Effective: September 29, 2015
Latest Legislation: House Bill 64 - 131st General Assembly
(A) Not later than July 1, 2018, each medicaid managed care organization shall implement strategies that base payments to providers on the value received from the providers' services, including their success in reducing waste in the provision of the services. Not later than July 1, 2020, each medicaid managed care organization shall ensure that at least fifty per cent of the aggregate net payments it makes to providers are based on the value received from the providers' services.
The department of medicaid may measure a medicaid managed care organization's compliance with this section based on the actions of the organization, the providers in the organization's provider panel, the organization's subcontractors, or any combination of the organization, providers, and subcontractors.
(B) The medicaid director shall adopt rules under section 5167.02 of the Revised Code as necessary to implement this section, including rules that specify how all of the following are to be determined:
(1) The value received from a provider's services;
(2) A provider's success in reducing waste in the provision of services;
(3) The percentage of a medicaid managed care organization's aggregate net payments to providers that are based on the value received from the providers' services.
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.