Chapter 5167: MEDICAID MANAGED CARE

5167.01 Definitions.

As used in this chapter:

(A) "Controlled substance" has the same meaning as in section 3719.01 of the Revised Code.

(B) "Dual eligible individual" has the same meaning as in section 5160.01 of the Revised Code.

(C) "Emergency services" has the same meaning as in the "Social Security Act," section 1932(b)(2), 42 U.S.C. 1396u-2(b)(2).

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

(E) "Medicaid managed care organization" means a managed care organization under contract with the department of medicaid pursuant to section 5167.10 of the Revised Code.

(F) "Medicaid waiver component" has the same meaning as in section 5166.01 of the Revised Code.

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

(H) "Prescribed drug" has the same meaning as in section 5164.01 of the Revised Code.

(I) "Provider" means any person or government entity that furnishes services to a medicaid recipient enrolled in a medicaid managed care organization, regardless of whether the person or entity has a provider agreement.

(J) "Provider agreement" has the same meaning as in section 5164.01 of the Revised Code.

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

5167.02 Rules.

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.

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

5167.03 [Renumbered from 5111.16] Care management system.

(A) As part of the medicaid program, the department of medicaid shall establish a care management system.

(B) The department shall implement the care management system in some or all counties and shall designate the medicaid recipients who are required or permitted to participate in the system. In the department's implementation of the system and designation of participants, all of the following apply:

(1) In the case of individuals who receive medicaid on the basis of being included in the category identified by the department as covered families and children, the department shall implement the care management system in all counties. All individuals included in the category shall be designated for participation, except for individuals included in one or more of the medicaid recipient groups specified in 42 C.F.R. 438.50(d). The department shall ensure that all participants are enrolled in medicaid managed care organizations that are health insuring corporations .

(2) In the case of individuals who receive medicaid on the basis of being aged, blind, or disabled, the department shall implement the care management system in all counties. Except as provided in division (C) of this section, all individuals included in the category shall be designated for participation. The department shall ensure that all participants are enrolled in medicaid managed care organizations that are health insuring corporations .

(3) Alcohol, drug addiction, and mental health services covered by medicaid shall not be included in any component of the care management system when the nonfederal share of the cost of those services is provided by a board of alcohol, drug addiction, and mental health services or a state agency other than the department of medicaid, but the recipients of those services may otherwise be designated for participation in the system.

(C)

(1) In designating participants who receive medicaid on the basis of being aged, blind, or disabled, the department shall not include any of the following, except as provided under division (C)(2) of this section:

(a) Individuals who are under twenty-one years of age;

(b) Individuals who are institutionalized;

(c) Individuals who become eligible for medicaid by spending down their income or resources to a level that meets the medicaid program's financial eligibility requirements;

(d) Dual eligible individuals;

(e) Individuals to the extent that they are receiving medicaid services through a medicaid waiver component.

(2) The department may designate any of the following individuals who receive medicaid on the basis of being aged, blind, or disabled as individuals who are permitted or required to participate in the care management system:

(a) Individuals who are under twenty-one years of age;

(b) Individuals who reside in a nursing facility;

(c) Individuals who, as an alternative to receiving nursing facility services, are participating in a home and community-based services medicaid waiver component;

(d) Dual eligible individuals.

(D) Subject to division (B) of this section, the department may do both of the following under the care management system:

(1) Require or permit participants in the system to obtain health care services from providers designated by the department;

(2) Require or permit participants in the system to obtain health care services through medicaid managed care organizations .

Renumbered from § 5111.16 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Amended by 129th General AssemblyFile No.127, HB 487, §101.01, eff. 9/10/2012.

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

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

Effective Date: 06-26-2003; 06-30-2005

5167.031 [Renumbered from 5111.161] Recognition of pediatric accountable care organizations.

(A) As used in this section:

(1) "Children's care network" means any of the following:

(a) A children's hospital;

(b) A group of children's hospitals;

(c) A group of pediatric physicians.

(2) "Children's hospital" has the same meaning as in section 2151.86 of the Revised Code.

(B) If the department of medicaid includes in the care management system, pursuant to section 5167.03 of the Revised Code, individuals under twenty-one years of age who are included in the category of individuals who receive medicaid on the basis of being aged, blind, or disabled, the department may recognize entities as pediatric accountable care organizations.

An entity recognized by the department as a pediatric accountable care organization may develop innovative partnerships between relevant groups and may contract directly or subcontract with the state to provide care coordination and other services to the medicaid recipients under twenty-one years of age described in this division who are permitted or required to participate in the care management system.

(C)

(1) To be recognized by the department as a pediatric accountable care organization, an entity shall meet the standards established by the department. Unless required by section 2706 of the "Patient Protection and Affordable Care Act," 124 Stat. 325 (2010) and the "Social Security Act," section 1895, 42 U.S.C. 1395jjj, the regulations adopted pursuant to those sections, and the laws of this state, the department shall not require that an entity be a health insuring corporation as a condition of receiving the department's recognition.

(2) Any of the following entities may receive the department's recognition, if the standards for recognition have been met:

(a) A children's care network;

(b) A children's care network that may include one or more other entities, including, but not limited to, health insuring corporations or other managed care organizations;

(c) Any other entity the department determines is qualified.

(D) The medicaid director shall consult with all of the following in adopting rules authorized by division (E) of this section necessary for an entity to be recognized by the department as a pediatric accountable care organization:

(1) The superintendent of insurance;

(2) Children's hospitals;

(3) Medicaid managed care organizations ;

(4) Any other relevant entities, as determined necessary by the department, with interests in pediatric accountable care organizations.

(E) In adopting rules under section 5167.02 of the Revised Code, the medicaid director shall do all of the following:

(1) Establish application procedures to be followed by an entity seeking recognition as a pediatric accountable care organization;

(2) Ensure that the standards for recognition as a pediatric accountable care organization are the same as and do not conflict with those specified in section 2706 of the "Patient Protection and Affordable Care Act," 124 Stat. 325 (2010) and the "Social Security Act," section 1895, 42 U.S.C. 1395jjj or the regulations adopted pursuant to those sections;

(3) Establish requirements regarding the access to pediatric specialty care provided through or by a pediatric accountable care organization;

(4) Establish accountability and financial requirements for an entity recognized as a pediatric accountable care organization;

(5) Establish quality improvement initiatives consistent with any state medicaid quality plan established by the department;

(6) Establish transparency and consumer protection requirements for an entity recognized as a pediatric accountable care organization;

(7) Establish a process for sharing data.

(F) This section does not limit the authority of the department of insurance to regulate the business of insurance in this state.

Renumbered from § 5111.161 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Amended by 129th General AssemblyFile No.127, HB 487, §101.01, eff. 9/10/2012.

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

Effective Date: 2007 HB119 09-29-2007

5167.31 [Renumbered from 5111.171] Financial incentive awards.

The department of medicaid may provide financial incentive awards to medicaid managed care organizations that meet or exceed performance standards specified in provider agreements or rules adopted by the medicaid director under section 5167.02 of the Revised Code. The department may specify in a contract with a medicaid managed care organization the amounts of financial incentive awards, methodology for distributing awards, types of awards, and standards for administration by the department.

Renumbered from § 5111.171 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Amended by 129th General AssemblyFile No.127, HB 487, §101.01, eff. 9/10/2012.

Effective Date: 06-26-2003

5167.10 [Renumbered from 5111.17] Authority to contract for managed care system.

(A) The department of medicaid may enter into contracts with managed care organizations, including health insuring corporations, under which the organizations are authorized to provide, or arrange for the provision of, health care services to medicaid recipients who are required or permitted to obtain health care services through managed care organizations as part of the care management system established under section 5167.03 of the Revised Code.

(B) (1) Subject to division (B)(2)(a) of this section, the department or its actuary shall base the hospital inpatient capital payment portion of the payment made to managed care organizations on data for services provided to all recipients enrolled in managed care organizations with which the department contracts, as reported by hospitals on relevant cost reports submitted pursuant to rules adopted under section 5167.02 of the Revised Code.

(2) [Effective 1/1/2014]

(a) The hospital inpatient capital payment portion of the payment made to medicaid managed care organizations shall not exceed any maximum rate established by the department pursuant to rules adopted under this section.

(b) If a maximum rate is established, a medicaid managed care organization shall not compensate hospitals for inpatient capital costs in an amount that exceeds that rate.

(C)

The department of medicaid shall allow a medicaid managed care organization to use providers to render care upon completion of the medicaid managed care organization's credentialing process.

Renumbered from § 5111.17 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013 and 1/1/2014.

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

Effective Date: 06-26-2003; 06-30-2005; 2007 HB119 09-29-2007; 2008 HB125 06-25-2008

5167.11 [Renumbered from 5111.177] Health insuring corporation contract to provide grievance process.

When contracting under section 5167.10 of the Revised Code with a health insuring corporation that holds a certificate of authority under Chapter 1751. of the Revised Code, the department of medicaid shall require the health insuring corporation to provide a grievance process for medicaid recipients in accordance with 42 C.F.R. 438, subpart F.

Renumbered from § 5111.177 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 09-29-2005

5167.12 [Renumbered from 5111.172] Requiring coverage of prescribed drugs for medicaid recipients.

(A) When contracting under section 5167.10 of the Revised Code with a managed care organization that is a health insuring corporation, the department of medicaid shall require the health insuring corporation to provide coverage of prescribed drugs for medicaid recipients enrolled in the health insuring corporation. In providing the required coverage, the health insuring corporation may, subject to the department's approval and the limitations specified in division (B) of this section, use strategies for the management of drug utilization.

(B) The department shall not permit a health insuring corporation to impose a prior authorization requirement in the case of a drug to which all of the following apply:

(1) The drug is an antidepressant or antipsychotic.

(2) The drug is administered or dispensed in a standard tablet or capsule form, except that in the case of an antipsychotic, the drug also may be administered or dispensed in a long-acting injectable form.

(3) The drug is prescribed by either of the following:

(a) A physician whom the health insuring corporation, pursuant to division (C) of section 5167.10 of the Revised Code, has credentialed to provide care as a psychiatrist;

(b) A psychiatrist practicing at a community mental health services provider certified by the department of mental health and addiction services under section 5119.36 of the Revised Code.

(4) The drug is prescribed for a use that is indicated on the drug's labeling, as approved by the federal food and drug administration.

(C)

The department shall permit a health insuring corporation to develop and implement a pharmacy utilization management program under which prior authorization through the program is established as a condition of obtaining a controlled substance pursuant to a prescription.

Renumbered from § 5111.172 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

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

Amended by 129th General AssemblyFile No.19, HB 93, §1, eff. 5/20/2011.

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

5167.13 [Renumbered from 5111.179] Contracts with managed care organizations; implementation of coordinated services program for medicaid recipients who abuse prescribed drugs.

Each contract the department of medicaid enters into with a managed care organization under section 5167.10 of the Revised Code shall require the managed care organization to implement a coordinated services program for medicaid recipients enrolled in the organization 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).

Renumbered from § 5111.179 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Added by 129th General AssemblyFile No.19, HB 93, §1, eff. 5/20/2011.

5167.14 [Renumbered from 5111.1710] Data security agreements for managed care organization's use of drug database.

Each contract the department of medicaid enters into with a managed care organization under section 5167.10 of the Revised Code shall require the managed care organization to enter into a data security agreement with the state board of pharmacy governing the managed care organization's use of the board's drug database established and maintained under section 4729.75 of the Revised Code.

This section does not apply if the board no longer maintains the drug database.

Renumbered from § 5111.1710 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Added by 129th General AssemblyFile No.19, HB 93, §1, eff. 5/20/2011.

5167.20 [Renumbered from 5111.162] Reference by managed care organization to noncontracting participant.

(A) Except as provided in division (B) of this section, when a participant in the care management system established under this chapter is enrolled in a medicaid managed care organization and the organization refers the participant to receive services, other than emergency services provided on or after January 1, 2007, at a hospital that participates in the medicaid program but is not under contract with the organization, the hospital shall provide the service for which the referral was made and shall accept from the organization, as payment in full, the amount derived from the payment rate used by the department to pay other hospitals of the same type for providing the same service to a medicaid recipient who is not enrolled in a medicaid managed care organization.

(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 adopt rules under section 5167.02 of the Revised Code specifying the circumstances under which a medicaid managed care organization is permitted to refer a participant in the care management system to a hospital that is not under contract with the organization.

Renumbered from § 5111.162 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 06-30-2005; 06-30-2006

5167.201 [Renumbered from 5111.163] Payment of nonsystem provider for emergency services.

When a participant in the care management system established under this chapter is enrolled in a medicaid managed care organization and receives emergency services on or after January 1, 2007, from a provider that is not under contract with the organization, the provider shall accept from the organization, as payment in full, not more than the amounts (less any payments for indirect costs of medical education and direct costs of graduate medical education) that the provider could collect if the participant received medicaid other than through enrollment in a managed care organization.

An agreement entered into by a participant, a participant's parent, or a participant's legal guardian that requires payment for emergency services in violation of this section is void and unenforceable.

Renumbered from § 5111.163 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 06-30-2006; 2007 HB119 09-29-2007

5167.21 [Renumbered from 5111.982] Payments to skilled nursing facility.

(A) As used in this section:

(1) "Covered skilled nursing facility services" has the same meaning as in the "Social Security Act," section 1888(e)(2)(A), 42 U.S.C. 1395yy(e)(2)(A).

(2) "Current medicare fee-for-service rate" means the fee-for-service rate in effect for a covered skilled nursing facility service under medicare at the time the service is provided.

(3) "Skilled nursing facility" has the same meaning as in the "Social Security Act," section 1819(a), 42 U.S.C. 1395i-3(a).

(B) Except as provided in division (C) of this section, a medicaid managed care organization shall pay a skilled nursing facility at least the current medicare fee-for-service rate, without deduction for any coinsurance, for covered skilled nursing facility services that the skilled nursing facility provides to a dual eligible individual if the medicaid managed care organization is responsible for the payment under the terms of a contract that the medicaid managed care organization, medicaid director, and United States secretary of health and human services jointly enter into under the integrated care delivery system authorized by section 5164.91 of the Revised Code.

(C) A medicaid managed care organization is required to pay the rate specified in division (B) of this section for covered skilled nursing facility services only if all of the following apply:

(1) The United States secretary agrees to the payment rate as part of the contract that the medicaid managed care organization, medicaid director, and United States secretary jointly enter into under the integrated care delivery system;

(2) The medicaid managed care organization receives a federal capitation payment that is an actuarially sufficient amount for the costs that the medicaid managed care organization incurs in paying the rate;

(3) No state funds are used for any part of the costs that the medicaid managed care organization incurs in paying the rate;

(4) The integrated care delivery system provides for dual eligible individuals to receive the covered skilled nursing facility services as part of the system.

Renumbered from § 5111.982 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Added by 129th General AssemblyFile No.194, HB 303, §1, eff. 3/20/2013.

5167.25 [Renumbered from 5111.178] Application for federal medicaid requirements waiver.

(A) The medicaid director shall determine whether a waiver of federal medicaid requirements is necessary to fulfill the requirements of section 3901.3814 of the Revised Code. If the director determines a waiver is necessary, the department of medicaid shall apply to the United States secretary of health and human services for the waiver.

(B)

(1) If the director determines that section 3901.3814 of the Revised Code can be implemented without a waiver or a waiver is granted, the department shall notify the department of insurance that the section can be implemented. Implementation of the section shall be effective eighteen months after the notice is sent.

(2) At the time the notice is given under division (B)(1) of this section, the department shall also give notice to each health insuring corporation that provides coverage to medicaid recipients. The notice shall inform the corporation that sections 3901.38 and 3901.381 to 3901.3814 of the Revised Code apply to claims for services rendered to recipients on the date determined under division (B)(1) of this section, instead of the prompt payment requirements of 42 C.F.R. 447.46. That date shall be specified in the notice.

Renumbered from § 5111.178 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 06-30-2006

5167.26 [Renumbered from 5111.175] Records for determining costs.

For the purpose of determining the amount the department of medicaid pays hospitals under section 5168.09 of the Revised Code and the amount of disproportionate share hospital payments paid by the medicare program pursuant to the "Social Security Act," section 1915, 42 U.S.C. 1396n, a medicaid managed care organization shall keep detailed records for each hospital with which it contracts , including records regarding the cost to the hospital of providing hospital services for the organization, payments made by the organization to the hospital for the services, utilization of hospital services by medicaid recipients enrolled in the organization, and other utilization data required by the department.

Renumbered from § 5111.175 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 06-26-2003

5167.30 [Renumbered from 5111.1711] Managed care performance payment program.

(A)

(1) The department of medicaid shall establish a managed care performance payment program. Under the program, the department may provide payments to medicaid managed care organizations that meet performance standards established by the department.

(2) In establishing performance standards, the department may consult any of the following:

(a) Any quality measurements developed under the pediatric quality measures program established pursuant to the "Social Security Act," section 1139A, 42 U.S.C. 1320b-9a;

(b) Any core set of adult health quality measures for medicaid eligible adults used for purposes of the "Social Security Act," section 1139A, 42 U.S.C. 1320b-9b, and any adult health quality used for purposes of the medicaid quality measurement program when the program is established under that section of the "Social Security Act";

(c) The most recent healthcare effectiveness data and information set and quality measurement tool established by the national committee for quality assurance.

(3) The standards that must be met to receive the payments may be specified in the contract the department enters into with a medicaid managed care organization.

(4) If a medicaid managed care organization meets the performance standards established by the department, the department shall make one or more performance payments to the organization. The amount of each performance payment, the number of payments, and the schedule for making the payments shall be established by the department. The payments shall be discontinued if the department determines that the organization no longer meets the performance standards. The department shall not make or discontinue payments based on any performance standard that has been in effect as part of the organization's contract for less than six months.

(B) For purposes of the program, the department shall establish an amount that is to be withheld each time a premium payment is made to a medicaid managed care organization. The amount shall be established as a percentage of each premium payment. The percentage shall be the same for all medicaid managed care organizations . The sum of all withholdings under this division shall not exceed two per cent of the total of all premium payments made to all medicaid managed care organizations .

Each medicaid managed care organization shall agree to the withholding as a condition of receiving or maintaining its provider agreement with the department.

When the amount is established and each time the amount is modified thereafter, the department shall certify the amount to the director of budget and management and begin withholding the amount from each premium the department pays to a medicaid managed care organization.

Renumbered from § 5111.1711 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

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

5167.40 [Renumbered from 5111.173] Appointment of temporary manager.

The department of medicaid shall appoint a temporary manager for a medicaid managed care organization if the department determines that the medicaid managed care organization has repeatedly failed to meet substantive requirements specified in the "Social Security Act," sections 1903(m) and 1932, 42 U.S.C. 1396b(m) and 1396u-2; or 42 C.F.R. 438 Part I. The appointment of a temporary manager does not preclude the department from imposing other sanctions available to the department against the medicaid managed care organization.

The medicaid managed care organization shall pay all costs of having the temporary manager perform the temporary manager's duties, including all costs the temporary manager incurs in performing those duties. If the temporary manager incurs costs or liabilities on behalf of the medicaid managed care organization, the medicaid managed care organization shall pay those costs and be responsible for those liabilities.

The appointment of a temporary manager is not subject to Chapter 119. of the Revised Code, but the managed care organization may request a reconsideration of the appointment. Reconsiderations shall be requested and conducted in accordance with rules the medicaid director shall adopt under section 5167.02 of the Revised Code.

The appointment of a temporary manager does not cause the medicaid managed care organization to lose the right to appeal, in accordance with Chapter 119. of the Revised Code, any proposed termination or any decision not to revalidate the medicaid managed care organization's provider agreement or the right to initiate the sale of the medicaid managed care organization or its assets.

Renumbered from § 5111.173 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 06-26-2003

5167.41 [Renumbered from 5111.174] Disenrolling some or all medicaid recipients enrolled in managed care organization.

The department of medicaid may disenroll some or all medicaid recipients enrolled in a medicaid managed care organization if the department proposes to terminate or not to renew the contract and determines that the recipients' access to medically necessary services is jeopardized by the proposal to terminate or not to renew the contract. The disenrollment is not subject to Chapter 119. of the Revised Code, but the medicaid managed care organization may request a reconsideration of the disenrollment. Reconsiderations shall be requested and conducted in accordance with rules the medicaid director shall adopt under section 5167.02 of the Revised Code. The request for, or conduct of, a reconsideration regarding a proposed disenrollment shall not delay the disenrollment.

Renumbered from § 5111.174 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 06-26-2003