5111.162 Reference by managed care organization to noncontracting participant.
5111.162 Reference by managed care organization to noncontracting participant.
(A) As used in this section:
(1) “Emergency services” has the same meaning as in section 1932(b)(2) of the “Social Security Act,” 79 Stat. 286 (1965), 42 U.S.C. 1396u-2 (b)(2 ), as amended.
(2) “Medicaid managed care organization” means a managed care organization that has entered into a contract with the department of job and family services pursuant to section 5111.17 of the Revised Code.
(B) Except as provided in division (C) of this section, when a participant in the care management system established under section 5111.16 of the Revised Code is enrolled in a medicaid managed care organization and the organization refers the participant to receive services, other than emergency services provided on or after January 1, 2007, at a hospital that participates in the medicaid program but is not under contract with the organization, the hospital shall provide the service for which the referral was made and shall accept from the organization, as payment in full, the amount derived from the reimbursement rate used by the department to reimburse other hospitals of the same type for providing the same service to a medicaid recipient who is not enrolled in a medicaid managed care organization.
(C) A hospital is not subject to division (B) of this section if all of the following are the case:
(1) The hospital is located in a county in which participants in the care management system are required before January 1, 2006, to be enrolled in a medicaid managed care organization that is a health insuring corporation;
(2) The hospital has entered into a contract before January 1, 2006, with at least one health insuring corporation serving the participants specified in division (C)(1) of this section;
(3) The hospital remains under contract with at least one health insuring corporation serving participants in the care management system who are required to be enrolled in a health insuring corporation.
(D) The director of job and family services shall adopt rules specifying the circumstances under which a medicaid managed care organization is permitted to refer a participant in the care management system to a hospital that is not under contract with the organization. The director may adopt any other rules necessary to implement this section. All rules adopted under this section shall be adopted in accordance with Chapter 119. of the Revised Code.
Effective Date: 06-30-2005; 06-30-2006