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Ohio Statutes, Title 51

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Ohio/Statutes

← All Ohio coverage

Title 51, Public Welfare

31 chapters · 2,012 sections in this title.

All chapters in Title 512,012 Ch 5123, Department of Developmental Disabilities182 Ch 5101, Department of Job and Family Service…145 Ch 5119, Department of Behavioral Health121 Ch 5120, Department of Rehabilitation and Cor…121 Ch 5165, Medicaid Coverage of Nursing Facilit…116 Ch 5103, Placement of Children113 Ch 5164, Medicaid State Plan Services113 Ch 5126, County Boards of Developmental Disab…111 Ch 5180, Department of Children and Youth94 Ch 5124, Intermediate Care Facility for Indiv…80 Ch 5153, County Children Services72 Ch 5104, Child Day-care69 Ch 5162, Medicaid and Medicaid Funds67 Ch 5168, Hospital Care Assurance Program; Hea…66

113 sections·Filtered byTitle 51✕Ch 5164✕

Ohio Rev. Code Ann. § 5164.404 Automated fraud-detection tools
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(A) The department of medicaid shall develop and implement automated fraud-detection tools to assist with identifying fraud through the use of the electronic verification systems developed, procured, certified, or approved under section 5164.401 of the Revised Code. Any fraud-det…
Ohio Rev. Code Ann. § 5164.405 Electronic verification annual report
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Annually, the department of medicaid shall submit a report to the general assembly detailing electronic verification systems developed, procured, certified, or approved under section 5164.401 of the Revised Code. The report shall be submitted to the general assembly in accordance…
Ohio Rev. Code Ann. § 5164.406 Rulemaking
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The department of medicaid shall adopt rules in accordance with Chapter 119. of the Revised Code to implement sections 5164.40 to 5164.406 of the Revised Code. The rules shall address all of the following: (A) Technical standards for electronic verification systems developed, pro…
Ohio Rev. Code Ann. § 5164.41 Family caregiver oversight

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(A) As used in this section, "home and community-based services medicaid waiver component" has the same meaning as in section 5166.01 of the Revised Code. (B) The department of medicaid shall establish oversight mechanisms concerning services provided by a family caregiver under …

Ohio Rev. Code Ann. § 5164.42 Electronic visit verification requirements

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(A) As used in this section and section 5164.421 of the Revised Code: (1) "Electronic visit verification" has the same meaning as in section 1903(l) of the "Social Security Act," 42 U.S.C. 1396b(l). (2) "GPS-based verification" means real-time satellite location data that can be …

Ohio Rev. Code Ann. § 5164.421 Electronic visit verification for high-risk providers

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(A) In addition to the electronic visit verification system described in section 5165.42 of the Revised Code, the department of medicaid shall establish requirements under which high risk in-home care service providers are required to verify data regarding the services provided t…

Ohio Rev. Code Ann. § 5164.43 Employee protections for reporting Medicaid fraud

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(A) As used in this section: (1) "Employee" means any person who performs a service for wages or other remuneration for an employer. (2) "Employer" means any person who has one or more employees and includes an agent of an employer, the state or any agency or instrumentality of t…

Ohio Rev. Code Ann. § 5164.44 Employee status of independent provider

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(A) As used in this section: (1) "Aide services" means all of the following: (a) Home 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 m…

Ohio Rev. Code Ann. § 5164.45 Contracts for examination, processing, and determination of medicaid claims

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(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 med…

Ohio Rev. Code Ann. § 5164.46 Electronic claims submission process; electronic fund transfers

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(A) As used in this section, "electronic claims submission process" means any of the following: (1) Electronic interchange of data; (2) Direct entry of data through an internet-based mechanism implemented by the department of medicaid; (3) Any other process for the electronic sub…

Ohio Rev. Code Ann. § 5164.47 Contracting for review and analysis, quality assurance and quality review

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(A) As used in this section, "OCHSPS" means the private, not-for-profit corporation known as the Ohio children's hospital solutions for patient safety, which was formed for the purpose of improving pediatric patient care in this state, which performs functions that are included w…

Ohio Rev. Code Ann. § 5164.471 Summary data regarding perinatal services

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Not less than once each year and in accordance with all state and federal laws governing the confidentiality of patient-identifying information, the department of medicaid shall make summary data regarding perinatal services available on request to local organizations concerned w…

Ohio Rev. Code Ann. § 5164.48 Medicaid payments made to organization on behalf of providers

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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 pr…

Ohio Rev. Code Ann. § 5164.55 Final fiscal audits

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The department of medicaid may conduct final fiscal audits of medicaid providers in accordance with the applicable requirements set forth in federal laws and regulations and determine any amounts the provider may owe the state. When conducting final fiscal audits, the department …

Ohio Rev. Code Ann. § 5164.56 Lien for amount owed by provider

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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 …

Ohio Rev. Code Ann. § 5164.57 Recovery of medicaid overpayments

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(A)(1) Except as provided in division (A)(2) and division (E) 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 overpa…

Ohio Rev. Code Ann. § 5164.58 Agency action to recover overpayment to provider

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(A) If a state agency that enters 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 t…

Ohio Rev. Code Ann. § 5164.59 Deduction of incorrect payments

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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.

Ohio Rev. Code Ann. § 5164.60 Interest on Medicaid provider excess payments

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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…

Ohio Rev. Code Ann. § 5164.61 Scope of available remedies for recovery of excess payments

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The authority, under state 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 Rev…

Ohio Rev. Code Ann. § 5164.70 Limitations on medicaid payments for services

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Except as otherwise required 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.

Ohio Rev. Code Ann. § 5164.71 Payments for freestanding medical laboratory charges

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Medicaid payments for freestanding medical laboratory charges shall not exceed the customary and usual fee for laboratory profiles.

Ohio Rev. Code Ann. § 5164.72 Limitations on payments for inpatient hospital care

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The number of days 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…

Ohio Rev. Code Ann. § 5164.721 Claims by freestanding birthing centers

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A hospital or 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 p…

Ohio Rev. Code Ann. § 5164.73 Division of payments between physician or podiatrist and nurse

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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 phys…

Ohio Rev. Code Ann. § 5164.74 Reimbursement of graduate medical education costs

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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 5…

Ohio Rev. Code Ann. § 5164.741 Payment for graduate medical education costs to noncontracting hospitals

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(A) Except as provided in division (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 …

Ohio Rev. Code Ann. § 5164.75 Medicaid payment for a drug subject to a federal upper reimbursement limit

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As used in this section, "federal upper reimbursement limit" means the limit established pursuant to the "Social Security Act," section 1927(e), 42 U.S.C. 1396r-8(e). The medicaid payment for a drug that is subject to a federal upper reimbursement limit shall not exceed, in the a…

Ohio Rev. Code Ann. § 5164.751 State maximum allowable cost program

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(A) As used in this section, "state maximum allowable 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. "St…

Ohio Rev. Code Ann. § 5164.7510 Pharmacy and therapeutics committee

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(A) There is hereby established the pharmacy and therapeutics 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 medicai…

Ohio Rev. Code Ann. § 5164.7511 Medication synchronization for medicaid recipients

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(A) As used in this section: (1) "Cost-sharing" means any cost-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…

Ohio Rev. Code Ann. § 5164.7512 Definitions for sections 5164.7512 to 5164.7514

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(A) As used in sections 5164.7512 to 5164.7514 of the Revised Code: (1) "Clinical practice guidelines" means a systematically developed statement to assist providers and medicaid recipients in making decisions about appropriate health care for specific clinical circumstances and …

Ohio Rev. Code Ann. § 5164.7514 Step therapy exemption process

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(A) All of the following shall apply to the step therapy exemption process established 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 easil…

Ohio Rev. Code Ann. § 5164.7515 Annual benchmark for prescribed drug spending growth

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(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, …

Ohio Rev. Code Ann. § 5164.752 Determining maximum dispensing fee

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In July of every 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 d…

Ohio Rev. Code Ann. § 5164.753 Dispensing fee

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In December 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 t…

Ohio Rev. Code Ann. § 5164.754 Agreement for multiple-state drug purchasing program

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(A) As used in this section, "dangerous drug" and "manufacturer of dangerous drugs" have the same meaning as in section 4729.01 of the Revised Code. (B) The medicaid director may enter into or administer an agreement or cooperative arrangement with other states to create or join …

Ohio Rev. Code Ann. § 5164.755 Supplemental drug rebate program

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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 th…

Ohio Rev. Code Ann. § 5164.756 Drug rebate agreement or supplemental drug rebate agreement for medicaid program not subject to public records law

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Any record, data, pricing information, or other information regarding a drug rebate agreement or a supplemental drug rebate agreement for the medicaid program that the department of medicaid receives from a pharmaceutical manufacturer or creates pursuant to negotiation of the agr…

Ohio Rev. Code Ann. § 5164.757 E-prescribing applications

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(A) As used in this section, "licensed health professional authorized to prescribe drugs" has the same meaning as in section 4729.01 of the Revised Code. (B) The medicaid director may acquire or specify technologies to provide information regarding medicaid recipient eligibility,…

Ohio Rev. Code Ann. § 5164.758 Adoption of rules for implementation of coordinated services program for medicaid users who abuse prescription drugs

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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 ne…

Ohio Rev. Code Ann. § 5164.759 Outpatient drug use review program

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In accordance with the "Social Security Act," section 1927(g), 42 U.S.C. 1396r-8(g), the department of medicaid shall establish an outpatient drug use review program to assure that prescriptions obtained by medicaid recipients are appropriate, medically necessary, and unlikely to…

Ohio Rev. Code Ann. § 5164.76 Manner of payment for community mental health service providers or facilities and alcohol and drug addiction services

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(A) In rules adopted under section 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 healt…

Ohio Rev. Code Ann. § 5164.761 Beta testing of updates to billing codes or payment rates

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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 up…

Ohio Rev. Code Ann. § 5164.78 Medicaid payment rates for certain neonatal and newborn services

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(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) Init…

Ohio Rev. Code Ann. § 5164.80 Public notice for changes to payment rates for medicaid assistance

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As necessary to comply with the "Social Security Act," section 1902(a)(13)(A), 42 U.S.C. 1396a(a)(13)(A), and any other federal law that requires public notice of proposed changes to payment rates for medicaid services, the medicaid director shall give public notice in the regist…

Ohio Rev. Code Ann. § 5164.82 Payment for provider-preventable condition

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The department of medicaid shall not knowingly make a medicaid payment for a provider-preventable condition for which federal financial participation is prohibited by regulations adopted under the "Patient Protection and Affordable Care Act," section 2702, 42 U.S.C. 1396b-1.

Ohio Rev. Code Ann. § 5164.85 Enrolling in group health plan

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(A) As used in this section, "cost-effective" and "group health plan" have the same meanings as in the "Social Security Act," section 1906, 42 U.S.C. 1396e, and any regulations adopted under that section. (B) The department of medicaid may implement a program pursuant to the "Soc…

Ohio Rev. Code Ann. § 5164.86 Qualified state long-term care insurance partnership program

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The medicaid director shall establish a qualified state long-term care insurance partnership program consistent with the definition of that term in the "Social Security Act," section 1917(b)(1)(C)(iii), 42 U.S.C. 1396p(b)(1)(C)(iii). An individual participating in the program who…

Ohio Rev. Code Ann. § 5164.88 Coordinated care through health homes

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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.