Library: Policy

317:35-3-1. Payment for Medicaid

Revised 7-1-03

(a) Payment eligibility.  In order for the Authority to make payment for Medicaid services, the individual must be determined eligible to have such payment made by:

• (1) having eligibility previously determined, or
• (2) making application for Medicaid at the time the medical services is requested, and having eligibility determined at that time.

(b) Recipient lock-in.  Medicaid recipients who have demonstrated Medicaid usage above the statistical norm, during a 12-month period, may be "locked-in" to one primary physician and/or one pharmacy.  If OHCA has determined that Medicaid has been over-utilized, the recipient is notified, by letter, of the need to select a primary physician and/or pharmacy and of their opportunity for a fair hearing.  A copy of the letter is sent to the DHS county office.  If the recipient does not select a physician and/or pharmacy, one is selected for her/him.  "Locked-in" recipients may obtain emergency services from a physician and/or an emergency room facility in the event of a medical emergency.