Chapter 5101:3-20 Primary Alternative Care and Treatment Program

(A) “Department” – The Ohio department of human job and family services (ODJFS).

(B) “Designated pharmacy” – A pharmacy participating in the medicaid program that agrees to serve as the sole dispenser of prescribed drugs for recipients enrolled in the PACT program.

(C) “Designated physician” – A doctor of medicine or osteopathy, or physician group practice participating in the medicaid program who is approved by the department for participation in the PACT program and who agrees to serve as the primary provider of nonemergency physician services for recipients enrolled in the PACT program.

(D) “Emergency services” – Those medical and/or pharmacological services rendered under unforseen conditions which that require immediate treatment, hospitalization and/or services necessary for the treatment of accidental injury, relief of acute pain, protection of the public health, and/or the amelioration of illness.

(E) “Enrollment” – The procedure by which a recipient is restricted to a single designated physician and/or a single designated pharmacy to receive the nonemergency services available under the medicaid program.

(F) “Managed care program (MCP)” – As used in this chapter, the definition of managed care program is the same as identified in rule 5101:3-26-01 of the Administrative Code.

(G) “Medicaid” – The medical assistance program administered by the department established by section 5111.01 of the Revised Code and Title XIX of the Social Security Act.

(H) “Medical necessity” – The department’s standard for all medical services as defined in rule 5101:3-1-01 of the Administrative Code.

(I) “MMIS” – The medicaid management information system for medical claims processing and information retrieval used by the department.

(J) “Medical technical advisors” – Physicians and/or pharmacists under contract with the department to review recipients’ medical records.

(K) “PACT program” – The primary alternative care and treatment program in which recipients who utilize medical services without medical necessity are restricted in accordance with rule 5101:3-20-02 of the Administrative Code to a designated physician and/or a designated pharmacy.

(L) “Prescription” – An order which that is issued by a licensed medical practitioner for the preparation and dispensation of drugs by a licensed pharmacist or physician.

(M) “Provider” – Any person, institution, group, or entity that furnishes medicaid services under a provider agreement with the department pursuant to Title XIX of the Social Security Act.

(N) “Referral services” – Those covered services provided by a nondesignated physician or podiatrist to an enrolled recipient on the request of the designated physician.

Effective: 01/10/2008

R.C. 119.032 review dates: 10/26/2007 and 01/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 12/1/83, 4/1/92, 11/1/97

(A) Referral and identification criteria

(1) The records of all medicaid recipients are subject to review by the department. Referral may be made to the PACT unit from providers or other bureaus within the department or other governmental agencies for review by the department if a recipient is suspected of receiving medicaid services that were not medically necessary; or, the recipient’s records are identified by exception processing techniques.

(2) The criteria that will be used as indicators in the exception process are the following:

(a) Use of more than three different prescribing providers per three-month time frame;

(b) Receipt of prescription drugs from more than three different pharmacies per three-month time frame;

(c) Receipt of more than twelve prescriptions including refills per three-month time frame;

(d) Receipt of more than six prescriptions including refills for drugs identified by therapeutic drug class as analgesic drugs per three-month time frame;

(e) Receipt of more than six prescriptions including refills for drugs identified by therapeutic drug class as psychotropic drugs per three-month time frame; or,

(f) Physician, clinic, and podiatric visits exceeding the limits set forth in rule 5101:3-4-06 of the Administrative Code.

(B) Selection process

(1) When a recipient has been referred or identified in accordance with paragraph

(A) of this rule, the department will review the recipient’s most recent twelve months of claims history available of physician and pharmacy services from MMIS generated reports to determine whether the recipient displayed patterns of utilizing medicaid services without medical necessity.

(2) Physicians in a group practice whose prescribing patterns were medically necessary may be considered as one provider. To determine if the total quantity of medication was medically necessary, prescription medications and refills received by the recipient will be considered.

(3) The review shall include examinations by a medical technical advisor or registered nurse. Aberrant provider practices identified during the review will be referred for appropriate action.

(4) If it is determined from the review of claims history in accordance with paragraph (B) of this rule that the recipient utilized medicaid services without medical necessity, the recipient shall be proposed for enrollment into the PACT program in accordance with paragraph (C) of this rule.

(C) Enrollment and selection of designated provider(s)

(1) When a recipient has been selected in accordance with paragraph (B) of this rule, the department will propose enrollment into the PACT program.

(2) Recipients proposed for enrollment in the PACT program will receive a notice of enrollment in accordance with rule 5101:6-2-40 of the Administrative Code.

(3) After notification in accordance with paragraph (C)(2) of this rule, any recipient who has been selected, in accordance with paragraph (B) of this rule, and who has not requested a hearing, or requested a hearing that resulted in upholding enrollment, shall be enrolled in the PACT program.

(4) Recipients to be enrolled will be given the opportunity to select a designated physician and/or designated pharmacy, subject to the approval of the department.

(5) If a recipient does not select a designated physician and/or pharmacy or, if the selected designated physician and/or pharmacy are not approved by the department, or if either provider selected or both are unwilling or unable to participate in the PACT program, the department may select a designated physician and/or pharmacy for the recipient.

(6) The enrolled recipient must obtain covered physician and pharmacy services from designated providers except for services received by referral from the designated physician, or for emergency services. Services rendered by a podiatrist are considered physician services and require a referral from the designated physician.

(7) The enrolled recipient is eligible for all services covered under medicaid as defined in division 5101:3 of the Administrative Code. All covered medicaid services other than physician and pharmacy services may be obtained from any participating medicaid provider.

(8) PACT enrollment will continue for eighteen months from the initial date of enrollment. Eligible medicaid recipients who become ineligible for medicaid during PACT enrollment will be reinstated in PACT for the balance of the enrollment period, lasting until the originally calculated ending date, should they again become eligible.

(9) If a PACT recipient enrolls in a managed care plan (MCP), the recipient shall be released from PACT enrollment. If the recipient’s originally calculated ending date has not yet been reached at the end of the MCP enrollment, the recipient shall be reinstated in the PACT program for the balance of the enrollment period.

(10) If a PACT recipient enters a long-term care facility and/or hospice, the recipient shall be released from PACT enrollment. If the recipient leaves the long-term care facility and/or hospice and the recipient’s originally calculated PACT enrollment ending date has not been reached, the recipient shall be reinstated in the PACT program for the balance of the enrollment period.

(11) While enrolled, a review of the recipient’s medical services will be performed at least every twelve months.

(D) Changing designated physician and/or designated pharmacy

(1) An enrolled recipient may change from one designated physician or designated pharmacy to another only if:

(a) Relocation, incapacity, closing of the physician’s office, or death of the designated physician or relocation or closing of the designated pharmacy causes the designated provider to be inaccessible to the recipient;

(b) Relocation or incapacity of the recipient causes the designated physician or designated pharmacy to be inaccessible;

(c) A change in the medical provider status of the designated physician or designated pharmacy results in the unavailability of medicaid reimbursement;

(d) The designated physician or designated pharmacy chooses to no longer provide services to the recipient;

(e) The medical needs of the recipient require a designated provider with a different specialty; or,

(f) The recipient requests to be assigned to another designated physician or designated pharmacy due to personal preference. Not more than three changes due to personal preference will be approved in an eighteen-month period.

(2) Recipients shall make all requests for designated provider changes in writing to the department. Provider changes if permitted under paragraph (D)(1) of this rule will be processed as soon as possible after receipt of the request.

(3) If the department denies the recipient’s request to change designated provider(s), the department shall notify the recipient in accordance with rule 5101:6-2-40 of the Administrative Code.

(E) Continued enrollment

(1) Enrollment in the PACT program may not be less than eighteen months and may be continued in eighteen-month periods. Prior to the end of eighteen months, and each successive eighteen-month period thereafter, the department will conduct a review of the recipient’s utilization of covered physician and pharmacy services during the most recent PACT enrollment period. The review will be in accordance with paragraph (B) of this rule, based in part on an MMIS generated report of that period.

(2) If it is determined that PACT program enrollment is to be continued, the department shall notify the recipient in accordance with the provisions of rule 5101:6-2-40 of the Administrative Code.

(F) Release from the PACT program

(1) After the review described in paragraph (E) of this rule, if the department determines that the recipient’s medicaid services were medically necessary, the recipient shall be released from PACT enrollment.

(2) If during the enrollment period extraordinary medical circumstances occur (e.g., end-state of a medically verified terminal illness) and if the department determines that the medicaid services were medically necessary, the recipient may be released from PACT enrollment.

(3) Recipients who have been released from PACT enrollment may have their claims histories reviewed by the department at any time in accordance with paragraph (A) of this rule. These reviews may result in subsequent PACT enrollment if the department determines that after being released from the PACT program the recipient utilized medicaid services without medical necessity.

Effective: 01/10/2008

R.C. 119.032 review dates: 10/26/2007 and 01/01/2013

Promulgated Under: 111.15

Statutory Authority: 5111.01, 5111.011

Rule Amplifies: 5111.01, 5111.011

Prior Effective Dates: 12/1/83, 4/1/86, 7/1/87, 2/1/90, 4/1/92, 11/1/97

(A) The role of the PACT designated physician is to eliminate unnecessary medical treatments by prudently coordinating medical care while providing high quality services to enrolled recipients. To ensure the quality of general medical care, the designated physician shall be a general practitioner, family practitioner, or an internist unless the medical needs of the recipient justify a physician of a different specialty. Designated physicians must be able to provide the full scope of services commensurate with the physician’s specialty (i.e., no limitations on the physician’s license or sanctions by medical governing bodies).

(B) The department shall have the right to approve or disapprove the provider(s) selected by recipients enrolled in the PACT program. In implementing a review of proposed providers, the department may conduct an investigation including, but not limited to:

(1) A comparison of services with the provider’s peers.

(2) Medicaid participation history, including any sanctions or warnings issued to the provider, the provider’s employer, the provider’s employees, related business entities or any other business relationship to the provider.

(3) Other records of health related programs including, but not limited to, medical associations, peer review organizations and licensing boards.

(C) The designated physician may withdraw from the PACT program for any reason with thirty days notice to the department. The department may, at its discretion, withdraw approval of a PACT designated physician upon thirty days notice for any reason including, but not limited to:

(1) Review of a recipient’s medical services reveals significantly more treatment/medication than in a previous time period with similar or identical diagnosis.

(2) The types and frequency of prescription drugs are not reasonable or medically necessary.

(3) The types and frequency of medical services are not reasonable or medically necessary.

(D) Participation or the lack of participation as a PACT designated physician will not affect the provider’s status as a medicaid provider in good standing with the department.

(E) A provider convicted of unlawful activity related to the delivery of medical services may be precluded from being a PACT designated provider.

(F) Medicaid payment is not available for covered physician and pharmacy services rendered by other than designated providers except for services received by referral from the designated physician, or for emergency services.

(G) For reimbursement, all medical services performed by medicaid providers shall be medically necessary as defined in rule 5101:3-1-01 of the Administrative Code.

(H) Designated providers shall be reasonably accessible to the recipient, taking into account such factors as geographic location, reasonable travel time and the availability of transportation.

(I) Each designated physician is eligible to bill and receive a monthly case management fee for each assigned and enrolled recipient. The monthly case management fee is available for the initial month and all subsequent full months for which the physician serves as an enrolled recipient’s designated physician.

Effective: 01/10/2008

R.C. 119.032 review dates: 10/26/2007 and 01/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 12/1/83, 4/1/92, 11/1/97