§ 5167.01 Definitions
§ 5167.02 Rules
§ 5167.03 Care management system
§ 5167.031 Recognition of pediatric accountable care organizations
§ 5167.04 Inclusion of alcohol, drug addiction, and mental health services in care management system
§ 5167.05 Inclusion of prescribed drugs in care management system
§ 5167.051 Coverage of services provided by pharmacist
§ 5167.10 Authority to contract with managed care orgainizations
§ 5167.101 Basis of hospital inpatient capital payment portion of payment to medicaid managed care organization
§ 5167.103 Performance metrics; publication
§ 5167.11 Managed care organization contract to provide grievance process
§ 5167.12 Requirements when prescribed drugs are included in care management system
§ 5167.122 Disclosure of sources of payment
§ 5167.123 Medicaid MCO contracts with 340B program participants
§ 5167.13 Implementation of coordinated services program for enrollees who abuse prescribed drugs
§ 5167.14 Data security agreements for managed care organization’s use of drug database
§ 5167.15 Chiropractic services
§ 5167.16 Home visits and cognitive behavioral therapy
§ 5167.17 Enhanced care management services for pregnant women and women capable of becoming pregnant
§ 5167.171 Uniform prior approval form for progesterone
§ 5167.173 Community health worker services or services provided by public health nurse
§ 5167.18 Identification of fraud, waste, and abuse
§ 5167.20 Reference by managed care organization to noncontracting participant
§ 5167.201 Payment of nonsystem provider for emergency services
§ 5167.21 Payments to skilled nursing facility
§ 5167.22 Recoupment of overpayment
§ 5167.221 Assessment of recoupment efforts
§ 5167.24 Third-party administrator as single pharmacy benefit manager
§ 5167.241 State pharmacy benefit manager contract; payment arrangements
§ 5167.243 Quarterly reports
§ 5167.244 Violations; penalty
§ 5167.245 Appeals process
§ 5167.26 Records for determining costs
§ 5167.30 Managed care performance payment program
§ 5167.31 Financial incentive awards
§ 5167.32 Improving integrity of care management system
§ 5167.33 Strategies regarding payment to providers
§ 5167.34 Immunity from liability
§ 5167.35 Meaningful employment of Medicaid recipients
§ 5167.40 Appointment of temporary manager
§ 5167.41 Disenrolling some or all medicaid recipients from MCO plan offered by a managed care organization
§ 5167.45 Information about medicaid recipients’ races, ethnicities, and primary languages
§ 5167.47 Compliance with federal mental health and addiction parity laws
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Terms Used In Ohio Code > Chapter 5167 - Medicaid Managed Care

  • Another: when used to designate the owner of property which is the subject of an offense, includes not only natural persons but also every other owner of property. See Ohio Code 1.02
  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
  • Care management system: means the system established under section 5167. See Ohio Code 5167.01
  • Certified nurse practitioner: means an advanced practice registered nurse who holds a current, valid license issued under Chapter 4723 of the Revised Code and is designated as a certified nurse practitioner in accordance with section 4723. See Ohio Code 1.64
  • Child: includes child by adoption. See Ohio Code 1.59
  • Clinical nurse specialist: means an advanced practice registered nurse who holds a current, valid license issued under Chapter 4723 of the Revised Code and is designated as a clinical nurse specialist in accordance with section 4723. See Ohio Code 1.64
  • Contract: A legal written agreement that becomes binding when signed.
  • Conviction: A judgement of guilt against a criminal defendant.
  • Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
  • Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
  • Enrollee: means a medicaid recipient who participates in the care management system and enrolls in a medicaid MCO plan. See Ohio Code 5167.01
  • Fraud: Intentional deception resulting in injury to another.
  • Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
  • Internet: means the international computer network of both federal and nonfederal interoperable packet switched data networks, including the graphical subnetwork known as the world wide web. See Ohio Code 1.59
  • Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
  • Liabilities: The aggregate of all debts and other legal obligations of a particular person or legal entity.
  • 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
  • Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
  • Oversight: Committee review of the activities of a Federal agency or program.
  • Person: includes an individual, corporation, business trust, estate, trust, partnership, and association. See Ohio Code 1.59
  • Population: means that shown by the most recent regular federal census. See Ohio Code 1.59
  • 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
  • state: means the state of Ohio. See Ohio Code 1.59
  • State pharmacy benefit manager: means the pharmacy benefit manager selected by and under contract with the medicaid director under section 5167. See Ohio Code 5167.01
  • Third-party administrator: means any person who adjusts or settles claims on behalf of an insuring entity in connection with life, dental, health, prescription drugs, or disability insurance or self-insurance programs and includes a pharmacy benefit manager. See Ohio Code 5167.01
  • United States: includes all the states. See Ohio Code 1.59
  • Whoever: includes all persons, natural and artificial; partners; principals, agents, and employees; and all officials, public or private. See Ohio Code 1.02