Ohio Revised Code Search

...medicaid recipient participating in the healthy Ohio program established under section 5166.40 of the Revised Code shall participate in the system. The general assembly's authorization through the enactment of legislation is needed before home and community-based services available under a medicaid waiver component or nursing facility services are included in the care management system, except that ICDS participant...

... shall not require that an entity be a health insuring corporation as a condition of receiving the department's recognition. (2) Any of the following entities may receive the department's recognition, if the standards for recognition have been met: (a) A children's care network; (b) A children's care network that may include one or more other entities, including, but not limited to, health insuring corporati...

...ude alcohol, drug addiction, and mental health services covered by medicaid in the care management system.

...The department of medicaid may include prescribed drugs covered by the medicaid program in the care management system.

...If the medicaid program covers the pharmacist services described in section 5164.14 of the Revised Code, the department of medicaid may include the services in the care management system.

...ovide, or arrange for the provision of, health care services to medicaid recipients who are required or permitted to participate in the care management system.

...(A) Subject to division (B) of this section, the department of medicaid or its actuary shall base the hospital inpatient capital payment portion of the payment made to a medicaid managed care organization on data for services provided to all of the organization's enrollees, as reported by hospitals on relevant cost reports submitted pursuant to rules adopted under section 5167.02 of the Revised Code. (B) The hospit...

...In addition to the managed care performance payment program created under section 5167.30 of the Revised Code, the department of medicaid shall establish performance metrics that will be used to evaluate and compare how medicaid managed care organizations perform under the contracts entered into under section 5167.10 of the Revised Code. The performance metrics may include financial incentives and penalties. The de...

...Each medicaid managed care organization shall provide a grievance process for the organization's enrollees in accordance with 42 C.F.R. 438, subpart F.

...ocation on behalf of a community mental health services provider whose mental health services are certified by the department of mental health and addiction services under section 5119.36 of the Revised Code; (c) A certified nurse practitioner, as defined in section 4723.01 of the Revised Code, who is certified in psychiatric mental health by a national certifying organization approved by the board of nursing unde...

...(A) The state pharmacy benefit manager shall, on request from the department of medicaid, disclose to the department all sources of payment it receives for prescribed drugs, including any financial benefits such as drug rebates, discounts, credits, clawbacks, fees, grants, chargebacks, reimbursements, or other payments related to services provided for the medicaid managed care organization. (B) Each medicaid manage...

...); (2) A fee that is not imposed on a health care provider that is not a 340B covered entity; (3) A fee amount that exceeds the amount for a health care provider that is not a 340B covered entity. (B) The organization, or its contracted third-party administrators, shall not discriminate against a 340B covered entity in a manner that prevents or interferes with a medicaid recipient's choice to receive a prescrip...

...Each medicaid managed care organization shall implement a coordinated services program for the organization's enrollees who are found to have obtained prescribed drugs under the medicaid program at a frequency or in an amount that is not medically necessary. The program shall be implemented in a manner that is consistent with section 1915(a)(2) of the "Social Security Act," 42 U.S.C. 1396n(a)(2), and 42 C.F.R. 431.54...

...Each medicaid managed care organization shall enter into a data security agreement with the state board of pharmacy governing the managed care organization's use of the board's drug database established and maintained under section 4729.75 of the Revised Code. This section does not apply if the board no longer maintains the drug database.

...When contracting under section 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.

...rogram established by the department of health pursuant to section 5180.21 of the Revised Code. (2) "Targeted case management" has the same meaning as in 42 C.F.R. 440.169(b). (B) A medicaid managed care organization shall provide to a medicaid recipient who meets the criteria in division (C) of this section, or arrange for such recipient to receive, both of the following types of services: (1) Home visits, ...

...rtality, as well as improve the overall health status of women capable of becoming pregnant for the purpose of ensuring optimal future birth outcomes.

...Each medicaid managed care organization shall, if the organization requires practitioners to obtain prior approval before administering progesterone to the organization's enrollees who are pregnant, use a uniform prior approval form for progesterone that is not more than one page.

...ion 4723.81 of the Revised Code. (4) "Public health nurse" means a registered nurse employed or contracted by a board of health. (5) "Qualified community hub" means a central clearinghouse for a network of community care coordination agencies that meets all of the following criteria: (a) Demonstrates to the director of health that it uses an evidenced-based, pay-for-performance community care coordination model...

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

...fore January 1, 2006, with at least one health insuring corporation serving the participants specified in division (B)(1) of this section; (3) The hospital remains under contract with at least one health insuring corporation serving participants in the care management system who are required to be enrolled in a medicaid MCO plan. (C) The medicaid director shall adopt rules under section 5167.02 of the Revised Co...

...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...

...rector, and United States secretary of health and human services jointly enter into under the integrated care delivery system authorized by section 5164.91 of the Revised Code. (C) A medicaid managed care organization is required to pay the rate specified in division (B) of this section for covered skilled nursing facility services only if all of the following apply: (1) The United States secretary agrees to ...

...When a medicaid managed care organization seeks to recoup an overpayment made to a provider, it shall provide the provider all of the details of the recoupment, including all of the following information: (A) The name, address, and medicaid identification number of the enrollee to whom the services were provided; (B) The date or dates that the services were provided; (C) The reason for the recoupment; (D) Th...

...The department of medicaid shall assess the efforts of medicaid managed care organizations to recoup overpayments made to providers who are network providers and providers who are not network providers. The assessments shall examine the amount of time recoupment efforts take starting from the time providers receive final payment and ending when the recoupment effort is completed. Each medicaid managed care organizati...