mental health service providers or facilities for providing community mental health services covered by the medicaid program pursuant to section 5164.15 of the Revised Code;

(2) Providers of alcohol and drug addiction services for providing alcohol and drug addiction services covered by the medicaid program.

(B) The director's authority to modify the manner, or to establish a new manner, for medicaid to pay for the services specified in division (A) of this section is not limited by any rules adopted under section 5119.22 or 5164.02 of the Revised Code that are in effect on June 26, 2003, and govern the way medicaid pays for those services. This is the case regardless of what state agency adopted the rules.

Section 5164.761 | Beta testing of updates to billing codes or payment rates.

• Effective: September 29, 2017
• Latest Legislation: House Bill 49 - 132nd General Assembly

Before the department of medicaid or department of mental health and addiction services updates medicaid billing codes or medicaid payment rates for community behavioral health services as part of the behavioral health redesign, the departments shall conduct a beta test of the updates. Any medicaid provider of community behavioral health services may volunteer to participate in the beta test. An update may not begin to be implemented outside of the beta test until at least half of the medicaid providers participating in the beta test are able to submit under the beta test a clean claim for community behavioral health services that is properly adjudicated not later than thirty days after the date the clean claim is submitted.

Section 5164.78 | Medicaid payment rates for certain neonatal and newborn services.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) The medicaid payment rates for the following neonatal and newborn services shall equal not less than seventy-five per cent of the medicare payment rates for the services in effect on the date the services are provided to medicaid recipients eligible for the services:

(1) Initial care for normal newborns;

(2) Subsequent day, hospital care for normal newborns;

(3) Same day, initial history and physical examination and discharge for normal newborns;

(4) Initial neonatal critical care for children not more than twenty-eight days old;

(5) Subsequent day, neonatal critical care for children not more than twenty-eight days old;

(6) Subsequent day, pediatric critical care for children at least twenty-nine days but less than two years old;

(7) Initial neonatal intensive care;

(8) Subsequent day, neonatal intensive noncritical care for children weighing less than one thousand five hundred grams;

(9) Subsequent day, neonatal intensive noncritical care for children weighing at least one thousand five hundred grams but not more than two thousand five hundred grams;

(10) Subsequent day, neonatal noncritical care for children weighing more than two thousand five hundred grams but not more than five thousand grams.

(B) The medicaid payment rates for other medicaid services selected by the medicaid director shall be less than the amount of the rates in effect on November 22, 2017, so that the cost of the rates set pursuant to division (A) of this section do not increase medicaid expenditures. The director may not select any medicaid service for which the medicaid payment rate is determined in accordance with state statutes.

Last updated October 5, 2023 at 3:24 PM

Section 5164.80 | Public notice for changes to payment rates for medicaid assistance.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

As necessary to comply with the "Social Security Act," section 1902(a)(13)(A), 42 U.S.C. 1396a(a)(13)(A), and any other federal law that requires public notice of proposed changes to payment rates for medicaid services, the medicaid director shall give public notice in the register of Ohio of any change to a method or standard used to determine the medicaid payment rate for a medicaid service.

Section 5164.82 | Payment for provider-preventable condition.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The department of medicaid shall not knowingly make a medicaid payment for a provider-preventable condition for which federal financial participation is prohibited by regulations adopted under the "Patient Protection and Affordable Care Act," section 2702, 42 U.S.C. 1396b-1.

Section 5164.85 | Enrolling in group health plan.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) As used in this section, "cost-effective" and "group health plan" have the same meanings as in the "Social Security Act," section 1906, 42 U.S.C. 1396e, and any regulations adopted under that section.

(B) The department of medicaid may implement a program pursuant to the "Social Security Act," section 1906, 42 U.S.C. 1396e, for the enrollment of medicaid-eligible individuals in group health plans when the department determines that enrollment is cost-effective.

Section 5164.86 | Qualified state long-term care insurance partnership program.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The medicaid director shall establish a qualified state long-term care insurance partnership program consistent with the definition of that term in the "Social Security Act," section 1917(b)(1)(C)(iii), 42 U.S.C. 1396p(b)(1)(C)(iii). An individual participating in the program who is subject to the medicaid estate recovery program instituted under section 5162.21 of the Revised Code shall be eligible for the reduced adjustment or recovery under division (D) of that section.

Section 5164.88 | Coordinated care through health homes.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The medicaid director may implement within the medicaid program a system under which medicaid recipients with chronic conditions are provided with coordinated care through health homes, as authorized by the "Social Security Act," section 1945, 42 U.S.C. 1396w-4.

Section 5164.881 | Health home services.

• Effective: October 12, 2016
• Latest Legislation: House Bill 158 - 131st General Assembly

The medicaid director, in consultation with the director of developmental disabilities, may develop and implement within the medicaid program a system under which eligible individuals with chronic conditions, as defined in the "Social Security Act," section 1945 (h)(1), 42 U.S.C. 1396w-4(h)(1), who also have developmental disabilities may receive health home services, as defined in the "Social Security Act," section 1945 (h)(4), 42 U.S.C. 1396w-4(h)(4). Any such system shall focus on the needs of individuals and have as its goal improving services and outcomes under the medicaid program by improving integration of long-term care services and supportive services with primary and acute health care services.

In developing any system under this section, the directors shall consult with representatives of county boards of developmental disabilities, the Ohio provider resource association, and the arc of Ohio. The directors may consult with any other individuals or entities that have an interest in the well being of individuals with developmental disabilities.

Section 5164.89 | Case management of nonemergency transportation services.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The department of medicaid may require county departments of job and family services to provide case management of nonemergency transportation services provided under the medicaid program. County departments shall provide the case management if required by the department in accordance with rules adopted under section 5164.02 of the Revised Code.

The department shall determine, for the purposes of claiming federal financial participation, whether it will claim expenditures for nonemergency transportation services as administrative or program expenditures.

Section 5164.90 | Transition of medicaid recipients to community settings.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) As used in this section, "MFP demonstration project" means a money follows the person demonstration project that the United States secretary of health and human services is authorized to award under section 6071 of the "Deficit Reduction Act of 2005" (Pub. L. No. 109-171, as amended).

(B) To the extent funds are available under an MFP demonstration project awarded to the department of medicaid, the director of medicaid may operate the helping Ohioans move, expanding (HOME) choice demonstration component of the medicaid program to transition medicaid recipients who qualify for the demonstration component to community settings.

Section 5164.91 | Integrated care delivery system.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The medicaid director may implement a demonstration project called the integrated care delivery system to test and evaluate the integration of the care that dual eligible individuals receive under medicare and medicaid. No provision of Title LI of the Revised Code applies to the integrated care delivery system if that provision implements or incorporates a provision of federal law governing medicaid and that provision of federal law does not apply to the system.

Section 5164.911 | Integrated care delivery system evaluation.

• Effective: March 20, 2014
• Latest Legislation: Senate Bill 206 - 130th General Assembly

(A) If the medicaid director implements the integrated care delivery system and except as provided in division (C) of this section, the director shall annually evaluate all of the following:

(1) The health outcomes of ICDS participants;

(2) How changes to the administration of the ICDS affect all of the following:

(a) Claims processing;

(b) The appeals process;

(c) The number of reassessments requested;

(d) Prior authorization requests for services.

(3) The provider panel selection process used by medicaid managed care organizations participating in the ICDS.

(B) When conducting an evaluation under division (A) of this section, the director shall do all of the following:

(1) For the purpose of division (A)(1) of this section, do both of the following:

(a) Compare the health outcomes of ICDS participants to the health outcomes of individuals who are not ICDS participants;

(b) Use both of the following:

(i) A control group consisting of ICDS participants who receive health care services from providers not participating in ICDS;

(ii) A control group consisting of ICDS participants who receive health care services from alternative providers that are not part of a participating medicaid managed care organization's provider panel but provide health care services in the geographic service area in which ICDS participants receive health care services.

(2) For the purpose of division (A)(2) of this section, do all of the following:

(a) To the extent the data is available, use data from all of the following:

(i) The fee-for-service component of the medicaid program;

(ii) Medicaid managed care organizations;

(iii) Managed care organizations participating in the medicare advantage program established under Part C of Title XVIII of the "Social Security Act," 42 U.S.C. 1395w-21 et seq.

(b) Identify all of the following:

(i) Changes in the amount of time it takes to process claims and the number of claims denied and the reasons for the changes;

(ii) The impact that changes to the administration of the ICDS had on the appeals process and number of reassessments requested;

(iii) The number of prior authorization denials that were overturned and the reasons for the overturned denials.

(3) Require medicaid managed care organizations participating in the ICDS to submit to the director any data the director needs for the evaluation.

(C) The director is not required to conduct an evaluation under this section for a year if the same evaluation is conducted for that year by an organization under contract with the United States department of health and human services.

Last updated May 6, 2021 at 5:21 PM

Section 5164.912 | Integrated care delivery system standardized claim form.

• Effective: October 17, 2019
• Latest Legislation: House Bill 166 - 133rd General Assembly

The medicaid director shall select from among universally accepted claim forms used in the United States a standardized claim form for each type of medicaid provider that provides medicaid services under the integrated care delivery system. The director shall create standardized claim codes to be used on the standardized claim forms. Each medicaid provider and medicaid provider's designee that bills for medicaid services provided under the integrated care delivery system shall use the appropriate standardized claim form and standardized claim codes.

Last updated May 6, 2021 at 5:22 PM

Section 5164.913 | Home health aide and personal care aide training.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A)(1) In addition to any other eligibility requirement of this chapter, to be eligible to serve as a personal care aide under the integrated care delivery system, an individual must successfully complete thirty hours of pre-service training acceptable to the department of medicaid.

To maintain eligibility, each personal care aide must successfully complete six hours of in-service training acceptable to the department. Such training must be completed every twelve months.

(2) In administering the integrated care delivery system, the department shall not require a personal care aide to do either of the following:

(a) Complete more than thirty hours of pre-service training;

(b) Complete more than six hours of in-service training in a twelve-month period.

(B) The department of medicaid shall not require an individual serving as a home health aide under the integrated care delivery system to complete more hours of pre-service training or annual in-service training than required by federal law.

(C) Only the following may supervise a home health aide or personal care aide under the integrated care delivery system:

(1) A registered nurse;

(2) A licensed practical nurse under the direction of a registered nurse.

Last updated October 6, 2023 at 5:07 PM

Section 5164.92 | Advanced diagnostic imaging services coverage under medicaid program.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

As used in this section, "advanced diagnostic imaging services" means magnetic resonance imaging services, computed tomography services, positron emission tomography services, cardiac nuclear medicine services, and similar imaging services.

The department of medicaid shall implement evidence-based, best practice guidelines or protocols and decision support tools for advanced diagnostic imaging services covered by the fee-for-service component of the medicaid program.

Section 5164.93 | Incentive payments for adoption and use of electronic health record technology.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) The department of medicaid may establish a program under which it provides incentive payments, as authorized by the "Social Security Act," section 1903(a)(3)(F) and (t), 42 U.S.C. 1396b(a)(3)(F) and (t), to encourage the adoption and use of electronic health record technology by medicaid providers who are identified under that federal law as eligible professionals.

(B) After the department has made a determination regarding the amount of a medicaid provider's electronic health record incentive payment or the denial of an incentive payment, the department shall notify the provider. The provider may request that the department reconsider its determination.

A request for reconsideration shall be submitted in writing to the department not later than fifteen days after the provider receives notification of the determination. The request shall be accompanied by written materials setting forth the basis for, and supporting, the reconsideration request.

On receipt of a timely request, the department shall reconsider the determination. On the basis of the written materials accompanying the request, the department may uphold, reverse, or modify its original determination. The department shall mail to the provider by certified mail a written notice of the reconsideration decision.

In accordance with Chapter 2505. of the Revised Code, the medicaid provider may appeal the reconsideration decision by filing a notice of appeal with the court of common pleas of Franklin county. The notice shall identify the decision being appealed and the specific grounds for the appeal. The notice of appeal shall be filed not later than fifteen days after the department mails its notice of the reconsideration decision. A copy of the notice of appeal shall be filed with the department not later than three days after the notice is filed with the court.

(C) The medicaid director may adopt rules under section 5162.02 of the Revised Code as necessary to implement this section. The rules, if any, shall be adopted in accordance with Chapter 119. of the Revised Code.

Section 5164.94 | Delivery of services in culturally and linguistically appropriate manners.

• Effective: March 20, 2014
• Latest Legislation: Senate Bill 206 - 130th General Assembly

The medicaid director shall implement within the medicaid program a system that encourages medicaid providers to provide medicaid services to medicaid recipients in culturally and linguistically appropriate manners.

Section 5164.95 | Standards for payments for telehealth services; eligible practitioners.

• Effective: April 6, 2023
• Latest Legislation: House Bill 509 - 134th General Assembly

(A) As used in this section, "telehealth service" means a health care service delivered to a patient through the use of interactive audio, video, or other telecommunications or electronic technology from a site other than the site where the patient is located.

(B) The department of medicaid shall establish standards for medicaid payments for health care services the department determines are appropriate to be covered by the medicaid program when provided as telehealth services. The standards shall be established in rules adopted under section 5164.02 of the Revised Code.

In accordance with section 5162.021 of the Revised Code, the medicaid director shall adopt rules authorizing the directors of other state agencies to adopt rules regarding the medicaid coverage of telehealth services under programs administered by the other state agencies. Any such rules adopted by the medicaid director or the directors of other state agencies are not subject to the requirements of division (F) of section 121.95 of the Revised Code.

(C)(1) To the extent permitted under rules adopted under section 5164.02 of the Revised Code and applicable federal law, the following practitioners are eligible to provide telehealth services covered pursuant to this section:

(a) A physician licensed under Chapter 4731. of the Revised Code to practice medicine and surgery, osteopathic medicine and surgery, or podiatric medicine and surgery;

(b) A psychologist, independent school psychologist, or school psychologist licensed under Chapter 4732. of the Revised Code;

(c) A physician assistant licensed under Chapter 4730. of the Revised Code;

(d) A clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner licensed under Chapter 4723. of the Revised Code;

(e) An independent social worker, independent marriage and family therapist, or professional clinical counselor licensed under Chapter 4757. of the Revised Code;

(f) An independent chemical dependency counselor licensed under Chapter 4758. of the Revised Code;

(g) A supervised practitioner or supervised trainee;

(h) An audiologist or speech-language pathologist licensed under Chapter 4753. of the Revised Code;

(i) An audiology aide or speech-language pathology aide, as defined in section 4753.072 of the Revised Code, or an individual holding a conditional license under section 4753.071 of the Revised Code;

(j) An occupational therapist or physical therapist licensed under Chapter 4755. of the Revised Code;

(k) An occupational therapy assistant or physical therapist assistant licensed under Chapter 4755. of the Revised Code.

(l) A dietitian licensed under Chapter 4759. of the Revised Code;

(m) A chiropractor licensed under Chapter 4734. of the Revised Code;

(n) A pharmacist licensed under Chapter 4729. of the Revised Code;

(o) A genetic counselor licensed under Chapter 4778. of the Revised Code;

(p) An optometrist licensed under Chapter 4725. of the Revised Code to practice optometry;

(q) A respiratory care professional licensed under Chapter 4761. of the Revised Code;

(r) A certified Ohio behavior analyst certified under Chapter 4783. of the Revised Code;

(s) A practitioner who provides services through a medicaid school program;

(t) Subject to section 5119.368 of the Revised Code, a practitioner authorized to provide services and supports certified under section 5119.36 of the Revised Code through a community mental health services provider or community addiction services provider;

(u) Any other practitioner the medicaid director considers eligible to provide telehealth services.

(2) In accordance with division (B) of this section and to the extent permitted under rules adopted under section 5164.02 of the Revised Code and applicable federal law, the following provider types are eligible to submit claims for medicaid payments for providing telehealth services:

(a) Any practitioner described in division (C)(1) of this section, except for those described in divisions (C)(1)(g), (i), and (k) of this section;

(b) A professional medical group;

(c) A federally qualified health center or federally qualified health center look-alike, as defined in section 3701.047 of the Revised Code;

(d) A rural health clinic;

(e) An ambulatory health care clinic;

(f) An outpatient hospital;

(g) A medicaid school program;

(h) Subject to section 5119.368 of the Revised Code, a community mental health services provider or community addiction services provider that offers services and supports certified under section 5119.36 of the Revised Code;

(i) Any other provider type the medicaid director considers eligible to submit the claims for payment.

(D)(1) When providing telehealth services under this section, a practitioner shall comply with all requirements under state and federal law regarding the protection of patient information. A practitioner shall ensure that any username or password information and any electronic communications between the practitioner and a patient are securely transmitted and stored.

(2) When providing telehealth services under this section, every practitioner site shall have access to the medical records of the patient at the time telehealth services are provided.

Last updated January 23, 2023 at 2:28 PM

Section 5164.951 | Standards for medicaid payments for services provided through teledentistry.

• Effective: March 20, 2019
• Latest Legislation: Senate Bill 259 - 132nd General Assembly

As used in this section, "teledentistry" has the same meaning as in section 4715.43 of the Revised Code.

The department of medicaid shall establish standards for medicaid payments for services provided through teledentistry. The standards shall provide coverage for services to the same extent that those services would be covered by the medicaid program if the services were provided without the use of teledentistry.

Section 5164.96 | Ground emergency medical transportation supplemental payment program.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) As used in this section, "ground emergency medical transportation service provider" means a public emergency medical service organization as defined in section 4765.01 of the Revised Code.

(B)(1) The medicaid director shall submit a medicaid state plan amendment to the United States centers for medicare and medicaid services seeking authorization to establish and administer a supplemental payment program to provide supplemental medicaid payments to eligible ground emergency medical transportation service providers. If approved, the medicaid director shall establish and administer the program.

(2) To be eligible to receive payments under the supplemental payment program, a ground emergency medical transportation service provider must hold a valid medicaid provider agreement and provide emergency medical transportation services to medicaid recipients.

(C) The medicaid director shall adopt rules in accordance with Chapter 119. of the Revised Code to implement this section.

Last updated October 6, 2023 at 5:09 PM