Chapter 5162 | Medicaid and Medicaid Funds

Section 5162.01 | Definitions.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) As used in the Revised Code:

(1) "Medicaid" and "medicaid program" mean the program of medical assistance established by Title XIX of the "Social Security Act," 42 U.S.C. 1396 et seq., including any medical assistance provided under the medicaid state plan or a federal medicaid waiver granted by the United States secretary of health and human services.

(2) "Medicare" and "medicare program" mean the federal health insurance program established by Title XVIII of the "Social Security Act," 42 U.S.C. 1395 et seq.

(B) As used in this chapter:

(1) "Exchange" has the same meaning as in 45 C.F.R. 155.20.

(2) "Expansion eligibility group" has the same meaning as in section 5163.01 of the Revised Code.

(3) "Federal financial participation" has the same meaning as in section 5160.01 of the Revised Code.

(4) "Federal poverty line" means the official poverty line defined by the United States office of management and budget based on the most recent data available from the United States bureau of the census and revised by the United States secretary of health and human services pursuant to the "Omnibus Budget Reconciliation Act of 1981," section 673(2), 42 U.S.C. 9902(2).

(5) "Healthcheck" has the same meaning as in section 5164.01 of the Revised Code.

(6) "Healthy start component" means the component of the medicaid program that covers pregnant women and children and is identified in rules adopted under section 5162.02 of the Revised Code as the healthy start component.

(7) "Home and community-based services" means services provided under a home and community-based services medicaid waiver component.

(8) "Home and community-based services medicaid waiver component" has the same meaning as in section 5166.01 of the Revised Code.

(9) "ICF/IID" has the same meaning as in section 5124.01 of the Revised Code.

(10) "Individualized education program" has the same meaning as in section 3323.011 of the Revised Code.

(11) "Medicaid managed care organization" has the same meaning as in section 5167.01 of the Revised Code.

(12) "Medicaid MCO plan" has the same meaning as in section 5167.01 of the Revised Code.

(13) "Medicaid provider" has the same meaning as in section 5164.01 of the Revised Code.

(14) "Medicaid services" has the same meaning as in section 5164.01 of the Revised Code.

(15) "Medicaid waiver component" has the same meaning as in section 5166.01 of the Revised Code;

(16) "Nursing facility" and "nursing facility services" have the same meanings as in section 5165.01 of the Revised Code.

(17) "Ordering or referring only provider" means a medicaid provider who orders, prescribes, refers, or certifies a service or item reported on a claim for medicaid payment but does not bill for medicaid services.

(18) "Political subdivision" means a municipal corporation, township, county, school district, or other body corporate and politic responsible for governmental activities only in a geographical area smaller than that of the state.

(19) "Prescribed drug" has the same meaning as in section 5164.01 of the Revised Code.

(20) "Provider agreement" has the same meaning as in section 5164.01 of the Revised Code.

(21) "Qualified medicaid school provider" means the board of education of a city, local, or exempted village school district, the governing board of an educational service center, the governing authority of a community school established under Chapter 3314. of the Revised Code, and Ohio deaf and blind education services to which both of the following apply:

(a) It holds a valid provider agreement.

(b) It meets all other conditions for participation in the medicaid school component of the medicaid program established in rules authorized by section 5162.364 of the Revised Code.

(22) "State agency" means every organized body, office, or agency, other than the department of medicaid, established by the laws of the state for the exercise of any function of state government.

(23) "Vendor offset" means a reduction of a medicaid payment to a medicaid provider to correct a previous, incorrect medicaid payment to that provider.

Last updated October 6, 2023 at 11:57 AM

Section 5162.02 | Rules for implementation of chapter.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The medicaid director shall adopt rules as necessary to implement this chapter.

Section 5162.021 | Adoption of rules by other state agencies.

• Effective: November 22, 2017
• Latest Legislation: House Bill 49 - 132nd General Assembly

The medicaid director shall adopt rules under sections 5160.02, 5162.02, 5163.02, 5164.02, 5165.02, 5166.02, and 5167.02 of the Revised Code as necessary to authorize the directors of other state agencies to adopt rules regarding medicaid components, or aspects of medicaid components, the other state agencies administer pursuant to contracts entered into under section 5162.35 of the Revised Code.

Section 5162.022 | Director's rules binding.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The medicaid director's rules governing medicaid are binding on other state agencies and political subdivisions that administer one or more components of the medicaid program, or one or more aspects of a component, pursuant to contracts entered into under section 5162.35 of the Revised Code. No state agency or political subdivision may establish, by rule or otherwise, a policy governing medicaid that is inconsistent with a medicaid policy established, in rule or otherwise, by the director.

Section 5162.03 | Administration of medicaid program.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

For the purpose of the "Social Security Act," section 1902(a)(5), 42 U.S.C. 1396a(a)(5), the department of medicaid shall act as the single state agency to supervise the administration of the medicaid program. As the single state agency, the department shall comply with 42 C.F.R. 431.10(e) and all other federal requirements applicable to the single state agency.

Section 5162.031 | Powers of director.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) The medicaid director may do all of the following as necessary for the department of medicaid to fulfill the duties it has, as the single state agency for the medicaid program, under the "Medicare Prescription Drug, Improvement, and Modernization Act of 2003" Pub. L. No. 108-173:

(1) Adopt rules in accordance with division (B) of this section;

(2) Assign duties to county departments of job and family services;

(3) Make payments to the United States department of health and human services from appropriations made to the department of medicaid for this purpose.

(B) Rules authorized by division (A)(1) of this section shall be adopted as follows:

(1) If the rules concern the department's duties regarding medicaid providers, under sections 5164.02 and 5165.02 of the Revised Code, as appropriate;

(2) If the rules concern the department's duties concerning individuals' eligibility for medicaid services, under section 5163.02 of the Revised Code;

(3) If the rules concern the department's duties concerning financial and operational matters between the department and county departments of job and family services, under section 5162.02 of the Revised Code.

Section 5162.04 | No state cause of action to enforce federal laws.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

As used in this section, "state agency" has the same meaning as in section 9.23 of the Revised Code.

No provision of Title LI of the Revised Code or any other law of this state that incorporates any provision of federal medicaid law, or that may be construed as requiring the state, a state agency, or any state official or employee to comply with that federal provision, shall be construed as creating a cause of action to enforce such state law beyond the causes of action available under federal law for enforcement of the provision of federal law.

Section 5162.05 | Implementation of medicaid program.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The medicaid program shall be implemented in accordance with all of the following:

(A) The medicaid state plan approved by the United States secretary of health and human services, including amendments to the plan approved by the United States secretary;

(B) Federal medicaid waivers granted by the United States secretary, including amendments to waivers approved by the United States secretary;

(C) Other types of federal approval, including demonstration grants, that establish requirements for components of the medicaid program;

(D) Except as otherwise authorized by a federal medicaid waiver granted by the United States secretary, all applicable federal statutes, regulations, and policy guidances;

(E) All applicable state statutes.

Section 5162.06 | Components requiring federal approval or funding.

• Effective: June 13, 2022
• Latest Legislation: House Bill 136 - 134th General Assembly

(A) Notwithstanding any other state statute except for section 5164.061 of the Revised Code, no component, or aspect of a component, of the medicaid program shall be implemented without all of the following:

(1) Subject to division (B) of this section, if the component, or aspect of the component, requires federal approval, receipt of the federal approval;

(2) Sufficient federal financial participation for the component or aspect of the component;

(3) Sufficient nonfederal funds for the component or aspect of the component that qualify as funds needed to obtain the federal financial participation.

(B) A component, or aspect of a component, of the medicaid program that requires federal approval may begin to be implemented before receipt of the federal approval if federal law authorizes implementation to begin before receipt of the federal approval. Implementation shall cease if the federal approval is ultimately denied.

Last updated March 17, 2022 at 9:04 AM

Section 5162.07 | Federal approval for permissive components not required.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The medicaid director shall seek federal approval for all components, and aspects of components, of the medicaid program for which federal approval is needed, except that the director is permitted rather than required to seek federal approval for components, and aspects of components, that state statutes permit rather than require be implemented. Federal approval shall be sought in the following forms as appropriate:

(A) The medicaid state plan;

(B) Amendments to the medicaid state plan;

(C) Federal medicaid waivers;

(D) Amendments to federal medicaid waivers;

(E) Other types of federal approval, including demonstration grants.

Section 5162.10 | Review of medicaid program; corrective action; sanctions.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The medicaid director may conduct reviews of the medicaid program. The reviews may include physical inspections of records and sites where medicaid services are provided and interviews of medicaid providers and medicaid recipients. If the director determines pursuant to a review that a person or government entity has violated a rule governing the medicaid program, the director may establish a corrective action plan for the violator and impose fiscal, administrative, or both types of sanctions on the violator in accordance with rules adopted under section 5162.02 of the Revised Code.

Section 5162.11 | Contract for data collection and warehouse functions assessment.

• Effective: September 29, 2015
• Latest Legislation: House Bill 64 - 131st General Assembly

(A) The department of medicaid shall enter into an agreement with the department of administrative services for the department of administrative services to contract through competitive selection pursuant to section 125.07 of the Revised Code with a vendor to perform an assessment of the data collection and data warehouse functions of the medicaid data warehouse system, including the ability to link the data sets of all agencies serving medicaid recipients.

The assessment of the data system shall include functions related to fraud and abuse detection, program management and budgeting, and performance measurement capabilities of all agencies serving medicaid recipients, including the departments of aging, health, job and family services, medicaid, mental health and addiction services, and developmental disabilities.

A qualified vendor with whom the department of administrative services contracts to assess the data system shall also assist the medicaid agencies in the definition of the requirements for an enhanced data system or a new data system and assist the department of administrative services in the preparation of a request for proposals to enhance or develop a data system.

(B) Based on the assessment performed pursuant to division (A) of this section, the department of administrative services shall seek a qualified vendor through competitive selection pursuant to Chapter 125. of the Revised Code to develop or enhance a data collection and data warehouse system for the department of medicaid and all agencies serving medicaid recipients.

The department of medicaid shall seek enhanced federal financial participation for ninety per cent of the funds required to establish or enhance the data system. The department of administrative services shall not award a contract for establishing or enhancing the data system until the department of medicaid receives approval from the United States secretary of health and human services for the ninety per cent federal financial participation.

Last updated October 2, 2023 at 4:07 PM

Section 5162.12 | Contracts for the management of Medicaid data requests.

• Effective: October 17, 2019
• Latest Legislation: House Bill 166 - 133rd General Assembly

(A) The medicaid director shall enter into a contract with one or more persons to receive and process, on the director's behalf, requests for medicaid recipient or claims payment data, data from reports of audits conducted under section 5165.109 of the Revised Code, or extracts or analyses of any of the foregoing data made by persons who intend to use the items prepared pursuant to the requests for commercial or academic purposes.

(B) At a minimum, a contract entered into under this section shall do both of the following:

(1) Authorize the contracting person to engage in the activities described in division (A) of this section for compensation, which must be stated as a percentage of the fees paid by persons who are provided the items;

(2) Require the contracting person to charge for an item prepared pursuant to a request a fee in an amount equal to one hundred two per cent of the cost the department of medicaid incurs in making the data used to prepare the item available to the contracting person.

(C) Except as required by federal or state law and subject to division (E) of this section, both of the following conditions apply with respect to a request for data described in division (A) of this section:

(1) The request shall be made through a person who has entered into a contract with the medicaid director under this section.

(2) An item prepared pursuant to the request may be provided to the department of medicaid and is confidential and not subject to disclosure under section 149.43 or 1347.08 of the Revised Code.

(D) The medicaid director shall use fees the director receives pursuant to a contract entered into under this section to pay obligations specified in contracts entered under this section. Any money remaining after the obligations are paid shall be deposited in the health care/medicaid support and recoveries fund created under section 5162.52 of the Revised Code.

(E) This section does not apply to requests for medicaid recipient or claims payment data, data from reports of audits conducted under section 5165.109 of the Revised Code, or extracts or analyses of any of the foregoing data that are for any of the following purposes:

(1) Treatment of medicaid recipients;

(2) Payment of medicaid claims;

(3) Establishment or management of medicaid third party liability pursuant to sections 5160.35 to 5160.43 of the Revised Code;

(4) Compliance with the terms of an agreement the medicaid director enters into for purposes of administering the medicaid program.

Section 5162.13 | Annual report.

• Effective: April 30, 2024
• Latest Legislation: House Bill 101 - 135th General Assembly

(A) On or before the first day of January of each year, the department of medicaid shall complete a report on the effectiveness of the medicaid program in meeting the health care needs of low-income pregnant women, infants, and children. The report shall include all of the following, delineated by race and ethnic group:

(1) The estimated number of pregnant women, infants, and children eligible for the program;

(2) The actual number of eligible persons enrolled in the program;

(3) The actual number of enrolled pregnant women categorized by estimated gestational age at time of enrollment;

(4) The average number of days between the following events:

(a) A pregnant woman's application for medicaid and enrollment in the fee-for-service component of medicaid;

(b) A pregnant woman's application for enrollment in a medicaid managed care organization and enrollment in the managed care organization.

The information described in divisions (A)(4)(a) and (b) of this section shall also be delineated by county and the urban and rural communities specified in rules adopted under section 3701.142 of the Revised Code.

(5) The number of prenatal, postpartum, and child health visits;

(6) The estimated number of enrolled women of child-bearing age who use a tobacco product;

(7) The estimated number of enrolled women of child-bearing age who participate in a tobacco cessation program or who use a tobacco cessation product;

(8) The rates at which enrolled pregnant women receive addiction or mental health services, progesterone therapy, and any other service specified by the department;

(9) A report on birth outcomes, including a comparison of low-birthweight births and infant mortality rates of medicaid recipients with the general female child-bearing and infant population in this state;

(10) A comparison of the prenatal, delivery, and child health costs of the program with such costs of similar programs in other states, where available;

(11) A report on performance data generated by the component of the state innovation model (SIM) grant pertaining to episode-based payments for perinatal care that was awarded to this state by the center for medicare and medicaid innovation in the United States centers for medicare and medicaid services;

(12) A report on funds allocated for infant mortality reduction initiatives in the urban and rural communities specified in rules adopted under section 3701.142 of the Revised Code;

(13) A report on the results of client responses to questions related to pregnancy services and healthcheck that are asked by the personnel of county departments of job and family services;

(14) A comparison of the performance of the fee-for-service component of medicaid with the performance of each medicaid managed care organization on perinatal health metrics;

(15) A report demonstrating cost savings resulting from program investments;

(16) Beginning two years after the effective date of this amendment , a report on the medicaid coverage of doula services required by section 5164.071 of the Revised Code, including:

(a) Outcomes related to maternal health and maternal morbidity;

(b) Infant health outcomes;

(c) The average costs of providing doula services to mothers and infants;

(d) Estimated cost increases or savings as a result of providing doula coverage.

(B) The department shall submit the report to the general assembly in accordance with section 101.68 of the Revised Code and to the joint medicaid oversight committee. The department also shall make the report available to the public.

(C) The department shall provide to the joint medicaid oversight committee a copy of the data used to calculate the information required in the report under division (A)(16) of this section.

Last updated February 14, 2024 at 11:26 AM

Section 5162.132 | Annual report outlining efforts to minimize fraud, waste, and abuse.

• Effective: March 20, 2014
• Latest Legislation: Senate Bill 206 - 130th General Assembly

Annually, the department of medicaid shall prepare a report on the department's efforts to minimize fraud, waste, and abuse in the medicaid program.

Each report shall be made available on the department's web site. The department shall submit a copy of each report to the governor, general assembly, and joint medicaid oversight committee. The copy to the general assembly shall be submitted in accordance with section 101.68 of the Revised Code. Copies of the report also shall be made available to the public on request.

Section 5162.133 | Annual program report; distribution; contents.

• Effective: March 20, 2014
• Latest Legislation: Senate Bill 206 - 130th General Assembly

Not less than once each year, the medicaid director shall submit a report on the medicaid buy-in for workers with disabilities program to the governor, general assembly, and joint medicaid oversight committee. The copy to the general assembly shall be submitted in accordance with section 101.68 of the Revised Code. The report shall include all of the following information:

(A) The number of individuals who participated in the medicaid buy-in for workers with disabilities program;

(B) The cost of the program;

(C) The amount of revenue generated by premiums that participants pay under section 5163.094 of the Revised Code;

(D) The average amount of earned income of participants' families;

(E) The average amount of time participants have participated in the program;

(F) The types of other health insurance participants have been able to obtain.

Section 5162.134 | Annual report of integrated care delivery system evaluation.

• Effective: March 20, 2014
• Latest Legislation: Senate Bill 206 - 130th General Assembly

Not later than the first day of each July, the medicaid director shall complete a report of the evaluation conducted under section 5164.911 of the Revised Code regarding the integrated care delivery system. The director shall provide a copy of the report to the general assembly and joint medicaid oversight committee. The copy to the general assembly shall be provided in accordance with section 101.68 of the Revised Code. The director also shall make the report available to the public.

Section 5162.135 | Infant mortality scorecard.

• Effective: April 6, 2017
• Latest Legislation: Senate Bill 332 - 131st General Assembly

(A) As used in this section, "stillbirth" has the same meaning as in section 3701.97 of the Revised Code.

(B) The department of medicaid shall create an infant mortality scorecard. The scorecard shall report all of the following:

(1) The performance of the fee-for-service component of medicaid and each medicaid managed care organization on population health measures, including the infant mortality rate, preterm birth rate, and low-birthweight rate, stillbirth rate, delineated in accordance with division (C) of this section;

(2) The performance of the fee-for-service component of medicaid and each medicaid managed care organization on service utilization and outcome measures using claims data and data from vital records;

(3) The number and percentage of women who are at least fifteen but less than forty-four years of age who are medicaid recipients;

(4) The number of medicaid recipients who delivered a newborn and the percentage of those who reported tobacco use at the time of delivery;

(5) The number of prenatal, postpartum, and adolescent wellness visits made by medicaid recipients;

(6) The percentage of pregnant medicaid recipients who initiated progesterone therapy during pregnancy;

(7) The percentage of female medicaid recipients of childbearing age who participate in a tobacco cessation program or use a tobacco cessation product;

(8) The percentage of female medicaid recipients of childbearing age who use long-acting reversible contraception;

(9) A comparison of the low-birthweight rate of medicaid recipients with the low-birthweight rate of women who are not medicaid recipients;

(10) Any other information on maternal and child health that the department considers appropriate.

(C) To the extent possible, the performance measures described in division (B)(1) of this section shall be delineated in the scorecard as follows:

(1) For each region of the state and the state as a whole, by race and ethnic group;

(2) For the urban and rural communities specified in rules adopted under section 3701.142 of the Revised Code, as well as for any other communities that are the subject of targeted infant mortality reduction initiatives administered by one or more state agencies, by race, ethnic group, and census tract.

The scorecard shall be updated each calendar quarter and made available on the department's internet web site.

(D) The department shall make available the data sources and methodology used to complete the scorecard to any person or government entity on request.

Last updated September 29, 2023 at 2:47 PM

Section 5162.136 | Review of barriers to interventions intended to reduce tobacco use, prevent prematurity, and promote optimal birth spacing.

• Effective: April 6, 2017
• Latest Legislation: Senate Bill 332 - 131st General Assembly

(A) The department of medicaid shall conduct periodic reviews to determine the barriers that medicaid recipients face in gaining full access to interventions intended to reduce tobacco use, prevent prematurity, and promote optimal birth spacing. The first review shall occur not later than sixty days after the effective date of this section. Thereafter, reviews shall be conducted every six months. The department shall prepare a report that summarizes the results of each review, which must contain the information specified in division (C)(1) or (2) of this section, as applicable. Each report shall be submitted to the commission on infant mortality, the joint medicaid oversight committee, and the general assembly. Submissions to the general assembly shall be made in accordance with section 101.68 of the Revised Code.

(B) The department shall make a presentation on each report at the first meeting of the commission on infant mortality that follows the report's submission to the commission.

(C)(1) All of the following shall be in the first report submitted in accordance with division (A) of this section:

(a) Identification of the access barriers described in division (A) of this section, the individuals affected by the barriers, and whether the barriers result from policies implemented by the department, medicaid managed care organizations, providers, or others;

(b) Recommendations for the expedient removal of the access barriers;

(c) An analysis of the performance of the fee-for-service component of medicaid and the performance of each medicaid managed care organization on health metrics pertaining to tobacco cessation, prematurity prevention, and birth spacing;

(d) Any other information the department considers pertinent to the report's topic.

(2) All of the following shall be in each subsequent report submitted in accordance with division (A) of this section:

(a) The progress that has been made on removing the access barriers described in division (A) of this section and the impact such progress has had on reducing the infant mortality rate in this state;

(b) A performance analysis of the fee-for-service component of medicaid and each medicaid managed care organization on health metrics pertaining to tobacco cessation, prematurity prevention, and birth spacing;

(c) Any other information the department considers pertinent.

Section 5162.137 | Cost savings study.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

Annually, the department of medicaid shall conduct a cost savings study of the medicaid program and prepare a report based on that study recommending measures to reduce costs under that program. The department shall submit its report to the governor.

Last updated October 6, 2023 at 4:53 PM

Section 5162.1310 | Evaluation of success of expansion eligibility group.

• Effective: October 17, 2019
• Latest Legislation: House Bill 166 - 133rd General Assembly

(A) The department of medicaid shall periodically evaluate the success that members of the expansion eligibility group have with the following:

(1) Obtaining employer-sponsored health insurance coverage;

(2) Improving health conditions that would otherwise prevent or inhibit stable employment;

(3) Improving the conditions of their employment, including duration and hours of employment.

(B) For the purpose of aiding the department's evaluations under this section, medicaid managed care organizations shall collect and submit to the department relevant data about members of the expansion eligibility group who are enrolled in the organizations' medicaid MCO plans. The department may request that a medicaid managed care organization collect and submit to the department additional data the department needs for the evaluation.

(C) The department shall complete a report for each evaluation conducted under this section. The director shall provide a copy of the report to the general assembly and joint medicaid oversight committee. The copy to the general assembly shall be provided in accordance with section 101.68 of the Revised Code.

Section 5162.15 | Information required where annual medicaid payments exceed $5 million.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) As used in this section;

"Agent" and "contractor" include any agent, contractor, subcontractor, or other person who, on behalf of an entity, furnishes or authorizes the furnishing of medicaid services, performs billing or coding functions, or is involved in monitoring of health care that an entity provides.

"Employee" includes any officer or employee (including management employees) of an entity.

"Entity" includes a governmental entity or an organization, unit, corporation, partnership, or other business arrangement, including any medicaid managed care organization, irrespective of the form of business structure or arrangement by which it exists, whether for-profit or not-for-profit. "Entity" does not include a government entity that administers one or more components of the medicaid program, unless the government entity receives medicaid payments for providing medicaid services.

"Federal health care programs" has the same meaning as in the "Social Security Act," section 1128B, 42 U.S.C. 1320a-7b(f).

(B) Each entity that receives or makes in a federal fiscal year payments under the medicaid program, either through the medicaid state plan or a federal medicaid waiver, totaling at least five million dollars shall, as a condition of receiving such payments, do all of the following not later than the first day of the succeeding calendar year:

(1) Establish written policies for all of the entity's employees, contractors, and agents that provide detailed information about the role of all of the following in preventing and detecting fraud, waste, and abuse in federal health care programs:

(a) Federal false claims law under 31 U.S.C. 3729 to 3733;

(b) Federal administrative remedies for false claims and statements available under 31 U.S.C. 3801 to 3812;

(c) Sections 124.341, 2913.40, 2913.401, and 2921.13 of the Revised Code and any other state laws pertaining to civil or criminal penalties for false claims and statements;

(d) Whistleblower protections under the laws specified in divisions (B)(1)(a) to (c) of this section.

(2) Include as part of the written policies required by division (B)(1) of this section detailed provisions regarding the entity's policies and procedures for preventing and detecting fraud, waste, and abuse.

(3) Disseminate the written policies required by division (B)(1) of this section to each of the entity's employees, contractors, and agents in a paper or electronic form and make the written policies readily available to the entity's employees, contractors, and agents.

(4) If the entity has an employee handbook, include in the employee handbook a specific discussion of the laws specified in division (B)(1) of this section, the rights of employees to be protected as whistleblowers, and the entity's policies and procedures for preventing and detecting fraud, waste, and abuse.

(5) Require the entity's contractors and agents to adopt the entity's written policies required by division (B)(1) of this section.

(C) An entity that furnishes medicaid services at multiple locations or under multiple contractual or other payment arrangements is required to comply with division (B) of this section if the entity receives in a federal fiscal year medicaid payments totaling in the aggregate at least five million dollars. This applies regardless of whether the entity submits claims for medicaid payments using multiple provider identification or tax identification numbers.

Section 5162.16 | Reporting fraud, waste, or abuse.

• Effective: September 29, 2017
• Latest Legislation: House Bill 49 - 132nd General Assembly

A government entity that administers one or more components of the medicaid program and has reasonable cause to believe that an instance of fraud, waste, or abuse has occurred in the medicaid program shall inform the department of medicaid. The department shall collect the information in the medicaid data warehouse system established under section 5162.11 of the Revised Code.

Section 5162.20 | Cost-sharing requirements.

• Effective: September 18, 2020
• Latest Legislation: House Bill 11 - 133rd General Assembly

(A) The department of medicaid shall institute cost-sharing requirements for the medicaid program. The department shall not institute cost-sharing requirements in a manner that does either of the following:

(1) Disproportionately impacts the ability of medicaid recipients with chronic illnesses to obtain medically necessary medicaid services;

(2) Violates section 5164.09 or 5164.10 of the Revised Code.

(B)(1) No provider shall refuse to provide a service to a medicaid recipient who is unable to pay a required copayment for the service.

(2) Division (B)(1) of this section shall not be considered to do either of the following with regard to a medicaid recipient who is unable to pay a required copayment:

(a) Relieve the medicaid recipient from the obligation to pay a copayment;

(b) Prohibit the provider from attempting to collect an unpaid copayment.

(C) Except as provided in division (F) of this section, no provider shall waive a medicaid recipient's obligation to pay the provider a copayment.

(D) No provider or drug manufacturer, including the manufacturer's representative, employee, independent contractor, or agent, shall pay any copayment on behalf of a medicaid recipient.

(E) If it is the routine business practice of a provider to refuse service to any individual who owes an outstanding debt to the provider, the provider may consider an unpaid copayment imposed by the cost-sharing requirements as an outstanding debt and may refuse service to a medicaid recipient who owes the provider an outstanding debt. If the provider intends to refuse service to a medicaid recipient who owes the provider an outstanding debt, the provider shall notify the recipient of the provider's intent to refuse service.

(F) In the case of a provider that is a hospital, the cost-sharing program shall permit the hospital to take action to collect a copayment by providing, at the time services are rendered to a medicaid recipient, notice that a copayment may be owed. If the hospital provides the notice and chooses not to take any further action to pursue collection of the copayment, the prohibition against waiving copayments specified in division (C) of this section does not apply.

(G) The department of medicaid may collaborate with a state agency that is administering, pursuant to a contract entered into under section 5162.35 of the Revised Code, one or more components, or one or more aspects of a component, of the medicaid program as necessary for the state agency to apply the cost-sharing requirements to the components or aspects of a component that the state agency administers.

Section 5162.21 | Medicaid estate recovery program.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) As used in this section and section 5162.211 of the Revised Code:

(1) "Estate" includes both of the following:

(a) All real and personal property and other assets to be administered under Title XXI of the Revised Code and property that would be administered under that title if not for section 2113.03 or 2113.031 of the Revised Code;

(b) Any other real and personal property and other assets in which an individual had any legal title or interest at the time of death (to the extent of the interest), including assets conveyed to a survivor, heir, or assign of the individual through joint tenancy, tenancy in common, survivorship, life estate, living trust, or other arrangement.

(2) "Institution" means a nursing facility, ICF/IID, or a medical institution.

(3) "Permanently institutionalized individual" means an individual to whom all of the following apply:

(a) Is an inpatient in an institution;

(b) Is required, as a condition of the medicaid program paying for the individual's services in the institution, to spend for costs of medical or nursing care all of the individual's income except for an amount for personal needs specified by the department of medicaid;

(c) Cannot reasonably be expected to be discharged from the institution and return home as determined by the department of medicaid.

(4) "Qualified state long-term care insurance partnership program" means the program established under section 5164.86 of the Revised Code.

(5) "Time of death" shall not be construed to mean a time after which a legal title or interest in real or personal property or other asset may pass by survivorship or other operation of law due to the death of the decedent or terminate by reason of the decedent's death.

(B) To the extent permitted by federal law, the department of medicaid shall institute a medicaid estate recovery program under which the department shall, except as provided in divisions (C) and (E) of this section, and subject to division (D) of this section, do all of the following:

(1) For the costs of medicaid services the medicaid program correctly paid or will pay on behalf of a permanently institutionalized individual of any age, seek adjustment or recovery from the individual's estate or on the sale of property of the individual or spouse that is subject to a lien imposed under section 5162.211 of the Revised Code;

(2) For the costs of medicaid services the medicaid program correctly paid or will pay on behalf of an individual fifty-five years of age or older who is not a permanently institutionalized individual, seek adjustment or recovery from the individual's estate;

(3) Seek adjustment or recovery from the estate of other individuals as permitted by federal law.

(C)(1) No adjustment or recovery may be made under division (B)(1) of this section from a permanently institutionalized individual's estate or on the sale of property of a permanently institutionalized individual that is subject to a lien imposed under section 5162.211 of the Revised Code or under division (B)(2) or (3) of this section from an individual's estate while either of the following are alive:

(a) The spouse of the permanently institutionalized individual or individual;

(b) The son or daughter of a permanently institutionalized individual or individual if the son or daughter is under age twenty-one or, under the "Social Security Act," section 1614, 42 U.S.C. 1382c, is considered blind or disabled.

(2) No adjustment or recovery may be made under division (B)(1) of this section from a permanently institutionalized individual's home that is subject to a lien imposed under section 5162.211 of the Revised Code while either of the following lawfully reside in the home:

(a) The permanently institutionalized individual's sibling who resided in the home for at least one year immediately before the date of the permanently institutionalized individual's admission to the institution and on a continuous basis since that time;

(b) The permanently institutionalized individual's son or daughter who provided care to the permanently institutionalized individual that delayed the permanently institutionalized individual's institutionalization and resided in the home for at least two years immediately before the date of the permanently institutionalized individual's admission to the institution and on a continuous basis since that time.

(D) In the case of a participant of the qualified state long-term care insurance partnership program, adjustment or recovery required by this section may be reduced in accordance with rules authorized by division (G) of this section.

(E) The department shall, in accordance with procedures and criteria established in rules authorized by division (G) of this section, waive seeking an adjustment or recovery otherwise required by this section if the medicaid director determines that adjustment or recovery would work an undue hardship. The department may limit the duration of the waiver to the period during which the undue hardship exists.

(F) For the purpose of determining whether an individual meets the definition of "permanently institutionalized individual" established for this section, a rebuttable presumption exists that the individual cannot reasonably be expected to be discharged from an institution and return home if either of the following is the case:

(1) The individual declares that he or she does not intend to return home.

(2) The individual has been an inpatient in an institution for at least six months.

(G) Rules adopted under section 5162.02 of the Revised Code shall do both of the following:

(1) For the purpose of division (D) of this section and consistent with the "Social Security Act," section 1917(b)(1)(C), 42 U.S.C. 1396p(b)(1)(C), provide for reducing an adjustment or recovery in the case of a participant of the qualified state long-term care insurance partnership program;

(2) For the purpose of division (E) of this section and consistent with the standards specified by the United States secretary of health and human services under the "Social Security Act," section 1917(b)(3), 42 U.S.C. 1396p(b)(3), establish procedures and criteria for waiving adjustment or recovery due to an undue hardship.

Section 5162.211 | Lien against property of recipient or spouse as part of estate recovery program.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) Except as provided in division (B) of this section and section 5162.23 of the Revised Code, no lien may be imposed against the property of an individual before the individual's death on account of medicaid services correctly paid or to be paid on the individual's behalf.

(B) Except as provided in division (C) of this section, the department of medicaid may impose a lien against the real property of a medicaid recipient who is a permanently institutionalized individual and against the real property of the recipient's spouse, including any real property that is jointly held by the recipient and spouse. The lien may be imposed on account of medicaid paid or to be paid on the recipient's behalf.

(C) No lien may be imposed under division (B) of this section against the home of a medicaid recipient if any of the following lawfully resides in the home:

(1) The recipient's spouse;

(2) The recipient's son or daughter who is under twenty-one years of age or, under the "Social Security Act," section 1614, 42 U.S.C. 1382c, considered to be blind or disabled;

(3) The recipient's sibling who has an equity interest in the home and resided in the home for at least one year immediately before the date of the recipient's admission to the institution.

(D) The medicaid director or a person designated by the director shall sign a certificate to effectuate a lien required to be imposed under this section. The county department of job and family services shall file for recording and indexing the certificate, or a certified copy, in the real estate mortgage records in the office of the county recorder in every county in which real property of the recipient or spouse is situated. From the time of filing the certificate in the office of the county recorder, the lien attaches to all real property of the recipient or spouse described in the certificate for all amounts for which adjustment or recovery may be made under section 5162.21 of the Revised Code and, except as provided in division (E) of this section, shall remain a lien until satisfied.

Upon filing the certificate in the office of the recorder, all persons are charged with notice of the lien and the rights of the department of medicaid thereunder.

The county recorder shall keep a record of every certificate filed showing its date, the time of filing, the name and residence of the recipient or spouse, and any release, waivers, or satisfaction of the lien.

The priority of the lien shall be established in accordance with state and federal law.

The department may waive the priority of its lien to provide for the costs of the last illness as determined by the department, administration, attorney fees, administrator fees, a sum for the payment of the costs of burial, which shall be computed by deducting from five hundred dollars whatever amount is available for the same purpose from all other sources, and a similar sum for the spouse of the decedent.

(E) A lien imposed with respect to a medicaid recipient under this section shall dissolve on the recipient's discharge from the institution and return home.

Section 5162.212 | Certification of amounts due under estate recovery program; collection.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The department of medicaid shall certify amounts due under the medicaid estate recovery program instituted under section 5162.21 of the Revised Code to the attorney general pursuant to section 131.02 of the Revised Code. The attorney general may enter into a contract with any person or government entity to collect the amounts due on behalf of the attorney general.

The attorney general, in entering into a contract under this section, shall comply with all of the requirements that must be met for the state to receive federal financial participation for the costs incurred in entering into the contract and carrying out actions under the contract. The contract may provide for the person or government entity with which the attorney general contracts to be compensated from the property recovered under the medicaid estate recovery program or may provide for another manner of compensation agreed to by the parties to the contract.

Regardless of whether the attorney general collects the amounts due under the medicaid estate recovery program or contracts with a person or government entity to collect the amounts due on behalf of the attorney general, the amounts due shall be collected in accordance with applicable requirements of federal statutes and regulations and state statutes and rules.

Section 5162.22 | Transfer of personal needs allowance account.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) As used in this section:

(1) "Commissioner" means a person appointed by a probate court under division (E) of section 2113.03 of the Revised Code to act as a commissioner.

(2) "Home" has the same meaning as in section 3721.10 of the Revised Code.

(3) "Personal needs allowance account" means an account or petty cash fund that holds the money of a resident of a residential facility or home and that the facility or home manages for the resident.

(4) "Residential facility" means a residential facility licensed under section 5119.34 of the Revised Code that provides accommodations, supervision, and personal care services for three to sixteen unrelated adults.

(B) Except as provided in divisions (C) and (D) of this section, the owner or operator of a home or residential facility shall transfer to the department of medicaid the money in the personal needs allowance account of a resident of the home or facility who was a medicaid recipient no earlier than sixty days but not later than ninety days after the resident dies. The home or facility shall transfer the money even though the owner or operator of the facility or home has not been issued letters testamentary or letters of administration concerning the resident's estate.

(C) If funeral or burial expenses for a resident of a home or residential facility who has died have not been paid and the only resource the resident had that could be used to pay for the expenses is the money in the resident's personal needs allowance account, or all other resources of the resident are inadequate to pay the full cost of the expenses, the money in the resident's personal needs allowance account shall be used to pay for the expenses rather than being transferred to the department of medicaid pursuant to division (B) of this section.

(D) If, not later than sixty days after a resident of a home or residential facility dies, letters testamentary or letters of administration are issued, or an application for release from administration is filed under section 2113.03 of the Revised Code, concerning the resident's estate, the owner or operator of the home or facility shall transfer the money in the resident's personal needs allowance account to the administrator, executor, commissioner, or person who filed the application for release from administration.

(E) The transfer or use of money in a resident's personal needs allowance account in accordance with division (B), (C), or (D) of this section discharges and releases the home or residential facility, and the owner or operator of the home, from any claim for the money from any source.

(F) If, sixty-one or more days after a resident of a home or residential facility dies, letters testamentary or letters of administration are issued, or an application for release from administration under section 2113.03 of the Revised Code is filed, concerning the resident's estate, the department of medicaid shall transfer the funds to the administrator, executor, commissioner, or person who filed the application, unless the department is entitled to recover the money under the medicaid estate recovery program instituted under section 5162.21 of the Revised Code.

Section 5162.23 | Recovering benefits incorrectly paid.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) The medicaid director shall adopt rules under section 5162.02 of the Revised Code permitting county departments of job and family services to take action to recover benefits incorrectly paid on behalf of medicaid recipients. The rules shall provide for recovery by the following methods:

(1) Soliciting voluntary payments from recipients or from persons holding property in which a recipient has a legal or equitable interest;

(2) Obtaining a lien on property pursuant to division (B) of this section.

(B) A county department of job and family services may bring a civil action in a court of common pleas against a medicaid recipient for the recovery of any medicaid payments determined by the court to have been paid incorrectly on behalf of the recipient. All persons holding property in which the recipient has a legal or equitable interest may be joined as parties. The court may issue pre-judgment orders, including injunctive relief or attachment under Chapter 2715. of the Revised Code, for the preservation of real or personal property in which the recipient may have a legal or equitable interest. If the court determines that medicaid payments were made incorrectly and issues a judgment to that effect, the county department may obtain a lien upon property of the recipient in accordance with Chapter 2329. of the Revised Code.

(C) The county department of job and family services shall retain fifty per cent of the balance remaining after deduction from the recovery of the amount required to be returned to the federal government and shall pay the other fifty per cent of the balance to the department of medicaid.

(D) Recovery of medicaid payments incorrectly made on behalf of a medicaid recipient may not be accomplished by reducing the amount of benefits the recipient is entitled to receive under another government assistance program.

(E) The remedies provided pursuant to this section do not affect any other remedies county departments of job and family services may have to recover benefits incorrectly paid on behalf of medicaid recipients.

Section 5162.24 | Recovering health care costs provided to child.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) As used in this section, "third party" has the same meaning as in section 5160.35 of the Revised Code.

(B) In addition to the authority granted under section 5160.38 of the Revised Code, the department of medicaid may, to the extent necessary to reimburse its costs, garnish the wages, salary, or other employment income of, and withhold amounts from state tax refunds to, any person to whom both of the following apply:

(1) The person is required by a court or administrative order to provide coverage of the cost of health care services to a child eligible for medicaid.

(2) The person has received payment from a third party for the costs of such services but has not used the payment to reimburse either the other parent or guardian of the child or the provider of the services.

(C) Claims for current and past due child support shall take priority over claims under division (B) of this section.

Section 5162.30 | Medicaid administrative claiming program.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) The medicaid director shall create a medicaid administrative claiming program under which federal financial participation is received for the administrative costs incurred by the department of health and the Arthur G. James cancer hospital and Richard J. Solove research institute of the Ohio state university in analyzing and evaluating both of the following pursuant to sections 3701.261 and 3701.262 of the Revised Code:

(1) Cancer reports under the Ohio cancer incidence surveillance system;

(2) The incidence, prevalence, costs, and medical consequences of cancer on medicaid recipients and other low-income populations.

(B) The medicaid director shall consult with the director of health in creating the medicaid administrative claiming program.

Section 5162.31 | Local funds expended for administration of the healthy start component.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

Local funds, whether from public or private sources, expended by a county department of job and family services for administration of the healthy start component shall be considered to have been expended by the state for the purpose of determining the extent to which the state has complied with any federal requirement that the state provide funds to match federal financial participation for the medicaid program. This section does not affect the amount of funds a county is entitled to receive under sections 5101.16 and 5101.161 of the Revised Code.

Section 5162.32 | Contracts with political subdivisions to pay nonfederal share.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The department of medicaid may enter into contracts with political subdivisions to use funds of the political subdivision to pay the nonfederal share of expenditures under the medicaid program. The determination and provision of federal financial participation to a subdivision entering into a contract under this section shall be determined by the department, subject to section 5162.40 of the Revised Code.

Section 5162.35 | Contracts for administration of components.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The department of medicaid may enter into contracts with one or more other state agencies or political subdivisions to have the state agency or political subdivision administer one or more components of the medicaid program, or one or more aspects of a component, under the department's supervision. A state agency or political subdivision that enters into such a contract shall comply with the terms of the contract and any rules the medicaid director has adopted governing the component, or aspect of the component, that the state agency or political subdivision is to administer, including any rules establishing review, audit, and corrective action plan requirements. A contract with a state agency shall be in the form of an interagency agreement.

A state agency or political subdivision that enters into a contract with the department under this section shall reimburse the department for the nonfederal share of the cost to the department of performing, or contracting for the performance of, a fiscal audit of the component of the medicaid program, or aspect of the component, that the state agency or political subdivision administers if rules governing the component, or aspect of the component, require that a fiscal audit be conducted.

Section 5162.36 | Medicaid school component.

• Effective: March 21, 2017
• Latest Legislation: House Bill 89 - 131st General Assembly

The medicaid director shall create, in accordance with sections 5162.36 to 5 162.366 of the Revised Code, the medicaid school component of the medicaid program.

Section 5162.361 | Claim by qualified medicaid school provider.

• Effective: March 21, 2017
• Latest Legislation: House Bill 89 - 131st General Assembly

A qualified medicaid school provider participating in the medicaid school component of the medicaid program may submit a claim to the department of medicaid for federal financial participation for providing, in schools, services covered by the medicaid school component to medicaid recipients who are eligible for the services. No qualified medicaid school provider may submit such a claim before the provider incurs the cost of providing the service.

The claim shall include certification of the qualified medicaid school provider's expenditures for the service. The certification shall show that the money the qualified medicaid school provider used for the expenditures was nonfederal money the provider may legally use for providing the service and that the amount of the expenditures was sufficient to pay the full cost of the service.

Except as otherwise provided in sections 5162.36 to 5 162.366 of the Revised Code, a qualified medicaid school provider is subject to all conditions of participation in the medicaid program that generally apply to providers of goods and services under the medicaid program, including conditions regarding claims, audits, and recovery of overpayments.

Section 5162.362 | Federal financial participation for medicaid school claims.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The department of medicaid shall seek federal financial participation for each claim a qualified medicaid school provider properly submits to the department under section 5162.361 of the Revised Code. The department shall disburse the federal financial participation the department receives from the federal government for such a claim to the qualified medicaid school provider that submitted the claim. The department may not pay the qualified medicaid school provider the nonfederal share of the cost of the services for which the claim was submitted.

Section 5162.363 | Administration of medicaid school component.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

The department of medicaid shall enter into an interagency agreement with the department of education and workforce under section 5162.35 of the Revised Code that provides for the department of education and workforce to administer the medicaid school component of the medicaid program other than the aspects of the component that sections 5162.36 to 5162.366 of the Revised Code require the department of medicaid to administer. The interagency agreement may include a provision that provides for the department of education and workforce to pay to the department of medicaid the nonfederal share of a portion of the administrative expenses the department of medicaid incurs in administering the aspects of the component that the department of medicaid administers.

To the extent authorized by rules authorized by section 5162.021 of the Revised Code, the department of education and workforce shall adopt rules establishing a process by which qualified medicaid school providers participating in the medicaid school component pay to the department of education and workforce the nonfederal share of the department's expenses incurred in administering the component. The rules shall be adopted in accordance with Chapter 119. of the Revised Code.

Last updated September 21, 2023 at 9:15 AM

Section 5162.364 | Adoption of rules for medicaid school component.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

The medicaid director shall adopt rules under section 5162.02 of the Revised Code as necessary to implement the medicaid school component of the medicaid program, including rules that establish or specify all of the following:

(A) Conditions a board of education of a city, local, or exempted school district, a governing board of an educational service center, governing authority of a community school established under Chapter 3314. of the Revised Code,, and Ohio deaf and blind education services must meet to participate in the component;

(B) Services the component covers;

(C) Payment rates for the services the component covers.

The rules shall be adopted in accordance with Chapter 119. of the Revised Code.

Last updated October 10, 2023 at 9:00 AM

Section 5162.365 | Responsibility for repaying overpayments.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) A qualified medicaid school provider is solely responsible for timely repaying any overpayment that the provider receives under the medicaid school component of the medicaid program and that is discovered by a federal or state audit. This is the case regardless of whether the audit's finding identifies the provider, department of medicaid, or department of education and workforce as being responsible for the overpayment.

(B) The department of medicaid shall not do any of the following regarding an overpayment for which a qualified medicaid school provider is responsible for repaying:

(1) Make a payment to the federal government to meet or delay the provider's repayment obligation;

(2) Assume the provider's repayment obligation;

(3) Forgive the provider's repayment obligation.

(C) Each qualified medicaid school provider shall indemnify and hold harmless the department of medicaid for any cost or penalty resulting from a federal or state audit finding that a claim submitted by the provider under section 5162.361 of the Revised Code did not comply with a federal or state requirement applicable to the claim, including a requirement of a medicaid waiver component.

Last updated September 21, 2023 at 9:17 AM

Section 5162.366 | Referrals for certain services under the Medicaid School Program.

• Effective: March 21, 2017
• Latest Legislation: House Bill 89 - 131st General Assembly

(A) Subject to division (B) of this section and for the purpose of a medicaid recipient receiving, in accordance with the recipient's individualized education program, physical therapy services, occupational therapy services, speech-language pathology services, or audiology services under the medicaid school component of the medicaid program:

(1) A physical therapist is a licensed practitioner of the healing arts for the purpose of 42 C.F.R. 440.110(a)(1) and may make a referral for physical therapy services for the recipient.

(2) An occupational therapist is a licensed practitioner of the healing arts for the purpose of 42 C.F.R. 440.110(b)(1) and may make a referral for occupational therapy services for the recipient.

(3) A speech-language pathologist is a licensed practitioner of the healing arts for the purpose of 42 C.F.R. 440.110(c)(1) and may make a referral for speech-language pathology services for the recipient.

(4) An audiologist is a licensed practitioner of the healing arts for the purpose of 42 C.F.R. 440.110(c)(1) and may make a referral for audiology services for the recipient.

(B) To be able to make a referral for a service under this section, a physical therapist, occupational therapist, speech-language pathologist, or audiologist must have a provider agreement. This does not preclude a physical therapist, occupational therapist, speech-language pathologist, or audiologist from being an ordering or referring only provider.

Section 5162.37 | Contract approval required.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

Any contract the department of medicaid enters into with the department of mental health and addiction services under section 5162.35 of the Revised Code is subject to the approval of the director of budget and management and shall require or specify all of the following:

(A) That section 5162.371 of the Revised Code be complied with;

(B) How providers will be paid for providing the services;

(C) The responsibilities of the department of mental health and addiction services with regard to providers, including program oversight and quality assurance.

Section 5162.371 | Contracts with department of mental health and addiction services; payment of nonfederal share of medicaid payment.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

If the department of medicaid enters into a contract with the department of mental health and addiction services under section 5162.35 of the Revised Code, the department of medicaid shall pay the nonfederal share of any medicaid payment to a provider for services under the component, or aspect of the component, the department of mental health and addiction services administers.

Section 5162.40 | Retaining or collecting percentage of federal financial participation.

• Effective: September 29, 2017
• Latest Legislation: House Bill 49 - 132nd General Assembly

(A) If a state agency or political subdivision administers one or more components of the medicaid program or administers one or more aspects of such a component, the department of medicaid may retain or collect not more than ten per cent of the federal financial participation the state agency or political subdivision obtains through an approved, administrative claim regarding the component or aspect of the component. If the department retains or collects a percentage of such federal financial participation, the percentage the department retains or collects shall be specified in a contract the department enters into with the state agency or political subdivision under section 5162.35 of the Revised Code.

(B) All amounts the department retains or collects under this section shall be deposited into the health care/medicaid support and recoveries fund created under section 5162.52 of the Revised Code.

Section 5162.41 | Retaining or collecting percentage of supplemental payment.

• Effective: September 29, 2017
• Latest Legislation: House Bill 49 - 132nd General Assembly

The department of medicaid may retain or collect a percentage of the federal financial participation included in a supplemental medicaid payment to one or more medicaid providers owned or operated by a state agency or political subdivision that brings the payment to such provider or providers to the upper payment limit established by 42 C.F.R. 447.272. If the department retains or collects a percentage of that federal financial participation, the medicaid director shall adopt a rule under section 5162.02 of the Revised Code specifying the percentage the department is to retain or collect. All amounts the department retains or collects under this section shall be deposited into the health care/medicaid support and recoveries fund created under section 5162.52 of the Revised Code.

Section 5162.50 | Health care-federal fund.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A) The health care - federal fund is hereby created in the state treasury. All of the following shall be credited to the fund:

(1) Funds that division (B) of section 5168.11 of the Revised Code requires be credited to the fund;

(2) The federal share of all rebates paid by drug manufacturers to the department of medicaid in accordance with a rebate agreement required by the "Social Security Act," section 1927, 42 U.S.C. 1396r-8;

(3) The federal share of all supplemental rebates paid by drug manufacturers to the department of medicaid in accordance with the supplemental drug rebate program established under section 5164.755 of the Revised Code;

(4) Except as otherwise provided by statute or as authorized by the controlling board, the federal share of all other medicaid-related revenues, collections, and recoveries.

(B) All money credited to the health care - federal fund pursuant to division (B) of section 5168.11 of the Revised Code shall be used solely for distributing funds to hospitals under section 5168.09 of the Revised Code. The department of medicaid shall use all other money credited to the fund to pay for other medicaid services and contracts.

Section 5162.52 | Health care/medicaid support and recoveries fund.

• Effective: October 17, 2019
• Latest Legislation: House Bill 166 - 133rd General Assembly

(A) The health care/medicaid support and recoveries fund is hereby created in the state treasury. All of the following shall be credited to the fund:

(1) Except as otherwise provided by statute or as authorized by the controlling board, the nonfederal share of all medicaid-related revenues, collections, and recoveries;

(2) Federal reimbursement received for payment adjustments made pursuant to section 1923 of the "Social Security Act," 42 U.S.C. 1396r-4, under the medicaid program to state mental health hospitals maintained and operated by the department of mental health and addiction services under division (A) of section 5119.14 of the Revised Code;

(3) Revenues the department of medicaid receives from another state agency for medicaid services pursuant to an interagency agreement;

(4) The money the department of medicaid receives in a fiscal year for performing eligibility verification services necessary for compliance with the independent, certified audit requirement of 42 C.F.R. 455.304;

(5) The nonfederal share of all rebates paid by drug manufacturers to the department of medicaid in accordance with a rebate agreement required by section 1927 of the "Social Security Act," 42 U.S.C. 1396r-8;

(6) The nonfederal share of all supplemental rebates paid by drug manufacturers to the department of medicaid in accordance with the supplemental drug rebate program established under section 5164.755 of the Revised Code;

(7) Amounts deposited into the fund pursuant to sections 5162.12, 5162.40, and 5162.41 of the Revised Code;

(8) The application fees charged to providers under section 5164.31 of the Revised Code;

(9) The fines collected under section 5165.1010 of the Revised Code;

(10) Amounts from assessments on hospitals under section 5168.06 of the Revised Code and intergovernmental transfers by governmental hospitals under section 5168.07 of the Revised Code that are deposited into the fund in accordance with the law.

(B) The department of medicaid shall use money credited to the health care/medicaid support and recoveries fund to pay for all of the following:

(1) Medicaid services;

(2) Costs associated with the administration of the medicaid program;

(3) Programs that serve youth involved with multiple government agencies;

(4) Innovative programs that the department has statutory authority to implement and that promote access to health care or help achieve long-term cost savings to the state.

Section 5162.56 | Health care special activities fund.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

There is created in the state treasury the health care special activities fund. The department of medicaid shall deposit all funds it receives pursuant to the administration of the medicaid program into the fund, other than any such funds that are required by law to be deposited into another fund. The department shall use the money in the fund to pay for expenses related to the services provided under, and the administration of, the medicaid program.

Section 5162.65 | Refunds and reconciliation fund.

• Effective: September 29, 2017
• Latest Legislation: House Bill 49 - 132nd General Assembly

There is hereby created in the state treasury the refunds and reconciliation fund.

Money the department of medicaid receives from a refund or reconciliation shall be deposited into the refunds and reconciliation fund if the department does not know the appropriate fund for the money at the time the department receives the money or if the money is to go to another government entity. Money transferred from the department of job and family services under section 5101.074 of the Revised Code also shall be deposited into the refunds and reconciliation fund.

Money in the refunds and reconciliation fund, including money transferred from the department of job and family services, shall be transferred to the appropriate fund once the appropriate fund is identified or shall be transferred to another government entity, as appropriate.

Section 5162.66 | Residents protection fund.

• Effective: September 29, 2017
• Latest Legislation: House Bill 49 - 132nd General Assembly

(A) There is hereby created in the state treasury the residents protection fund. All of the following shall be deposited into the fund:

(1) The proceeds of all fines, including interest, collected under sections 5165.60 to 5165.89 of the Revised Code;

(2) The proceeds of all fines, including interest, collected under section 173.42 of the Revised Code;

(3) The portions of civil money penalties and corresponding interest that are disbursed on or after July 1, 2017, to the department of medicaid pursuant to 42 C.F.R. 488.845.

(B)(1) Money deposited into the fund pursuant to divisions (A)(1) and (2) of this section shall be used for all of the following:

(a) Protection of the health or property of residents of nursing facilities in which the department of health finds deficiencies, including payment for the costs of relocation of residents to other facilities;

(b) Maintenance of operation of a facility pending correction of deficiencies or closure;

(c) Reimbursement of residents for the loss of money managed by the facility under section 3721.15 of the Revised Code;

(d) Provision of funds for costs incurred by a temporary resident safety assurance manager appointed under section 5165.78 of the Revised Code.

(2) Subject to 42 C.F.R. 488.845(g)(2), money deposited into the fund pursuant to division (A)(3) of this section shall be used to improve the quality of medicaid services provided by medicare-certified home health agencies.

(C) The fund shall be maintained and administered by the department of medicaid under rules developed in consultation with the departments of health and aging and adopted under section 5162.02 of the Revised Code. The rules shall be adopted in accordance with Chapter 119. of the Revised Code.

Section 5162.70 | Reforms to medicaid program.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) As used in this section:

(1) "CPI" means the consumer price index for all urban consumers as published by the United States bureau of labor statistics.

(2) "CPI medical inflation rate" means the inflation rate for medical care, or the successor term for medical care, for the midwest region as specified in the CPI.

(3) "JMOC projected medical inflation rate" means the following:

(a) The projected medical inflation rate for a fiscal biennium determined by the actuary with which the joint medicaid oversight committee contracts under section 103.414 of the Revised Code if the committee agrees with the actuary's projected medical inflation rate for that fiscal biennium;

(b) The different projected medical inflation rate for a fiscal biennium determined by the joint medicaid oversight committee under section 103.414 of the Revised Code if the committee disagrees with the projected medical inflation rate determined for that fiscal biennium by the actuary with which the committee contracts under that section.

(4) "Successor term" means a term that the United States bureau of labor statistics uses in place of another term in revisions to the CPI.

(B) The medicaid director shall implement reforms to the medicaid program that do all of the following:

(1) Limit the growth in the per member per month cost of the medicaid program, as determined on an aggregate basis for all eligibility groups, for a fiscal biennium to not more than the lesser of the following:

(a) The average annual increase in the CPI medical inflation rate for the most recent three-year period for which the necessary data is available as of the first day of the fiscal biennium, weighted by the most recent year of the three years;

(b) The JMOC projected medical inflation rate for the fiscal biennium.

(2) Achieve the limit in the growth of the per member per month cost of the medicaid program under division (B)(1) of this section by doing all of the following:

(a) Improving the physical and mental health of medicaid recipients;

(b) Providing for medicaid recipients to receive medicaid services in the most cost-effective and sustainable manner;

(c) Removing barriers that impede medicaid recipients' ability to transfer to lower cost, and more appropriate, medicaid services, including home and community-based services;

(d) Establishing medicaid payment rates that encourage value over volume and result in medicaid services being provided in the most efficient and effective manner possible;

(e) Implementing fraud and abuse prevention and cost avoidance mechanisms to the fullest extent possible.

(3) Reduce the prevalence of comorbid health conditions among, and the mortality rates of, medicaid recipients;

(4) Reduce infant mortality rates among medicaid recipients.

(C) When determining the growth in the per member per month cost of the medicaid program for purposes of the reforms required by this section, the medicaid director shall not exclude any medicaid eligibility group, provider wages, or service. The director may exclude one-time expenses or expenses that are not directly related to enrollees.

(D) The medicaid director shall implement the reforms under this section in accordance with evidence-based strategies that include measurable goals.

(E) By October first of each calendar year, the medicaid director shall submit to the joint medicaid oversight committee a report detailing the reforms implemented under this section. In even-numbered years, the report shall include the department's historical and projected medicaid program expenditure and utilization trend rates by medicaid program and service category for each year of the upcoming fiscal biennium and an explanation of how the trend rates were calculated.

(F) The reforms implemented under this section shall, without making the medicaid program's eligibility requirements more restrictive, reduce the relative number of individuals enrolled in the medicaid program who have the greatest potential to obtain the income and resources that would enable them to cease enrollment in medicaid and instead obtain health care coverage through employer-sponsored health insurance or an exchange.

Last updated October 6, 2023 at 12:23 PM

Section 5162.71 | Implementation of systems to improve health and reduce health disparities.

• Effective: March 20, 2014
• Latest Legislation: Senate Bill 206 - 130th General Assembly

The medicaid director shall implement within the medicaid program systems that do both of the following:

(A) Improve the health of medicaid recipients through the use of population health measures;

(B) Reduce health disparities, including, but not limited to, those within racial and ethnic populations.

Section 5162.72 | Strategies to address social determinants of health.

• Effective: October 17, 2019
• Latest Legislation: House Bill 166 - 133rd General Assembly

The medicaid director shall implement within the medicaid program strategies that address social determinants of health, including employment, housing, transportation, food, interpersonal safety, and toxic stress.

Section 5162.73 | Dental services for pregnant Medicaid recipients.

• Effective: September 18, 2020
• Latest Legislation: House Bill 11 - 133rd General Assembly

(A) The Department of Medicaid may establish and administer a program to provide dental services to pregnant Medicaid recipients. If the program is established, all of the following shall apply:

(1) Medicaid recipients who are members of the group described in section 5163.06 of the Revised Code shall be eligible to receive two dental cleanings per year.

(2) The Department shall give priority to those Medicaid recipients residing in areas of the state with high preterm birth rates.

(3) The Department shall inform Medicaid recipients about the program and market the program to Medicaid recipients.

(B) The Department of Medicaid shall establish reimbursement rates for entities that educate Medicaid recipients about the importance of prenatal and postnatal dental care as part of the program described in section 3701.615 of the Revised Code, including reimbursement rates for all or part of the costs associated with developing and distributing educational materials related to the importance of prenatal and postnatal dental care.

Section 5162.75 | Notification of veteran services.

• Effective: September 13, 2022
• Latest Legislation: Senate Bill 160 - 134th General Assembly

The medicaid director shall provide, to a veteran who has submitted an application for the medicaid program, information about the county veterans service office that can assist with investigating and applying for benefits through the United States department of veterans affairs. As used in this section, "veteran" has the same meaning as in section 5901.01 of the Revised Code.

Last updated October 20, 2022 at 4:52 PM

Section 5162.80 | Good faith estimates for charges and payments.

• Effective: January 1, 2017
• Latest Legislation: House Bill 52 - 131st General Assembly

(A) A provider of medical services licensed, accredited, or certified under Chapter 3721., 3727., 4715., 4725., 4731., 4732., 4734., 4747., 4753., 4755., 4757., or 4779. of the Revised Code shall provide in writing, before products, services, or procedures are provided, a reasonable, good-faith estimate of all of the following for the provider's non-emergency products, services, or procedures:

(1) The amount the provider will charge the patient or the consumer's health plan issuer for the product, service, or procedure;

(2) The amount the health plan issuer intends to pay for the product, service, or procedure;

(3) The difference, if any, that the consumer or other party responsible for the consumer's care would be required to pay to the provider for the product, service, or procedure.

(B) Any health plan issuer contacted by a provider described in division (A) of this section in order for the provider to obtain information so that the provider can comply with division (A) of this section shall provide such information to the provider within a reasonable time of the provider's request.

(C) As used in this section, "health plan issuer" means an entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the superintendent of insurance, that contracts, or offers to contract, to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services under a health benefit plan, including a sickness and accident insurance company and a health insuring corporation. "Health plan issuer" also includes a managed care organization under contract with the department of medicaid and, if the services are to be provided on a fee-for-service basis, the Medicaid program.

(D) The medicaid director shall adopt rules, in accordance with Chapter 119. of the Revised Code, to carry out this section.

Section 5162.82 | Payment rate increase report to JMOC.

• Effective: September 30, 2021
• Latest Legislation: House Bill 110 - 134th General Assembly

Before making any payment rate increases greater than ten per cent under the medicaid program, the medicaid director shall notify the joint medicaid oversight committee of the increase and be available to testify before the joint medicaid oversight committee regarding the increase.

Last updated September 9, 2021 at 3:02 PM