Section 5167.221 | Assessment of Recoupment Efforts.
Effective: October 17, 2019 Latest Legislation: House Bill 166 – 133rd General Assembly The department of medicaid shall assess the efforts of medicaid managed care organizations to recoup overpayments made to providers who are network providers and providers who are not network providers. The assessments shall examine the amount of time recoupment efforts take starting […]
Section 5167.24 | Third-Party Administrator as Single Pharmacy Benefit Manager.
Effective: October 17, 2019 Latest Legislation: House Bill 166 – 133rd General Assembly (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 benefit […]
Section 5167.241 | State Pharmacy Benefit Manager Contract; Payment Arrangements.
Effective: October 17, 2019 Latest Legislation: House Bill 166 – 133rd General Assembly (A)(1) Medicaid managed care organizations shall use the state pharmacy benefit manager selected under section 5167.24 of the Revised Code pursuant to the terms of the master contract entered into under that section. All payment arrangements between the department of medicaid, medicaid […]
Section 5167.243 | Quarterly Reports.
Effective: October 17, 2019 Latest Legislation: House Bill 166 – 133rd General Assembly (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 care management […]
Section 5167.244 | Violations; Penalty.
Effective: October 17, 2019 Latest Legislation: House Bill 166 – 133rd General Assembly 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 […]
Section 5167.245 | Appeals Process.
Effective: October 17, 2019 Latest Legislation: House Bill 166 – 133rd General Assembly 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 […]
Section 5167.20 | Reference by Managed Care Organization to Noncontracting Participant.
Effective: October 17, 2019 Latest Legislation: House Bill 166 – 133rd General Assembly (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 […]
Section 5167.201 | Payment of Nonsystem Provider for Emergency Services.
Effective: October 17, 2019 Latest Legislation: House Bill 166 – 133rd General Assembly 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 […]
Section 5167.21 | Payments to Skilled Nursing Facility.
Effective: September 29, 2013 Latest Legislation: House Bill 59 – 130th General Assembly (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 skilled […]
Section 5167.22 | Recoupment of Overpayment.
Effective: October 17, 2019 Latest Legislation: House Bill 166 – 133rd General Assembly 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 […]