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 nursing facility service under medicare at the time the service is provided.
(3) "Skilled nursing facility" has the same meaning as in the "Social Security Act," section 1819(a), 42 U.S.C. 1395i-3(a).
(B) Except as provided in division (C) of this section, a medicaid managed care organization shall pay a skilled nursing facility at least the current medicare fee-for-service rate, without deduction for any coinsurance, for covered skilled nursing facility services that the skilled nursing facility provides to a dual eligible individual if the medicaid managed care organization is responsible for the payment under the terms of a contract that the medicaid managed care organization, medicaid director, and United States secretary of health and human services jointly enter into under the integrated care delivery system authorized by section 5164.91 of the Revised Code.
(C) A medicaid managed care organization is required to pay the rate specified in division (B) of this section for covered skilled nursing facility services only if all of the following apply:
(1) The United States secretary agrees to the payment rate as part of the contract that the medicaid managed care organization, medicaid director, and United States secretary jointly enter into under the integrated care delivery system;
(2) The medicaid managed care organization receives a federal capitation payment that is an actuarially sufficient amount for the costs that the medicaid managed care organization incurs in paying the rate;
(3) No state funds are used for any part of the costs that the medicaid managed care organization incurs in paying the rate;
(4) The integrated care delivery system provides for dual eligible individuals to receive the covered skilled nursing facility services as part of the system.
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.