Ohio Revised Code Search

... 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.

...for annual and quarterly cost reports, delineated by the following categories: (1) Adults for whom financial eligibility for the medicaid program is determined by utilizing the modified adjusted gross income standard and who are not members of the expansion eligibility group; (2) Children for whom financial eligibility for the medicaid program is determined by utilizing the modified adjusted gross income standard...

...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.

...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 payment portion of the payment made to medicaid managed care organizations shall not exceed any maximum rate established in rules adopted under section 5167.02 of the Revised Code. If a maximum rate is established, a medicaid managed care or...

...s the department uses to determine how well medicaid managed care organizations perform. The department shall update its internet web site each quarter to reflect any changes it makes to the metrics.

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

... 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 care organization and medicaid...

...cks, reimbursements, or other payments related to services provided for the medicaid managed care organization. (B) Each medicaid managed care organization shall disclose to the department of medicaid in the format specified by the department the organization's administrative costs associated with providing pharmacy services under the care management system.

...payment rate for a prescribed drug provided by a 340B grantee to an individual as a result of health care services provided by the grantee directly to the individual, that is less than the payment rate applied to health care providers that are not 340B grantees; (2) A fee that is not imposed on a health care provider that is not a 340B grantee; (3) A fee amount that exceeds the amount for a health care provider t...

...und 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(e).

...g 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.

...m" 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 receive, both of the following types of services: (1)...

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

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

...formance community care coordination model (endorsed by the federal agency for healthcare research and quality, the national institutes of health, and the centers for medicare and medicaid services or their successors) or 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 ...

...d 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...

...n 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 enrollee received medicaid other than through enrollment in a medicaid MCO plan. A...

...ed nursing 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 man...

...zation 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) The method by which the provider may ...

...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...

..., 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 responsible for processing all pharmacy claims under the care management system. The department of medicaid is responsible for enforcing the contract after the procurement proc...

...ate 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 adopted by the centers for medicare and medicaid services, and an...

... following information from the immediately preceding quarter: (1) The prices that the state pharmacy benefit manager negotiated for prescribed drugs under the care management system. The price must include any rebates the state pharmacy benefit manager received from the drug manufacturer; (2) The prices the state pharmacy benefit manager paid to pharmacies for prescribed drugs; (3) Any rebate amounts the state...