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 but is not under contract with the organization, the hospital shall provide the service for which the referral was made and shall accept from the organization, as payment in full, the amount derived from the payment rate used by the department of medicaid to pay other hospitals of the same type for providing the same service to a medicaid recipient who is not enrolled in a medicaid MCO plan.
(B) A hospital is not subject to division (A) of this section if all of the following are the case:
(1) The hospital is located in a county in which participants in the care management system are required before January 1, 2006, to be enrolled in a medicaid MCO plan;
(2) The hospital has entered into a contract before January 1, 2006, with at least one health insuring corporation serving the participants specified in division (B)(1) of this section;
(3) The hospital remains under contract with at least one health insuring corporation serving participants in the care management system who are required to be enrolled in a medicaid MCO plan.
(C) The medicaid director shall adopt rules under section 5167.02 of the Revised Code specifying the circumstances under which a medicaid managed care organization is permitted to refer an enrollee to a hospital that is not under contract with the organization.
Structure Ohio Revised Code
Chapter 5167 | Medicaid Managed Care
Section 5167.01 | Definitions.
Section 5167.03 | Care Management System.
Section 5167.031 | Recognition of Pediatric Accountable Care Organizations.
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 5167.102 | 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 5167.14 | 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 5167.171 | 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 5167.45 | Information About Medicaid Recipients' Races, Ethnicities, and Primary Languages.
Section 5167.47 | Compliance With Federal Mental Health and Addiction Parity Laws.