Effective: September 29, 2017
Latest Legislation: House Bill 49 - 132nd General Assembly
(A)(1) The department of medicaid shall establish a managed care performance payment program. Under the program, the department may provide payments to medicaid managed care organizations that meet performance standards established by the department.
(2) In establishing performance standards, the department may consult any of the following:
(a) Any quality measurements developed under the pediatric quality measures program established pursuant to the "Social Security Act," section 1139A, 42 U.S.C. 1320b-9a;
(b) Any core set of adult health quality measures for medicaid eligible adults used for purposes of the "Social Security Act," section 1139A, 42 U.S.C. 1320b-9b, and any adult health quality used for purposes of the medicaid quality measurement program when the program is established under that section of the "Social Security Act";
(c) The most recent healthcare effectiveness data and information set and quality measurement tool established by the national committee for quality assurance.
(3) The standards that must be met to receive the payments may be specified in the contract the department enters into with a medicaid managed care organization.
(4) If a medicaid managed care organization meets the performance standards established by the department, the department shall make one or more performance payments to the organization. The amount of each performance payment, the number of payments, and the schedule for making the payments shall be established by the department. The payments shall be discontinued if the department determines that the organization no longer meets the performance standards. The department shall not make or discontinue payments based on any performance standard that has been in effect as part of the organization's contract for less than six months.
(B) For purposes of the program, the department shall establish an amount that is to be withheld each time a premium payment is made to a medicaid managed care organization. The amount shall be established as a percentage of each premium payment. The percentage shall be the same for all medicaid managed care organizations. The sum of all withholdings under this division shall not exceed five per cent of the total of all premium payments made to all medicaid managed care organizations.
Each medicaid managed care organization shall agree to the withholding as a condition of receiving or maintaining its provider agreement with the department.
When the amount is established and each time the amount is modified thereafter, the department shall certify the amount to the director of budget and management and begin withholding the amount from each premium the department pays to a medicaid managed care 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.