Ohio Revised Code
Chapter 5167 | Medicaid Managed Care
Section 5167.031 | Recognition of Pediatric Accountable Care Organizations.

Effective: September 29, 2013
Latest Legislation: House Bill 59 - 130th General Assembly
(A) As used in this section:
(1) "Children's care network" means any of the following:
(a) A children's hospital;
(b) A group of children's hospitals;
(c) A group of pediatric physicians.
(2) "Children's hospital" has the same meaning as in section 2151.86 of the Revised Code.
(B) If the department of medicaid includes in the care management system, pursuant to section 5167.03 of the Revised Code, individuals under twenty-one years of age who are included in the category of individuals who receive medicaid on the basis of being aged, blind, or disabled, the department may recognize entities as pediatric accountable care organizations.
An entity recognized by the department as a pediatric accountable care organization may develop innovative partnerships between relevant groups and may contract directly or subcontract with the state to provide care coordination and other services to the medicaid recipients under twenty-one years of age described in this division who are permitted or required to participate in the care management system.
(C)(1) To be recognized by the department as a pediatric accountable care organization, an entity shall meet the standards established by the department. Unless required by section 2706 of the "Patient Protection and Affordable Care Act," 124 Stat. 325 (2010) and the "Social Security Act," section 1895, 42 U.S.C. 1395jjj, the regulations adopted pursuant to those sections, and the laws of this state, the department shall not require that an entity be a health insuring corporation as a condition of receiving the department's recognition.
(2) Any of the following entities may receive the department's recognition, if the standards for recognition have been met:
(a) A children's care network;
(b) A children's care network that may include one or more other entities, including, but not limited to, health insuring corporations or other managed care organizations;
(c) Any other entity the department determines is qualified.
(D) The medicaid director shall consult with all of the following in adopting rules authorized by division (E) of this section necessary for an entity to be recognized by the department as a pediatric accountable care organization:
(1) The superintendent of insurance;
(2) Children's hospitals;
(3) Medicaid managed care organizations;
(4) Any other relevant entities, as determined necessary by the department, with interests in pediatric accountable care organizations.
(E) In adopting rules under section 5167.02 of the Revised Code, the medicaid director shall do all of the following:
(1) Establish application procedures to be followed by an entity seeking recognition as a pediatric accountable care organization;
(2) Ensure that the standards for recognition as a pediatric accountable care organization are the same as and do not conflict with those specified in section 2706 of the "Patient Protection and Affordable Care Act," 124 Stat. 325 (2010) and the "Social Security Act," section 1895, 42 U.S.C. 1395jjj or the regulations adopted pursuant to those sections;
(3) Establish requirements regarding the access to pediatric specialty care provided through or by a pediatric accountable care organization;
(4) Establish accountability and financial requirements for an entity recognized as a pediatric accountable care organization;
(5) Establish quality improvement initiatives consistent with any state medicaid quality plan established by the department;
(6) Establish transparency and consumer protection requirements for an entity recognized as a pediatric accountable care organization;
(7) Establish a process for sharing data.
(F) This section does not limit the authority of the department of insurance to regulate the business of insurance in this state.