Ohio Revised Code Search

...the convening of the general assembly a medicaid caseload and expenditure forecast report, prepared in consultation with the department of medicaid. For each component identified in divisions (A) to (Q) of this section, the report shall include proposed, actual, or estimated medicaid program data for each fiscal year of the proposed budget biennium and for each fiscal year of the current budget biennium. If determine...

... (2) "Department of aging-administered medicaid waiver component" means each of the following: (a) The medicaid-funded component of the PASSPORT program created under section 173.52 of the Revised Code; (b) The medicaid-funded component of the assisted living program created under section 173.54 of the Revised Code; (c) Any other medicaid waiver component, as defined in section 5166.01 of the Revised Code, tha...

...ch reimbursement may be made under the medicaid program or that states income and expense and is or may be used to determine a rate of reimbursement under the medicaid program. (2) "Provider" means any person who has signed a provider agreement with the department of medicaid to provide goods or services pursuant to the medicaid program or any person who has signed an agreement with a party to such a provider ...

...(A) As used in this section: (1) "Medicaid services" has the same meaning as in section 5164.01 of the Revised Code. (2) "Property" means any real or personal property or other asset in which a person has any legal title or interest. (B) No person shall knowingly do any of the following in an application for enrollment in the medicaid program or in a document that requires a disclosure of assets for the purp...

...n of any criminal proceeding charging a medicaid fraud offense, the state, at any time during the pendency of the proceeding, may file a medicaid fraud lien notice with the county recorder of any county in which forfeitable property subject to forfeiture may be located. No fee shall be required for filing the notice. The recorder immediately shall record the notice pursuant to section 317.08 of the Revised Code. ...

...d treatment program, a component of the medicaid program. (3) "Pupil" means a person under age twenty-two enrolled in the schools of a city, local, exempted village, or joint vocational school district. (4) "Parent" means either parent with the following exceptions: (a) If one parent has custody by court order, "parent" means the parent with custody. (b) If neither parent has legal custody, "parent" means th...

...f the exiting operator's debt under the medicaid program or the portion of the debt that represents the franchise permit fee the exiting operator owes; (2) The entering operator involved in the change of operator with the exiting operator specified in division (B)(1) of this section. (C) "Allowable costs" means an ICF/IID's costs that the department of developmental disabilities determines are reasonable. Fines...

...ties shall determine each ICF/IID's per medicaid day capital component rate. An ICF/IID's rate for a fiscal year shall equal the sum of the following: (1) The lesser of the following: (a) The sum of all of the following: (i) The ICF/IID's per diem fair rental value rate for the fiscal year as determined under division (B) of this section; (ii) The ICF/IID's per diem equipment rate for the fiscal year as deter...

...ment due an exiting operator under the medicaid program the total amount specified in the notice provided under division (C) of section 5124.52 of the Revised Code that the exiting operator owes or may owe to the department and United States centers for medicare and medicaid services under the medicaid program. (B) In the case of a change of operator and subject to division (E) of this section, the following ...

...board of developmental disabilities has medicaid local administrative authority to, and shall, do all of the following for an individual with a developmental disability who resides in the county that the county board serves and seeks or receives home and community-based services: (1) Perform assessments and evaluations of the individual. As part of the assessment and evaluation process, all of the following apply: ...

... right of recovery to the department of medicaid and a county department of job and family services against the liability of a third party for the cost of medical assistance paid on behalf of the recipient. When an action or claim is brought against a third party by a medical assistance recipient, any payment, settlement or compromise of the action or claim, or any court award or judgment, is subject to the recovery ...

...A) As used in the Revised Code: (1) "Medicaid" and "medicaid program" mean the program of medical assistance established by Title XIX of the "Social Security Act," 42 U.S.C. 1396 et seq., including any medical assistance provided under the medicaid state plan or a federal medicaid waiver granted by the United States secretary of health and human services. (2) "Medicare" and "medicare program" mean the federal h...

...(A) The medicaid director shall enter into a contract with one or more persons to receive and process, on the director's behalf, requests for medicaid recipient or claims payment data, data from reports of audits conducted under section 5165.109 of the Revised Code, or extracts or analyses of any of the foregoing data made by persons who intend to use the items prepared pursuant to the requests for commercial or acad...

...(A) The department of medicaid shall institute cost-sharing requirements for the medicaid program. The department shall not institute cost-sharing requirements in a manner that does either of the following: (1) Disproportionately impacts the ability of medicaid recipients with chronic illnesses to obtain medically necessary medicaid services; (2) Violates section 5164.09 or 5164.10 of the Revised Code. (B)(1) N...

...ned by the actuary with which the joint medicaid oversight committee contracts under section 103.414 of the Revised Code if the committee agrees with the actuary's projected medical inflation rate for that fiscal biennium; (b) The different projected medical inflation rate for a fiscal biennium determined by the joint medicaid oversight committee under section 103.414 of the Revised Code if the committee disagrees...

...tial eligibility determinations for the medicaid program; (b) An appeal from an initial eligibility determination pursuant to section 5160.31 of the Revised Code. (2)(a) Except as provided in division (A)(2)(b) of this section, this section shall not be used by a court to determine the effect of a trust on an individual's initial eligibility for the medicaid program. (b) The prohibition in division (A)(2)(a) of th...

...health redesign" means revisions to the medicaid program's coverage of community behavioral health services beginning July 1, 2017, including revisions that update medicaid billing codes and payment rates for community behavioral health services. (C) "Clean claim" has the same meaning as in 42 C.F.R. 447.45(b). (D) "Community behavioral health services" means both of the following: (1) Alcohol and drug addictio...

...rson who has an ownership interest in a medicaid provider in an amount designated in rules authorized by this section. (4) "Person subject to the criminal records check requirement" means the following: (a) A medicaid provider who is notified under division (E)(1) of this section that the provider is subject to a criminal records check; (b) An owner or prospective owner, officer or prospective officer, or bo...

...g at least five per cent ownership in a medicaid provider. (B)(1) No medicaid provider shall do any of the following: (a) By deception, obtain or attempt to obtain payments under the medicaid program to which the provider is not entitled pursuant to the provider's provider agreement, or the rules of the federal government or the medicaid director relating to the program; (b) Willfully receive payments to whi...

...regulation to the "state" or the "state medicaid agency" means the department of medicaid. (2) "Disqualifying indictment" means an indictment of a medicaid provider or its officer, authorized agent, associate, manager, employee, or, if the provider is a noninstitutional provider, its owner, if either of the following applies: (a) The indictment charges the person with committing an act to which both of the foll...

...(A) The department of medicaid may suspend a medicaid provider's provider agreement without prior notice if the department has evidence that the provider presents a danger of immediate and serious harm to the health, safety, or welfare of medicaid recipients. The department also shall suspend all medicaid payments to the medicaid provider for services rendered, regardless of the date that the services were rendered, ...

... (2) "Revalidate" means to approve a medicaid provider's continued enrollment as a medicaid provider in accordance with the revalidation process established in rules authorized by section 5164.32 of the Revised Code. (B) This section does not apply to either of the following: (1) Any action taken or decision made by the department of medicaid with respect to entering into or refusing to enter into a contract...

...(A) The department of medicaid may contract with any person or persons as a fiscal agent for the examination, processing, and determination of medicaid claims. The contracting party may provide any of the following services, as required by the contract: (1) Design and operate medicaid management information systems, including the provision of data processing services; (2) Determine the amounts of payments to ...

...)(2) of this section, the department of medicaid may recover a medicaid payment or portion of a payment made to a medicaid provider to which the provider is not entitled if the department notifies the provider of the overpayment during the five-year period immediately following the end of the state fiscal year in which the overpayment was made. (2) In the case of a hospital medicaid provider, if the department deter...

...sharing requirements instituted for the medicaid program under section 5162.20 of the Revised Code. (2) "Medication synchronization" means a pharmacy service that synchronizes the filling or refilling of prescriptions in a manner that allows the dispensed drugs to be obtained on the same date each month. (3) "Prescriber" has the same meaning as in section 4729.01 of the Revised Code. (B) With respect to coverage o...

...loped statement to assist providers and medicaid recipients in making decisions about appropriate health care for specific clinical circumstances and conditions. (2) "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols, and clinical practice guidelines used by the medicaid program to determine whether or not a health care service or drug is appropriate and consis...

...ed and implemented by the department of medicaid pursuant to division (B)(2) of section 5164.7512 of the Revised Code: (1) The process shall be clear and convenient. (2) The process shall be easily accessible on the department's web site. (3) The process shall require that a medicaid provider initiate a step therapy exemption request on behalf of a medicaid recipient. (4) The process shall require supporting...

...f the exiting operator's debt under the medicaid program or the portion of the debt that represents the franchise permit fee the exiting operator owes; (2) The entering operator involved in the change of operator with the exiting operator specified in division (A)(1) of this section. (B) "Allowable costs" are a nursing facility's costs that the department of medicaid determines are reasonable. Fines paid under ...

... (D) of this section, the department of medicaid may withhold from payment due an exiting operator under the medicaid program the total amount specified in the notice provided under division (C) of section 5165.52 of the Revised Code that the exiting operator owes or may owe to the department under the medicaid program. (B) In the case of a change of operator and subject to division (E) of this section, the follow...

... level four finding, the department of medicaid or contracting agency shall, subject to sections 5165.79 to 5165.83 of the Revised Code, impose a remedy for the deficiency or cluster of deficiencies. The department or agency may act under either division (A)(1) or (2) of this section: (1) The department or agency may impose one or more of the following remedies: (a) Issue an order terminating the nursing fac...

...pe level two finding, the department of medicaid or a contracting agency may, subject to sections 5165.82 and 5165.83 of the Revised Code, impose one or more of the following remedies: (1) Do either of the following: (a) Issue an order denying medicaid payments to the facility for all medicaid eligible residents admitted after the effective date of the order; (b) Impose a fine. (2) Issue an order denying med...

... immediate jeopardy, the department of medicaid or a contracting agency shall impose one or more of the remedies described in division (A)(1) of this section and, in addition, may take one or both of the actions described in division (A)(2) of this section. (1) The department or agency shall impose one or more of the following remedies: (a) Appoint, subject to the continuing consent of the provider, a tempor...

... United States centers for medicare and medicaid services every six months to evaluate the safety and quality of care provided by a nursing facility as required under the special focus facility program. (B) The department of medicaid shall issue an order terminating a nursing facility's participation in the medicaid program if either of the following apply: (1) The nursing facility fails to graduate from the sp...

...or 5165.84 of the Revised Code denying medicaid payments to a nursing facility for all medicaid eligible residents admitted after its effective date, or an order issued under section 5165.72, 5165.73, or 5165.74 of the Revised Code denying medicaid payments to a nursing facility for medicaid eligible residents admitted after the effective date of the order who have specified diagnoses or special care needs, sha...

... Title XIX. (B) If the department of medicaid or a contracting agency imposes a fine on a nursing facility under section 5165.72, 5165.73, or 5165.74 of the Revised Code, it may impose one or more of the following: (1) One hundred sixty per cent of the amount calculated under division (C) of this section for any deficiency or cluster of deficiencies that constitutes a severity level four and scope level fou...

...ng facility notifies the department of medicaid or a contracting agency, at any time during the six-month period following the exit interview of a survey that was the basis for citing a deficiency or deficiencies, that the deficiency or deficiencies have been substantially corrected in accordance with the plan of correction submitted and approved under section 5165.69 of the Revised Code, the department of hea...

...t," 42 U.S.C. 1396a(f), under which the medicaid program's eligibility requirements for aged, blind, and disabled individuals are more restrictive than the eligibility requirements for the supplemental security income program. "Administrative agency" means, with respect to a home and community-based services medicaid waiver component, the department of medicaid or, if a state agency or political subdivision contra...

...(A) The medicaid director shall adopt rules in accordance with Chapter 119. of the Revised Code governing medicaid waiver components. The rules may establish all of the following: (1) Eligibility requirements for the medicaid waiver components; (2) The type, amount, duration, and scope of medicaid services the medicaid waiver components cover; (3) The conditions under which the medicaid waiver components cov...

...each home and community-based services medicaid waiver component: (A) Only an individual who qualifies for a component shall receive that component's medicaid services. (B) A level of care determination shall be made as part of the process of determining whether an individual qualifies for a component and shall be made each year after the initial determination if, during such a subsequent year, the administr...

...am" means the program the department of medicaid administers that provides state plan services and medicaid waiver component services pursuant to rules adopted for the medicaid program and a medicaid waiver that went into effect July 1, 1998. (B) The department of medicaid may create and administer two or more medicaid waiver components under which home and community-based services are provided to eligible ind...

...66.161 of the Revised Code, "ODA or MCD medicaid waiver component" means all of the following: (1) The medicaid-funded component of the PASSPORT program; (2) The medicaid-funded component of the assisted living program; (3) The Ohio home care waiver program. (B) The medicaid director may create a home and community-based services medicaid waiver component as part of the integrated care delivery system. If...

...The department of medicaid shall enter into a contract with the department of developmental disabilities under section 5162.35 of the Revised Code with regard to one or more of the medicaid waiver components created by the department of medicaid under section 5166.20 of the Revised Code. The contract shall include the medicaid waiver component known as the transitions developmental disabilities waiver. The contract s...

...emented 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 employment. (B) As part of that program, each medicaid managed care orga...

...(A) As used in this section, "medicaid estate recovery program" means the program instituted under section 5162.21 of the Revised Code. (B) The administrator of the medicaid estate recovery program shall prescribe a form on which a beneficiary of a transfer on death designation affidavit as provided in section 5302.22 of the Revised Code, who survives the deceased owner of the real property or an interest in the rea...

...(A) The department of medicaid shall create the medicaid-funded component of the PASSPORT program. In creating the medicaid-funded component, the department of medicaid shall collaborate with the department of aging. (B) All of the following apply to the medicaid-funded component of the PASSPORT program: (1) The department of aging shall administer the medicaid-funded component through a contract entered into w...

...(A) The department of medicaid shall create the medicaid-funded component of the assisted living program. In creating the medicaid-funded component, the department of medicaid shall collaborate with the department of aging. (B) Unless the medicaid-funded component of the assisted living program is terminated under division (C) of this section, all of the following apply: (1) The department of aging shall admini...

... corporation that provides coverage to medicaid recipients shall post a performance bond in the amount of three million dollars as security to fulfill the obligations of the health insuring corporation to pay claims of contracted providers for covered health care services provided to medicaid recipients. The bond shall be payable to the department of insurance in the event that the health insuring corporation ...

... (b) On January 1, 2015, the ICF/IID's medicaid-certified capacity was at least twenty per cent less than the greatest medicaid-certified capacity it had before it became a downsized ICF/IID or partially converted ICF/IID. (2) An ICF/IID's sleeping room in which more than two residents reside if both of the following apply: (a) All of the residents of the sleeping room are under twenty-one years of age. (b)...

...January of each year, the department of medicaid shall complete a report on the effectiveness of the medicaid program in meeting the health care needs of low-income pregnant women, infants, and children. The report shall include all of the following, delineated by race and ethnic group: (1) The estimated number of pregnant women, infants, and children eligible for the program; (2) The actual number of eligible pe...

... Revised Code. (B) The department of medicaid shall create an infant mortality scorecard. The scorecard shall report all of the following: (1) The performance of the fee-for-service component of medicaid and each medicaid managed care organization on population health measures, including the infant mortality rate, preterm birth rate, low-birthweight rate, and stillbirth rate, delineated in accordance with divis...

...A qualified medicaid school provider participating in the medicaid school component of the medicaid program may submit a claim to the department of medicaid for federal financial participation for providing, in schools, services covered by the medicaid school component to medicaid recipients who are eligible for the services. No qualified medicaid school provider may submit such a claim before the provider incurs the...

...(A) The health care/medicaid support and recoveries fund is hereby created in the state treasury. All of the following shall be credited to the fund: (1) Except as otherwise provided by statute or as authorized by the controlling board, the nonfederal share of all medicaid-related revenues, collections, and recoveries; (2) Federal reimbursement received for payment adjustments made pursuant to section 1923 of the...

...into a contract with the department of medicaid under section 5162.35 of the Revised Code identifies that a medicaid overpayment has been made to a medicaid provider, the state agency may commence actions to recover the overpayment on behalf of the department. (B) In recovering an overpayment pursuant to this section, a state agency shall comply with the following procedures: (1) The state agency shall attemp...

... (D) of this section, the department of medicaid shall fine the provider of a nursing facility if the report of an audit conducted under section 5165.109 of the Revised Code regarding a cost report for the nursing facility includes either of the following: (1) Adverse findings that exceed three per cent of the total amount of medicaid-allowable costs reported in the cost report; (2) Adverse findings that exceed twe...

...nursing facility's participation in the medicaid program; (2) Appointment of a temporary manager of a facility under division (A)(1)(b) or (2)(b) of section 5165.72, or division (A)(1)(d) of section 5165.77 of the Revised Code; (3) An order issued under section 5165.72, 5165.73, 5165.74, 5165.77, or 5165.84 of the Revised Code denying medicaid payments to a facility for all medicaid eligible residents admitted ...

...sion (B) of this section, the total per medicaid day payment rate that the department of developmental disabilities shall pay to an ICF/IID provider for ICF/IID services the provider's ICF/IID provides during a fiscal year shall equal the sum of all of the following: (1) The per medicaid day capital component rate determined for the ICF/IID under section 5124.17 of the Revised Code; (2) The per medicaid day dir...

...an order terminating the county board's medicaid local administrative authority over all or part of home and community-based services, medicaid case management services, or all or part of both of those services. The department shall provide a copy of the order to the board of county commissioners, senior probate judge, county auditor, and president and superintendent of the county board. The department shall specify ...

...ities shall pay the nonfederal share of medicaid expenditures for the following home and community-based services provided to an individual with a developmental disability who the county board determines under section 5126.041 of the Revised Code is eligible for county board services: (1) Home and community-based services provided by the county board to such an individual; (2) Home and community-based services prov...

...rnishes or authorizes the furnishing of medicaid services, performs billing or coding functions, or is involved in monitoring of health care that an entity provides. "Employee" includes any officer or employee (including management employees) of an entity. "Entity" includes a governmental entity or an organization, unit, corporation, partnership, or other business arrangement, including any medicaid managed ca...

..."Expansion eligibility group" means the medicaid eligibility group described in section 1902(a)(10)(A)(i)(VIII) of the "Social Security Act," 42 U.S.C. 1396a(a)(10)(A)(i)(VIII). "Federal financial participation" has the same meaning as in section 5160.01 of the Revised Code. "Federal poverty line" has the same meaning as in section 5162.01 of the Revised Code. "Healthy start component" has the same meaning as in s...

...(A) The medicaid director shall adopt rules as necessary to implement this chapter. The rules shall be adopted in accordance with Chapter 119. of the Revised Code. (B) The rules shall establish all of the following: (1) The amount, duration, and scope of the medicaid services covered by the medicaid program; (2) The medicaid payment rate for each medicaid service or, in lieu of the rate, the method by which the ra...

...ts meet federal and state standards for medicaid certification, if all of the following apply: (a) The nursing facility initially obtained both its nursing home license under Chapter 3721. of the Revised Code and medicaid certification on or after January 1, 2008. (b) The nursing facility is located in a county that has a bed need excess at the time the provider excludes the parts from the provider agreement. (c) ...

...5165.26 of the Revised Code. (B) The medicaid director shall establish an alternative purchasing model for nursing facility services provided by designated discrete units of nursing facilities to medicaid recipients with specialized health care needs. The director shall do all of the following with regard to the model: (1) Establish criteria that a discrete unit of a nursing facility must meet to be designated ...

...396u-2(b)(2). (G) "Enrollee" means a medicaid recipient who participates in the care management system and enrolls in a medicaid MCO plan. (H) "ICDS participant" has the same meaning as in section 5164.01 of the Revised Code. (I) "Medicaid managed care organization" means a managed care organization under contract with the department of medicaid pursuant to section 5167.10 of the Revised Code. (J) "Medica...

...he following apply if the department of medicaid, pursuant to section 5164.38 of the Revised Code, refuses to enter into, terminates, or refuses to revalidate a provider agreement that authorizes a person or government entity to provide supported living under the medicaid program: (1) In the case of a refusal to enter into a provider agreement, the person or government entity's application to provide medicaid-funded...

... meets federal and state standards for medicaid certification; (2) Prohibit the provider from doing either of the following: (a) Discriminating against a resident on the basis of race, color, sex, creed, or national origin; (b) Subject to division (D) of this section, failing or refusing to do either of the following: (i) Admit as a resident of the ICF/IID an individual because the individual is, or may (as a...

...pmental disabilities and department of medicaid written notice of a change of operator if the ICF/IID participates in the medicaid program and the entering operator seeks to continue the ICF/IID's participation. The written notice shall be provided to the department of developmental disabilities and department of medicaid in accordance with the method specified in rules authorized by section 5124.53 of the Rev...

...alth and developmental disabilities and medicaid director at least ninety days' notice of the person's intent to make the conversion. (2) The person complies with the requirements of sections 5124.50 to 5124.53 of the Revised Code regarding a voluntary termination if those requirements are applicable. (3) If the person intends to convert all of the ICF/IID's beds, the person notifies each of the ICF/IID's residents...

...developmental disabilities-administered medicaid waiver component" means a medicaid waiver component administered by the department of developmental disabilities pursuant to section 5166.21 of the Revised Code. (B) If a county board of developmental disabilities determines that available resources are not sufficient to meet the needs of all individuals who request non-medicaid programs or services, it shall establi...

... (b) Is required, as a condition of the medicaid program paying for the individual's services in the institution, to spend for costs of medical or nursing care all of the individual's income except for an amount for personal needs specified by the department of medicaid; (c) Cannot reasonably be expected to be discharged from the institution and return home as determined by the department of medicaid. (4) "Qu...

...(A) The medicaid director may do the following for any reason permitted or required by federal law and when the director determines that the action is in the best interests of medicaid recipients or the state: (1) Deny, refuse to revalidate, suspend, or terminate a provider agreement; (2) Exclude an individual, provider of services or goods, or other entity from participation in the medicaid program. (B) No ...

...anism implemented by the department of medicaid; (3) Any other process for the electronic submission of claims that is specified in rules adopted under section 5162.02 of the Revised Code. (B) Not later than January 1, 2013, and except as provided in division (C) of this section, each medicaid provider shall do both of the following: (1) Use only an electronic claims submission process to submit to the depar...

...nt is located. (B) The department of medicaid shall establish standards for medicaid payments for health care services the department determines are appropriate to be covered by the medicaid program when provided as telehealth services. The standards shall be established in rules adopted under section 5164.02 of the Revised Code. In accordance with section 5162.021 of the Revised Code, the medicaid director shal...

...nursing facility's participation in the medicaid program shall be terminated under sections 5165.60 to 5165.89 of the Revised Code as follows: (1) If the department of medicaid is terminating the facility's participation, it shall issue an order terminating the facility's provider agreement. (2) If the department of health, acting as a contracting agency, is terminating the facility's participation, it shall ...

...(A) The department of medicaid may create the following: (1) One or more medicaid waiver components under which home and community-based services are provided to individuals with developmental disabilities as an alternative to placement in ICFs/IID; (2) One or more medicaid waiver components under which home and community-based services are provided in the form of any of the following: (a) Early intervention and s...

...(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 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...

...(A) The total per medicaid day payment rate determined under section 5124.15 of the Revised Code shall not be the initial rate for ICF/IID services provided by a new ICF/IID. Instead, the initial total per medicaid day payment rate for ICF/IID services provided by a new ICF/IID shall be determined in accordance with this section. (B) The initial total per medicaid day payment rate for ICF/IID services provided by ...

...onverted; (2) The fiscal impact on the medicaid program; (3) The availability of home and community-based services. (C) The notice provided to the directors under division (A)(1) of this section shall specify whether some or all of the ICF/IID's beds are to be converted. If some but not all of the beds are to be converted, the notice shall specify how many of the ICF/IID's beds are to be converted and how many of ...

...(A) The department of medicaid shall enter into an agreement with the department of administrative services for the department of administrative services to contract through competitive selection pursuant to section 125.07 of the Revised Code with a vendor to perform an assessment of the data collection and data warehouse functions of the medicaid data warehouse system, including the ability to link the data sets of ...

...The department of medicaid shall enter into an interagency agreement with the department of education and workforce under section 5162.35 of the Revised Code that provides for the department of education and workforce to administer the medicaid school component of the medicaid program other than the aspects of the component that sections 5162.36 to 5162.366 of the Revised Code require the department of medicaid to ad...

...ection 5163.05 of the Revised Code, the medicaid program shall cover all mandatory eligibility groups. (B) The medicaid program shall cover all of the optional eligibility groups that state statutes require the medicaid program to cover. (C) The medicaid program may cover any of the optional eligibility groups to which either of the following applies: (1) State statutes expressly permit the medicaid program to cov...

...munity-based services furnished under a medicaid waiver granted by the United States secretary of health and human services under the "Social Security Act," section 1915(c) or (d), 42 U.S.C. 1396n(c) or (d). (3) "Institutionalized individual" means a resident of a nursing facility, an inpatient in a medical institution for whom a payment is made based on a level of care provided in a nursing facility, or an individu...

...ovider under a home and community-based medicaid waiver component administered by the department of medicaid. "Criminal records check" has the same meaning as in section 109.572 of the Revised Code. "Disqualifying offense" means any of the offenses listed or described in divisions (A)(3)(a) to (e) of section 109.572 of the Revised Code. "Independent provider" means a person who has a provider agreement to pr...

...acility appointed by the department of medicaid or a contracting agency under sections 5165.60 to 5165.89 of the Revised Code shall meet all of the following qualifications: (1) Be licensed as a nursing home administrator under Chapter 4751. of the Revised Code; (2) Have demonstrated competence as a nursing home administrator; (3) Have had no disciplinary action taken against the temporary manager by any li...

...dual's buckeye account that consists of medicaid funds deposited under division (B) of section 5166.402 of the Revised Code or section 5166.404 of the Revised Code. (4) "Core portion" means the portion of a healthy Ohio program participant's buckeye account that consists of the following: (a) The amount of contributions to the account; (b) The amounts awarded to the account under divisions (C) and (D) of section 5...

...ded in division (C) of this section, a medicaid managed care organization shall pay a skilled nursing facility at least the current medicare fee-for-service rate, without deduction for any coinsurance, for covered skilled nursing facility services that the skilled nursing facility provides to a dual eligible individual if the medicaid managed care organization is responsible for the payment under the terms of a...

...(A) JMOC shall oversee the medicaid program on a continuing basis. As part of its oversight, JMOC shall do all of the following: (1) Review how the medicaid program relates to the public and private provision of health care coverage in this state and the United States; (2) Review the reforms implemented under section 5162.70 of the Revised Code and evaluate the reforms' successes in achieving their objectives; (3)...

...administered in a manner that provides medicaid coverage of and expands access to all of the following as necessary to meet the needs of individuals receiving home and community-based services covered by medicaid components the department of aging administers: (A) To the extent permitted by the medicaid waivers authorizing department of aging-administered medicaid waiver components, all of the following medic...

...(A) As used in this section: (1) "Medicaid estate recovery program" means the program instituted under section 5162.21 of the Revised Code. (2) "Person responsible for the estate" means the executor, administrator, commissioner, or person who filed pursuant to section 2113.03 of the Revised Code for release from administration of an estate. (B) The person responsible for the estate of a decedent subject to t...

...e payment was made to the department of medicaid or the applicable medicaid managed care organization. After a claim is final, the claim is subject to adjustment only if an action for recovery of an overpayment was commenced under division (B) of this section before the date the claim became final and the recovery is agreed to by the department or medicaid managed care organization under division (C) of this section....

...(A) The medicaid director shall adopt rules under section 5162.02 of the Revised Code permitting county departments of job and family services to take action to recover benefits incorrectly paid on behalf of medicaid recipients. The rules shall provide for recovery by the following methods: (1) Soliciting voluntary payments from recipients or from persons holding property in which a recipient has a legal or e...

...(A) A qualified medicaid school provider is solely responsible for timely repaying any overpayment that the provider receives under the medicaid school component of the medicaid program and that is discovered by a federal or state audit. This is the case regardless of whether the audit's finding identifies the provider, department of medicaid, or department of education and workforce as being responsible for the over...

...(A) The Department of Medicaid may establish and administer a program to provide dental services to pregnant Medicaid recipients. If the program is established, all of the following shall apply: (1) Medicaid recipients who are members of the group described in section 5163.06 of the Revised Code shall be eligible to receive two dental cleanings per year. (2) The Department shall give priority to those Medicaid r...

...the state has an insurable interest in medicaid recipients because of the state's statutory right to recover from the estate of a recipient state funds used to provide the recipient with medicaid services. (B) As used in this section: (1) "Beneficiary" means the person or entity designated in a life insurance policy to receive the proceeds of the policy on the death of the insured or maturity of the policy. ...

... 4729.01 of the Revised Code. (B) The medicaid director may acquire or specify technologies to provide information regarding medicaid recipient eligibility, claims history, and drug coverage to medicaid providers through electronic health record and e-prescribing applications. If such technologies are acquired or specified, the e-prescribing applications shall enable a medicaid provider who is a licensed heal...

...(A) The medicaid payment rates for the following neonatal and newborn services shall equal not less than seventy-five per cent of the medicare payment rates for the services in effect on the date the services are provided to medicaid recipients eligible for the services: (1) Initial care for normal newborns; (2) Subsequent day, hospital care for normal newborns; (3) Same day, initial history and physical exa...

...(A) The department of medicaid may make medicaid payments to a nursing facility provider under this chapter to reserve a bed for a recipient during a temporary absence under conditions prescribed by the department, to include hospitalization for an acute condition, visits with relatives and friends, and participation in therapeutic programs outside the facility, when the resident's plan of care provides for such abse...

...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, as payment in full, t...

...(A) If the department of medicaid includes prescribed drugs in the care management system as authorized under section 5167.05 of the Revised Code, the medicaid director, through a procurement process, shall select a third-party administrator to serve as the single pharmacy benefit manager used by medicaid managed care organizations under the care management system. The state pharmacy benefit manager shall be responsi...

...ng services provided or arranged for by medicaid managed care organizations, are high-quality and delivered through evidence-based or innovative, promising home visiting models, including models used by home visiting contractors who provide services within one or more community HUBs that fully or substantially comply with the pathways community HUB certification standards developed by the pathways community HUB insti...

...d for, or otherwise made available by a medicaid health insuring corporation pursuant to the corporation's contract with the state. (b) If the centers for medicare and medicaid services of the United States department of health and human services determines that the taxation of transactions described in division (B)(11)(a) of this section constitutes an impermissible health care-related tax under the "Social Secur...

...ised Code: (1) "JMOC" means the joint medicaid oversight committee created under this section. (2) "State and local government medicaid agency" means all of the following: (a) The department of medicaid; (b) Each state agency and political subdivision with which the department of medicaid contracts under section 5162.35 of the Revised Code to have the state agency or political subdivision administer one or mo...

...m" means the program that consists of a medicaid-funded component created under section 173.54 of the Revised Code and a state-funded component created under section 173.543 of the Revised Code and provides assisted living services to individuals who meet the program's applicable eligibility requirements. "Assisted living services" means the following home and community-based services: personal care, homemaker, ch...

... (1) "Department of aging-administered medicaid waiver component" means both of the following: (a) The medicaid-funded component of the PASSPORT program; (b) The medicaid-funded component of the assisted living program. (2) "PACE program" means the component of the medicaid program the department of aging administers pursuant to section 173.50 of the Revised Code. (B) If the department of aging determines that t...

...(A) The administrator of the medicaid estate recovery program established pursuant to section 5162.21 of the Revised Code may present an affidavit to a financial institution requesting that the financial institution release account proceeds to recover the cost of services correctly provided to a medicaid recipient who is subject to the medicaid estate recovery program. The affidavit shall include all of the fol...

...unt of any overpayments made under the medicaid program to the exiting operator, including overpayments the exiting operator disputes, and other actual and potential debts the exiting operator owes or may owe to the department and United States centers for medicare and medicaid services under the medicaid program, including a franchise permit fee. (B) In estimating the exiting operator's other actual and pot...

...nds to pay the nonfederal share of the medicaid expenditures that the county board is required by sections 5126.059 and 5126.0510 of the Revised Code to pay: (1) To the extent consistent with the levy that generated the taxes, the following taxes: (a) Taxes levied pursuant to division (L) of section 5705.19 of the Revised Code and section 5705.222 of the Revised Code; (b) Taxes levied under section 5705.191 ...

...(A) The department of medicaid shall conduct periodic reviews to determine the barriers that medicaid recipients face in gaining full access to interventions intended to reduce tobacco use, prevent prematurity, and promote optimal birth spacing. The first review shall occur not later than sixty days after the effective date of this section. Thereafter, reviews shall be conducted every six months. The department shal...

...e the individual's death on account of medicaid services correctly paid or to be paid on the individual's behalf. (B) Except as provided in division (C) of this section, the department of medicaid may impose a lien against the real property of a medicaid recipient who is a permanently institutionalized individual and against the real property of the recipient's spouse, including any real property that is join...

...e or local correctional facility was a medicaid recipient immediately prior to being confined in the facility, all of the following apply: (1) The person's eligibility for medicaid while so confined shall be suspended due to the confinement. (2) No medicaid payment shall be made for any care, services, or supplies provided to the person during the suspension described in division (B)(1) of this section. (3) T...

...(A) The medicaid program shall cover all mandatory services. (B) The medicaid program shall cover all of the optional services that state statutes require the medicaid program to cover. (C) The medicaid program may cover any of the optional services to which either of the following applies: (1) State statutes expressly permit the medicaid program to cover the optional service; (2) State statutes do not addr...

...ractitioner obtaining approval from the medicaid program prior to the service, device, or drug being performed, received, or prescribed, as applicable. (B)(1) The medicaid program shall cover evaluation and management services provided by a chiropractor if the chiropractor is licensed to practice chiropractic under Chapter 4734. of the Revised Code. (2) The medicaid director may adopt rules under section 5164.02 ...

... (B) of this section, the department of medicaid shall collect an application fee from a medicaid provider before doing any of the following: (1) Entering into a provider agreement with a medicaid provider that seeks initial enrollment as a provider; (2) Entering into a provider agreement with a former medicaid provider that seeks re-enrollment as a provider; (3) Revalidating a medicaid provider's continued enroll...

...(B) of this section, the department of medicaid may deny medicaid payment to a hospital for direct graduate medical education costs associated with the delivery of medicaid services to any medicaid recipient if the hospital refuses without good cause to contract with a medicaid managed care organization that serves the area in which the hospital is located. (B) A hospital is not subject to division (A) of thi...

...5.01 of the Revised Code. (B)(1) The medicaid director shall submit a medicaid state plan amendment to the United States centers for medicare and medicaid services seeking authorization to establish and administer a supplemental payment program to provide supplemental medicaid payments to eligible ground emergency medical transportation service providers. If approved, the medicaid director shall establish and admi...

...lf of an applicant for or recipient of medicaid. A representative may be a family member, attorney, hospital social worker, or any other person chosen to act on behalf of an applicant or recipient. (B) The department of medicaid may require each applicant for or recipient of medicaid who applies or intends to apply for admission to a nursing facility or resides in a nursing facility to undergo an assessment t...

...(A) The total per medicaid day payment rate determined under section 5165.15 of the Revised Code shall not be the initial rate for nursing facility services provided by a new nursing facility. Instead, the initial total per medicaid day payment rate for nursing facility services provided by a new nursing facility shall be determined in the following manner: (1) The initial rate for ancillary and support costs shal...

... United States centers for medicare and medicaid services or on the effective date of applicable department of medicaid rules, whichever is later, but not sooner than April 1, 2024, the total per medicaid day payment rate for nursing facility services provided on or after that date in private rooms approved by the department of medicaid under division (C) of this section shall be the sum of both of the following: ...

...rector" means the following: (a) The medicaid director in the context of both of the following: (i) The Ohio home care waiver program; (ii) The integrated care delivery system medicaid waiver component authorized by section 5166.16 of the Revised Code. (b) The director of aging in the context of the medicaid-funded component of the PASSPORT program. (3) "Authorized representative" means the following: ...

...As part of the medicaid program, the department of medicaid shall establish a care management system. The department shall implement the system in some or all counties. The department shall designate the medicaid recipients who are required or permitted to participate in the care management system. Those who shall be required to participate in the system include medicaid recipients who receive cognitive behavioral ...

...ng 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 case management benefit; (2)...

...ho are residents of this state, are not medicaid recipients, and whose income is at or below the federal poverty line. The medicaid director shall adopt rules under section 5168.02 of the Revised Code specifying the hospital services to be provided under this section. (B) Nothing in this section shall be construed to prevent a hospital from requiring an individual to apply for the medicaid program before the hospi...

... the provider agreement required by the medicaid program. No provider shall charge a child or youth with special health care needs or the child or youth's parent or guardian for services authorized by the department under division (B) or (D) of this section. The department, in accordance with rules adopted under division (A)(3) of section 3701.021 of the Revised Code, may disqualify any provider from further parti...

...ed Code, both of the following apply to medicaid health insuring corporation performance bonds and securities: (1) Proceeds from the bond issued or securities held pursuant to section 1751.271 of the Revised Code that have been paid to or deposited with the department of insurance shall be considered special deposits for purposes of satisfying claims of contracted providers for covered health care services provided ...

...or partially converted ICF/IID: (a) A medicaid-certified capacity that is at least ten per cent less than its medicaid-certified capacity on the day immediately preceding the day it becomes a downsized ICF/IID or partially converted ICF/IID; (b) At least five fewer beds certified as ICF/IID beds than it has on the day immediately preceding the day it becomes a downsized ICF/IID or partially converted ICF/IID. (...

... providers, may seek reconsideration of medicaid payment rates established under this chapter. Except as provided in divisions (B) to (E) of this section, the only issue that a provider, group, or association may raise in the rate reconsideration is whether the rate was calculated in accordance with this chapter and the rules adopted under section 5124.03 of the Revised Code. The provider, group, or association may s...

...ment due an exiting operator under the medicaid program shall be deposited into the medicaid payment withholding fund created by the controlling board pursuant to section 131.35 of the Revised Code. Money in the fund shall be used as follows: (1) To pay an exiting operator when a withholding is released to the exiting operator under section 5124.526 or 5124.527 of the Revised Code; (2) To pay the department ...

... (D) of this section, an ICF/IID with a medicaid- certified capacity exceeding eight shall not admit an individual as a resident unless all of the following apply: (a) The provider of the ICF/IID provides written notice about the individual's potential admission, and all information about the individual in the provider's possession, to the county board of developmental disabilities serving the county in which the in...

...lowing: (1) Accept the department of medicaid's right of recovery under section 5160.37 of the Revised Code and the assignment of rights to the department that are described in section 5160.38 of the Revised Code; (2) Respond to an inquiry by the department regarding a claim for payment of a medical item or service that was submitted to the third party not later than six years after the date of the provision of...

...The medicaid director may conduct reviews of the medicaid program. The reviews may include physical inspections of records and sites where medicaid services are provided and interviews of medicaid providers and medicaid recipients. If the director determines pursuant to a review that a person or government entity has violated a rule governing the medicaid program, the director may establish a corrective action ...

...(A) The medicaid program shall include coverage of inpatient care and follow-up care for a mother and her newborn as follows: (1) The medicaid program shall cover a minimum of forty-eight hours of inpatient care following a normal vaginal delivery and a minimum of ninety-six hours of inpatient care following a cesarean delivery. Services covered as inpatient care shall include medical, educational, and any other ser...

...e Revised Code. (B) The department of medicaid shall establish a process by which a physician assistant may enter into a provider agreement. (C)(1) Subject to division (C)(2) of this section, a claim for medicaid payment for a medicaid service provided by a physician assistant to a medicaid recipient may be submitted by the physician assistant who provided the service or the physician, group practice, clinic,...

...der a home and community-based services medicaid waiver component administered by the department of medicaid, other than such a person or government entity that is certified under the medicare program. "Waiver agency" does not mean an independent provider as defined in section 5164.341 of the Revised Code. (B) This section does not apply to any individual who is subject to a database review or criminal records che...

...ome health aide services covered by the medicaid program as part of the home health services benefit pursuant to 42 C.F.R. 440.70(b)(2); (b) Home care attendant services covered by a participating medicaid waiver component, as defined in section 5166.30 of the Revised Code; (c) Any of the following covered by a home and community-based services medicaid waiver component: (i) Personal care aide services; (ii) ...

...The medicaid director may implement a system under which medicaid payments for medicaid services are made to an organization on behalf of medicaid providers. The system may not provide for an organization to receive an amount that exceeds, in aggregate, the amount the medicaid program would have paid directly to medicaid providers if not for this section.

... freestanding birthing center that is a medicaid provider may submit to the department of medicaid or the department's fiscal agent a medicaid claim that is both of the following: (A) For a long-acting reversible contraceptive device that is covered by medicaid and provided to a medicaid recipient during the period after the recipient gives birth in the hospital or center and before the recipient is discharged from...

...The medicaid director shall adopt rules under section 5164.02 of the Revised Code governing the calculation and payment of, and the allocation of payments for, graduate medical education costs associated with medicaid services rendered to medicaid recipients. Subject to section 5164.741 of the Revised Code, the rules shall provide for payment of graduate medical education costs associated with medicaid services...

...(A) Not later than July 1, 2020, the medicaid director shall establish an annual benchmark for prescribed drug spending growth under the medicaid program. If the director determines that prescribed drug spending in a given year is projected to exceed the benchmark for that year, the director shall identify specific prescribed drugs that significantly contribute to exceeding the benchmark. (B) For a prescribed drug ...

...5.34 of the Revised Code, the total per medicaid day payment rate that the department of medicaid shall pay a nursing facility provider for nursing facility services the provider's nursing facility provides during a state fiscal year shall be determined as follows: (A) Determine the sum of all of the following: (1) The per medicaid day payment rate for ancillary and support costs determined for the nursing faci...

...The medicaid director may establish a centers of excellence component of the medicaid program. The purpose of the centers of excellence component is to increase the efficiency and quality of nursing facility services provided to medicaid recipients with complex nursing facility service needs. The director may adopt rules under section 5165.02 of the Revised Code governing the component, including rules that est...

...rtion of a nursing facility's total per medicaid day payment rate determined under divisions (A) and (B) of section 5165.15 of the Revised Code. (2) "CMS" means the United States centers for medicare and medicaid services. (3) "Long-stay resident" means an individual who has resided in a nursing facility for at least one hundred one days. (4) "Nursing facilities for which a quality score was determined" incl...

...e immediate jeopardy, the department of medicaid or a contracting agency shall permit the nursing facility to continue participating in the medicaid program for up to six months after the exit interview, if all of the following apply: (1) The facility meets the requirements, established in regulations issued by the United States secretary of health and human services under Title XIX for certification of nursin...

...of the Revised Code, the department of medicaid or contracting agency shall arrange for the safe and orderly transfer of all residents, including residents who are not medicaid eligible residents, to other appropriate care settings. Whenever a nursing facility's participation in the medicaid program is terminated under sections 5165.60 to 5165.89 of the Revised Code, the department or agency shall arrange for ...

...(A) The medicaid director shall establish a medicaid waiver component under which an individual eligible for medicaid on the basis of being included in the expansion eligibility group must satisfy at least one of the following requirements to be able to enroll in medicaid as part of the expansion eligibility group: (1) Be at least fifty-five years of age; (2) Be employed; (3) Be enrolled in school or an occu...

...Revised Code. (B) If the department of medicaid includes in the care management system, pursuant to section 5167.03 of the Revised Code, individuals under twenty-one years of age who are included in the category of individuals who receive medicaid on the basis of being aged, blind, or disabled, the department may recognize entities as pediatric accountable care organizations. An entity recognized by the depart...

...d 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 apply: (1) The drug is an ant...

...(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...

...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...

...section 5162.21 of the Revised Code. "Medicaid estate recovery program" means the program instituted under section 5162.21 of the Revised Code. (B) The administrator of the medicaid estate recovery program shall prescribe a form on which a surviving tenant under a survivorship tenancy or such a surviving tenant's representative is to indicate both of the following: (1) Whether the deceased survivorship tenant...

...all issue a direct payment permit to a medicaid health insuring corporation that authorizes the medicaid health insuring corporation to pay all taxes due on sales described in division (B)(11) of section 5739.01 of the Revised Code directly to the state. Each medicaid health insuring corporation shall pay pursuant to such direct payment authority all sales tax levied on such sales by sections 5739.02, 5739.021...

...ix to the governor's budget; (8) The medicaid caseload and expenditure forecast report prepared by the office of budget and management, in consultation with the department of medicaid, under section 126.021 of the Revised Code. The report shall be submitted to the general assembly as a supplemental budget document to provide an in-depth analysis of the governor's budget recommendations for the medicaid budget as a...

...ral assembly, the auditor of state, the medicaid director, the director of health, or the director of budget and management, or upon the attorney general's becoming aware of criminal or improper activity related to Chapter 3721. and the medicaid program, the attorney general shall investigate any criminal or civil violation of law related to Chapter 3721. of the Revised Code or the medicaid program. (B) When...

...nvironment pursuant to the medicare and medicaid programs and applicable state laws and rules adopted by the director of health; (2) The right to be free from physical, verbal, mental, and emotional abuse and to be treated at all times with courtesy, respect, and full recognition of dignity and individuality; (3) Upon admission and thereafter, the right to adequate and appropriate medical treatment and nursing ...

...may be necessary. (E) In the case of a medicaid health insuring corporation that has posted a bond or deposited securities in accordance with section 1751.271 of the Revised Code, the plan proposed under division (D) of this section may include the use of the proceeds of the bond or securities to first pay the claims of contracted providers for covered health care services provided to medicaid recipients, then...

... into a contract with the department of medicaid under section 5167.10 of the Revised Code and a data security agreement with the board required by section 5167.14 of the Revised Code, the board shall provide to the medical director or the pharmacy director information from the database relating to a medicaid recipient enrolled in the managed care organization, including information in the database related to prescri...

... program; (h) County administration of medicaid, excluding administrative expenditures for transportation services covered by the medicaid program. (6) "Title IV-A program" has the same meaning as in section 5101.80 of the Revised Code. (B) Each board of county commissioners shall pay the county share of public assistance expenditures in accordance with section 5101.161 of the Revised Code. Except as provided in d...

...ces agency. (b) If the department of medicaid contracts with the department of job and family services to hear appeals authorized by section 5160.31 of the Revised Code regarding medical assistance programs, "agency" includes the department of medicaid. (2) "Appellant" means an applicant, participant, former participant, recipient, or former recipient of a family services program who is entitled by federal or s...

...The department of medicaid shall enter into a contract with the department of developmental disabilities under section 5162.35 of the Revised Code that provides for the department of developmental disabilities to assume the powers and duties of the department of medicaid with regard to the medicaid program's coverage of ICF/IID services. The contract shall include a schedule for the assumption of the powers and...

...of the Revised Code, the department of medicaid shall enter into a provider agreement with an ICF/IID operator who applies, and is eligible, for the provider agreement. (B) A provider agreement shall require the department of developmental disabilities, pursuant to its agreement with the department of medicaid under section 5124.02 of the Revised Code, to make medicaid payments to the provider in accordance w...

...of developmental disabilities may pay a medicaid rate add-on to an ICF/IID provider for outlier ICF/IID services the ICF/IID provides to qualifying ventilator-dependent residents on or after September 29, 2013, if the provider applies to the department of developmental disabilities to receive the rate add-on and the department approves the application. The department of developmental disabilities may approve a provid...

...The medicaid director shall appoint one assistant director for the department of medicaid. The assistant director shall exercise powers, and perform duties, as ordered by the medicaid director. The assistant director shall act as the medicaid director in the medicaid director's absence or disability and when the position of medicaid director is vacant.

...ceiving approval from the department of medicaid or its designee, including a medicaid managed care organization, prior to the service, device, or drug being performed, received, or prescribed, as applicable. "Prior authorization" includes prospective or utilization review procedures conducted prior to providing a health care service, device, or drug. (5) "Urgent care services" means a medical care or other service ...

...(A) The medicaid director may do all of the following as necessary for the department of medicaid to fulfill the duties it has, as the single state agency for the medicaid program, under the "Medicare Prescription Drug, Improvement, and Modernization Act of 2003" Pub. L. No. 108-173: (1) Adopt rules in accordance with division (B) of this section; (2) Assign duties to county departments of job and family ser...

...The medicaid program shall be implemented in accordance with all of the following: (A) The medicaid state plan approved by the United States secretary of health and human services, including amendments to the plan approved by the United States secretary; (B) Federal medicaid waivers granted by the United States secretary, including amendments to waivers approved by the United States secretary; (C) Other type...

...The medicaid director shall seek federal approval for all components, and aspects of components, of the medicaid program for which federal approval is needed, except that the director is permitted rather than required to seek federal approval for components, and aspects of components, that state statutes permit rather than require be implemented. Federal approval shall be sought in the following forms as approp...

...(A) The medicaid director shall create a medicaid administrative claiming program under which federal financial participation is received for the administrative costs incurred by the department of health and the Arthur G. James cancer hospital and Richard J. Solove research institute of the Ohio state university in analyzing and evaluating both of the following pursuant to sections 3701.261 and 3701.262 of the ...

...The medicaid director shall adopt rules as necessary to implement this chapter. The rules shall establish eligibility requirements for the medicaid program. The rules may establish requirements for applying for medicaid and determining and verifying eligibility for medicaid. The rules shall be adopted in accordance with section 111.15 of the Revised Code. ( Notwithstanding any provision of state law, includi...

...The medicaid director shall adopt rules under section 5163.02 of the Revised Code as necessary to provide medicaid coverage for the optional eligibility group described in section 1902(a)(10)(A)(ii)(XIII) of the "Social Security Act," 42 U.S.C. 1396a(a)(10)(A)(ii)(XIII). By requiring the medicaid program to provide coverage to the optional eligibility group consisting of employed individuals with disabilities unde...

... 4723.89 of the Revised Code. (B) The medicaid program shall cover doula services that are provided by a doula if the doula has a valid provider agreement and is certified under section 4723.89 of the Revised Code. Medicaid payments for doula services shall be determined on the basis of each pregnancy, regardless of whether multiple births occur as a result of that pregnancy. (C) Any provider outcome measurements...

...ments of developmental disabilities and medicaid may approve, reduce, deny, or terminate a medicaid service included in the individual service plan developed for a medicaid recipient with a developmental disability who is eligible for medicaid case management services. If either department approves, reduces, denies, or terminates a service, that department shall timely notify the medicaid recipient that the recipient...

...(A) Each medicaid provider agreement shall expire not later than five years from its effective date. If a provider agreement entered into before the effective date of this amendment does not have a time limit, the department of medicaid shall convert the agreement to a provider agreement with a time limit. (B) The medicaid director shall adopt rules under section 5164.02 of the Revised Code as necessary to i...

...The medicaid director, in rules adopted under section 5164.02 of the Revised Code, may establish and implement a supplemental drug rebate program under which drug manufacturers may be required to provide the department of medicaid a supplemental rebate as a condition of having the drug manufacturers' drug products covered by the medicaid program without prior approval. The department may receive a supplemental ...

...ction 5164.02 of the Revised Code, the medicaid director shall modify the manner or establish a new manner in which the following are paid under medicaid: (1) Community mental health service providers or facilities for providing community mental health services covered by the medicaid program pursuant to section 5164.15 of the Revised Code; (2) Providers of alcohol and drug addiction services for providing a...

...(A) If the medicaid director implements the integrated care delivery system and except as provided in division (C) of this section, the director shall annually evaluate all of the following: (1) The health outcomes of ICDS participants; (2) How changes to the administration of the ICDS affect all of the following: (a) Claims processing; (b) The appeals process; (c) The number of reassessments requested; (d...

...The medicaid director shall select from among universally accepted claim forms used in the United States a standardized claim form for each type of medicaid provider that provides medicaid services under the integrated care delivery system. The director shall create standardized claim codes to be used on the standardized claim forms. Each medicaid provider and medicaid provider's designee that bills for medicaid serv...

...(A) The total per medicaid day payment rate determined under section 5165.15 of the Revised Code shall not be paid for nursing facility services provided by a nursing facility, or discrete unit of a nursing facility, designated by the department of medicaid as an outlier nursing facility or unit. Instead, the provider of a designated outlier nursing facility or unit shall be paid each state fiscal year a total per me...

...(A) As used in this section, "medicaid maximum allowable amount" means one hundred per cent of a nursing facility's total per medicaid day payment rate. (B) Instead of paying the total per medicaid day payment rate determined under section 5165.15 of the Revised Code, the department of medicaid shall pay the provider of a nursing facility the lesser of the following for nursing facility services the nursing ...

...oluntary termination, the department of medicaid shall estimate the amount of any overpayments made under the medicaid program to the exiting operator, including overpayments the exiting operator disputes, and other actual and potential debts the exiting operator owes or may owe to the department under the medicaid program, including a franchise permit fee. (B) In estimating the exiting operator's other actual and...

... following: (1) That the department of medicaid or a contracting agency will issue an order under section 5165.84 of the Revised Code denying payment for any medicaid eligible residents admitted on and after the effective date of the order if the facility does not substantially correct, within ninety days after the exit interview, the deficiency or deficiencies cited in the statement of deficiencies in accorda...

...(A) The department of medicaid or a contracting agency shall issue an order denying medicaid payments to a nursing facility for all medicaid eligible residents admitted to the facility on or after the effective date of the order, if the facility has failed to substantially correct within ninety days after the exit interview a deficiency or cluster of deficiencies in accordance with the plan of correction it su...

...cient and economical administration of medicaid waiver components, the department of medicaid may transfer an individual enrolled in a medicaid waiver component administered by the department to another medicaid waiver component the department administers if the individual is eligible for the medicaid waiver component and the transfer does not jeopardize the individual's health or safety.

...t to division (D) of this section, the medicaid director shall adopt rules under section 5166.02 of the Revised Code establishing the payment amounts or the methods by which the payment amounts are to be determined for home and community-based services specified in division (A)(1) of section 5166.20 of the Revised Code and provided under the components of the medicaid program that the department of developmenta...

...on of the participant's eligibility for medicaid before the sixty-first day after the documentation is requested. (3) The participant becomes eligible for medicaid on a basis other than being included in the category identified by the department of medicaid as covered families and children or being included in the expansion eligibility group. (4) The participant becomes a ward of the state. (5) The participant cea...

...(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) 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...

...ic office" also means the department of medicaid if it elects to receive notices under division (D) of this section regarding independent providers. (5) "Public office" has the same meaning as in section 117.01 of the Revised Code. (6) "Participating private party" means any person or private entity that is allowed to request a criminal records check pursuant to division (A)(2) or (3) of section 109.572 of the Revi...

...of the Revised Code; (2) Applying to medicaid provider agreements under the medicaid program; (3) Applying to the purchase of examinations from a sole supplier by a state licensing board under Title XLVII of the Revised Code; (4) Applying to entertainment contracts for the Ohio state fair entered into by the Ohio expositions commission, provided that the controlling board has given its approval to the commis...

...be considered for employment. (b) The medicaid program does not pay the responsible party for the fee it pays to the bureau under this section. (G) Divisions (D) to (F) of this section do not apply with regard to an applicant or employee if the applicant or employee is referred to a responsible party by an employment service that supplies full-time, part-time, or temporary staff for direct-care positions and both...

...f, an offense materially related to the medicaid program. (c) A principal owner or manager of the provider who provides direct care has entered a guilty plea for, been convicted of, or been found eligible for intervention in lieu of conviction for an offense listed or described in divisions (A)(3)(a) to (e) of section 109.572 of the Revised Code, but only if the provider, principal owner, or manager does not meet ...

...agency agreement with the department of medicaid under section 5162.35 of the Revised Code under which the department of aging is required to establish for each biennium a unified long-term care budget for home and community-based services covered by medicaid components the department of aging administers. The interagency agreement shall require the department of aging to do all of the following: (1) Administ...

...hall not be administered as part of the medicaid program. (B) For an individual to be eligible for the state-funded component of the PASSPORT program, the individual must meet one of the following requirements and meet the additional eligibility requirements applicable to the individual established in rules adopted under division (D) of this section: (1) The individual must have been enrolled in the state-funde...

...4729.65 of the Revised Code; (vi) The medicaid fraud investigation and prosecution fund; (vii) The bureau of criminal identification and investigation asset forfeiture and cost reimbursement fund created by section 109.521 of the Revised Code; (viii) The casino control commission enforcement fund created by section 3772.36 of the Revised Code; (ix) The auditor of state investigation and forfeiture trust fund ...

... the child if the child is eligible for medicaid. The party shall include in the notice the name and address of the insurer. Any physician, clinical nurse specialist, certified nurse practitioner, hospital, or other provider of medical services covered by the medicaid program who is notified under this section of the existence of a health insurance or health care policy, contract, or plan with coverage for children w...

...maximum amount permitted a recipient of medicaid. The notice shall include an explanation of the potential effect on the resident's eligibility for medicaid if the amount in the resident's accounts and the petty cash fund, plus the value of other nonexempt resources, exceeds the maximum assets a medicaid recipient may retain. (D) Except as otherwise provided in section 3.061 of the Revised Code, each home that mana...

...; (3) The resident is a recipient of medicaid and the home's participation in the medicaid program has been involuntarily terminated or denied by the federal government; (4) The resident is a beneficiary under the medicare program and the home's certification under the medicare program has been involuntarily terminated or denied by the federal government. (E) If a resident is to be transferred or discharged ...

... "This home is not a participant in the medicaid program administered by the Ohio department of medicaid. Consequently, you may be discharged from this home if you are unable to pay for the services provided by this home." If the prospective resident has a sponsor whose identity is made known to the home, the home shall also inform the sponsor, before admission of the resident, of the home's status relative to ...

...be considered for employment. (b) The medicaid program does not reimburse the home health agency for the fee it pays to the bureau under this section. (F) Divisions (C) to (E) of this section do not apply with regard to an applicant or employee if the applicant or employee is referred to a home health agency by an employment service that supplies full-time, part-time, or temporary staff for positions that involve...

...ome and community-based services" means medicaid-funded home and community-based services specified in division (A)(1) of section 5166.20 of the Revised Code provided under the medicaid waiver components the department of developmental disabilities administers pursuant to section 5166.21 of the Revised Code. Except as provided in section 5123.0412 of the Revised Code, home and community-based services provided under ...

... home and community-based services and medicaid case management services. The rules shall provide for private providers of the services to receive one hundred per cent of the medicaid allowable payment amount and for government providers of the services to receive the federal share of the medicaid allowable payment, less the amount withheld as a fee under section 5123.0412 of the Revised Code. The rules shall ...

...rter per cent of the total value of all medicaid paid claims for home and community-based services provided during the year to an individual eligible for services from the county board. A county board shall not pass on to a provider of home and community-based services the cost of a fee charged to the county board under this section. (B) The amounts collected from the fees charged under this section shall be depos...

...noses or special care needs for which a medicaid payment rate is set pursuant to section 5124.152 of the Revised Code; (B) The medicaid director and director of developmental disabilities determine that there is a need under the medicaid program for the proposed new residential facility or modification to the existing residential facility and that approving the application for the initial residential facility l...

...(A) As used in this section: (1) "Medicaid-certified capacity" has the same meaning as in section 5124.01 of the Revised Code. (2) "Residential facility" has the same meaning as in section 5123.19 of the Revised Code. (B)(1) The director of developmental disabilities may change the terms of an agreement entered into with a county board of developmental disabilities or private, nonprofit agency pursuant to section ...

...of developmental disabilities may pay a medicaid rate add-on to an ICF/IID provider for outlier ICF/IID services the ICF/IID provides to residents identified as needing intensive behavioral support services, if the provider applies to the department to receive the rate add-on and the department approves the application. The department may approve a provider's application if both of the following apply: (1) The prov...

...United States centers for medicare and medicaid services under the medicaid program by completing all final fiscal audits not already completed and performing all other appropriate actions the department determines to be necessary. The department shall issue an initial debt summary report on this matter not later than sixty days after the date the exiting operator files the properly completed cost report requir...

... dual eligible individual is a medicare-medicaid enrollee (MME). (B) "Exchange" has the same meaning as in 45 C.F.R. 155.20. (C) "Federal financial participation" means the federal government's share of expenditures made by an entity in implementing a medical assistance program. (D) "Medical assistance program" means all of the following: (1) The medicaid program; (2) The children's health insurance program; (3...

...The medicaid director's rules governing medicaid are binding on other state agencies and political subdivisions that administer one or more components of the medicaid program, or one or more aspects of a component, pursuant to contracts entered into under section 5162.35 of the Revised Code. No state agency or political subdivision may establish, by rule or otherwise, a policy governing medicaid that is incons...

...(A) The department of medicaid shall periodically evaluate the success that members of the expansion eligibility group have with the following: (1) Obtaining employer-sponsored health insurance coverage; (2) Improving health conditions that would otherwise prevent or inhibit stable employment; (3) Improving the conditions of their employment, including duration and hours of employment. (B) For the purpose of ...

...ty shall transfer to the department of medicaid the money in the personal needs allowance account of a resident of the home or facility who was a medicaid recipient no earlier than sixty days but not later than ninety days after the resident dies. The home or facility shall transfer the money even though the owner or operator of the facility or home has not been issued letters testamentary or letters of admini...

...The department of medicaid shall seek federal financial participation for each claim a qualified medicaid school provider properly submits to the department under section 5162.361 of the Revised Code. The department shall disburse the federal financial participation the department receives from the federal government for such a claim to the qualified medicaid school provider that submitted the claim. The depart...

...The department of medicaid may retain or collect a percentage of the federal financial participation included in a supplemental medicaid payment to one or more medicaid providers owned or operated by a state agency or political subdivision that brings the payment to such provider or providers to the upper payment limit established by 42 C.F.R. 447.272. If the department retains or collects a percentage of that federa...

...rug manufacturers to the department of medicaid in accordance with a rebate agreement required by the "Social Security Act," section 1927, 42 U.S.C. 1396r-8; (3) The federal share of all supplemental rebates paid by drug manufacturers to the department of medicaid in accordance with the supplemental drug rebate program established under section 5164.755 of the Revised Code; (4) Except as otherwise provided by...

...dual who applies to participate in the medicaid buy-in for workers with disabilities program. "Earned income" has the meaning established by rules authorized by section 5163.098 of the Revised Code. "Employed individual with a medically improved disability" has the same meaning as in the "Social Security Act," section 1905(v), 42 U.S.C. 1396d(v). "Family" means an applicant or participant and the spouse and d...

... or molecular breast imaging. (B) The medicaid program shall cover all of the following: (1) To detect the presence of breast cancer in adult women, screening mammography; (2) To detect the presence of breast cancer in adult women meeting any of the conditions described in division (C)(2) of this section, supplemental breast cancer screening; (3) To detect the presence of cervical cancer, cytologic screening....

...d in division (C) of this section, the medicaid program shall cover prescribed, orally administered cancer medications on at least the same basis that it covers intraveneously administered or injected cancer medications. In implementing this section, the department of medicaid shall not institute cost-sharing requirements under section 5162.20 of the Revised Code for prescribed, orally administered cancer medi...

...(A) The medicaid program shall cover both of the following, subject to division (C) of this section: (1) All tobacco cessation medications approved by the United States food and drug administration; (2) All forms of tobacco cessation services recommended by the United States preventive services task force, including individual, group, and telephone counseling and any combination thereof. (B) The department of m...

...an December 31, 2018, the department of medicaid shall develop and implement revisions to the system by which persons and government entities become and remain medicaid providers so that there is a single system of records for the system and the persons and government entities do not have to submit duplicate data to the state to become or remain medicaid providers for any component or aspect of a component of the med...

...Under the medicaid program, any amount determined to be owed the state by a final fiscal audit conducted pursuant to section 5164.55 of the Revised Code, upon the issuance of an adjudication order pursuant to Chapter 119. of the Revised Code that contains a finding that there is a preponderance of the evidence that a medicaid provider will liquidate assets or file bankruptcy in order to prevent payment of the a...

...The department of medicaid may deduct from medicaid payments for medicaid services rendered by a medicaid provider any amounts the provider owes the state as the result of incorrect medicaid payments the department has made to the provider.

...apeutics committee of the department of medicaid. The committee shall assist the department with developing and maintaining a preferred drug list for the medicaid program. The committee shall review and recommend to the medicaid director the drugs that should be included on the preferred drug list. The recommendations shall be made based on the evaluation of competent evidence regarding the relative safety, efficac...

...Before the department of medicaid or department of mental health and addiction services updates medicaid billing codes or medicaid payment rates for community behavioral health services as part of the behavioral health redesign, the departments shall conduct a beta test of the updates. Any medicaid provider of community behavioral health services may volunteer to participate in the beta test. An update may not begin ...

... proposed changes to payment rates for medicaid services, the medicaid director shall give public notice in the register of Ohio of any change to a method or standard used to determine the medicaid payment rate for a medicaid service.

...on project awarded to the department of medicaid, the director of medicaid may operate the helping Ohioans move, expanding (HOME) choice demonstration component of the medicaid program to transition medicaid recipients who qualify for the demonstration component to community settings.

...(A) The department of medicaid may establish a program under which it provides incentive payments, as authorized by the "Social Security Act," section 1903(a)(3)(F) and (t), 42 U.S.C. 1396b(a)(3)(F) and (t), to encourage the adoption and use of electronic health record technology by medicaid providers who are identified under that federal law as eligible professionals. (B) After the department has made a deter...

...The medicaid director shall implement within the medicaid program a system that encourages medicaid providers to provide medicaid services to medicaid recipients in culturally and linguistically appropriate manners.

...)(2) of this section, the department of medicaid shall determine each nursing facility's per medicaid day payment rate for direct care costs by multiplying the facility's semiannual case-mix score determined under section 5165.192 of the Revised Code by the cost per case-mix unit determined under division (C) of this section for the facility's peer group. (2) Beginning January 1, 2024, during state fiscal years 20...

...(A) The department of medicaid shall redetermine a provider's medicaid payment rate for a nursing facility using revised information if any of the following results in a determination that the provider received a higher medicaid payment rate for the nursing facility than the provider was entitled to receive: (1) The provider properly amends a cost report for the nursing facility under section 5165.107 of the Revised...

...ity provider, shall submit a claim for medicaid payment for a service provided to a nursing facility resident if the service is included in a medicaid payment made to the nursing facility provider under this chapter or in the allowable expenses reported on a provider's cost report for a nursing facility. No nursing facility provider shall submit a separate claim for medicaid payment for a service provided to a...

...The department of medicaid may conduct a post-payment review of a claim submitted by a nursing facility provider and paid by the medicaid program to determine whether the provider was overpaid. The department shall provide the provider a written summary of the review's results. The review's results are not subject to an adjudication under Chapter 119. of the Revised Code; however, the provider may request that ...

...perator shall provide the department of medicaid written notice of a change of operator if the nursing facility participates in the medicaid program and the entering operator seeks to continue the nursing facility's participation. The written notice shall be provided to the department in accordance with the method specified in rules authorized by section 5165.53 of the Revised Code. The written notice shall be provid...

...yment due an exiting operator under the medicaid program shall be deposited into the medicaid payment withholding fund created by the controlling board pursuant to section 131.35 of the Revised Code. Money in the fund shall be used as follows: (1) To pay an exiting operator when a withholding is released to the exiting operator under section 5165.526 or 5165.527 of the Revised Code; (2) To pay the department of...

...hree or four finding, the department of medicaid or a contracting agency may, subject to sections 5165.82 and 5165.83 of the Revised Code, impose one or more of the following remedies: (A) Do either of the following: (1) Issue an order denying medicaid payments to the facility for all medicaid eligible residents admitted after the effective date of the order; (2) Impose a fine. (B) Issue an order denying me...

...(A) If the department of medicaid determines that a nursing facility is experiencing or is likely to experience a serious financial loss or failure that jeopardizes or is likely to jeopardize the health, safety, and welfare of its residents, the department, subject to the provider's consent, may appoint a temporary resident safety assurance manager in the nursing facility to take actions the department determin...

...A medicaid provider of nursing services may provide nursing services in a group visit under a home and community-based services medicaid waiver component if the component covers the nursing services, the number of medicaid recipients who receive the nursing services during the group visit does not exceed four, and all of the following apply to all of those medicaid recipients: (A) They are enrolled in the component;...

...5160.01 of the Revised Code. (B) The medicaid director shall establish a medicaid waiver component to provide continuous medicaid enrollment for children from birth through three years of age. A child who is determined eligible for medical assistance under Title XIX of the "Social Security Act" or child health assistance under Title XXI of the "Social Security Act" shall remain eligible for those benefits until th...

... (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 hospital inpatient capital pa...

...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.

...of the Revised Code, the department of medicaid may do any of the following if a nursing facility or hospital fails to pay the full amount of a franchise permit fee installment when due: (1) Withhold an amount less than or equal to the installment and penalty assessed under section 5168.51 of the Revised Code from a medicaid payment due the nursing facility or hospital until the nursing facility or hospital p...

...age changes, the new percentage. (H) "Medicaid managed care organization" has the same meaning as in section 5167.01 of the Revised Code. (I) "Medicaid provider" has the same meaning as in section 5164.01 of the Revised Code. (J) "Ohio medicaid member month" means a month in which a medicaid recipient residing in this state is enrolled in a health insuring corporation plan. (K) "Other Ohio member month" means...

...ee shall have a component based on Ohio medicaid member months and another component based on other Ohio member months. (B) The department of medicaid shall determine the amount of  the monthly franchise fee to be imposed on a health insuring  corporation plan under the component based on Ohio medicaid member  months. The determination shall be made as part of the process of  determining the annual capitated paymen...

...ve of payments received pursuant to the medicaid program for the period ending September 30, 2009, as reflected in its annual report for the preceding calendar year; (2) With respect to a domestic insurance company that is not a health insuring corporation, one and four-tenths per cent of the gross amount of premiums received from policies covering risks within this state, exclusive of premiums received under the m...

...e of payments received pursuant to the medicaid program for the period ending September 30, 2009, as reflected in its annual report; (2) If the company is not a health insuring corporation, one and four-tenths per cent of the balance of premiums received, exclusive of premiums received under the medicare program and exclusive of payments received pursuant to the medicaid program for the period ending September...

... JMOC chairperson may request that the medicaid director appear before JMOC to provide information and answer questions about the medicaid program. If so requested, the medicaid director shall appear before JMOC at the time and place specified in the request.

...e department or its designee; (3) The medicaid director and the staff of the department of medicaid who are involved in the administration of the medicaid program if the self-employed provider is to provide, or provides, community-based long-term care services under a component of the medicaid program that the department of aging administers; (4) A court or hearing officer involved in a case dealing with any of t...

...To be eligible for the medicaid-funded component of the assisted living program, an individual must meet all of the following requirements: (A) Need an intermediate level of care as determined by an assessment conducted under section 173.546 of the Revised Code; (B) While receiving assisted living services under the medicaid-funded component, reside in a residential care facility that is authorized by a valid...

...ible individuals may be enrolled in the medicaid-funded component of the assisted living program in accordance with this section. An individual is eligible for the assisted living program's home first component if both of the following apply: (1) The individual has been determined to be eligible for the medicaid-funded component of the assisted living program. (2) At least one of the following applies: (a) T...

...0, 2019, the person is eligible for the medicaid program or is a medicaid recipient. (iv) Except as provided in division (A)(7)(b)(iii) of this section, the person is not eligible for or a recipient, enrollee, or beneficiary of any governmental health care program. (8) "Nonprofit health care referral organization" means an entity that is not operated for profit and refers patients to, or arranges for the provisio...

...h the certification requirements of the medicaid program cites the defendant's receipt of the residential habilitation, care, and treatment in the facility as being inappropriate under the certification requirements, if the defendant's receipt of the residential habilitation, care, and treatment in the facility potentially jeopardizes the facility's continued receipt of federal medicaid moneys, and if as a result of ...

...dents residing in the district who are medicaid recipients. The director shall furnish such numbers upon receipt of lists of student names furnished by the district board, in such form as the director may require. The medicaid director shall provide the director of developmental disabilities with the data necessary for compliance with this section. Section 3319.321 of the Revised Code does not apply to the ...

... section 3517.01 of the Revised Code. "Medicaid provider" has the same meaning as in section 5164.01 of the Revised Code. (B) No candidate for the office of attorney general or county prosecutor or such a candidate's campaign committee shall knowingly accept any contribution from a medicaid provider or from any person having an ownership interest in the medicaid provider. (C) Whoever violates this section is g...

...tate treasury the department of health medicaid fund. All funds the department of health receives for the purpose of paying the expenses the department incurs under the medicaid program shall be deposited into the fund. The department shall use the money in the fund to pay the expenses the department incurs under the medicaid program.

...ded, or nursing facility beds under the medicaid program, Title XIX of the "Social Security Act," 49 Stat. 286 (1965), 42 U.S.C. 1396, as amended; (3) An increase of hospital beds reported in an application submitted under section 3722.03 of the Revised Code as long-term care beds. (B) For the purpose of implementing this section, the director shall do all of the following: (1) Not later than October 1, 2023...

... United States centers for medicare and medicaid services regulations, the compassionate caregiver shall comply with all regulations and guidance issued by the centers for medicare and medicaid services, as well as the facility's visitor policy established under division (D) of this section. When visiting a resident in a long-term care facility that is not governed by centers for medicare and medicaid services regula...

...by the federal centers for medicare and medicaid services or an organization acceptable to the department under division (C) of this section. (2) To be eligible for recognition as a thrombectomy-capable stroke center under section 3727.13 of the Revised Code, a hospital must be certified as a thrombectomy-capable stroke center by an accrediting organization approved by the federal centers for medicare and medicaid...

...surance shall notify the department of medicaid of all long-term care insurance policies that meet all of the following requirements: (A) Comply with sections 3923.41 to 3923.48 of the Revised Code and the rules adopted under section 3923.47 of the Revised Code; (B) Provide benefits for home and community-based services in addition to nursing home care; (C) Include case management services in its coverage of...

...ces that are reimbursed under the state medicaid plan: (1) A public nonemergency medical service organization; (2) An urban or rural public transit system; (3) A private nonprofit organization that receives grants under section 5501.07 of the Revised Code. (N)(1) An entity, to the extent it provides ambulette services, if the entity meets all of the following conditions: (a) The entity is certified by the depart...

...l health and addiction services and the medicaid director shall adopt rules as necessary to implement the residential state supplement program, including the requirements that an individual must satisfy to be eligible for payments under the program. The rules shall be adopted in accordance with Chapter 119. of the Revised Code. The rules adopted by the director of mental health and addiction services may establish t...

...ment of developmental disabilities for medicaid waiver state match, the department shall expend, in fiscal year 2009 and each fiscal year thereafter, not less than the amount appropriated in appropriation item 322-416, medicaid waiver - state match, in fiscal year 2008 to do both of the following: (1) Pay the nonfederal share of medicaid expenditures for home and community-based services that section 5123....

...(A) The total per medicaid day payment rate determined under section 5124.15 of the Revised Code shall not be paid for ICF/IID services provided by an ICF/IID, or discrete unit of an ICF/IID, designated by the department of developmental disabilities as an outlier ICF/IID or unit. Instead, the provider of a designated outlier ICF/IID or unit shall be paid each fiscal year a total per medicaid day payment rate that th...

...bilities shall redetermine a provider's medicaid payment rate for an ICF/IID using revised information if either of the following results in a determination that the provider received a higher medicaid payment rate for the ICF/IID than the provider was entitled to receive: (1) The provider properly amends a cost report for the ICF/IID under section 5124.107 of the Revised Code; (2) The department makes a finding ...

...ner of an ICF/IID participating in the medicaid program shall provide the department of developmental disabilities and department of medicaid written notice of a facility closure or voluntary termination not less than ninety days before the effective date of the facility closure or voluntary termination. The written notice shall be provided to the department of developmental disabilities and department of medi...

...ll of the items and services covered by medicaid as ICF/IID services and as home and community-based services. The department shall develop the pamphlet in consultation with persons and organizations interested in matters pertaining to individuals eligible for ICF/IID services and home and community-based services. (B) Each ICF/IID provider shall provide the pamphlet to the residents of the ICF/IID who receive ICF/I...

...oard. (2) Employs or contracts with a medicaid services manager, or has entered into an agreement with another county board that employs or contracts with a medicaid services manager to have that medicaid services manager serve both counties. The superintendent of a county board shall not serve as the medicaid services manager of the county board.

...is deemed to refer to the department of medicaid or medicaid director, as the case may be, to the extent the reference is about a duty or authority of the department of medicaid or medicaid director regarding a medical assistance program.

...Not less than once each year, the medicaid director shall submit a report on the medicaid buy-in for workers with disabilities program to the governor, general assembly, and joint medicaid oversight committee. The copy to the general assembly shall be submitted in accordance with section 101.68 of the Revised Code. The report shall include all of the following information: (A) The number of individuals who pa...

...ministers one or more components of the medicaid program and has reasonable cause to believe that an instance of fraud, waste, or abuse has occurred in the medicaid program shall inform the department of medicaid. The department shall collect the information in the medicaid data warehouse system established under section 5162.11 of the Revised Code.

...The department of medicaid shall certify amounts due under the medicaid estate recovery program instituted under section 5162.21 of the Revised Code to the attorney general pursuant to section 131.02 of the Revised Code. The attorney general may enter into a contract with any person or government entity to collect the amounts due on behalf of the attorney general. The attorney general, in entering into a cont...

...The department of medicaid may enter into contracts with one or more other state agencies or political subdivisions to have the state agency or political subdivision administer one or more components of the medicaid program, or one or more aspects of a component, under the department's supervision. A state agency or political subdivision that enters into such a contract shall comply with the terms of the contra...

...The medicaid director shall create, in accordance with sections 5162.36 to 5 162.366 of the Revised Code, the medicaid school component of the medicaid program.

...The medicaid director shall adopt rules under section 5162.02 of the Revised Code as necessary to implement the medicaid school component of the medicaid program, including rules that establish or specify all of the following: (A) Conditions a board of education of a city, local, or exempted school district, a governing board of an educational service center, governing authority of a community school established u...

...f this section and for the purpose of a medicaid recipient receiving, in accordance with the recipient's individualized education program, physical therapy services, occupational therapy services, speech-language pathology services, or audiology services under the medicaid school component of the medicaid program: (1) A physical therapist is a licensed practitioner of the healing arts for the purpose of 42 C.F.R. 44...

...If the department of medicaid enters into a contract with the department of mental health and addiction services under section 5162.35 of the Revised Code, the department of medicaid shall pay the nonfederal share of any medicaid payment to a provider for services under the component, or aspect of the component, the department of mental health and addiction services administers.

...ses greater than ten per cent under the medicaid program, the medicaid director shall notify the joint medicaid oversight committee of the increase and be available to testify before the joint medicaid oversight committee regarding the increase.

...Under the medicaid buy-in for workers with disabilities program, an individual who does all of the following in accordance with rules authorized by section 5163.098 of the Revised Code qualifies for the medicaid program: (A) Applies for the medicaid buy-in for workers with disabilities program; (B) Provides satisfactory evidence of all of the following: (1) That the individual is at least sixteen years of age...

...The medicaid program shall cover occupational therapy services provided by an occupational therapist licensed under section 4755.08 of the Revised Code. Coverage shall not be limited to services provided in a hospital or nursing facility. Any licensed occupational therapist may enter into a provider agreement with the department of medicaid to provide occupational therapy services under the medicaid program.

...The medicaid program may cover one or more state plan home and community-based services that the department of medicaid selects for coverage. A medicaid recipient of any age may receive a state plan home and community-based service if the recipient has countable income not exceeding two hundred twenty-five per cent of the federal poverty line, has a medical need for the service, and meets all other eligibility requir...

... any action taken by the department of medicaid under section 5164.38 or 5164.57 of the Revised Code or any other state statute governing the medicaid program that requires the department to give notice of an opportunity for a hearing in accordance with Chapter 119. of the Revised Code, if the department gives notice of the opportunity for a hearing but the medicaid provider or other entity subject to the notic...

...ction 5160.10 of the Revised Code, the medicaid director chooses to contract with a person to perform either or both of the following services, the director may contract with any qualified person, including OCHSPS, to perform the service or services on behalf of the department of medicaid: (1) Review and analyze claims for medicaid services provided to children in accordance with all state and federal laws gov...

...Any medicaid provider who, without intent, obtains payments under the medicaid program in excess of the amount to which the provider is entitled is liable for payment of interest on the amount of the excess payments for a period determined by the department, but not to exceed the period from the date on which payment was made to the date on which repayment is made to the state. The interest shall be paid at the avera...

... and federal law, of the department of medicaid or a county department of job and family services to recover excess medicaid payments made to a medicaid provider is not limited by the availability of remedies under sections 5162.21 and 5162.23 of the Revised Code for recovering benefits paid on behalf of medicaid recipients.

...The medicaid director shall adopt rules under section 5164.02 of the Revised Code to implement a coordinated services program for medicaid recipients 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 the "Social Security Act," section 1915(a)(2), 42 U.S.C....

...f the Revised Code. The department of medicaid shall establish standards for medicaid payments for services provided through teledentistry. The standards shall provide coverage for services to the same extent that those services would be covered by the medicaid program if the services were provided without the use of teledentistry.

...al is an applicant for or recipient of medicaid, the individual may appeal pursuant to section 5160.31 of the Revised Code. If the individual is not an applicant for or recipient of medicaid, the individual may appeal pursuant to a process the department of medicaid shall establish, which shall be similar to the appeals process established by section 5101.35 of the Revised Code. The department of medicaid shal...

...of the Revised Code, the department of medicaid shall enter into a provider agreement with a nursing facility operator who applies, and is eligible, for the provider agreement. (B) A provider agreement shall require the department to make medicaid payments to the provider in accordance with this chapter for nursing facility services the nursing facility provides to its residents who are medicaid recipients el...

...the nursing facility participate in the medicaid program shall qualify all of the nursing facility's medicaid-certified beds in the medicare program. The medicaid director may adopt rules under section 5165.02 of the Revised Code to establish the time frame in which a nursing facility must comply with this requirement. (B) The department of veterans services is not required to qualify all of the medicaid-cert...

...The department of medicaid shall develop an addendum to the cost report form that a nursing facility provider may use to set forth costs that the provider believes the department may dispute. The department may consider such costs in determining a nursing facility's medicaid payment rate. If the department does not consider such costs in determining a nursing facility's medicaid payment rate, the provider may s...

...thorized by this section, the total per medicaid day payment rate determined under section 5165.15 of the Revised Code shall not be paid for nursing facility services that a nursing facility not designated as an outlier nursing facility or unit provides to a resident who meets the criteria for admission to a designated outlier nursing facility or unit, as specified in rules authorized by section 5165.153 of the Revis...

...(A) The department of medicaid shall determine each nursing facility's per medicaid day payment rate for ancillary and support costs. A nursing facility's rate shall be the rate determined under division (C) of this section for the nursing facility's peer group. (B) For the purpose of determining nursing facilities' rates for ancillary and support costs, the department shall establish six peer groups composed as f...

...(A) The department of medicaid shall determine each nursing facility's per medicaid day payment rate for capital costs. A nursing facility's rate shall be the rate determined under division (C) of this section for the nursing facility's peer group. (B) For the purpose of determining nursing facilities' rates for capital costs, the department shall establish six peer groups. (1) Each nursing facility located in an...

...ch state fiscal year, the department of medicaid shall determine the critical access incentive payment for each nursing facility that qualifies as a critical access nursing facility. To qualify as a critical access nursing facility for a state fiscal year, a nursing facility must meet all of the following requirements: (1) The nursing facility must be located in an area that, on December 31, 2011, was designated a...

... to submit a claim to the department of medicaid regarding the medicare cost-sharing expenses of a resident of the nursing facility who, under federal law, is eligible to have the medicaid program pay for a part of the cost-sharing expenses if the provider determines that, under rules adopted under section 5165.02 of the Revised Code, the nursing facility would not receive a medicaid payment for any part of the...

...The department of medicaid shall determine the actual amount of debt an exiting operator owes the department under the medicaid program by completing all final fiscal audits not already completed and performing all other appropriate actions the department determines to be necessary. The department shall issue an initial debt summary report on this matter not later than sixty days after the date the exiting operator f...

...The medicaid director may not submit a request to the United States secretary of health and human services for a medicaid waiver under the "Social Security Act," section 1115, 42 U.S.C. 1315, unless the director provides the speaker of the house of representatives and president of the senate written notice of the director's intent to submit the request at least ten days before the date the director submits the ...

...The department of medicaid may review and approve, modify, or deny written plans of care and individual service plans that section 5166.04 of the Revised Code requires be created for individuals determined eligible for a home and community-based services medicaid waiver component. If a state agency or political subdivision contracts with the department under section 5162.35 of the Revised Code to administer a h...

...for a period of time the department of medicaid shall specify, financial records documenting the costs of medicaid services provided under the home and community-based services medicaid waiver components that the agency administers, including records of independent audits. The administrative agency shall make the financial records available on request to the United States secretary of health and human services...

...If the department of medicaid terminates the 209(b) option, the department shall establish a medicaid waiver component under which an individual who has cystic fibrosis and is enrolled in the program for children and youth with special health care needs by the department of health under section 3701.023 of the Revised Code or the program the department of health administers pursuant to division (G) of that section ma...

...sist of both of the following: (a) The medicaid funds deposited into the account under division (B) of this section and division (A) of section 5166.404 of the Revised Code; (b) Contributions made by the participant and on the participant's behalf under divisions (C) and (D) of this section. (2) A buckeye account shall not have more than ten thousand dollars in it at one time. (B) Subject to division (A)(2) of th...

...hall, 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 managed care organization shall disclose to th...

...(A) No contract between a medicaid managed care organization, including 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 administere...

...ealth, and the centers for medicare and medicaid services or their successors) or uses certified community health workers or public health nurses to connect at-risk individuals 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 cert...

...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...

...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...

...essments deposited into the health care/medicaid support and recoveries fund created under section 5162.52 of the Revised Code; (2) The total amount of intergovernmental transfers required to be made in the same program year by governmental hospitals under section 5168.07 of the Revised Code, less the amount of transfers deposited into the health care/medicaid support and recoveries fund created under section 5162.5...

...stributing 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 assessed according to the r...

...(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...

...r 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 medicaid pro...

...s for a fiscal year, the department of medicaid shall use at least all of the following: (1) Information from medicaid cost reports filed under section 5165.10 of the Revised Code that are the most recent at the time the determination is made; (2) The projected total medicaid payment rates for nursing facility services for the fiscal year; (3) The projected total number of medicaid days for the fiscal year.

...ion 5168.65 of the Revised Code from a medicaid payment due the ICF/IID until the ICF/IID pays the installment and penalty; (2) Offset an amount less than or equal to the installment and penalty assessed under section 5168.65 of the Revised Code from a medicaid payment due the ICF/IID; (3) Provide for the department of medicaid to terminate the ICF/IID's provider agreement. (B) The department may offset a med...

...money in the fund shall be used to make medicaid payments to medicaid providers and medicaid managed care organizations. (B) Any interest or other investment proceeds earned on money in the fund shall be credited to the fund and used to make medicaid payments in accordance with division (A) of this section.

...(A) At least quarterly, the medicaid director shall report to the members of the joint medicaid oversight committee and the executive director of the joint medicaid oversight committee both of the following: (1) The fee rates and the aggregate total of the fees assessed for each of the following: (a) The hospital assessment established under section 5168.21 of the Revised Code; (b) The nursing home and hospital...

...(A) The medicaid director shall impose a penalty for each day that a hospital fails to report the information required under section 5168.05 of the Revised Code on or before the dates specified in that section. The amount of the penalty shall be established by the director in rules adopted under section 5168.02 of the Revised Code. (B) In addition to any other remedy available to the department of medicaid under law...

...to a prescription, for the benefit of a medicaid recipient with a diagnosis of incontinence, and by a medicaid provider that maintains a valid provider agreement under section 5164.30 of the Revised Code with the department of medicaid, provided that the medicaid program covers diapers or incontinence underpads as an incontinence garment. (b) As used in division (B)(56)(a) of this section, "incontinence underpad" ...

... (b) The director of health; (c) The medicaid director; (d) The director of mental health and addiction services; (e) The administrator of workers' compensation. (2) Members of the advisory council shall also include individuals who are working to address prescription drug availability and affordability in any of the following areas: (a) Insurance; (b) Local, state, and federal government service; ...

...ct entered into with the department of medicaid as an interagency agreement under section 5162.35 of the Revised Code, the department of aging shall carry out the day-to-day administration of the component of the medicaid program known as the program of all-inclusive care for the elderly or PACE. The department of aging shall carry out its PACE administrative duties in accordance with the provisions of the int...

...ible individuals may be enrolled in the medicaid-funded component of the PASSPORT program in accordance with this section. An individual is eligible for the PASSPORT program's home first component if both of the following apply: (1) The individual has been determined to be eligible for the medicaid-funded component of the PASSPORT program. (2) At least one of the following applies: (a) The individual has bee...

...vidual must have an application for the medicaid-funded component of the assisted living program pending and the department or the department's designee must have determined that the individual meets the nonfinancial eligibility requirements of the medicaid-funded component and not have reason to doubt that the individual meets the financial eligibility requirements of the medicaid-funded component. (C) While rece...

...erage that provides for the coverage of medicaid recipients, or an evidence of coverage that provides for the coverage of beneficiaries under any other federal health care program regulated by a federal regulatory body, or an evidence of coverage that provides for the coverage of beneficiaries under any contract covering officers or employees of the state that has been entered into by the department of administrative...

... for policies used for the coverage of medicaid recipients, or for policies used for the coverage of beneficiaries under any other federal health care program regulated by a federal regulatory body, or for policies used for the coverage of beneficiaries under any contract covering officers or employees of the state that has been entered into by the department of administrative services, if both of the followin...

...o 5 U.S.C.A. 8905, or for policies for medicaid recipients, or for policies for beneficiaries of any other federal health care program regulated by a federal regulatory body, or for policies for beneficiaries of contracts covering officers or employees of the state entered into by the department of administrative services, if both of the following apply: (1) The solicitation document has been approved by the U...

...n pleas on behalf of the department of medicaid, and the prosecuting attorney of the county in which a violation of division (B) of section 2913.401 of the Revised Code occurs may bring a civil action in the court of common pleas of that county on behalf of the county department of job and family services, against a person who violates division (B) of section 2913.401 of the Revised Code for the recovery of th...

... United States centers for medicare and medicaid services. (3) "Medical claim" has the same meaning as in section 2305.113 of the Revised Code. (4) "Reimbursement determination" means an insurer's determination of whether the insurer will reimburse a health care provider for health care services and the amount of that reimbursement. (5) "Reimbursement policies" means an insurer's policies and procedures governi...

...her the obligee if the children are not medicaid recipients, or to the department of medicaid when a medicaid assignment is in effect for any child under the support order. (E) The cost of providing health insurance coverage for a child subject to an order shall be defrayed by a credit against that parent's annual income when calculating support as required under section 3119.02 of the Revised Code using the basic ...

...of children and youth, or department of medicaid regarding the provision of public family services, including the provision of the following services to prevent or reduce economic or personal dependency and to strengthen family life: (a) Services authorized by a Title IV-A program, as defined in section 5101.80 of the Revised Code; (b) Social services authorized by Title XX of the "Social Security Act" and prov...

...alth services may advocate on behalf of medicaid recipients enrolled in medicaid managed care organizations and medicaid-eligible individuals, any of whom have been identified as needing addiction or mental health services.

...o pay; (c) Meet the requirements for a medicaid provider agreement and enter into the agreement with the department of medicaid to provide primary care services to medicaid recipients. (3) The department of health agrees, as provided in section 3702.75 of the Revised Code, to repay, so long as the primary care physician performs the service obligation agreed to under division (B)(1) of this section, all or part of ...

...o pay; (c) Meet the requirements for a medicaid provider agreement and enter into the agreement with the department of medicaid to provide dental services to medicaid recipients. (3) The department of health agrees, as provided in section 3702.85 of the Revised Code, to repay, so long as the individual performs the service obligation agreed to under division (C)(1) of this section, all or part of the principal and ...

... pay; (c) Meet the requirements for a medicaid provider agreement and enter into the agreement with the department of medicaid to provide chiropractic services to medicaid recipients. (3) The department of health agrees, as provided in section 3702.98 of the Revised Code, to repay all or part of the principal and interest of a government or other educational loan taken by the individual for expenses described in ...

...om the federal centers for medicare and medicaid services or an accrediting organization approved under 42 U.S.C. 1395bb(a) demonstrating that the hospital is certified or accredited. (B) When filing an application to renew a license issued under section 3722.03 of the Revised Code, an applicant may avoid an inspection by the director if the applicant submits with the application a copy of the hospital's most recen...

... United States centers for medicare and medicaid services, unless the hospital does not provide all of the seventy services, in which case the list shall include as many of those services as the hospital does provide. (3) In selecting a shoppable service for purposes of inclusion on the list, a hospital shall do both of the following: (a) Consider how frequently the hospital provides the service and the hospital'...

...laims of contracted providers against a medicaid health insuring corporation for covered health care services provided to medicaid recipients, all claims against the insurer for liability for bodily injury or for injury to or destruction of tangible property that are not under policies, and all claims of a guaranty association or foreign guaranty association. All claims under life insurance, annuity policies, and fun...

... of long-term care services, including medicaid; (2) Available long-term care services and providers; (3) Changes or improvements in long-term care services or providers; (4) Alternatives to the purchase of private long-term care insurance; (5) The effect of inflation on benefits and the importance of inflation protection; (6) Consumer suitability standards and guidelines; (7) Any other topics required by t...

...lan, including an eligible recipient of medicaid, and includes all of the following terms: (1) "Enrollee" and "subscriber" as defined by section 1751.01 of the Revised Code; (2) "Member" as defined by section 1739.01 of the Revised Code; (3) "Insured" and "plan member" pursuant to Chapter 3923. of the Revised Code; (4) "Beneficiary" as defined by section 3901.38 of the Revised Code. (K) "Health care contrac...

...r compensation is based on the current medicaid or medicare physician fee schedule, and the change in payment or compensation results solely from a change in that physician fee schedule. (b) A routine change or update of the health care contract is made in response to any addition, deletion, or revision of any service code, procedure code, or reporting code, or a pricing change is made by any third party sourc...

...wing: (a) The centers of medicare and medicaid services, for reimbursement of conditional payments made pursuant to the "Medicare Secondary Payer Act," 42 U.S.C. 1395y; (b) The Ohio department of medicaid, or a medical assistance provider to whom the department has assigned a right of recovery for a claim for which the department has notified the provider that the department intends to recoup the department's pri...

... individuals seeking to be eligible for medicaid reimbursement as state of Ohio certified doulas; (3) Provide general advice, guidance, and recommendations to the department of medicaid regarding the medicaid coverage of doula services required under section 5164.071 of the Revised Code; (4) Beginning two years after April 30, 2024, and annually thereafter, submit a report to the general assembly in accordance wi...

...mental nutrition assistance program or medicaid (excluding administrative expenditures for transportation services covered by the medicaid program) even though the county expenditures meet or exceed the maximum allowable reimbursement amount established by rules adopted under section 5101.161 of the Revised Code. The director of job and family services may adopt internal management rules in accordance with sect...

...tance group. (E) An adult eligible for medicaid who is sanctioned under division (A)(3) of this section for a failure or refusal, without good cause, to comply in full with a provision of a self-sufficiency contract related to work responsibilities under sections 5107.40 to 5107.69 of the Revised Code loses eligibility for medicaid unless the adult is otherwise eligible for medicaid pursuant to an eligibility ...

...ities is to pay the nonfederal share of medicaid expenditures for one or more of the home and community-based services that the county board would, if not for the agreement, be required by section 5126.0510 of the Revised Code to pay. The agreement shall specify which home and community-based services the agreement covers. The department shall pay the nonfederal share of medicaid expenditures for th...

...such costs in determining an ICF/IID's medicaid payment rate. If the department does not consider such costs in determining an ICF/IID's medicaid payment rate, the provider may seek reconsideration of the determination in accordance with section 5124.38 of the Revised Code. If the department subsequently includes such costs in an ICF/IID's medicaid payment rate, the department shall pay the provider interest a...

...within thirty days; (2) Reduce the per medicaid day payment rate for the provider's ICF/IID by the amount specified in division (B) of this section for the period of time specified in division (C) of this section. (B) For the purpose of division (A)(2) of this section, an ICF/IID's per medicaid day payment rate shall be reduced by the following amount: (1) In the case of a reduction made during the period be...

...ties shall determine each ICF/IID's per medicaid day direct care costs component rate. An ICF/IID's rate shall be determined as follows: (1) Determine the product of the following: (a) The ICF/IID's quarterly case-mix score determined or assigned under section 5124.193 of the Revised Code for the following calendar quarter: (i) For the rate determined for fiscal year 2019, the calendar quarter ending December 3...

...with division (C) of this section a per medicaid day quality incentive payment for each ICF/IID that earns for the fiscal year at least one point under division (B) of this section. (B) Each fiscal year beginning with fiscal year 2022, the department, in accordance with rules authorized by this section, shall award to an ICF/IID points for quality indicators the ICF/IID meets for the fiscal year. The quality indica...

...r one hundred per cent of the total per medicaid day payment rate determined for the ICF/IID under this chapter to reserve a bed for a resident who is a medicaid recipient if all of the following apply: (1) The recipient is temporarily absent from the ICF/IID for a reason that makes the absence qualified for payments under this section as specified in rules authorized by this section; (2) The resident's plan of car...

...orts each year to determine ICFs/IID's medicaid payment rates under this chapter in time to pay the rates by August fifteenth of each fiscal year. If the department is unable to calculate the rates so that they can be paid by that date, the department shall pay each provider the rate calculated for the provider's ICFs/IID under those sections at the end of the previous fiscal year. If the department also is una...

...vidual's age and cultural group. (P) "Medicaid case management services" means case management services provided to an individual with a developmental disability that the state medicaid plan requires. (Q) "Prevocational services" means services that provide learning and work experiences, including volunteer work experiences, from which an individual can develop general strengths and skills that are not specific t...

...ities shall pay the nonfederal share of medicaid expenditures for medicaid case management services the county board provides to an individual with a developmental disability who the county board determines under section 5126.041 of the Revised Code is eligible for county board services.

...(A) When the medicaid director is authorized by a statute to adopt a rule, the director shall adopt the rule in accordance with the following: (1) Chapter 119. of the Revised Code if either of the following applies: (a) The statute authorizing the rule requires that the rule be adopted in accordance with Chapter 119. of the Revised Code. (b) Unless division (A)(2)(b) of this section applies, the statute auth...

...The medicaid director is the executive head of the department of medicaid. All duties conferred on the department by law or order of the director are under the director's control and shall be performed in accordance with rules the director adopts.

...If the medicaid director determines that a position with the department of medicaid can best be filled in accordance with division (A)(2) of section 124.30 of the Revised Code or without regard to a residency requirement established by a rule adopted by the director of administrative services, the medicaid director shall provide the director of administrative services certification of the determination.

...The department of medicaid shall collaborate with the superintendent of the bureau of criminal identification and investigation to develop procedures and formats necessary to produce the notices described in division (D) of section 109.5721 of the Revised Code in a format that is acceptable for use by the department. The medicaid director may adopt rules under section 5160.02 of the Revised Code necessary for such co...

...ute enacted by the general assembly to medicaid or the medicaid program also means CHIP to the extent, if any, that CHIP is provided under the medicaid program. (B) As used in this chapter, "federal poverty line" means the official poverty line defined by the United States office of management and budget based on the most recent data available from the United States bureau of the census and revised by the Unit...

...The medicaid director shall adopt rules under sections 5160.02, 5162.02, 5163.02, 5164.02, 5165.02, 5166.02, and 5167.02 of the Revised Code as necessary to authorize the directors of other state agencies to adopt rules regarding medicaid components, or aspects of medicaid components, the other state agencies administer pursuant to contracts entered into under section 5162.35 of the Revised Code.

... U.S.C. 1396a(a)(5), the department of medicaid shall act as the single state agency to supervise the administration of the medicaid program. As the single state agency, the department shall comply with 42 C.F.R. 431.10(e) and all other federal requirements applicable to the single state agency.

...Annually, the department of medicaid shall prepare a report on the department's efforts to minimize fraud, waste, and abuse in the medicaid program. Each report shall be made available on the department's web site. The department shall submit a copy of each report to the governor, general assembly, and joint medicaid oversight committee. The copy to the general assembly shall be submitted in accordance with s...

...ministers one or more components of the medicaid program or administers one or more aspects of such a component, the department of medicaid may retain or collect not more than ten per cent of the federal financial participation the state agency or political subdivision obtains through an approved, administrative claim regarding the component or aspect of the component. If the department retains or collects a percenta...

...cial activities fund. The department of medicaid shall deposit all funds it receives pursuant to the administration of the medicaid program into the fund, other than any such funds that are required by law to be deposited into another fund. The department shall use the money in the fund to pay for expenses related to the services provided under, and the administration of, the medicaid program.

...fter July 1, 2017, to the department of medicaid pursuant to 42 C.F.R. 488.845. (B)(1) Money deposited into the fund pursuant to divisions (A)(1) and (2) of this section shall be used for all of the following: (a) Protection of the health or property of residents of nursing facilities in which the department of health finds deficiencies, including payment for the costs of relocation of residents to other facilities...

...The medicaid director shall implement within the medicaid program systems that do both of the following: (A) Improve the health of medicaid recipients through the use of population health measures; (B) Reduce health disparities, including, but not limited to, those within racial and ethnic populations.

...n under contract with the department of medicaid and, if the services are to be provided on a fee-for-service basis, the Medicaid program. (D) The medicaid director shall adopt rules, in accordance with Chapter 119. of the Revised Code, to carry out this section.

...al shall be denied eligibility for the medicaid buy-in for workers with disabilities program on the basis that the individual receives services under a home and community-based services medicaid waiver component.

...rvices requires that a provision of the medicaid buy-in for workers with disabilities program be changed or removed in order for the secretary to approve the program or to avoid an extended delay in the secretary's approval, the medicaid director shall make the change or removal. The change or removal may cause the medicaid buy-in for workers with disabilities program to include a provision that is inconsistent...

...(A) The medicaid director shall adopt rules under section 5163.02 of the Revised Code as necessary to implement the medicaid buy-in for workers with disabilities program. The rules shall do all of the following: (1) Specify assets, asset values, and amounts to be disregarded in determining asset and income eligibility limits for the program; (2) Establish meanings for the terms "earned income," "health insur...

...e available to pregnant women under the medicaid program during presumptive eligibility periods. ( 2) "Qualified provider" has the same meaning as in section 1920(b)(2) of the "Social Security Act," 42 U.S.C. 1396r-1(b)(2). (B) The medicaid director shall implement the presumptive eligibility for pregnant women option. Any entity that is eligible to be a qualified provider and requests to serve as a qualified prov...

...n individual presumptively eligible for medicaid under sections 5163.10 to 5163.102 of the Revised Code when the individual is ineligible for the medicaid program. (2) "Qualified entity" has the same meaning as in section 5163.101 of the Revised Code. (3) "Qualified provider" has the same meaning as in section 5163.10 of the Revised Code. (B) Notwithstanding sections 5163.10 to 5163.102 of the Revised Code, ...

...(A) The department of medicaid shall do all of the following with regard to the application procedures for the healthy start component of the medicaid program: (1) Establish a short application form for the component that requires the applicant to provide no more information than is necessary for making determinations of eligibility for the component, except that the form may require applicants to provide the...

...ed in division (B) of this section, the medicaid program shall cover remote ultrasound procedures and remote fetal nonstress tests, utilizing established current procedural terminology codes (CPT codes) for those procedures for when the patient is in a residence or other off-site location from the patient's medicaid provider. (B) The coverage under division (A) of this section applies only under the following circ...

...The medicaid program may cover a health care service that a pharmacist provides to a medicaid recipient in accordance with Chapter 4729. of the Revised Code, including any of the following services: (A) Managing drug therapy under a consult agreement pursuant to section 4729.39 of the Revised Code; (B) Administering immunizations in accordance with section 4729.41 of the Revised Code; (C) Administering drugs ...

...5119.36 of the Revised Code. (B) The medicaid program may cover the following mental health services when provided by community mental health services providers or facilities: (1) Outpatient mental health services, including, but not limited to, preventive, diagnostic, therapeutic, rehabilitative, and palliative interventions rendered to individuals in an individual or group setting by a mental health professio...

...The department of medicaid shall establish a credentialing program that includes a credentialing committee to review the competence, professional conduct, and quality of care provided by medicaid providers. Any activities performed by the credentialing committee shall be considered activities of a peer review committee of a health care entity and shall be subject to sections 2305.25 to 2305.253 of the Revised Code....

...vernment entity may participate in the medicaid program as a medicaid provider without a valid provider agreement with the department of medicaid.

...ed by federal statute or regulation, no medicaid payment for any medicaid service provided by a hospital, nursing facility, or ICF/IID shall exceed the limits established under Subpart C of 42 C.F.R. Part 447.

... of inpatient hospital care for which a medicaid payment is made on behalf of a medicaid recipient to a hospital that is not paid under a diagnostic-related-group prospective payment system shall not exceed thirty days during a period beginning on the day of the recipient's admission to the hospital and ending sixty days after the termination of that hospital stay, except that the department of medicaid may make exce...

...The division of any medicaid payment between a collaborating physician or podiatrist and a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner for services performed by the nurse shall be determined and agreed on by the nurse and collaborating physician or podiatrist. In no case shall the medicaid payment exceed the medicaid payment that the physician or podiatrist would have re...

...ble cost" means the per unit amount the medicaid program pays a terminal distributor of dangerous drugs for a prescribed drug included in the state maximum allowable cost program established under division (B) of this section. "State maximum allowable cost" excludes dispensing fees and copayments, coinsurance, or other cost-sharing charges, if any. (B) Subject to section 5167.123 of the Revised Code, the medicaid d...

...y even-numbered year, the department of medicaid shall initiate a confidential survey of the cost of dispensing drugs incurred by terminal distributors of dangerous drugs in this state. The survey shall be used as the basis for establishing the medicaid program's dispensing fees for terminal distributors in accordance with section 5164.753 of the Revised Code. The survey shall be completed and its results published n...

...cember of every even-numbered year, the medicaid director shall establish dispensing fees, effective the following July, for terminal distributors of dangerous drugs that are providers of drugs under the medicaid program. In establishing dispensing fees, the director shall take into consideration the results of the survey conducted under section 5164.752 of the Revised Code. The director may establish dispensing fees...

...plemental drug rebate agreement for the medicaid program that the department of medicaid receives from a pharmaceutical manufacturer or creates pursuant to negotiation of the agreement is not a public record under section 149.43 of the Revised Code and shall be treated by the department as confidential information.

...The medicaid director may implement within the medicaid program a system under which medicaid recipients with chronic conditions are provided with coordinated care through health homes, as authorized by the "Social Security Act," section 1945, 42 U.S.C. 1396w-4.

...The medicaid director, in consultation with the director of developmental disabilities, may develop and implement within the medicaid program a system under which eligible individuals with chronic conditions, as defined in the "Social Security Act," section 1945 (h)(1), 42 U.S.C. 1396w-4(h)(1), who also have developmental disabilities may receive health home services, as defined in the "Social Security Act," section ...

...The medicaid director may implement a demonstration project called the integrated care delivery system to test and evaluate the integration of the care that dual eligible individuals receive under medicare and medicaid. No provision of Title LI of the Revised Code applies to the integrated care delivery system if that provision implements or incorporates a provision of federal law governing medicaid and that p...

... imaging services. The department of medicaid shall implement evidence-based, best practice guidelines or protocols and decision support tools for advanced diagnostic imaging services covered by the fee-for-service component of the medicaid program.

...ider shall file with the department of medicaid an annual cost report for each of the provider's nursing facilities that participate in the medicaid program. The cost report for a year shall cover the calendar year or the portion of the calendar year during which the nursing facility participated in the medicaid program. Except as provided in division (D) of this section, the cost report is due not later than ...

...y under that section, the department of medicaid shall provide immediate written notice to the provider that the provider agreement for the nursing facility will be terminated in thirty days unless the provider submits a complete and adequate cost report for the nursing facility within thirty days. During the thirty-day termination period or any additional time allowed for an appeal of the proposed termination of a p...

...equired by the rules, the department of medicaid. The resident assessment data shall be submitted not later than fifteen days after the end of the calendar quarter for which the data is compiled. If the resident assessment data is to be submitted to the department of medicaid, it shall be submitted to the department through the medium or media specified in the rules. Rules adopted under section 5165.02 of the Revis...

...ized by this section, the department of medicaid shall do all of the following: (a) Every quarter, determine the following two case-mix scores for each nursing facility: (i) A quarterly case-mix score that includes each resident who is a medicaid recipient and is not a low case-mix resident; (ii) A quarterly case-mix score that includes each resident regardless of payment source. (b) Every six months, det...

...(A) The department of medicaid may, pursuant to rules authorized by this section, conduct an exception review of resident assessment data submitted by a nursing facility provider under section 5165.191 of the Revised Code. The department may conduct an exception review based on the findings of a medicaid certification survey conducted by the department of health, a risk analysis, or prior performance of the provider....

...The department of medicaid shall determine each nursing facility's per medicaid day payment rate for tax costs. The rate for tax costs determined under this division for a nursing facility shall be used for subsequent years until the department conducts a rebasing. To determine a nursing facility's rate for tax costs, the department shall divide the nursing facility's desk-reviewed, actual, allowable tax costs paid f...

... facility adds or replaces one or more medicaid certified beds to or at the nursing facility, or renovates one or more of the nursing facility's beds, the medicaid payment rate for the added, replaced, or renovated beds shall be the same as the medicaid payment rate for the nursing facility's existing beds.

...The department of medicaid shall not reduce a nursing facility's medicaid payment rate determined under this chapter on the basis that the provider charges a lower rate to any resident who is not eligible for medicaid.

...The medicaid director shall adopt rules under section 5165.02 of the Revised Code that establish a process under which a nursing facility provider, or a group or association of nursing facility providers, may seek reconsideration of medicaid payment rates established under this chapter, including a rate for direct care costs recalculated before the effective date of the rate as a result of an exception review o...

...ized by this chapter, the department of medicaid may impose the following penalties on a nursing facility provider: (A) If the provider does not furnish invoices or other documentation that the department requests during an audit within sixty days after the request, a fine of no more than the greater of the following: (1) One thousand dollars per audit; (2) Twenty-five per cent of the cumulative amount by which th...

...(B) of this section, the department of medicaid shall deduct the following from the next available medicaid payment the department makes to a nursing facility provider who continues to participate in medicaid: (1) Any amount the provider is required to refund, and any interest charged, under section 5165.41 of the Revised Code; (2) The amount of any penalty imposed on the provider under section 5165.42 of th...

...dit disallowance that the department of medicaid makes as the result of an audit under section 5165.109 of the Revised Code; (B) Any adverse finding that results from an exception review of resident assessment data conducted for a nursing facility under section 5165.193 of the Revised Code after the effective date of the nursing facility's medicaid payment rate for direct care costs that is based on the reside...

... nursing facility participating in the medicaid program shall provide the department of medicaid written notice of a facility closure or voluntary withdrawal of participation not less than ninety days before the effective date of the facility closure or voluntary withdrawal of participation. The written notice shall be provided to the department in accordance with the method specified in rules authorized by se...

...The medicaid director may adopt rules under section 5165.02 of the Revised Code governing adjustments to the medicaid payment rate for a nursing facility that undergoes a change of operator. No rate adjustment resulting from a change of operator shall be effective before the effective date of the entering operator's provider agreement. This is the case regardless of whether the provider agreement is entered int...

...The medicaid director shall adopt rules under section 5165.02 of the Revised Code to implement sections 5165.50 to 5165.53 of the Revised Code, including rules applicable to an exiting operator that provides written notification under section 5165.50 of the Revised Code of a voluntary withdrawal of participation. Rules adopted under this section shall comply with the "Social Security Act," section 1919(c)(2)(F)...

... into a contract with the department of medicaid under section 5165.63 of the Revised Code. (D)(1) "Deficiency" means a finding cited by the department of health during a survey, on the basis of one or more actions, practices, situations, or incidents occurring at a nursing facility, that constitutes a severity level three finding, severity level four finding, scope level three finding, or scope level four fin...

...ll cite it. However, the department of medicaid or a contracting agency shall impose a remedy only as provided in division (C) of section 5165.72 of the Revised Code. (F) Immediately upon determining the severity and scope of a finding at a nursing facility, the department of health shall notify the department of medicaid and any contracting agency of the finding, the severity and scope of the finding, and whet...

...l be the designee of the department of medicaid for the purpose of conducting a hearing pursuant to section 3721.162 of the Revised Code concerning a nursing facility's decision to transfer or discharge a resident if the resident is a medicaid recipient or medicare beneficiary.

...lly accountable for funds expended for medicaid services covered by the home and community-based services medicaid waiver components that the agency administers.

... into a contract with the department of medicaid under section 5162.35 of the Revised Code to administer a home and community-based services medicaid waiver component, or one or more aspects of such a component, shall provide the department a written assurance that the agency or subdivision will not violate any of the requirements of sections 5166.01 to 5166.07 of the Revised Code.

...The department of medicaid shall ensure that each ICDS participant who is a survivor of the Holocaust that occurred in Europe during World War II receives, while enrolled in the ICDS medicaid waiver component, home and community-based services of the type and in at least the amount, duration, and scope that the participant is assessed to need and would have received if the participant were enrolled in an ODA or MCD m...

...ogram participant ceases to qualify for medicaid due to increased family countable income and purchases a health insurance policy or obtains health care coverage under an eligible employer-sponsored health plan, the amount remaining in the former participant's buckeye account shall be transferred to an account to be known as a bridge account. The amount so transferred may be used only to pay for the following: (1) I...

... 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 department shall make available on its internet web site the metrics the department uses to...

...tion 5167.10 of the 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.

...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 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.

...year or at a later date approved by the medicaid director, shall submit to the department of medicaid a financial statement for the preceding calendar year that accurately reflects the income, expenses, assets, liabilities, and net worth of the hospital, and accompanying notes. A hospital that has a fiscal year different from the calendar year shall file its financial statement within one hundred eighty days of the e...

...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...

...(A) The medicaid director shall adopt rules in accordance with Chapter 119. of the Revised Code as necessary to implement sections 5168.20 to 5168.28 of the Revised Code, including rules that specify the percentage of hospitals' total facility costs to be used in calculating hospitals' assessments under section 5168.21 of the Revised Code. (B) The rules adopted under this section may do the following: (1) Provi...

...The medicaid director shall implement the assessment imposed by section 5168.21 of the Revised Code in a manner that does not cause a reduction in federal financial participation for the medicaid program under the "Social Security Act," section 1903(w), 42 U.S.C. 1396b(w).

...The department of medicaid shall do all of the following: (A) Subject to sections 5168.44, 5168.45, and 5168.48 of the Revised Code and divisions (C) and (D) of this section and for the purposes specified in section 5168.54 of the Revised Code, determine an annual franchise permit fee on each nursing home in an amount equal to the franchise permit fee rate multiplied by the product of the following: (1) The ...

...after July 17, 2009, the department of medicaid shall apply to the United States secretary of health and human services for a waiver under the "Social Security Act," section 1903(w)(3)(E), 42 U.S.C. 1396b(w)(3)(E), as necessary to do both of the following regarding the franchise permit fee assessed under section 5168.42 of the Revised Code: (1) Reduce the franchise permit fee rate to zero dollars for each nu...

... of the Revised Code, the department of medicaid shall use the money in the fund to make medicaid payments to providers of nursing facility services and providers of home and community-based services, and to fund expanding the state ombudsman long-term care program and resident and family surveys at the department of aging, the addition of surveyors at the department of health, and to fund quality and consumer inform...

...The medicaid director shall adopt rules in accordance with Chapter 119. of the Revised Code to do both of the following: (A) Prescribe the actions the department of medicaid will take to cease implementation of sections 5168.40 to 5168.56 of the Revised Code if the United States centers for medicare and medicaid services determines that the franchise permit fee established by those sections is an impermissibl...

... job and family services, department of medicaid, commission on minority health, Ohio fatherhood commission, and children's trust fund board, to implement the help me grow program, to ensure coordination of early childhood programs, and to maximize reimbursement for the help me grow program from any federal source. In addition to creating the central intake and referral system as described in section 5180.22 of th...

...the location of the enrollee for whom a medicaid health insurance corporation receives managed care premiums. Such sales shall be sourced to the locations of the enrollees in the same proportion as the managed care premiums received by the medicaid health insuring corporation on behalf of enrollees located in a particular taxing jurisdiction in Ohio as compared to all managed care premiums received by the medicaid he...

...he person's trade or profession; (b) Medicaid-funded services, including administrative and management services, provided pursuant to a contract or medicaid provider agreement that meets the requirements of the medicaid program. (c) Services, other than administrative or management services or any of the services described in division (B)(2)(a) or (b) of this section, that are commonly purchased by the public a...

...investigate state and local government medicaid agencies. Subject to division (B) of this section, all of the following apply to an investigation: (1) JMOC, including its employees, may inspect the offices of a state and local government medicaid agency as necessary for the conduct of the investigation. (2) No person shall deny JMOC or a JMOC employee access to such an office when access is needed for such an...

...a person or government entity furnishes medicaid services under a provider agreement with the department of medicaid. (C) "Rule" means any rule, regulation, or standard, having a general and uniform operation, adopted, promulgated, and enforced by any agency under the authority of the laws governing such agency, and includes any appendix to a rule. "Rule" does not include any internal management rule of an agency ...

...rans services; (T) The department of medicaid, which shall be administered by the medicaid director; (U) The department of education and workforce, which shall be administered by the director of education and workforce. The director of each department shall exercise the powers and perform the duties vested by law in such department.

... the provisions are suspended; (b) The medicaid director provides the certification under section 5160.051 of the Revised Code that a position with the department of medicaid can best be filled if the provisions are suspended. (3) The acceptance or refusal by an eligible person of a temporary appointment shall not affect the person's standing on the eligible list for permanent appointment, nor shall the period...

...artments of job and family services and medicaid to deploy private sector tools for digital identity management, authentication, and verification for individuals receiving medicaid benefits, supplemental nutrition assistance program benefits, or benefits funded by the temporary assistance for needy families block grant. These private sector tools shall include joining available multistate cooperatives to identify ind...

...unt, as defined by rules adopted by the medicaid director, up to and including the maximum resource limitation, of a medicaid recipient who has died after receiving care in a long-term care facility, and for whom there is no identifiable heir or sponsor, are not subject to this chapter. (S)(1) Funds held or owed by a holder pursuant to a preneed funeral contract, as defined in section 4717.01 of the Revised Code, u...

...diate level of care. The department of medicaid or an agency under contract pursuant to division (C) of this section shall conduct the assessment. The assessment may be performed concurrently with a long-term care consultation provided under section 173.42 of the Revised Code. (B) An applicant or applicant's representative has the right to appeal an assessment's findings. Section 5160.31 of the Revised Code a...

...th insuring corporation to cover solely medicaid recipients; (2) A health insuring corporation to cover solely medicare beneficiaries; (3) A health insuring corporation to cover solely medicaid recipients and medicare beneficiaries; (4) A health insuring corporation to cover solely federal employees and other individuals eligible for coverage in the federal employees health benefits program pursuant to 5 U.S.C. 89...

...insuring corporation that covers solely medicaid recipients; (2) A health insuring corporation that covers solely medicare beneficiaries; (3) A health insuring corporation that covers solely medicaid recipients and medicare beneficiaries. (C) An examination, pursuant to section 3901.07 of the Revised Code, of an insurance company holding a certificate of authority under this chapter to organize and operate a...

..., as amended; (B) Coverage provided to medicaid recipients; (C) Coverage provided to participants of the children's buy-in program.

...neral's designee, if the department of medicaid is seeking to recover the costs of medicaid services from the deceased pursuant to section 5162.21 or 5162.211 of the Revised Code. The person granted administration may be a creditor of the estate. (D) This section applies to the appointment of an administrator de bonis non.

...g her pregnancy, was a recipient of the medicaid program or other public health insurance program and, if so, the dates her eligibility began and ended; (ii) Whether the mother, during her pregnancy, was covered by private health insurance and, if so, the dates the coverage began and ended, the name of the insurance provider, the type of coverage, and the identification number of the coverage; (iii) The name an...

...) Medical assistance provided under the medicaid program shall not include coverage for gender transition services for minor individuals. (B) This section does not apply to any of the following: (1) The circumstances described in section 3129.04 of the Revised Code; (2) Mental health services provided for a gender-related condition; (3) Any services that are not gender transition services.

...ervice established by the department of medicaid under the medicaid program.

... and family services, the department of medicaid, and the department of rehabilitation and corrections, shall provide any information and data to the secretary of state that is collected in the course of normal business and that is necessary to register to vote, to update an elector's registration, or to maintain the statewide voter registration database, except where prohibited by federal law or regulation. The depa...

...3701.0210 of the Revised Code. (C) A medicaid provider, as defined in section 5164.01 of the Revised Code, is eligible to be a provider of the same goods and services for the program for children and youth with special health care needs that the provider is approved to provide for the medicaid program and the director shall approve such a provider for participation in the program for children and youth with specia...

...hose chapters; (c) The department of medicaid or a county department of job and family services, in accordance with Chapters 5160., 5161., 5162., 5163., 5164., 5165., 5166., and 5167. of the Revised Code and the rules adopted under those chapters; (d) The attorney general, in accordance with sections 2743.51 to 2743.72 of the Revised Code and any rules that may be adopted under those sections; (e) A patient,...

...cally underserved population, including medicaid recipients and individuals without health insurance. (c) The advisory group shall recommend not fewer than six practices that serve rural areas of this state, as those areas are determined by the advisory group. (d) A member of the advisory group shall abstain from participating in any vote taken regarding the recommendation of a practice if the member would rec...

... United States centers for medicare and medicaid services as part of the certification process for the medicare program established under Title XVIII of the "Social Security Act," 79 Stat. 286 (1935), 42 U.S.C.A. 1395, as amended, and the medicaid program established under Title XIX of the "Social Security Act," 79 Stat. 286 (1965), 42 U.S.C. 1396. (4) The director shall not establish a fee for any service for whi...

...3701. or 4123. of the Revised Code, the medicaid program, or any self-insurance plan. (H) "Government unit" means the state and any county, municipal corporation, township, or other political subdivision of the state, or any department, division, board, or other agency of the state or a political subdivision. (I) "Health maintenance organization" means a public or private organization organized under the law of a...

...ome does not participate in medicare or medicaid; (3) All of the long-term care beds being added to the nursing home are to be used solely for the provision of palliative care, as defined in section 3712.01 of the Revised Code. ( B) The continued use of long-term care beds added to a nursing home under this section is a reviewable activity under sections 3702.51 to 3702.62 of the Revised Code if either of the fol...

...ticipate in the medicare program or the medicaid program if on January 1, 1994, the facility, infirmary, or entity was providing care exclusively to members of the religious order; (x) A county home or district home that has never been licensed as a residential care facility. (2) "Unrelated individual" means one who is not related to the owner or operator of a home or to the spouse of the owner or operator as a...

...ning to home health care adopted by the medicaid director for the medicaid program. Skilled nursing care provided pursuant to this division may be provided by a home health agency certified for participation in the medicare program, a hospice care program licensed under Chapter 3712. of the Revised Code, or a member of the staff of a residential care facility who is qualified to perform skilled nursing care. A resi...

...these functions with the department of medicaid and the United States department of health and human services. The director may also enter into agreements with the department of medicaid under which the department of health is designated to perform functions under sections 5165.60 to 5165.89 of the Revised Code. The director, in accordance with Chapter 119. of the Revised Code, shall adopt rules necessary to i...

...eneral assembly that the department of medicaid shall terminate the medicaid provider agreements of those homes that do not comply with the requirements of this section for the submission of a written fire safety plan and the deadline for entering into contracts for the installation of systems.

...d, the state departments of health and medicaid, the state and local offices of the department of aging, and any Ohio nursing home ombudsman program. (B) Written acknowledgment of the receipt of copies of the materials listed in this section shall be made part of the resident's record and the staff member's personnel record. (C) The administrator shall post all of the following prominently within the home: (1...

...g of the complaint to the department of medicaid if the department has a right of recovery under section 5160.37 of the Revised Code against the liability of the home for the cost of medicaid services arising out of injury, disease, or disability of the resident or former resident.

... United States centers for medicare and medicaid services, specifically: "__standardcharges.[jsonxmlcsv]." (G) For purposes of division (F)(3) of this section, the director of health shall develop a template that each hospital shall use in formatting the list. In developing the template, the director shall do both of the following: (1) Consider any applicable federal guidelines for formattin...

...teria specified in rules adopted by the medicaid director under section 3798.13 of the Revised Code. (J) "More stringent" has the same meaning as in 45 C.F.R. 160.202. (K) "Personal representative" means a person who has authority under applicable law to make decisions related to health care on behalf of an adult or emancipated minor, or the parent, legal guardian, or other person acting in loco parentis who is...

...(A) The medicaid director shall prescribe by rules adopted in accordance with Chapter 119. of the Revised Code a standard authorization form for the use and disclosure of protected health information by covered entities in this state. The form shall meet all requirements specified in 45 C.F.R. 164.508 and, where applicable, 42 C.F.R. part 2. (B) If a form the medicaid director prescribes under division (A) of this ...

...enced in 42 U.S.C. 1396a(a)(25); (6) A medicaid managed care organization that has entered into a contract with the department of medicaid pursuant to section 5167.10 of the Revised Code; (7) Any other person or government entity that is, by law, contract, or agreement, responsible for paying for or processing a claim for payment for the provision of dangerous drugs or pharmacy services. (F) "Pharmacy audit" means...

...coverage under a plan through medicare, medicaid, or the federal employees benefit program; any coverage issued under Chapter 55 of Title 10 of the United States Code and any coverage issued as a supplement to that coverage. (M) "Health care professional" means a physician, psychologist, nurse practitioner, or other health care practitioner licensed, accredited, or certified to perform health care services con...

...pose requirements on the department of medicaid, when it has been assigned the rights of an individual who is eligible for medicaid and who is covered under a health care policy, contract, or plan issued by the health insurer, that are different from the requirements applicable to an agent or assignee of any other individual so covered.

...n. (2) The credentialing process for a medicaid managed care plan starts when the provider submits a credentialing form and the provider's national provider number issued by the centers for medicare and medicaid services. (3) The requirement that the credentialing process be completed within the ninety-day period specified in division (C)(1) of this section does not apply to a contracting entity if a provi...

...and 5108. of the Revised Code; (3) The medicaid program; (4) The supplemental nutrition assistance program pursuant to the Food and Nutrition Act of 2008 (7 U.S.C. 2011 et seq.; (5) Any Ohio program under a plan approved under Title I, X, XIV, or XVI of the "Social Security Act." Wage information provided by employers to the director shall be furnished to the income and eligibility verification system. Such ...

... in a home and community-based services medicaid waiver component, as defined in section 5166.01 of the Revised Code; (16) A facility operated by the board of health of a city or general health district or the authority having the duties of a board of health under section 3709.05 of the Revised Code; (17) A women, infants, and children clinic; (18) A mobile dental facility, as defined in section 4715.70 of t...

... this section, "340B covered entity, " "medicaid managed care organization, " and "third-party administrator" have the same meanings as in section 5167.01 of the Revised Code. (B) A contract between a terminal distributor of dangerous drugs and a 340B covered entity shall require the terminal distributor to comply with division (C) of this section. (C) When paying a 340B covered entity for a dangerous drug dispen...

...urred. The board also shall notify the medicaid director if the board determines that the violation may have been committed by a provider of services under a program administered by the department of medicaid.

... violation. If a refund is owed to the medicaid program, the auditor of state also shall report the amount to the department of medicaid. The state medical board also may implement procedures to detect violations of section 4731.66 or 4731.69 of the Revised Code.

...refund or reconciliation related to the medicaid program, the department shall transfer the money to the department of medicaid for deposit into the refunds and reconciliation fund created under section 5162.65 of the Revised Code.

...Title IV-E and costs reimbursable under medicaid; (2) Procedures to monitor cost reports submitted by the agencies or entities. (B) The procedures established under division (A)(2) of this section shall be implemented not later than October 1, 2003. The procedures shall be used to do both of the following: (1) Determine which of the costs are reimbursable under Title IV-E; (2) Ensure that costs reimbursab...

...eria: (1) Under rules adopted by the medicaid director governing medicaid payments for long-term care services, the children require a skilled level of care. (2) The children require the services of a doctor of medicine or osteopathic medicine at least once a week due to the instability of their medical conditions. (3) The children require the services of a registered nurse on a daily basis. (4) The child...

...ties shall pay the nonfederal share of medicaid expenditures for medicaid case management services and home and community-based services for which no county board of developmental disabilities is required by section 5126.059 or 5126.0510 of the Revised Code to pay.

...r. The programs may include one or more medicaid waiver components that the director administers pursuant to section 5166.21 of the Revised Code. The programs may do one or more of the following: (1) Establish models that incorporate elements common to effective intervention programs and evidence-based practices in services for children with intensive behavioral needs; (2) Design a template for individualized educa...

...overnment entity's authority to provide medicaid-funded supported living is revoked or renewal of the authority is refused pursuant to section 5123.1610 of the Revised Code, neither the person or government entity nor a related party of the person or government entity may apply for authority to provide medicaid-funded supported living again earlier than the date this is five years after the date the authority is rev...

...The medicaid program shall cover ICF/IID services when all of the following apply: (A) The ICF/IID services are provided to a medicaid recipient eligible for the services. (B) The ICF/IID services are provided by an ICF/IID for which the provider has a valid provider agreement. (C) Federal financial participation is available for the ICF/IID services.

...irector of health for participation in medicaid; (2) The ICF/IID is licensed by the director of developmental disabilities as a residential facility; (3) Subject to division (B) of this section, the operator and ICF/IID comply with all applicable state and federal statutes and rules. (B) A state rule that requires an ICF/IID operator to have received approval of a plan for the proposed ICF/IID pursuant to se...

...g which the ICF/IID participated in the medicaid program. Except as provided in division (E) of this section, the cost report is due not later than ninety days after the end of the calendar year, or portion of the calendar year, that the cost report covers. (B)(1) If an ICF/IID undergoes a change of provider that the department determines, in accordance with rules adopted under section 5124.03 of the Revised Code, i...

...thorized by this section, the total per medicaid day payment rate determined under section 5124.15 of the Revised Code shall not be paid for ICF/IID services that an ICF/IID not designated as an outlier ICF/IID or unit provides to a resident who meets the criteria for admission to a designated outlier ICF/IID or unit, as specified in rules authorized by section 5124.152 of the Revised Code. Instead, the provide...

...s is not required to pay the total per medicaid day payment rates determined under section 5124.15 of the Revised Code for ICF/IID services provided by developmental centers. Instead, the department may determine the medicaid payment rates for developmental centers according to the reasonable cost principles of Title XVIII.

...ties shall determine each ICF/IID's per medicaid day indirect care costs component rate. An ICF/IID's rate shall be the lesser of the individual rate determined under division (B) of this section and the maximum rate determined for the ICF/IID's peer group under division (C) of this section. (B) An ICF/IID's individual rate is the sum of the following: (1) The ICF/IID's desk-reviewed, actual, allowable, per diem ...

...ties shall determine each ICF/IID's per medicaid day other protected costs component rate. An ICF/IID's rate shall be the ICF/IID's desk-reviewed, actual, allowable, per diem other protected costs from the applicable cost report year, adjusted for inflation using the following: (A) Subject to division (B) of this section, the consumer price index for all urban consumers for nonprescription drugs and medical supplie...

...bilities shall not reduce an ICF/IID's medicaid payment rate determined under this chapter on the basis that the provider charges a lower rate to any resident who is not eligible for medicaid.

...No medicaid payment shall be made to an ICF/IID provider for the day a medicaid recipient is discharged from the ICF/IID, unless the recipient is discharged from the ICF/IID because all of the beds in the ICF/IID are converted from providing ICF/IID services to providing home and community-based services pursuant to section 5124.60 or 5124.61 of the Revised Code.

...Medicaid payments may be made for ICF/IID services provided not later than thirty days after the effective date of an involuntary termination of the ICF/IID that provides the services if the services are provided to a medicaid recipient who is eligible for the services and resided in the ICF/IID before the effective date of the involuntary termination.

... the following from the next available medicaid payment the department makes to an ICF/IID provider who continues to participate in medicaid: (1) Any amount the provider is required to refund, and any interest charged, under section 5124.41 of the Revised Code; (2) The amount of any penalty imposed on the provider under section 5124.42 of the Revised Code. (B) The department and an ICF/IID provider may enter...

...tor of the ICF/IID for purposes of the medicaid program, including medicaid payments, until the effective date of the entering operator's provider agreement if the provider agreement is entered into under section 5124.511 or 5124.512 of the Revised Code.

...ised Code governing adjustments to the medicaid reimbursement rate for an ICF/IID that undergoes a change of operator. No rate adjustment resulting from a change of operator shall be effective before the effective date of the entering operator's provider agreement. This is the case regardless of whether the provider agreement is entered into under section 5124.511, section 5124.512, or, pursuant to section 512...

...opmental disabilities or department of medicaid of whether or when a change of operator occurs; (B) The department of medicaid's determination of the effective date of an entering operator's provider agreement under section 5124.511, section 5124.512, or, pursuant to section 5124.515, section 5124.07 of the Revised Code.

...United States centers for medicare and medicaid services under the medicaid program, as follows: (A) Unless the department issues the initial debt summary report required by section 5124.525 of the Revised Code not later than sixty days after the date the exiting operator files the properly completed cost report required by section 5124.522 of the Revised Code, sixty-one days after the date the exiting operat...

...s solely to pay the nonfederal share of medicaid expenditures it is required to pay under sections 5126.059 and 5126.0510 of the Revised Code. Tax equity payments shall not be used to pay any salary or other compensation to county board personnel. (2) Upon the written request of a county board, the director of developmental disabilities may authorize a county board to use tax equity payments for infrastructure...

...The medicaid director may appoint such employees as are necessary for the efficient operation of the department of medicaid. The director may prescribe the title and duties of the employees.

...The medicaid director may require any of the employees of the department of medicaid who may be charged with custody or control of any public money or property or who is required to give bond, to give a bond, properly conditioned, in a sum to be fixed by the director which when approved by the director, shall be filed in the office of the secretary of state. The cost of such bonds, when approved by the director...

...The medicaid director may expend funds appropriated or available to the department of medicaid from persons and government entities. For purposes of this section, the director may enter into contracts or agreements with persons and government entities and make grants to persons and government entities. To the extent permitted by federal law, the director may advance funds to a grantee when necessary for the gra...

...ogram administered by the department of medicaid or any private entity under contract with a public entity to implement a program administered by the department, the department may seek to obtain federal financial participation for costs incurred by the entity. Federal financial participation may be sought from programs operated pursuant to Title XIX of the "Social Security Act," 42 U.S.C. 1396, et seq., and an...

...(A) The department of medicaid may conduct any audits or investigations that are necessary in the performance of the department's duties, and to that end, the department has the same power as a judge of a county court to administer oaths and to enforce the attendance and testimony of witnesses and the production of books or papers. The department shall keep a record of the department's audits and investigatio...

...On the request of the medicaid director, the auditor of state may conduct an audit of any medical assistance recipient. If the auditor decides to conduct an audit under this section, the auditor shall enter into an interagency agreement with the department of medicaid that specifies that the auditor agrees to comply with section 5160.45 of the Revised Code with respect to any information the auditor receives pu...

...rinted format, in the possession of the medicaid director or any county director of job and family services, regarding medical assistance programs. The auditor of state and attorney general shall do both of the following regarding the records: (1) Provide safeguards that restrict access to the records to purposes directly connected with an audit or investigation, prosecution, or criminal or civil proceeding co...

...d Code is received by the department of medicaid or an entity with which the department has entered into an agreement under section 5160.30 of the Revised Code, the department or entity shall do both of the following on at least a quarterly basis and in accordance with federal regulations: (a) Review the information to determine whether it indicates a change in circumstances that may affect eligibility for a med...

...zed by this section, the department of medicaid shall do one or more of the following: (1) Administer an appeals process similar to the appeals process established under section 5101.35 of the Revised Code; (2) Contract with the department of job and family services pursuant to section 5162.35 of the Revised Code to provide for the department of job and family services to hear the appeals in accordance with se...

...shall cooperate with the department of medicaid in identifying individuals for the purpose of establishing third party liability regarding medical assistance programs. (B) In furtherance of the requirement in division (A) of this section and to allow the department to determine any period that the individual or the individual's spouse or dependent may have been covered by the third party and the nature of the...

...red, or maintained by the department of medicaid, a county department of job and family services, or an entity performing duties on behalf of the department or a county department. (B) Except as permitted by this section, section 5160.47, or rules authorized by section 5160.48 or 5160.481 of the Revised Code, or when required by federal law, no person or government entity shall use or disclose information rega...

...(A) The medicaid director shall adopt rules under section 5160.02 of the Revised Code implementing sections 5160.45 to 5160.481 of the Revised Code and governing the custody, use, disclosure, and preservation of the information generated or received by the department of medicaid, county departments of job and family services, other state and county entities, contractors, grantees, private entities, or officials...

...The medicaid director may provide for the department of medicaid to develop, participate in the development of, negotiate, and enter into one or more interstate compacts on behalf of this state with agencies of any other states, for the provision of medical assistance to children in relation to whom all of the following apply: (A) They have special needs. (B) This state or another state that is a party to the...

...A completed application for medicaid shall be treated as an application for the children's health insurance program if the application is for an assistance group that includes a child under nineteen years of age and is denied.

...(A) The medicaid director may submit a waiver request to the United States secretary of health and human services to provide health assistance to any individual who meets all of the following requirements: (1) Is the parent of a child who is under nineteen years of age, resides with the parent, and is enrolled in the children's health insurance program part I or II or the medicaid program; (2) Is uninsured; ...

...onent, or aspect of a component, of the medicaid program shall be implemented without all of the following: (1) Subject to division (B) of this section, if the component, or aspect of the component, requires federal approval, receipt of the federal approval; (2) Sufficient federal financial participation for the component or aspect of the component; (3) Sufficient nonfederal funds for the component or aspect of...

...r than the first day of each July, the medicaid director shall complete a report of the evaluation conducted under section 5164.911 of the Revised Code regarding the integrated care delivery system. The director shall provide a copy of the report to the general assembly and joint medicaid oversight committee. The copy to the general assembly shall be provided in accordance with section 101.68 of the Revised Cod...

...Annually, the department of medicaid shall conduct a cost savings study of the medicaid program and prepare a report based on that study recommending measures to reduce costs under that program. The department shall submit its report to the governor.

... of the Revised Code, the department of medicaid may, to the extent necessary to reimburse its costs, garnish the wages, salary, or other employment income of, and withhold amounts from state tax refunds to, any person to whom both of the following apply: (1) The person is required by a court or administrative order to provide coverage of the cost of health care services to a child eligible for medicaid. (2) ...

...The department of medicaid may enter into contracts with political subdivisions to use funds of the political subdivision to pay the nonfederal share of expenditures under the medicaid program. The determination and provision of federal financial participation to a subdivision entering into a contract under this section shall be determined by the department, subject to section 5162.40 of the Revised Code.

...The medicaid director shall implement within the medicaid program strategies that address social determinants of health, including employment, housing, transportation, food, interpersonal safety, and toxic stress.