Ohio § 3701.023

§ 3701.023.

(A) The department of health shall review applications for eligibility for the program

for children and youth with special health care needs that are submitted to the department

by city and general health districts and physician providers approved in accordance

with division (C) of this section.  The department shall determine whether the applicants meet the medical and financial

eligibility requirements established by the director of health pursuant to division (A)(1) of section 3701.021 of the Revised Code , and by the department in the manual of operational procedures and guidelines for

the program for children and youth with special health care needs developed pursuant

to division (B) of that section.  Referrals of potentially eligible children and youth for the program may be submitted

to the department on behalf of the child or youth by parents, guardians, public health

nurses, or any other interested person.  The department of health may designate other agencies to refer applicants to the

department of health. (B) In accordance with the procedures established in rules adopted under division (A)(4) of section 3701.021 of the Revised Code , the department of health shall authorize a provider or providers to provide to any

Ohio resident under twenty-one years of age, without charge to the resident or the

resident's family and without restriction as to the economic status of the resident

or the resident's family, diagnostic services necessary to determine whether the resident

has a medical diagnosis resulting in, or potentially resulting in, special health

care needs. (C) The department of health shall review the applications of health professionals, hospitals,

medical equipment suppliers, and other individuals, groups, or agencies that apply

to become providers.  The department shall enter into a written agreement with each applicant who is determined,

pursuant to the requirements set forth in rules adopted under division (A)(2) of section 3701.021 of the Revised Code , to be eligible to be a provider in accordance with the provider agreement required

by the medicaid program.  No provider shall charge a child or youth with special health care needs or the

child or youth's parent or guardian for services authorized by the department under

division (B) or (D) of this section. The department, in accordance with rules adopted under division (A)(3) of section 3701.021 of the Revised Code , may disqualify any provider from further participation in the program for violating

any requirement set forth in rules adopted under division (A)(2) of that section.  The disqualification shall not take effect until a written notice, specifying the

requirement violated and describing the nature of the violation, has been delivered

to the provider and the department has afforded the provider an opportunity to appeal

the disqualification under division (H) of this section. (D) The department of health shall evaluate applications from city and general health

districts and approved physician providers for authorization to provide treatment

services, service coordination, and related goods to children or youth determined

to be eligible for the program for children and youth with special health care needs

pursuant to division (A) of this section.  The department shall authorize necessary treatment services, service coordination,

and related goods for each eligible child or youth in accordance with an individual

plan of treatment for the child or youth.  As an alternative, the department may authorize payment of health insurance premiums

on behalf of eligible children or youth when the department determines, in accordance

with criteria set forth in rules adopted under division (A)(9) of section 3701.021 of the Revised Code , that payment of the premiums is cost-effective. (E) The department of health shall pay, from appropriations to the department, any necessary

expenses, including but not limited to, expenses for diagnosis, treatment, service

coordination, supportive services, transportation, and accessories and their upkeep,

provided to children and youth with special health care needs, provided that the provision

of the goods or services is authorized by the department under division (B) or (D)

of this section.  Money appropriated to the department of health may also be expended for reasonable

administrative costs incurred by the program.  The department of health also may purchase liability insurance covering the provision

of services under the program for children and youth with special health care needs

by physicians and other health care professionals. Payments made to providers by the department of health pursuant to this division for

inpatient hospital care, outpatient care, and all other medical assistance furnished

to eligible recipients shall be made in accordance with rules adopted by the director

of health pursuant to division (A) of section 3701.021 of the Revised Code . The departments of health and medicaid shall jointly implement procedures to ensure

that duplicate payments are not made under the program for children and youth with

special health care needs and the medicaid program and to identify and recover duplicate

payments. (F) At the time of applying for participation in the program for children and youth with

special health care needs, a child or youth with special health care needs or the

child or youth's parent or guardian shall disclose the identity of any third party

against whom the child or youth or the child or youth's parent or guardian has or

may have a right of recovery for goods and services provided under division (B) or

(D) of this section.  The department of health shall require a child or youth with special health care

needs who receives services from the program or the child or youth's parent or guardian

to apply for all third-party benefits for which the child or youth may be eligible

and require the child or youth, parent, or guardian to apply all third-party benefits

received to the amount determined under division (E) of this section as the amount

payable for goods and services authorized under division (B) or (D) of this section.  The department is the payer of last resort and shall pay for authorized goods or

services, up to the amount determined under division (E) of this section for the authorized

goods or services, only to the extent that payment for the authorized goods or services

is not made through third-party benefits.  When a third party fails to act on an application or claim for benefits by a child

or youth with special health care needs or the child or youth's parent or guardian,

the department shall pay for the goods or services only after ninety days have elapsed

since the date the child or youth, parents, or guardians made an application or claim

for all third-party benefits.  Third-party benefits received shall be applied to the amount determined under division

(E) of this section.  Third-party payments for goods and services not authorized under division (B) or

(D) of this section shall not be applied to payment amounts determined under division

(E) of this section.  Payment made by the department shall be considered payment in full of the amount

determined under division (E) of this section.  Medicaid payments for persons eligible for the medicaid program shall be considered

payment in full of the amount determined under division (E) of this section. (G) The department of health shall administer a program to provide services to Ohio residents

who are twenty-one or more years of age who have cystic fibrosis and who meet the

eligibility requirements established in rules adopted by the director of health pursuant

to division (A)(7) of section 3701.021 of the Revised Code , subject to all provisions of this section, but not subject to section 3701.024 of the Revised Code . (H) The department of health shall provide for appeals, in accordance with rules adopted

under section 3701.021 of the Revised Code , of denials of applications for the program for children and youth with special health

care needs under division (A) or (D) of this section, disqualification of providers,

or amounts paid under division (E) of this section.  Appeals under this division are not subject to Chapter 119. of the Revised Code. The department may designate ombudspersons to assist children and youth with special

health care needs or their parents or guardians, upon the request of the children

or youth, parents, or guardians, in filing appeals under this division and to serve

as children or youth's, parents', or guardians' advocates in matters pertaining to

the administration of the program for children and youth with special health care

needs and eligibility for program services.  The ombudspersons shall receive no compensation but shall be reimbursed by the department,

in accordance with rules of the office of budget and management, for their actual

and necessary travel expenses incurred in the performance of their duties. (I) The department of health, and city and general health districts providing service

coordination pursuant to division (A)(2) of section 3701.024 of the Revised Code , shall provide service coordination in accordance with the standards set forth in

the rules adopted under section 3701.021 of the Revised Code , without charge, and without restriction as to economic status. (J)(1) The department of health may establish a manufacturer discount program under which

a manufacturer of a drug or nutritional formula is permitted to enter into an agreement

with the department to provide a discount on the price of the drug or nutritional

formula distributed to children and youth with special health care needs participating

in the program for children and youth with special health care needs.  The program shall be administered in accordance with rules adopted under section 3701.021 of the Revised Code . (2) If a manufacturer enters into an agreement with the department as described in division

(J)(1) of this section, the manufacturer and the department may negotiate the amount

and terms of the discount. (3) In lieu of establishing a discount program as described in division (J)(1) of this

section, the department and a manufacturer of a drug or nutritional formula may discuss

a donation of drugs, nutritional formulas, or money by the manufacturer to the department. (K) As used in this division “209(b) option” has the same meaning as in section 5166.01 of the Revised Code . The program for children and youth with special health care needs and the program

the department of health administers pursuant to division (G) of this section shall

continue to assist individuals who have cystic fibrosis and are enrolled in those

programs in qualifying for medicaid under the spenddown process in the same manner

it assists such individuals on September 29, 2015, regardless of whether the department

of medicaid continues to implement the 209(b) option.