Ohio Revised Code Search

...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 a...

...vices 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.

...cquisition 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 3...

...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...

...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.

...he 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.

...tal 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 pr...

...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.

...learinghouse 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 ...

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

...f 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...

...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...

...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...

...gotiated 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 pass...

...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.

...ug. 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.

...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 o...

...all 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 ...

...al 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 f...

...ategies 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.

...fy 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.

...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.

...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 com...

... 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 m...