Chapter 5160-20 | Coordinated Services Program

Rule 5160-20-01 | Coordinated services program: definitions.

• Effective: February 1, 2026
• Promulgated Under: 119.03

The following definitions apply to rule 5160-20-04 of the Administrative Code

(A) "Abuse" means recipient practices that result in unnecessary cost to the medicaid program as defined in rule 5160-26-01 of the Administrative Code.

(B) "Abuse potential drug" means any drug that contains substances which have a potential for abuse because of depressant or stimulant effects on the central nervous system or hallucinogenic effects. Abuse potential drugs include any drug that is reportable to the Ohio automated RX reporting system (OARRS) as described in rules 4729:8-2-01 and 4729:8-2-02 of the Administrative Code, in addition to muscle relaxants and other non-controlled drugs as determined by ODM. Drugs used for medication assisted treatment (MAT) are excluded from consideration.

(C) "Assigned provider" means a pharmacy provider that is authorized to and is not excluded from receiving reimbursement for health care services rendered to an individual. The assigned pharmacy provider is selected to serve as the pharmacy provider for an individual enrolled in the coordinated services program (CSP).

(D) "Coordinated services program" is a program required by section 5164.758 of the Revised Code.

(E) "Fraud" for the purpose of this rule, includes but is not limited to, forged prescriptions, possession and use of multiple medicaid cards, card loaning, and sharing of drugs or other supplies obtained through medicaid.

(F) "Managed care entity" (MCE) means defined in rule 5160-26-01 of the Administrative Code.

(G) "Managed care organization (MCO)" means as defined in rule 5160-26-01 of the Administrative Code.

(H) "Medicare" means defined in rule 5160-1-05 of the Administrative Code.

(I) "Medication Assisted Treatment" (MAT) means as defined in rule 5160-1-73 of the Administrative Code.

(J) "Polypharmacy" for the purpose of this chapter means that a recipient utilized three or more pharmacies, within ninety calendar days, throughout a twelve-month overall period, to fill abuse potential drugs. MAT drugs are excluded from consideration. Individual pharmacies are determined by the national provider identification (NPI) number. Consideration of pharmacy types should be examined as a recipient may need to use multiple pharmacies for specialty services.

(K) "Polyprescriber" for the purpose of this chapter means that a recipient obtained prescriptions for abuse potential drugs from four or more prescribers, within ninety calendar days, throughout a twelve-month overall period. MAT drugs are excluded from consideration. Affiliated prescribers with a shared business structure, including prescribers serving in rural health centers, federally qualified health centers, and group practices are considered a single prescriber for CSP purposes. Prescriber identification numbers are used for the determination of multiple prescriber use.

(L) "Polyprescription" for the purpose of this chapter means that a recipient obtained four or more distinct (defined as having different active ingredients or dosage forms) OARRS reportable drugs or muscle relaxants, within ninety calendar days, throughout a twelve-month overall period. MAT drugs are excluded from consideration.

(M) "Single pharmacy benefit manager (SPBM)" means as defined in rule 5160-26-01 of the Administrative Code.

(N) "Waste" means receipt of or the attempt to obtain items or services when there may be no intent to deceive or misrepresent, but poor treatment or care coordination methods result in unnecessary costs.

Last updated February 2, 2026 at 8:12 AM

Supplemental Information

Authorized By: 5164.02, 5164.758
Amplifies: 5164.02, 5164.758
Five Year Review Date: 2/1/2031
Prior Effective Dates: 12/1/1983, 4/1/1986, 7/1/1987, 2/1/1990, 4/1/1992, 11/1/1997, 1/1/2008, 1/1/2012, 1/1/2017, 1/1/2018, 1/1/2019, 1/1/2021, 10/1/2022

Rule 5160-20-04 | Coordinated services program: enrollment and operation.

• Effective: February 1, 2026
• Promulgated Under: 119.03

(A) The coordinated services program (CSP) provides continuity of care, helps reduce inappropriate or unnecessary utilization of pharmacy services, fraud, and excessive use, waste, or abuse of prescribed abuse potential drugs. A recipient enrolled in CSP remains eligible for all medically-necessary medicaid-covered services, but is assigned a designated pharmacy provider through which pharmacy services are received. Only controlled substances, as defined in 21 U.S.C. 801 as in effect July 6, 2025, are to be received from a designated pharmacy provider. Drugs used for medication assisted treatment (MAT) are excluded.

(B) CSP enrollment criteria. The enrollment criteria of this rule are based upon available utilization data within the past twelve rolling calendar months, referrals received for fraud, waste, or abuse activities, or self-reported referrals from the recipient. A recipient who self refers, is referred for abuse, fraud, or waste, or who meets three or more of the enrollment criteria will be enrolled unless the recipient meets a specific exclusion criteria.

(1) Self-referral criteria:

A recipient elects to refer oneself to the coordinated services program.

(2) Referrals to the CSP can come from the Ohio department of medicaid (ODM) if a recipient is suspected of or was verified to be involved in practices consistent with "abuse," "fraud," and "waste," as defined in rule 5160-20-01 of the Administrative Code.

(3) Enrollment criteria:

(a) Polypharmacy as defined in rule 5160-20-01 of the Administrative Code;

(b) Polyprescriber as defined in rule 5160-20-01 of the Administrative Code;

(c) Polyprescription as defined in rule 5160-20-01 of the Administrative Code; or

(d) Combinations of abuse potential drugs, as identified by ODM and available on the ODM website, that are duplicative, contraindicative, or which when combined may cause negative health outcomes.

(C) CSP exclusion criteria. If a recipient meets any of the following criteria, CSP enrollment will not occur.

(1) The recipient is enrolled in both the medicare and medicaid programs.

(2) The recipient has been identified as having cancer within the last twelve months.

(3) The recipient is receiving services through hospice.

(4) It is determined to be inappropriate to enroll the recipient in CSP based on clinical evidence reviewed by ODM, managed care organization (MCO), or single pharmacy benefit manager (SPBM) clinical staff.

(D) Initial enrollment, continued enrollment, and disenrollment procedures.

(1) Initial enrollment. If a recipient is selected for enrollment in CSP using criteria from paragraph (B) of this rule, the recipient is enrolled in CSP for twenty-four months, which begin at the effective date of enrollment.

(a) A recipient proposed for enrollment in CSP receives the "Notice of Proposed Enrollment in the Coordinated Services Program (CSP)" (ODM 01717), including the effective date of enrollment, from the MCO in accordance with division 5101:6 of the Administrative Code.

(b) If a recipient enrolled in CSP becomes ineligible for medicaid, then resumes eligibility for medicaid within the initial enrollment period, the recipient is reinstated into CSP until the initial enrollment period is exhausted.

(2) Continued enrollment. If after the initial enrollment period, ODM or the MCO determines a recipient's service utilization continues to support the reasons for enrollment in the CSP program described in paragraph (B) of this rule, the recipient continues enrollment in CSP for an additional twenty-four months. There is no limit to the number of times a recipient may be selected for continued enrollment in CSP.

(a) ODM notifies the recipient of the continued enrollment by issuing the "Notice of Continued Enrollment in the Coordinated Services Program (CSP)" (ODM 01705) in accordance with division 5101:6 of the Administrative Code.

(b) (b) If a recipient enrolled in CSP becomes ineligible for medicaid, then resumes eligibility for medicaid within a continued enrollment period, the recipient is reinstated into CSP until the continued enrollment period is exhausted.

(3) Disenrollment. If a recipient enrolled in CSP meets any of the criteria described in paragraph (C) of this rule, the recipient is disenrolled from CSP.

(E) Pharmacy provider assignment and changes. A recipient enrolled in CSP may request an assigned pharmacy provider within thirty days of the mailing date on the initial or continued enrollment notification. This pharmacy provider serves as the recipient's assigned pharmacy provider as defined in rule 5160-9-01 of the Administrative Code.

(1) The MCO or the SPBM selects an assigned pharmacy provider for the recipient for any of the following reasons:

(a) The recipient does not select an assigned pharmacy provider within thirty calendar days of the mailing date on the initial enrollment notification;

(b) The recipient's selected assigned pharmacy provider is denied by the MCO, or the SPBM; or

(c) The selected assigned pharmacy provider is unwilling or unable to accept the recipient.

(2) A recipient may request to change an assigned pharmacy provider, or ODM, the MCO, or the SPBM may direct a recipient to make an alternative selection of an assigned pharmacy provider if:

(a) The assigned pharmacy provider closes or relocates;

(b) The recipient moved or is unable to travel to the pharmacy provider;

(c) The assigned pharmacy provider is no longer an enrolled pharmacy provider; or

(d) The assigned pharmacy provider chooses not to provide services to the recipient.

(3) If the MCO denies the recipient's request to change the assigned provider, the recipient is notified by issuance of the "Notice of Denial of Assigned Provider or Pharmacy in the Coordinated Services Program (CSP)" (ODM 01718) in accordance with division 5101:6 of the Administrative Code.

(4) Secondary assignments are allowed if the recipient needs to utilize a secondary pharmacy provider for specialty medications, compounding, risk evaluation and mitigation system (REMS) program, or limited distribution network.

Last updated February 2, 2026 at 8:13 AM

Supplemental Information

Authorized By: 5164.02, 5164.758
Amplifies: 5164.02, 5164.758
Five Year Review Date: 2/1/2031