Ohio Revised Code Search

...macist services described in section 5164.14 of the Revised Code, the department of medicaid may include the services in the care management system.

...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.

...(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 hospit...

...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 de...

...nization's enrollees in accordance with 42 C.F.R. 438, subpart F.

...rse 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 boar...

...(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 manage...

...ing 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 rei...

...915(a)(2) of the "Social Security Act," 42 U.S.C. 1396n(a)(2), and 42 C.F.R. 431.54(e).

...stablished and maintained under section 4729.75 of the Revised Code. This section does not apply if the board no longer maintains the drug database.

... 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.

... 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 ...

...ed 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.

...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.

...als 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 approp...

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

...(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...

...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...

...l 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...

...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...

...ngle 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...

...it 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 ...

... 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 o...

...it 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.