Ohio Revised Code Search

...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.

...The department of medicaid may enter into contracts with managed care organizations under which the organizations are authorized to provide, or arrange for the provision of, health care services to medicaid recipients who are required or permitted to participate in the care management system.

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

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

...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.

...he drug is prescribed for a use that is indicated on the drug's labeling, as approved by the federal food and drug administration. (C) The department shall authorize a medicaid MCO plan to include a pharmacy utilization management program under which prior authorization through the program is established as a condition of obtaining a controlled substance pursuant to a prescription. (D) Each medicaid managed car...

...(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...

...(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...

...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.

...(A) As used in this section: (1) "Help me grow program" means the program 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 ...

...Each medicaid managed care organization shall provide enhanced care management services for pregnant women and women capable of becoming pregnant in the communities specified in rules adopted under section 3701.142 of the Revised Code. The services shall be provided in a manner intended to decrease the incidence of prematurity, low birth weight, and infant mortality, as well as improve the overall health status of wo...

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

...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 certification program; (c) Has a plan, approved by the medicaid director, specifying how the board of health or community hub e...

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

...(A) Except as provided in division (B) of this section, when a medicaid managed care organization refers an enrollee to receive services, other than emergency services provided on or after January 1, 2007, at a hospital that participates in the medicaid program but is not under contract with the organization, the hospital shall provide the service for which the referral was made and shall accept from the organization...

...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 enrollee received medicaid other than through enrollment in a medicaid MCO plan. An agreement entered into by an enrollee, an enrollee's parent, or an enrollee's legal guardian that requires payment for emergency services in violation of this section is ...

...g facility provides to a dual eligible individual if the medicaid managed care organization is responsible for the payment under the terms of a contract that the medicaid managed care organization, medicaid director, 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...

...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...

...cy benefit manager that may directly or indirectly present any conflict of interest with the pharmacy benefit manager's relationship with or obligation to the department or a medicaid managed care organization; (2) All common ownership, members of a board of directors, managers, or other control of the pharmacy benefit manager (or any of the pharmacy benefit manager's affiliated companies) with any of the following...

...(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...

...e pharmacy benefit manager passed on to individual pharmacies; (4) The percentage of savings in drug prices that are passed on to participants in the care management system; (5) The information described in division (C) of section 5167.24 of the Revised Code; (6) Any other information required by the director. (B) The director may ask the state pharmacy benefit manager to provide additional information as nec...

...No person shall violate the terms of the master state pharmacy benefit manager contract under section 5167.24 of the Revised Code or section 5167.241 of the Revised Code. Whoever violates those sections is subject to a civil penalty in an amount to be determined by the medicaid director.