Ohio Revised Code Chapter 5164 - Medicaid State Plan Services

• Section 5164.01 - Definitions.
  As used in this chapter: (A) "Adjudication" has the same meaning as in section 119.01 of the Revised Code. (B) "Early and periodic screening,...
• Section 5164.02 - [Renumbered From 5111.02] Rules To Implement Chapter.
  (A) The medicaid director shall adopt rules as necessary to implement this chapter. The rules shall be adopted in accordance with Chapter 119. of...
• Section 5164.03 - Mandatory And Optional Services.
  (A) The medicaid program shall cover all mandatory services. (B) The medicaid program shall cover all of the optional services that state statutes require...
• Section 5164.05 - [Renumbered From 5111.04] Coverage Of Services Provided By Outpatient Health Facilities.
  (A) As used in this section: (1) "Outpatient health facility" means a facility that provides comprehensive primary health services by or under the direction...
• Section 5164.06 - [Renumbered From 5111.029] Medicaid Coverage Of Occupational Therapy Services.
  The medicaid program shall cover occupational therapy services provided by an occupational therapist licensed under section 4755.08 of the Revised Code. Coverage shall not...
• Section 5164.07 - [Renumbered From 5111.018] Coverage Of Inpatient Care And Follow-up Care For A Mother And Her Newborn.
  (A) The medicaid program shall include coverage of inpatient care and follow-up care for a mother and her newborn as follows: (1) The medicaid...
• Section 5164.08 - [Renumbered From 5111.024] Screening Mammography And Cytologic Screening For Cervical Cancer.
  (A) As used in this section, "screening mammography" means a radiologic examination utilized to detect unsuspected breast cancer at an early stage in asymptomatic...
• Section 5164.09 - Equivalant Coverage For Orally And Intravenously Administered Cancer Medications.
  (A) Except as provided in division (C) of this section, the medicaid program shall cover prescribed, orally administered cancer medications on at least the...
• Section 5164.15 - [Renumbered From 5111.023] Mental Health Services.
  (A) As used in this section: (1) "Community mental health services provider or facility" means a community mental health services provider or facility that...
• Section 5164.20 - [Renumbered From 5111.027] Medicaid Not To Cover Drugs For Erectile Dysfunction.
  The medicaid program shall not cover prescribed drugs for treatment of erectile dysfunction. Renumbered from § 5111.027 by 130th General Assembly File No. 25,...
• Section 5164.25 - [Renumbered From 5111.042] Recipient With Developmental Disability Who Is Eligible For Medicaid Case Management Services.
  The departments of developmental disabilities and medicaid may approve, reduce, deny, or terminate a medicaid service included in the individualized service plan developed for...
• Section 5164.26 - [Renumbered From 5111.016] Healthcheck Component.
  The department of medicaid shall establish a combination of written and oral methods designed to provide information about healthcheck to all persons eligible for...
• Section 5164.30 - Provider Agreement With Department Required.
  No person or government entity may participate in the medicaid program as a medicaid provider without a valid provider agreement with the department of...
• Section 5164.301 - [Renumbered From 5111.053] Medicaid Provider Agreements For Physician Assistants.
  (A) As used in this section, "group practice" has the same meaning as in section 4731.65 of the Revised Code. (B) The department of...
• Section 5164.31 - [Renumbered From 5111.063] Funding For Implementing The Provider Screening Requirements.
  (A) For the purpose of raising funds necessary to pay the expenses of implementing the provider screening requirements of subpart E of 42 C.F.R....
• Section 5164.32 - [Renumbered From 5111.028] Expiration Of Medicaid Provider Agreements.
  (A) Each medicaid provider agreement shall expire not later than five years from its effective date . If a provider agreement entered into before...
• Section 5164.33 - Denying, Terminating, And Suspending Provider Agreements.
  (A) The medicaid director may do the following for any reason permitted or required by federal law and when the director determines that the...
• Section 5164.34 - Criminal Records Check Of Provider Personnel, Owners And Officers.
  (A) As used in this section: (1) "Criminal records check" has the same meaning as in section 109.572 of the Revised Code. (2) "Disqualifying...
• Section 5164.341 - [Renumbered From 5111.034] Criminal Records Check By Independent Provider.
  (A) As used in this section: "Anniversary date" means the later of the effective date of the provider agreement relating to the independent provider...
• Section 5164.342 - [Renumbered From 5111.033] Criminal Records Checks By Waiver Agencies.
  (A) As used in this section: "Applicant" means a person who is under final consideration for employment with a waiver agency in a full-time,...
• Section 5164.35 - [Renumbered From 5111.03] Provider Offenses.
  (A) As used in this section, "owner" means any person having at least five per cent ownership in a medicaid provider. (B) (1) No...
• Section 5164.36 - [Renumbered From 5111.035] Credible Allegation Of Fraud; Supsension Of Provider Agreement.
  (A) As used in this section: (1) " Credible allegation of fraud" has the same meaning as in 42 C.F.R. 455.2, except that for...
• Section 5164.37 - [Renumbered From 5111.031] Action Against Noninstitutional Medicaid Provider.
  (A) As used in this section: (1) "Independent provider" has the same meaning as in section 5164.341 of the Revised Code. (2) "Noninstitutional medicaid...
• Section 5164.38 - [Renumbered From 5111.06] Adjudication Orders Of Department.
  (A) As used in this section: (1) "Party" has the same meaning as in division (G) of section 119.01 of the Revised Code. (2)...
• Section 5164.39 - [Renumbered From 5111.062] Hearing Not Required Unless Timely Requested.
  In any action taken by the department of medicaid under section 5164.38 or 5164.57 of the Revised Code or any other state statute governing...
• Section 5164.44 - [Effective 3/23/2016] Employee Status Of Independent Provider.
  (A) As used in this section: (1) "Aide services" means all of the following: (a) Home health aide services covered by the medicaid program...
• Section 5164.45 - [Renumbered From 5111.05] Contracts For Examination, Processing, And Determination Of Medicaid Claims.
  (A) The department of medicaid may contract with any person or persons as a fiscal agent for the examination, processing, and determination of medicaid...
• Section 5164.46 - [Renumbered From 5111.052] Electronic Claims Submission Process; Electronic Fund Transfers.
  (A) As used in this section, "electronic claims submission process" means any of the following: (1) Electronic interchange of data; (2) Direct entry of...
• Section 5164.47 - [Renumbered From 5111.054] Contracting For Review And Analysis, Quality Assurance And Quality Review.
  (A) As used in this section , "OCHSPS" means the private, not-for-profit corporation known as the Ohio children's hospital solutions for patient safety, which...
• Section 5164.48 - [Renumbered From 5111.051] Medicaid Payments Made To Organization On Behalf Of Providers.
  The medicaid director may implement a system under which medicaid payments for medicaid services are made to an organization on behalf of medicaid providers...
• Section 5164.55 - Final Fiscal Audits.
  The department of medicaid may conduct final fiscal audits of medicaid providers in accordance with the applicable requirements set forth in federal laws and...
• Section 5164.56 - [Renumbered From 5111.022] Lien For Amount Owed By Provider.
  Under the medicaid program, any amount determined to be owed the state by a final fiscal audit conducted pursuant to section 5164.55 of the...
• Section 5164.57 - [Renumbered From 5111.061] Recovery Of Medicaid Overpayments.
  (A) (1) Except as provided in division (A)(2) of this section, the department of medicaid may recover a medicaid payment or portion of a...
• Section 5164.58 - [Renumbered From 5111.914] Agency Action To Recover Overpayment To Provider.
  (A) If a state agency that enters into a contract with the department of medicaid under section 5162.35 of the Revised Code identifies that...
• Section 5164.59 - Deduction Of Incorrect Payments.
  The department of medicaid may deduct from medicaid payments for medicaid services rendered by a medicaid provider any amounts the provider owes the state...
• Section 5164.60 - Interest On Medicaid Provider Excess Payments.
  Any medicaid provider who, without intent, obtains payments under the medicaid program in excess of the amount to which the provider is entitled is...
• Section 5164.61 - Scope Of Available Remedies For Recovery Of Excess Payments.
  The authority, under state and federal law, of the department of medicaid or a county department of job and family services to recover excess...
• Section 5164.70 - [Renumbered From 5111.021] Limitations On Medicaid Payments For Services.
  Except as otherwise required by federal statute or regulation, no medicaid payment for any medicaid service shall exceed the following: (A) If the medicaid...
• Section 5164.71 - Payments For Freestanding Medical Laboratory Charges.
  Medicaid payments for freestanding medical laboratory charges shall not exceed the customary and usual fee for laboratory profiles. Added by 130th General Assembly File...
• Section 5164.72 - Limitations On Payments For Inpatient Hospital Care.
  The number of days of inpatient hospital care for which a medicaid payment is made on behalf of a medicaid recipient to a hospital...
• Section 5164.73 - Division Of Payments Between Physician Or Podiatrist And Nurse.
  The division of any medicaid payment between a collaborating physician or podiatrist and a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner for...
• Section 5164.74 - [Renumbered From 5111.19] Reimbursement Of Graduate Medical Education Costs.
  The medicaid director shall adopt rules under section 5164.02 of the Revised Code governing the calculation and payment of, and the allocation of payments...
• Section 5164.741 - [Renumbered From 5111.191] Payment For Graduate Medical Education Costs To Noncontracting Hospitals.
  (A) Except as provided in division (B) of this section, the department of medicaid may deny medicaid payment to a hospital for direct graduate...
• Section 5164.75 - [Renumbered From 5111.086] Medicaid Payment For A Drug Subject To A Federal Upper Reimbursement Limit.
  As used in this section, "federal upper reimbursement limit" means the limit established pursuant to the "Social Security Act," section 1927(e), 42 U.S.C. 1396r-8(e)....
• Section 5164.751 - [Renumbered From 5111.082] State Maximum Allowable Cost Program.
  (A) As used in this section , "state maximum allowable cost" means the per unit amount the medicaid program pays a terminal distributor of...
• Section 5164.752 - Determining Maximum Dispensing Fee.
  In July of every even-numbered year, the department of medicaid shall initiate a confidential survey of the cost of dispensing drugs incurred by terminal...
• Section 5164.753 - [Renumbered From 5111.071] Dispensing Fee.
  In December of every even-numbered year, the medicaid director shall establish a dispensing fee, effective the following July, for terminal distributors of dangerous drugs...
• Section 5164.754 - [Renumbered From 5111.0114] Agreement For Multiple-state Drug Purchasing Program.
  (A) As used in this section, "dangerous drug" and "manufacturer of dangerous drugs" have the same meaning as in section 4729.01 of the Revised...
• Section 5164.755 - [Renumbered From 5111.081] Supplemental Drug Rebate Program.
  The medicaid director , in rules adopted under section 5164.02 of the Revised Code, may establish and implement a supplemental drug rebate program under...
• Section 5164.756 - [Renumbered From 5101.31] Drug Rebate Agreement Or Supplemental Drug Rebate Agreement For Medicaid Program Not Subject To Public Records Law.
  Any record, data, pricing information, or other information regarding a drug rebate agreement or a supplemental drug rebate agreement for the medicaid program that...
• Section 5164.757 - E-prescribing Applications.
  (A) As used in this section, "licensed health professional authorized to prescribe drugs" has the same meaning as in section 4729.01 of the Revised...
• Section 5164.758 - [Renumbered From 5111.085] Adoption Of Rules For Implementation Of Coordinated Services Program For Medicaid Users Who Abuse Prescription Drugs.
  The medicaid director shall adopt rules under section 5164.02 of the Revised Code to implement a coordinated services program for medicaid recipients who are...
• Section 5164.759 - [Renumbered From 5111.08] Outpatient Drug Use Review Program.
  In accordance with the "Social Security Act," section 1927(g), 42 U.S.C. 1396r-8(g), the department of medicaid shall establish an outpatient drug use review program...
• Section 5164.7510 - [Renumbered From 5111.084] Pharmacy And Therapeutics Committee.
  (A) There is hereby established the pharmacy and therapeutics committee of the department of medicaid. The committee shall assist the department with developing and...
• Section 5164.76 - [Renumbered From 5111.025] Manner Of Payment For Community Mental Health Service Providers Or Facilities And Alcohol And Drug Addiction Services.
  (A) In rules adopted under section 5164.02 of the Revised Code, the medicaid director shall modify the manner or establish a new manner in...
• Section 5164.77 - [Renumbered From 5111.0213] Adjustment Of Medicaid Payments; Payment For Aide Or Nursing Services.
  (A) As used in this section: (1) "Aide services" means all of the following: (a) Home health aide services available under the home health...
• Section 5164.80 - [Renumbered From 5111.0212] Public Notice For Changes To Payment Rates For Medicaid Assistance.
  As necessary to comply with the "Social Security Act," section 1902(a)(13)(A), 42 U.S.C. 1396a(a)(13)(A), and any other federal law that requires public notice of...
• Section 5164.82 - [Renumbered From 5111.0214] Payment For Provider-preventable Condition.
  The department of medicaid shall not knowingly make a medicaid payment for a provider-preventable condition for which federal financial participation is prohibited by regulations...
• Section 5164.85 - [Renumbered From 5111.13] Enrolling In Group Health Plan.
  (A) As used in this section, "cost-effective" and "group health plan" have the same meanings as in the "Social Security Act," section 1906, 42...
• Section 5164.86 - [Renumbered From 5111.18] Qualified State Long-term Care Insurance Partnership Program.
  The medicaid director shall establish a qualified state long-term care insurance partnership program consistent with the definition of that term in the "Social Security...
• Section 5164.88 - [Renumbered From 5111.14] Coordinated Care Through Health Homes.
  The medicaid director may implement within the medicaid program a system under which medicaid recipients with chronic conditions are provided with coordinated care through...
• Section 5164.881 - Health Home Services.
  The medicaid director, in consultation with the director of developmental disabilities, may develop and implement within the medicaid program a system under which eligible...
• Section 5164.89 - [Renumbered From 5111.141] Case Management Of Nonemergency Transportation Services.
  The department of medicaid may require county departments of job and family services to provide case management of nonemergency transportation services provided under the...
• Section 5164.90 - [Renumbered From 5111.96] Transition Of Medicaid Recipients To Community Settings.
  (A) As used in this section, "MFP demonstration project" means a money follows the person demonstration project that the United States secretary of health...
• Section 5164.91 - [Renumbered From 5111.981] Integrated Care Delivery System.
  The medicaid director may implement a demonstration project called the integrated care delivery system to test and evaluate the integration of the care that...
• Section 5164.911 - Integrated Care Delivery System Evaluation.
  (A) If the medicaid director implements the integrated care delivery system and except as provided in division (C) of this section, the director shall...
• Section 5164.92 - [Renumbered From 5111.0210] Advanced Diagnostic Imaging Services Coverage Under Medicaid Program.
  As used in this section, "advanced diagnostic imaging services" means magnetic resonance imaging services, computed tomography services, positron emission tomography services, cardiac nuclear medicine...
• Section 5164.93 - [Renumbered From 5111.0215] Incentive Payments For Adoption And Use Of Electronic Health Record Technology.
  (A) The department of medicaid may establish a program under which it provides incentive payments, as authorized by the " Social Security Act," section...
• Section 5164.94 - Delivery Of Services In Culturally And Linguistically Appropriate Manners.
  The medicaid director shall implement within the medicaid program a system that encourages medicaid providers to provide medicaid services to medicaid recipients in culturally...
• Section 5164.95 - Standards For Payments For Telehealth Services.
  (A) As used in this section, "telehealth service" means a health care service delivered to a patient through the use of interactive audio, video,...

Last modified: October 10, 2016