Chapter 5167 | Medicaid Managed Care

Section 5167.01 | Definitions.

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

As used in this chapter:

(A) "340B covered entity" means an entity described in section 340B(a)(4) of the "Public Health Service Act," 42 U.S.C. 256b(a)(4) and includes any pharmacy under contract with the entity to dispense drugs on behalf of the entity.

(B) "Affiliated company" means an entity, including a third-party payer or specialty pharmacy, with common ownership, members of a board of directors, or managers, or that is a parent company, subsidiary company, jointly held company, or holding company with respect to the other entity.

(C) "Care management system" means the system established under section 5167.03 of the Revised Code.

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

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

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

(G) "Enrollee" means a medicaid recipient who participates in the care management system and enrolls in a medicaid MCO plan.

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

(I) "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.

(J) "Medicaid MCO plan" means a plan that a medicaid managed care organization, pursuant to its contract with the department of medicaid under section 5167.10 of the Revised Code, makes available to medicaid recipients participating in the care management system.

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

(L) "Network provider" has the same meaning as in 42 C.F.R. 438.2.

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

(N) "Part B drug" means a drug or biological described in section 1842(o)(1)(C) of the "Social Security Act," 42 U.S.C. 1395u(o)(1)(C).

(O) "Pharmacy benefit manager" has the same meaning as in section 3959.01 of the Revised Code.

(P) "Practice of pharmacy" has the same meaning as in section 4729.01 of the Revised Code.

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

(R) "Prior authorization requirement" has the same meaning as in section 5160.34 of the Revised Code.

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

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

(U) "State pharmacy benefit manager" means the pharmacy benefit manager selected by and under contract with the medicaid director under section 5167.24 of the Revised Code.

(V) "Third-party administrator" means any person who adjusts or settles claims on behalf of an insuring entity in connection with life, dental, health, prescription drugs, or disability insurance or self-insurance programs and includes a pharmacy benefit manager.

Section 5167.02 | Rules.

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

The medicaid director shall adopt rules as necessary to implement this chapter. The rules shall be adopted in accordance with Chapter 119. of the Revised Code.

Section 5167.03 | Care management system.

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

As part of the medicaid program, the department of medicaid shall establish a care management system. The department shall implement the system in some or all counties.

The department shall designate the medicaid recipients who are required or permitted to participate in the care management system. Those who shall be required to participate in the system include medicaid recipients who receive cognitive behavioral therapy as described in division (A)(2) of section 5167.16 of the Revised Code. Except as provided in section 5166.406 of the Revised Code, no medicaid recipient participating in the healthy Ohio program established under section 5166.40 of the Revised Code shall participate in the system.

The general assembly's authorization through the enactment of legislation is needed before home and community-based services available under a medicaid waiver component or nursing facility services are included in the care management system, except that ICDS participants may be required or permitted to obtain such services under the system. Medicaid recipients who receive such services may be designated for voluntary or mandatory participation in the system in order to receive other health care services included in the system.

The department may require or permit participants in the care management system to do either or both of the following:

(A) Obtain health care services from providers designated by the department;

(B) Enroll in a medicaid MCO plan.

Section 5167.031 | Recognition of pediatric accountable care organizations.

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

(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.

Section 5167.04 | Inclusion of alcohol, drug addiction, and mental health services in care management system.

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

The department of medicaid shall include alcohol, drug addiction, and mental health services covered by medicaid in the care management system.

Section 5167.05 | Inclusion of prescribed drugs in care management system.

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

The department of medicaid may include prescribed drugs covered by the medicaid program in the care management system.

Section 5167.051 | Coverage of services provided by pharmacist.

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

If the medicaid program covers the pharmacist services described in section 5164.14 of the Revised Code, the department of medicaid may include the services in the care management system.

Section 5167.10 | Authority to contract with managed care orgainizations.

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

The department of medicaid may enter into contracts with managed care organizations under which the organizations are authorized to provide, or arrange for the provision of, health care services to medicaid recipients who are required or permitted to participate in the care management system.

Section 5167.101 | Basis of hospital inpatient capital payment portion of payment to medicaid managed care organization.

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

(A) Subject to division (B) of this section, the department of medicaid or its actuary shall base the hospital inpatient capital payment portion of the payment made to a medicaid managed care organization on data for services provided to all of the organization's enrollees, as reported by hospitals on relevant cost reports submitted pursuant to rules adopted under section 5167.02 of the Revised Code.

(B) The hospital inpatient capital payment portion of the payment made to medicaid managed care organizations shall not exceed any maximum rate established in rules adopted under section 5167.02 of the Revised Code.

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

Section 5167.103 | Performance metrics; publication.

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

In addition to the managed care performance payment program created under section 5167.30 of the Revised Code, the department of medicaid shall establish performance metrics that will be used to evaluate and compare how medicaid managed care organizations perform under the contracts entered into under section 5167.10 of the Revised Code. The performance metrics may include financial incentives and penalties.

The department shall make available on its internet web site the metrics the department uses to determine how well medicaid managed care organizations perform. The department shall update its internet web site each quarter to reflect any changes it makes to the metrics.

Section 5167.11 | Managed care organization contract to provide grievance process.

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

Each medicaid managed care organization shall provide a grievance process for the organization's enrollees in accordance with 42 C.F.R. 438, subpart F.

Section 5167.12 | Requirements when prescribed drugs are included in care management system.

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

If prescribed drugs are included in the care management system:

(A) Medicaid MCO plans may include strategies for the management of drug utilization, but any such strategies are subject to the limitations and requirements of this section and the approval of the department of medicaid.

(B) A medicaid MCO plan shall not impose a prior authorization requirement in the case of a drug to which all of the following apply:

(1) The drug is an antidepressant or antipsychotic.

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

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

(a) A physician who has registered the physician's psychiatric specialty with the department;

(b) A psychiatrist who is practicing at a location on behalf of a community mental health services provider whose mental health services are certified by the department of mental health and addiction services under section 5119.36 of the Revised Code;

(c) A certified nurse practitioner, as defined in section 4723.01 of the Revised Code, who is certified in psychiatric mental health by a national certifying organization approved by the board of nursing under section 4723.46 of the Revised Code;

(d) A clinical nurse specialist, as defined in section 4723.01 of the Revised Code, who is certified in psychiatric mental health by a national certifying organization approved by the board of nursing under section 4723.46 of the Revised Code.

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

(C) The department shall authorize a medicaid MCO plan to include a pharmacy utilization management program under which prior authorization through the program is established as a condition of obtaining a controlled substance pursuant to a prescription.

(D) Each medicaid managed care organization and medicaid MCO plan shall comply with sections 5164.091, 5164.10, 5164.7511, 5164.7512, and 5164.7514 of the Revised Code as if the organization were the department and the plan were the medicaid program.

Last updated October 6, 2023 at 10:44 AM

Section 5167.122 | Disclosure of sources of payment.

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

(A) The state pharmacy benefit manager shall, on request from the department of medicaid, disclose to the department all sources of payment it receives for prescribed drugs, including any financial benefits such as drug rebates, discounts, credits, clawbacks, fees, grants, chargebacks, reimbursements, or other payments related to services provided for the medicaid managed care organization.

(B) Each medicaid managed care organization shall disclose to the department of medicaid in the format specified by the department the organization's administrative costs associated with providing pharmacy services under the care management system.

Section 5167.123 | Medicaid MCO contracts with 340B program participants.

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

(A) No contract between a medicaid managed care organization, including a third-party administrator, and a 340B covered entity shall contain any of the following provisions:

(1) A payment rate for a prescribed drug that is less than the national average drug acquisition cost rate for that drug as determined by the United States centers for medicare and medicaid services, measured at the time the drug is administered or dispensed, or, if no such rate is available at that time, a reimbursement rate that is less than the wholesale acquisition cost of the drug, as defined in 42 U.S.C. 1395w-3a(c)(6)(B);

(2) A fee that is not imposed on a health care provider that is not a 340B covered entity;

(3) A fee amount that exceeds the amount for a health care provider that is not a 340B covered entity.

(B) The organization, or its contracted third-party administrators, shall not discriminate against a 340B covered entity in a manner that prevents or interferes with a medicaid recipient's choice to receive a prescription drug from a 340B covered entity or its contracted pharmacies.

(C) Any provision of a contract entered into between the organization and a 340B covered entity that is contrary to division (A) of this section is unenforceable and shall be replaced with the dispensing fee or payment rate that applies for health care providers that are not 340B covered entities.

Section 5167.13 | Implementation of coordinated services program for enrollees who abuse prescribed drugs.

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

Each medicaid managed care organization shall implement a coordinated services program for the organization's enrollees who are found to have obtained prescribed drugs under the medicaid program at a frequency or in an amount that is not medically necessary. The program shall be implemented in a manner that is consistent with section 1915(a)(2) of the "Social Security Act," 42 U.S.C. 1396n(a)(2), and 42 C.F.R. 431.54(e).

Section 5167.14 | Data security agreements for managed care organization's use of drug database.

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

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

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

Section 5167.15 | Chiropractic services.

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

When contracting under section 5167.10 of the Revised Code with a medicaid managed care organization, the department of medicaid shall require the organization to comply with section 5164.061 of the Revised Code as if the organization were the department.

This section does not limit the authority of a medicaid managed care organization to implement measures designed to improve quality and reduce costs.

Last updated March 22, 2022 at 2:04 PM

Section 5167.16 | Home visits and cognitive behavioral therapy.

• Effective: September 30, 2021
• Latest Legislation: House Bill 110 - 134th General Assembly

(A) As used in this section:

(1) "Help me grow program" means the program established by the department of health pursuant to section 3701.61 of the Revised Code.

(2) "Targeted case management" has the same meaning as in 42 C.F.R. 440.169(b).

(B) A medicaid managed care organization shall provide to a medicaid recipient who meets the criteria in division (C) of this section, or arrange for such recipient to receive, both of the following types of services:

(1) Home visits, which shall include depression screenings, for which federal financial participation is available under the targeted case management benefit;

(2) Cognitive behavioral therapy, provided by a community mental health services provider, that is determined to be medically necessary through a depression screening conducted as part of a home visit.

(C) A medicaid recipient qualifies to receive the services specified in division (B) of this section if the medicaid recipient is enrolled in the help me grow program, enrolled in the medicaid managed care organization providing or arranging for the services, and is either pregnant or the birth mother of a child under five years of age.

(D) If requested by a medicaid recipient eligible for the cognitive behavioral therapy covered under division (B)(2) of this section, the therapy shall be provided in the recipient's home. The medicaid managed care organization shall inform the medicaid recipient of the right to make the request and how to make it.

Last updated September 29, 2023 at 2:54 PM

Section 5167.17 | Enhanced care management services for pregnant women and women capable of becoming pregnant.

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

Each medicaid managed care organization shall provide enhanced care management services for pregnant women and women capable of becoming pregnant in the communities specified in rules adopted under section 3701.142 of the Revised Code. The services shall be provided in a manner intended to decrease the incidence of prematurity, low birth weight, and infant mortality, as well as improve the overall health status of women capable of becoming pregnant for the purpose of ensuring optimal future birth outcomes.

Section 5167.171 | Uniform prior approval form for progesterone.

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

Each medicaid managed care organization shall, if the organization requires practitioners to obtain prior approval before administering progesterone to the organization's enrollees who are pregnant, use a uniform prior approval form for progesterone that is not more than one page.

Section 5167.173 | Community health worker services or services provided by public health nurse.

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

(A) As used in this section:

(1) "Board of health" means the board of health of a city or general health district or the authority having the duties of a board of health under section 3709.05 of the Revised Code.

(2) "Certified community health worker" has the same meaning as in section 4723.01 of the Revised Code.

(3) "Community health worker services" means the services described in section 4723.81 of the Revised Code.

(4) "Public health nurse" means a registered nurse employed or contracted by a board of health.

(5) "Qualified community hub" means a central clearinghouse for a network of community care coordination agencies that meets all of the following criteria:

(a) Demonstrates to the director of health that it uses an evidenced-based, pay-for-performance community care coordination model (endorsed by the federal agency for healthcare research and quality, the national institutes of health, and the centers for medicare and medicaid services or their successors) or uses certified community health workers or public health nurses to connect at-risk individuals to health, housing, transportation, employment, education, and other social services;

(b) Is a board of health or demonstrates to the director of health that it has achieved, or is engaged in achieving, certification from a national hub certification program;

(c) Has a plan, approved by the medicaid director, specifying how the board of health or community hub ensures that children served by it receive appropriate developmental screenings as specified in the publication titled "Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents," available from the American academy of pediatrics, as well as appropriate early and periodic screening, diagnostic, and treatment services.

(B) Each medicaid managed care organization shall provide to an enrollee who meets the criteria in division (C) of this section, or arrange for the enrollee to receive, both of the following services provided by a certified community health worker or public health nurse, as applicable, who is employed by, or works under a contract with, a qualified community hub:

(1) Community health worker services or services provided by a public health nurse;

(2) Other services that are not community health worker services or services provided by a public health nurse but are performed for the purpose of ensuring that the enrollee is linked to employment services, housing, educational services, social services, or medically necessary physical and behavioral health services.

(C) An enrollee qualifies to receive the services specified in division (B) of this section if the enrollee is pregnant or capable of becoming pregnant, resides in a community served by a qualified community hub, and has been recommended to receive the services by a physician, public health nurse, or another licensed health professional specified in rules adopted under division (D) of this section.

(D) The medicaid director shall adopt rules under section 5167.02 of the Revised Code specifying the licensed health professionals, in addition to physicians and public health nurses, who may recommend that an enrollee receive the services specified in division (B) of this section.

Section 5167.18 | Identification of fraud, waste, and abuse.

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

Each medicaid managed care organization shall comply with federal and state efforts to identify fraud, waste, and abuse in the medicaid program.

Section 5167.20 | Reference by managed care organization to noncontracting participant.

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

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

(B) A hospital is not subject to division (A) of this section if all of the following are the case:

(1) The hospital is located in a county in which participants in the care management system are required before January 1, 2006, to be enrolled in a medicaid MCO plan;

(2) The hospital has entered into a contract before January 1, 2006, with at least one health insuring corporation serving the participants specified in division (B)(1) of this section;

(3) The hospital remains under contract with at least one health insuring corporation serving participants in the care management system who are required to be enrolled in a medicaid MCO plan.

(C) The medicaid director shall adopt rules under section 5167.02 of the Revised Code specifying the circumstances under which a medicaid managed care organization is permitted to refer an enrollee to a hospital that is not under contract with the organization.

Section 5167.201 | Payment of nonsystem provider for emergency services.

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

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

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

Section 5167.21 | Payments to skilled nursing facility.

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

(A) As used in this section:

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

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

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

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

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

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

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

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

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

Section 5167.22 | Recoupment of overpayment.

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

When a medicaid managed care organization seeks to recoup an overpayment made to a provider, it shall provide the provider all of the details of the recoupment, including all of the following information:

(A) The name, address, and medicaid identification number of the enrollee to whom the services were provided;

(B) The date or dates that the services were provided;

(C) The reason for the recoupment;

(D) The method by which the provider may contest the proposed recoupment.

Section 5167.221 | Assessment of recoupment efforts.

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

The department of medicaid shall assess the efforts of medicaid managed care organizations to recoup overpayments made to providers who are network providers and providers who are not network providers. The assessments shall examine the amount of time recoupment efforts take starting from the time providers receive final payment and ending when the recoupment effort is completed. Each medicaid managed care organization shall submit to the department information regarding such recoupment efforts that the department needs to perform the assessments. The department shall specify what information is so needed. Following the assessments, the department shall include in the contracts entered into with medicaid managed care organizations under section 5167.10 of the Revised Code terms the department determines are reasonable to establish limits on such recoupment efforts. The terms shall include exceptions for cases of fraud and other types of deception.

Section 5167.24 | Third-party administrator as single pharmacy benefit manager.

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

(A) If the department of medicaid includes prescribed drugs in the care management system as authorized under section 5167.05 of the Revised Code, the medicaid director, through a procurement process, shall select a third-party administrator to serve as the single pharmacy benefit manager used by medicaid managed care organizations under the care management system. The state pharmacy benefit manager shall be responsible for processing all pharmacy claims under the care management system. The department of medicaid is responsible for enforcing the contract after the procurement process.

(B) As part of the procurement process, the director shall do all of the following:

(1) Accept applications from entities seeking to become the state pharmacy benefit manager;

(2) Establish eligibility criteria an entity must meet in order to become the state pharmacy benefit manager;

(3) Select and contract with a single state pharmacy benefit manager;

(4) Develop a master contract to be used by the director when contracting with the state pharmacy benefit manager, which shall prohibit the state pharmacy benefit manager from requiring a medicaid recipient to obtain a specialty drug from a specialty pharmacy owned or otherwise associated with the state pharmacy benefit manager.

(C) A prospective state pharmacy benefit manager shall disclose to the director all of the following during the procurement process:

(1) Any activity, policy, practice, contract or arrangement of the state pharmacy benefit manager that may directly or indirectly present any conflict of interest with the pharmacy benefit manager's relationship with or obligation to the department or a medicaid managed care organization;

(2) All common ownership, members of a board of directors, managers, or other control of the pharmacy benefit manager (or any of the pharmacy benefit manager's affiliated companies) with any of the following:

(a) A medicaid managed care organization and its affiliated companies;

(b) An entity that contracts on behalf of a pharmacy or any pharmacy services administration organization and its affiliated companies;

(c) A drug wholesaler or distributor and its affiliated companies;

(d) A third-party payer and its affiliated companies;

(e) A pharmacy and its affiliated companies.

(3) Any direct or indirect fees, charges, or any kind of assessments imposed by the pharmacy benefit manager on pharmacies licensed in this state with which the pharmacy benefit manager shares common ownership, management, or control; or that are owned, managed, or controlled by any of the pharmacy benefit manager's affiliated companies;

(4) Any direct or indirect fees, charges, or any kind of assessments imposed by the pharmacy benefit manager on pharmacies licensed in this state

(6) Any financial terms and arrangements between the pharmacy benefit manager and a prescription drug manufacturer or labeler, including formulary management, drug substitution programs, educational support claims processing, or data sales fees.

(D) The director shall select a provisional state pharmacy benefit manager not later than July 1, 2020.

(1) Once a provisional state pharmacy benefit manager has been selected, full implementation of the entity as the state pharmacy benefit manager shall be subject to that entity's demonstrated ability to fulfill the duties and obligations of the state pharmacy benefit manager as illustrated through a readiness review process established by the director. Any entity failing to complete the readiness review process shall be deemed as having not met the criteria of the review process. The selected entity shall not enter into contracts with the department or medicaid managed care organizations as the state pharmacy benefit manager before the date on which the entity has satisfactorily completed the readiness review process.

(2) If the director determines that, for reasons beyond the director's control, selection of a provisional state pharmacy benefit manager cannot occur before July 1, 2020, the director shall notify the joint medicaid oversight committee of the reasons for the delay and identify the steps the director is taking to complete the selection as expeditiously as possible.

Section 5167.241 | State pharmacy benefit manager contract; payment arrangements.

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

(A)(1) Medicaid managed care organizations shall use the state pharmacy benefit manager selected under section 5167.24 of the Revised Code pursuant to the terms of the master contract entered into under that section.

All payment arrangements between the department of medicaid, medicaid managed care organizations, and the state pharmacy benefit manager shall comply with state and federal statutes, regulations adopted by the centers for medicare and medicaid services, and any other agreement between the department and the centers for medicare and medicaid services. The director may change a payment arrangement in order to comply with state and federal statutes, regulations adopted by the centers for medicare and medicaid services, or any other agreement between the department and the centers for medicare and medicaid services.

Section 5167.243 | Quarterly reports.

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

(A) The state pharmacy benefit manager shall provide to the medicaid director a written quarterly report containing the following information from the immediately preceding quarter:

(1) The prices that the state pharmacy benefit manager negotiated for prescribed drugs under the care management system. The price must include any rebates the state pharmacy benefit manager received from the drug manufacturer;

(2) The prices the state pharmacy benefit manager paid to pharmacies for prescribed drugs;

(3) Any rebate amounts the state pharmacy benefit manager passed on to individual pharmacies;

(4) The percentage of savings in drug prices that are passed on to participants in the care management system;

(5) The information described in division (C) of section 5167.24 of the Revised Code;

(6) Any other information required by the director.

(B) The director may ask the state pharmacy benefit manager to provide additional information as necessary and shall collect other clinical data from the state pharmacy benefit manager as the director sees fit.

(C) At the time of contract execution, renewal, or modification, the department shall modify the reporting requirements under its medicaid managed care organization contracts as necessary to meet the requirements of this section.

Section 5167.244 | Violations; penalty.

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

No person shall violate the terms of the master state pharmacy benefit manager contract under section 5167.24 of the Revised Code or section 5167.241 of the Revised Code. Whoever violates those sections is subject to a civil penalty in an amount to be determined by the medicaid director.

Section 5167.245 | Appeals process.

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

The medicaid director shall establish an appeals process by which pharmacies may appeal to the department of medicaid any disputes relating to the maximum allowable cost set by the state pharmacy benefit manager for a prescribed drug. All pharmacies participating in the care management system shall use the appeals process to resolve any disputes relating to the maximum allowable cost set by the state pharmacy benefit manager.

Section 5167.26 | Records for determining costs.

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

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

Section 5167.30 | Managed care performance payment program.

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

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

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

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

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

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

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

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

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

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

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

Section 5167.31 | Financial incentive awards.

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

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

Section 5167.32 | Improving integrity of care management system.

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

Not later than July 1, 2016, the department of medicaid shall implement strategies to improve the integrity of the care management system, including strategies to do both of the following:

(A) Increase the department's oversight of medicaid managed care organizations;

(B) Provide incentives for identifying fraud, waste, and abuse in the care management system.

Section 5167.33 | Strategies regarding payment to providers.

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

(A) Not later than July 1, 2018, each medicaid managed care organization shall implement strategies that base payments to providers on the value received from the providers' services, including their success in reducing waste in the provision of the services. Not later than July 1, 2020, each medicaid managed care organization shall ensure that at least fifty per cent of the aggregate net payments it makes to providers are based on the value received from the providers' services.

The department of medicaid may measure a medicaid managed care organization's compliance with this section based on the actions of the organization, the providers in the organization's provider panel, the organization's subcontractors, or any combination of the organization, providers, and subcontractors.

(B) The medicaid director shall adopt rules under section 5167.02 of the Revised Code as necessary to implement this section, including rules that specify how all of the following are to be determined:

(1) The value received from a provider's services;

(2) A provider's success in reducing waste in the provision of services;

(3) The percentage of a medicaid managed care organization's aggregate net payments to providers that are based on the value received from the providers' services.

Section 5167.34 | Immunity from liability.

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

A medicaid managed care organization, its officers, employees, or other persons associated with the managed care organization are not liable in a civil action for damages or other relief for furnishing information to the department of medicaid regarding potential fraud, waste, or abuse in the medicaid program.

Section 5167.35 | Meaningful employment of Medicaid recipients.

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

(A) Consistent with the requirements of the care management system implemented on February 1, 2023, to address medicaid population health and social determinants of health and encourage optimal health and self-sufficiency of medicaid enrollees, the department of medicaid, in collaboration with the department of job and family services, shall develop a program to assist medicaid enrollees with securing meaningful employment.

(B) As part of that program, each medicaid managed care organization shall develop a specialized component of its medicaid MCO plan to provide referral and support to medicaid enrollees in obtaining and maintaining meaningful employment. Each medicaid managed care organization shall give priority to identified enrollees who are of working age and are able-bodied, or who would benefit from assistance to overcome unemployment or underemployment. In carrying out the requirements of this section, each medicaid managed care organization shall do all of the following:

(1) Identify any barriers that an identified enrollee has to achieving greater financial independence, including the following:

(a) Education;

(b) Employment;

(c) Physical and behavioral health care;

(d) Transportation;

(e) Childcare;

(f) Housing;

(g) Legal history, including prior conviction of a criminal offense.

(2) Develop state and local relationships that link and refer identified enrollees to assessments, resources, and supports that assist with obtaining and maintaining meaningful employment.

(3) Utilize a standard health risk assessment form established by the medicaid director to identify enrollees to receive assistance under the program established by this section.

(C)(1) Not later than six months after the effective date of this section, the medicaid director and the director of job and family services shall convene a workgroup. The workgroup shall consist of the following members, selected by the directors:

(a) Representatives of the director of opportunities for Ohioans with disabilities, the director of developmental disabilities, and director of mental health and addiction services;

(b) Representatives of the Ohio job and family services directors' association and workforce development agencies;

(c) Representatives of technical, career, and higher education;

(d) Representatives of each medicaid managed care organization;

(e) Representatives of other organizations with expertise and resources involved in career and job development, as determined by the medicaid director and director of job and family services.

(2) The workgroup shall do all of the following:

(a) Identify state and local resources that provide job skills and career development, including available resources to support identified enrollees to seek employment and develop needed skills;

(b) Develop models for local agreements or protocols for collaboration between medicaid managed care organizations and other community agencies;

(c) Identify conflicts among program requirements that should be addressed by state agencies and the general assembly to facilitate identified enrollees' ability to secure and maintain employment.

(D) The medicaid director may do any of the following with respect to the program established under this section:

(1) Establish additional requirements for medicaid managed care organizations;

(2) Create supplemental assessments to assist in identifying barriers to achieving financial independence, in addition to the barriers identified in division (B)(1) of this section;

(3) Adopt rules, in accordance with Chapter 119. of the Revised Code, as necessary to implement these provisions.

(E) The medicaid director and the director of job and family services shall report to the governor, the senate medicaid committee, and any other standing legislative committee having jurisdiction over medicaid regarding the implementation and operation of the program. The directors shall report on a periodic basis during the first year of the program. Thereafter, the directors shall report not less than annually.

Last updated October 6, 2023 at 5:12 PM

Section 5167.40 | Appointment of temporary manager.

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

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

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

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

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

Section 5167.41 | Disenrolling some or all medicaid recipients from MCO plan offered by a managed care organization.

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

The department of medicaid may disenroll some or all medicaid recipients from a medicaid MCO plan offered by a medicaid managed care organization if the department proposes to terminate or not to renew the contract entered into under section 5167.10 of the Revised Code and determines that the recipients' access to medically necessary services is jeopardized by the proposal to terminate or not to renew the contract. The disenrollment is not subject to Chapter 119. of the Revised Code, but the medicaid managed care organization may request a reconsideration of the disenrollment. Reconsiderations shall be requested and conducted in accordance with rules the medicaid director shall adopt under section 5167.02 of the Revised Code. The request for, or conduct of, a reconsideration regarding a proposed disenrollment shall not delay the disenrollment.

Section 5167.45 | Information about medicaid recipients' races, ethnicities, and primary languages.

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

The department of medicaid shall include information about medicaid recipients' races, ethnicities, and primary languages in data the department shares with medicaid managed care organizations. Medicaid managed care organizations shall include this information in the data the organizations share with providers.

Section 5167.47 | Compliance with federal mental health and addiction parity laws.

• Effective: March 24, 2021
• Latest Legislation: Senate Bill 284 - 133rd General Assembly

(A) When contracting with a medicaid managed care organization, the department of medicaid shall require the medicaid managed care organization to provide to medicaid enrollees the same benefits and rights as required under division (B) of section 3902.36 of the Revised Code.

(B) The medicaid director shall do both of the following:

(1) Implement and enforce division (B) of section 3902.36 of the Revised Code with respect to medicaid managed care organizations;

(2) Enforce, monitor compliance with, and ensure continued compliance with this section.

(C) The director may adopt rules under section 5167.02 of the Revised Code as necessary to carry out the provisions of this section.