Ohio Revised Code
Chapter 5167 | Medicaid Managed Care
Section 5167.01 | Definitions.

Effective: April 12, 2021
Latest Legislation: Senate Bill 263 - 133rd General Assembly
As used in this chapter:
(A) "340B covered entity" means an entity described in section 340B(a)(4) of the "Public Health Service Act," 42 U.S.C. 256b(a)(4) and includes any pharmacy under contract with the entity to dispense drugs on behalf of the entity.
(B) "Affiliated company" means an entity, including a third-party payer or specialty pharmacy, with common ownership, members of a board of directors, or managers, or that is a parent company, subsidiary company, jointly held company, or holding company with respect to the other entity.
(C) "Care management system" means the system established under section 5167.03 of the Revised Code.
(D) "Controlled substance" has the same meaning as in section 3719.01 of the Revised Code.
(E) "Dual eligible individual" has the same meaning as in section 5160.01 of the Revised Code.
(F) "Emergency services" has the same meaning as in the "Social Security Act," section 1932(b)(2), 42 U.S.C. 1396u-2(b)(2).
(G) "Enrollee" means a medicaid recipient who participates in the care management system and enrolls in a medicaid MCO plan.
(H) "ICDS participant" has the same meaning as in section 5164.01 of the Revised Code.
(I) "Medicaid managed care organization" means a managed care organization under contract with the department of medicaid pursuant to section 5167.10 of the Revised Code.
(J) "Medicaid MCO plan" means a plan that a medicaid managed care organization, pursuant to its contract with the department of medicaid under section 5167.10 of the Revised Code, makes available to medicaid recipients participating in the care management system.
(K) "Medicaid waiver component" has the same meaning as in section 5166.01 of the Revised Code.
(L) "Network provider" has the same meaning as in 42 C.F.R. 438.2.
(M) "Nursing facility services" has the same meaning as in section 5165.01 of the Revised Code.
(N) "Part B drug" means a drug or biological described in section 1842(o)(1)(C) of the "Social Security Act," 42 U.S.C. 1395u(o)(1)(C).
(O) "Pharmacy benefit manager" has the same meaning as in section 3959.01 of the Revised Code.
(P) "Practice of pharmacy" has the same meaning as in section 4729.01 of the Revised Code.
(Q) "Prescribed drug" has the same meaning as in section 5164.01 of the Revised Code.
(R) "Prior authorization requirement" has the same meaning as in section 5160.34 of the Revised Code.
(S) "Provider" means any person or government entity that furnishes services to a medicaid recipient enrolled in a medicaid MCO plan, regardless of whether the person or entity has a provider agreement.
(T) "Provider agreement" has the same meaning as in section 5164.01 of the Revised Code.
(U) "State pharmacy benefit manager" means the pharmacy benefit manager selected by and under contract with the medicaid director under section 5167.24 of the Revised Code.
(V) "Third-party administrator" means any person who adjusts or settles claims on behalf of an insuring entity in connection with life, dental, health, prescription drugs, or disability insurance or self-insurance programs and includes a pharmacy benefit manager.

Structure Ohio Revised Code

Ohio Revised Code

Title 51 | Public Welfare

Chapter 5167 | Medicaid Managed Care

Section 5167.01 | Definitions.

Section 5167.02 | Rules.

Section 5167.03 | Care Management System.

Section 5167.031 | Recognition of Pediatric Accountable Care Organizations.

Section 5167.04 | Inclusion of Alcohol, Drug Addiction, and Mental Health Services in Care Management System.

Section 5167.05 | Inclusion of Prescribed Drugs in Care Management System.

Section 5167.051 | Coverage of Services Provided by Pharmacist.

Section 5167.10 | Authority to Contract With Managed Care Orgainizations.

Section 5167.101 | Basis of Hospital Inpatient Capital Payment Portion of Payment to Medicaid Managed Care Organization.

Section 5167.102 | Use of Providers to Render Care to Enrollees.

Section 5167.103 | Performance Metrics; Publication.

Section 5167.11 | Managed Care Organization Contract to Provide Grievance Process.

Section 5167.12 | Requirements When Prescribed Drugs Are Included in Care Management System.

Section 5167.122 | Disclosure of Sources of Payment.

Section 5167.123 | Medicaid Mco Contracts With 340b Program Participants.

Section 5167.13 | Implementation of Coordinated Services Program for Enrollees Who Abuse Prescribed Drugs.

Section 5167.14 | Data Security Agreements for Managed Care Organization's Use of Drug Database.

Section 5167.15 | Chiropractic Services.

Section 5167.16 | Home Visits and Cognitive Behavioral Therapy.

Section 5167.17 | Enhanced Care Management Services for Pregnant Women and Women Capable of Becoming Pregnant.

Section 5167.171 | Uniform Prior Approval Form for Progesterone.

Section 5167.173 | Community Health Worker Services or Services Provided by Public Health Nurse.

Section 5167.18 | Identification of Fraud, Waste, and Abuse.

Section 5167.20 | Reference by Managed Care Organization to Noncontracting Participant.

Section 5167.201 | Payment of Nonsystem Provider for Emergency Services.

Section 5167.21 | Payments to Skilled Nursing Facility.

Section 5167.22 | Recoupment of Overpayment.

Section 5167.221 | Assessment of Recoupment Efforts.

Section 5167.24 | Third-Party Administrator as Single Pharmacy Benefit Manager.

Section 5167.241 | State Pharmacy Benefit Manager Contract; Payment Arrangements.

Section 5167.243 | Quarterly Reports.

Section 5167.244 | Violations; Penalty.

Section 5167.245 | Appeals Process.

Section 5167.26 | Records for Determining Costs.

Section 5167.30 | Managed Care Performance Payment Program.

Section 5167.31 | Financial Incentive Awards.

Section 5167.32 | Improving Integrity of Care Management System.

Section 5167.33 | Strategies Regarding Payment to Providers.

Section 5167.34 | Immunity From Liability.

Section 5167.40 | Appointment of Temporary Manager.

Section 5167.41 | Disenrolling Some or All Medicaid Recipients From Mco Plan Offered by a Managed Care Organization.

Section 5167.45 | Information About Medicaid Recipients' Races, Ethnicities, and Primary Languages.

Section 5167.47 | Compliance With Federal Mental Health and Addiction Parity Laws.