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Ohio Statutes, Title 51

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Ohio/Statutes

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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

2,012 sections·Filtered byTitle 51✕

Ohio Rev. Code Ann. § 5166.405 Cessation of participation
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(A) A healthy Ohio program participant's participation in the program shall cease if any of the following applies: (1) Unless the participant is pregnant, a monthly installment payment to the participant's buckeye account is sixty days late. (2) The participant fails to submit do…
Ohio Rev. Code Ann. § 5166.406 Exhaustion of payout limits
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If a healthy Ohio program participant exhausts the annual or lifetime payout limits specified in division (D) of section 5166.401 of the Revised Code, the participant shall be transferred to the fee-for-service component of medicaid or the care management system. A participant wh…
Ohio Rev. Code Ann. § 5166.407 Disqualification for medicaid; disposition of remainder in buckeye account
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(A) If a healthy Ohio program 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 participa…
Ohio Rev. Code Ann. § 5166.408 Referral to workforce development agency

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Each county department of job and family services shall offer to refer to a local board each healthy Ohio program participant who resides in the county served by the county department and is either unemployed or employed for less than an average of twenty hours per week. The refe…

Ohio Rev. Code Ann. § 5166.409 Rules

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The medicaid director shall adopt rules under section 5166.02 of the Revised Code to do all of the following: (A) For the purpose of division (F)(1)(a) of section 5166.402 of the Revised Code, establish requirements regarding preventative health services for healthy Ohio program …

Ohio Rev. Code Ann. § 5166.45 Medicaid enrollment for chidren through age three

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(A) As used in this section, "medical assistance program" and "refugee medical assistance program" have the same meanings as in section 5160.01 of the Revised Code. (B) The medicaid director shall establish a medicaid waiver component to provide continuous medicaid enrollment for…

Ohio Rev. Code Ann. § 5166.50 Reentry services waiver

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(A) Within one year of the effective date of this section, the department of medicaid shall apply for a medicaid waiver component to provide reentry services to medicaid-eligible imprisoned individuals for ninety days before an imprisoned individual's expected release date. The b…

Ohio Rev. Code Ann. § 5167.01 Definitions

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As used in this chapter: (A) "340B grantee" means an entity described in section 340B(a)(4)(A)-(K) of the "Public Health Service Act," 42 U.S.C. 256b(a)(4)(A)-(K) that is designated as an active (A)-(K) entity under the health resources and services administration covered entity …

Ohio Rev. Code Ann. § 5167.02 Rules

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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.

Ohio Rev. Code Ann. § 5167.03 Care management system

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(A) 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. (B) The department shall designate the medicaid recipients who are required or permitted to participate in …

Ohio Rev. Code Ann. § 5167.031 Recognition of pediatric accountable care organizations

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(A) As used in this section: (1) "Children's care network" means any of the following: (a) A children's hospital; (b) A group of children's hospitals; (c) A group of pediatric physicians. (2) "Children's hospital" has the same meaning as in section 2151.86 of the Revised Code. (B…

Ohio Rev. Code Ann. § 5167.04 Inclusion of alcohol, drug addiction, and mental health services in care management system

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The department of medicaid shall include alcohol, drug addiction, and mental health services covered by medicaid in the care management system.

Ohio Rev. Code Ann. § 5167.05 Inclusion of prescribed drugs in care management system

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

Ohio Rev. Code Ann. § 5167.051 Coverage of services provided by pharmacist

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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.

Ohio Rev. Code Ann. § 5167.09 Managed care financial dashboard information

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The department of medicaid shall include all of the following on the department's managed care financial dashboard: (A) Actuarial metrics for annual and quarterly cost reports, delineated by the following categories: (1) Adults for whom financial eligibility for the medicaid prog…

Ohio Rev. Code Ann. § 5167.10 Authority to contract with managed care orgainizations

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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 manag…

Ohio Rev. Code Ann. § 5167.101 Basis of hospital inpatient capital payment portion of payment to medicaid managed care organization

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(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 re…

Ohio Rev. Code Ann. § 5167.103 Performance metrics; publication

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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 contra…

Ohio Rev. Code Ann. § 5167.11 Managed care organization contract to provide grievance process

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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.

Ohio Rev. Code Ann. § 5167.12 Requirements when prescribed drugs are included in care management system

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If prescribed drugs are included 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 medi…

Ohio Rev. Code Ann. § 5167.122 Disclosure of sources of payment

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(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, charge…

Ohio Rev. Code Ann. § 5167.123 Medicaid MCO contracts with 340B program participants

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(A) No contract between a medicaid managed care organization, including a third-party administrator, and a 340B grantee shall contain any of the following provisions: (1) A payment rate for a prescribed drug provided by a 340B grantee to an individual as a result of health care s…

Ohio Rev. Code Ann. § 5167.13 Implementation of coordinated services program for enrollees who abuse prescribed drugs

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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 …

Ohio Rev. Code Ann. § 5167.14 Data security agreements for managed care organization's use of drug database

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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 n…

Ohio Rev. Code Ann. § 5167.15 Chiropractic services

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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 li…

Ohio Rev. Code Ann. § 5167.16 Home visits and cognitive behavioral therapy

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(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 organizat…

Ohio Rev. Code Ann. § 5167.17 Enhanced care management services for pregnant women and women capable of becoming pregnant

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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 i…

Ohio Rev. Code Ann. § 5167.171 Uniform prior approval form for progesterone

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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…

Ohio Rev. Code Ann. § 5167.173 Community health worker services or services provided by public health nurse

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(A) As used in this section: (1) "Board of health" means 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. (2) "Certified community health worker" has the same meaning as in …

Ohio Rev. Code Ann. § 5167.18 Identification of fraud, waste, and abuse

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Each medicaid managed care organization shall comply with federal and state efforts to identify fraud, waste, and abuse in the medicaid program. Upon the identification of credible evidence of fraud, waste, or abuse, or materially inconsistent billing, each medicaid managed care …

Ohio Rev. Code Ann. § 5167.20 Reference by managed care organization to noncontracting participant

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(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 c…

Ohio Rev. Code Ann. § 5167.201 Payment of nonsystem provider for emergency services

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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…

Ohio Rev. Code Ann. § 5167.21 Payments to skilled nursing facility

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(A) As used in this section: (1) "Covered skilled nursing facility services" has the same meaning as in the "Social Security Act," section 1888(e)(2)(A), 42 U.S.C. 1395yy(e)(2)(A). (2) "Current medicare fee-for-service rate" means the fee-for-service rate in effect for a covered …

Ohio Rev. Code Ann. § 5167.22 Recoupment of overpayment

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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 t…

Ohio Rev. Code Ann. § 5167.221 Assessment of recoupment efforts

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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 star…

Ohio Rev. Code Ann. § 5167.23 Medicaid MCO payment integrity actions

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(A) As used in this section, "deconfliction" means the systematic coordination between medicaid managed care organizations and multiple state and federal oversight agencies to share investigative data, eliminate overlapping inquiries, and streamline the prosecution of fraudulent …

Ohio Rev. Code Ann. § 5167.24 Third-party administrator as single pharmacy benefit manager

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(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 benefi…

Ohio Rev. Code Ann. § 5167.241 State pharmacy benefit manager contract; payment arrangements

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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 …

Ohio Rev. Code Ann. § 5167.243 Quarterly reports

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(A) The state pharmacy benefit manager shall provide to the medicaid director a written quarterly report containing the following information from the immediately preceding quarter: (1) The prices that the state pharmacy benefit manager negotiated for prescribed drugs under the c…

Ohio Rev. Code Ann. § 5167.244 Violations; penalty

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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 d…

Ohio Rev. Code Ann. § 5167.245 Appeals process

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The medicaid director shall establish an appeals process by which pharmacies may appeal to the department of medicaid any disputes relating to the maximum allowable cost set by the state pharmacy benefit manager for a prescribed drug. All pharmacies participating in the care mana…

Ohio Rev. Code Ann. § 5167.26 Records for determining costs

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For the purpose of determining the amount the department of medicaid pays hospitals under section 5168.09 of the Revised Code and the amount of disproportionate share hospital payments paid by the medicare program pursuant to section 1915 of the "Social Security Act," 42 U.S.C. 1…

Ohio Rev. Code Ann. § 5167.30 Managed care performance payment program

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(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 performan…

Ohio Rev. Code Ann. § 5167.31 Financial incentive awards

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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 …

Ohio Rev. Code Ann. § 5167.32 Improving integrity of care management system

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Not later than July 1, 2016, the department of medicaid shall implement strategies to improve the integrity of the care management system, including strategies to do both of the following: (A) Increase the department's oversight of medicaid managed care organizations; (B) Provide…

Ohio Rev. Code Ann. § 5167.33 Strategies regarding payment to providers

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(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 …

Ohio Rev. Code Ann. § 5167.34 Immunity from liability

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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…

Ohio Rev. Code Ann. § 5167.35 Meaningful employment of Medicaid recipients

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(A) Consistent with the requirements of the care management system implemented 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 coll…

Ohio Rev. Code Ann. § 5167.40 Appointment of temporary manager

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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 1…

Ohio Rev. Code Ann. § 5167.41 Disenrolling some or all medicaid recipients from MCO plan offered by a managed care organization

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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 determ…