Ohio Code 5167.30 – Managed care performance payment program
(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.
Terms Used In Ohio Code 5167.30
- Contract: A legal written agreement that becomes binding when signed.
- Medicaid managed care organization: means a managed care organization under contract with the department of medicaid pursuant to section 5167. See Ohio Code 5167.01
- Provider: means any person or government entity that furnishes services to a medicaid recipient enrolled in a medicaid MCO plan, regardless of whether the person or entity has a provider agreement. See Ohio Code 5167.01
(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.