Ohio Revised Code Search

...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.

...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...

...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 regardin...

...(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...

...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 distrib...

...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.

...(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 provide...

...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.

...(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 empl...

...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...

...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. T...

...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.

...(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 wit...

...As used in sections 5168.01 to 5168.14 of the Revised Code: (A) "Bad debt," "charity care," "courtesy care," and "contractual allowances" have the same meanings given these terms in regulations adopted under Title XVIII of the "Social Security Act," 42 U.S.C. 1395 et seq. (B) "Cost reporting period" means the twelve-month period used by a hospital in reporting costs for purposes of Title XVIII of the "Social Securi...

...(A) The medicaid director shall adopt rules in accordance with Chapter 119. of the Revised Code for the purpose of administering sections 5168.01 to 5168.14 of the Revised Code, including rules that do all of the following: (1) Define as a "disproportionate share hospital" any hospital included under the "Social Security Act," section 1923(b), 42 U.S.C. 1396r-4(b), and any other hospital the director determines ap...

...The requirements of sections 5168.06 to 5168.09 of the Revised Code apply only as long as the United States centers for medicare and medicaid services determines that the assessment imposed under section 5168.06 of the Revised Code is a permissible health care-related tax pursuant to the "Social Security Act," section 1903(w), 42 U.S.C. 1396b(w). Whenever the department of medicaid is informed that the assessment is ...

...The department of medicaid shall operate the hospital care assurance program established by sections 5168.01 to 5168.14 of the Revised Code on a program year basis. The department shall complete all program requirements on or before the thirtieth day of September each year.

...be prepared by an independent certified public accountant and reflect an official audit report prepared in a manner consistent with generally accepted accounting principles. The financial statement shall, to the extent that the hospital has sufficient financial records, show bad debt and charity care separately from courtesy care and contractual allowances. (B) Except as provided in division (C) of this section, ea...

...(A) For the purpose of distributing funds to hospitals under the medicaid program pursuant to sections 5168.01 to 5168.14 of the Revised Code and depositing funds into the health care/medicaid support and recoveries fund created under section 5162.52 of the Revised Code, there is hereby imposed an assessment on all hospitals. Each hospital's assessment shall be based on total facility costs. All hospitals shall be as...

...(A) The department of medicaid may require governmental hospitals to make intergovernmental transfers each program year for the purpose of distributing funds to hospitals under the medicaid program pursuant to sections 5168.01 to 5168.14 of the Revised Code and depositing funds into the health care/medicaid support and recoveries fund created under section 5162.52 of the Revised Code. The department shall not require...

... a request, the department shall hold a public hearing not later than thirty days after the preliminary determinations are issued to reconsider the preliminary determinations. The department shall issue to each hospital a written notice of the date, time, and place of the hearing at least ten days prior to the hearing. On the basis of the evidence submitted to the department or presented at the public hearing, the de...

...The medicaid director shall adopt rules under section 5168.02 of the Revised Code establishing a methodology to pay hospitals that is sufficient to expend all money in the indigent care pool. Under the rules: (A) The department of medicaid may classify similar hospitals into groups and allocate funds for distribution within each group. (B) The department shall establish a method of allocating funds to hospitals, ta...

...Except for moneys deposited into the health care/medicaid support and recoveries fund created under section 5162.52 of the Revised Code, the department of medicaid shall not use money paid to the department under sections 5168.06 and 5168.07 of the Revised Code or money that the department pays to hospitals under section 5168.09 of the Revised Code to replace any funds appropriated by the general assembly for the med...

...(A) Except as provided in section 5162.52 of the Revised Code, all payments of assessments by hospitals under section 5168.06 of the Revised Code and all intergovernmental transfers under section 5168.07 of the Revised Code shall be deposited in the state treasury to the credit of the hospital care assurance program fund, hereby created. All investment earnings of the hospital care assurance program fund shall be cre...

...s patient-identifying material is not a public record under section 149.43 of the Revised Code, and no patient-identifying material shall be released publicly by the department of medicaid or by any person under contract with the department who has access to such information.