Ohio Revised Code Search

...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 wo...

...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.

...ion 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...

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

...east 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...

...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 enr...

...(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 me...

...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) Th...

...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 organizati...

...ess 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, select...

...(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 adopte...

...l 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...

...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...

... 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.

...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.

...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, resour...

... 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 ...

...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...