Chapter 5101:3-25 Children's Buy-In Program

As used in Chapter 5101:3-25 of the Administrative Code:

(A) “Abuse” means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the children’s buy-in (CBI) program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes consumer practices that result in unnecessary cost to the CBI program.

(B) “Advance directive” means written instructions such as a living will or durable power of attorney for health care relating to the provision of health care.

(C) “Applicant” means an individual seeking to purchase coverage under the CBI program and includes natural and adoptive parents and legal guardians of an individual.

(D) “Automatic renewal” means the process by which an eligible individual automatically terminated from managed care membership has membership in the same MCP renewed without the individual having to contact ODJFS or ODJFS-approved entity.

(E) “Automatic termination” means the process by which a member’s managed care membership is terminated, not at the request of the member, but for the reasons described in rule 5101:3-25-02.1 of the Administrative Code.

(F) “CAP” means corrective action plan.

(G) “Capitation” means the monthly payment amount per member to which the MCP is entitled as compensation for performing its obligations in accordance with this chapter and/or the grant agreement with ODJFS.

(H) “Care treatment plan” is the treatment plan developed by the MCP for the enrollee.

(I) “Case management” means activities performed on behalf of enrollees that include services described in paragraph (A)(7) of rule 5101:3-25-03.1 of the Administrative Code.

(J) “C.F.R.” means the Code of Federal Regulations, as amended, unless otherwise specified.

(K) “Children’s buy-in (CBI) program” means the program established under sections 5101.5211 to 5101.5216 of the Revised Code.

(L) “CLIA” means the clinical laboratory improvement amendments regulated by the federal centers for medicare and medicaid services (CMS) under 42 C.F.R. Part 493, laboratory requirements.

(M) “Covered services” means those medical services set forth in rule 5101:3-25-03 of the Administrative Code.

(N) “COB (coordination of benefits)” means a procedure establishing the order in which health care entities pay their claims. For the purpose of this chapter, the MCP is the payer of last resort except for services provided under Title V programs. For CBI-covered services rendered by Title V programs, the MCP shall be the primary payer.

(O) “Emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the following: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.

(P) “Emergency services” means covered inpatient services, outpatient services, or medical transportation services that are provided by a qualified provider and are needed to evaluate, treat, or stabilize an emergency medical condition as defined in paragraph (O) of this rule. As used in this chapter, providers of emergency services include physicians or other health care professionals or health care facilities not under employment or under contractual arrangement with an MCP.

(Q) “Enrollee,” otherwise known as “member,” means a child who receives health benefits coverage through the CBI program.

(R) “Fraud” means any intentional deception or misrepresentation made by an individual or entity with the knowledge that the deception could result in some unauthorized benefit to the individual, the entity, or some other person. This includes any act that constitutes fraud under applicable federal or state law. Member fraud means the altering of information or documents in order to fraudulently receive unauthorized benefits or to knowingly permit others to use the member’s identification card to obtain services or supplies.

(S) “Grant agreement” means the legally binding contract providing for the distribution of funds by ODJFS to a not-for-profit health insuring corporation for the provision of specific services for individuals enrolled in the CBI program. This grant agreement is signed and entered into by ODJFS and the grantee for a specified time period.

(T) “HIC” means a “health insuring corporation” as defined in section 1751.01 of the Revised Code.

(U) “Hospital” means an institution located at a single site that is engaged primarily in providing healthcare services to inpatients, by or under the supervision of an organized medical staff of physicians licensed under Chapter 4731. of the Revised Code, diagnostic services and therapeutic services for medical diagnosis and treatment or rehabilitation of injured, disabled, or sick persons. “Hospital” does not mean an institution that is operated by the United States government or the Ohio department of mental health.

(V) “Hospital services” means those inpatient and outpatient services that are generally and customarily provided by hospitals.

(W) “Inpatient facility” means an acute or general hospital.

(X) “LEP” means limited-English proficiency.

(Y) “LRP” means limited-reading proficiency.

(Z) “MCP” means a managed care plan that has entered into a grant agreement with ODJFS to provide medical services to CBI program enrollees pursuant to this chapter.

(AA) “Medicaid” means medical assistance provided under a state plan approved under Title XIX of the Social Security Act.

(BB) “Medicaid MCP” means an MCP as defined in rule 5101:3-26-01 of the Administrative Code.

(CC) “Medically necessary,” otherwise known as “medical necessity,” means services that are necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased, or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. A medically necessary service must:

(1) Meet generally accepted standards of medical practice;

(2) Be appropriate to the illness or injury for which it is performed, as to type of service and expected outcome;

(3) Be appropriate to the intensity of service and level of setting;

(4) Provide unique, essential, and appropriate information when used for diagnostic purposes; and

(5) Be the lowest cost alternative that effectively addresses and treats the medical problem.

(DD) “Medicare” is the federally financed medical assistance program determined under Title XVIII of the Social Security Act.

(EE) “Member cost-sharing” means co-payments, deductibles, and co-insurance payments that are the member’s responsibility.

(FF) “ODI” means the Ohio department of insurance.

(GG) “ODJFS” means the Ohio department of job and family services, or its designee.

(HH) “ODJFS approval” means written approval by ODJFS and does not constitute approval by any other state or federal agency.

(II) “Oral interpretation services” means services provided to LRP consumers to ensure that they receive MCP information in a format and manner that is easily understood by those consumers.

(JJ) “Oral translation services” means services provided to LEP consumers to ensure that they receive MCP information translated into the primary language of the consumer.

(KK) “PCP (primary care provider)” means an individual physician (M.D. or D.O.), certain physician group practice, or advanced practice nurse as defined in section 4723.43 of the Revised Code, or advanced practice nurse group practice within an acceptable specialty, contracting with an MCP to provide services as specified in paragraph (B) of rule 5101:3-25-03.1 of the Administrative Code. Acceptable specialty types include family/general practice, internal medicine, pediatrics, and obstetrics/gynecology (OB/GYNs).

(LL) “Pending enrollee,” otherwise known as “pending member,” means an individual whose premium has been paid but whose MCP membership is not yet effective.

(MM) “Personal representative” means a person standing in the place of the individual as defined in 45 C.F.R. 164.502 (August 14, 2002).

(NN) “Post-stabilization care services” means covered services related to an emergency medical condition that a treating provider views as medically necessary after an emergency medical condition has been stabilized in order to maintain the stabilized condition, or under the circumstances described in 42 C.F.R. 422.113 (March 22, 2005) to improve or resolve the member’s condition.

(OO) “Premium” means a periodic payment as described in rule 5101:1-42-30 of the Administrative Code.

(PP) “Protected health information (PHI)” means information received from or on behalf of ODJFS that meets the definition of PHI as defined by the Health Insurance Portability and Accountability Act (HIPAA) and the regulations promulgated by the United States department of health and human services, specifically 45 C.F.R. 164.501 (February 26, 2003).

(QQ) “Provider” means a hospital, health care facility, physician, dentist, pharmacist, or otherwise licensed, certified, or otherwise appropriate individual that is authorized to or may be entitled to reimbursement for health care services rendered to an MCP’s member.

(RR) “Provider panel,” otherwise known as “panel,” means an MCP’s providers as specified in paragraph (A)(3) of rule 5101:3-25-05 of the Administrative Code.

(SS) “QAPI” means a quality assessment and performance improvement program as described in rule 5101:3-25-07.1 of the Administrative Code.

(TT) “Reconsideration,” otherwise known as “second level appeal,” means a member’s appeal to an independent review entity, other than the MCP, after an adverse determination by the MCP.

(UU) “Risk” or “underwriting risk” means the possibility that an MCP may incur a loss because the cost of providing services may exceed the payments made by ODJFS to the contractor for services covered under the grant agreement.

(VV) “Self-referral” means the process by which an MCP member may access certain services without the PCP’s and/or MCP’s prior approval.

(WW) “Service area” means the geographic area specified in the MCP’s grant agreement.

(XX) “SFY (state fiscal year)” means the period July first through June thirtieth, corresponding to the state of Ohio’s fiscal year.

(YY) “Subcontract” means a written contract between an MCP and a third party, or between the third party and a fourth party, or between any subsequent parties, to perform a specific part of the obligations specified under the grant agreement with ODJFS.

(ZZ) “Title V,” otherwise known as the “program for medically handicapped children,” means the program established under sections 3701.021 to 3701.0210 of the Revised Code.

(AAA) “Third party administrator (TPA)” means any entity utilized in accordance with the provisions of this chapter of the Administrative Code to manage or administer a portion of services in fulfillment of the grant agreement with ODJFS.

(BBB) “Third party payer” means any individual, entity, or program that is or may be liable to pay all or part of the expenditures for medical services furnished under the CBI program.

(CCC) “Tort action,” otherwise known as “subrogation,” means the right of ODJFS to recover payment received from a third party payer who may be liable for the cost of medical services and care arising out of an injury, disease, or disability to the member.

(DDD) “United States” means the fifty states, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.

Replaces: 5101:3-25-01

Effective: 06/30/2008

R.C. 119.032 review dates: 06/30/2013

Promulgated Under: 119.03

Statutory Authority: 5101.5215

Rule Amplifies: 5101.5211, 5101.5212, 5101.5213, 5101.5214, 5101.5215, 5101.5216

Prior Effective Dates: 4/1/08

(A) Individuals eligible to purchase CBI coverage will be covered by MCPs pursuant to a grant agreement with ODJFS. Individuals’ eligibility for CBI coverage will be determined in accordance with rule 5101:1-42-30 of the Administrative Code.

(B) The MCP must accept initial MCP membership transactions on behalf of individuals without regard to an individual’s race, color, religion, gender, sexual orientation, age, disability, national origin, veteran’s status, ancestry, health status, or need for health services.

(C) The following apply to MCP membership:

(1) As part of the application for health care services, ODJFS shall request that the applicant provide health status information including the applicant’s choice of a primary care provider for each individual as well as each individual’s current diagnoses, providers, and upcoming surgeries, appointments, and/or procedures.

(2) In no event shall an MCP notify a pending member or his or her personal representative about coverage until MCP membership is confirmed by ODJFS as specified in paragraph (D)(3) of this rule.

(D) Commencement of coverage.

(1) CBI coverage will not occur prior to June 1, 2008.

(2) The initial month of CBI coverage through an MCP will be determined by ODJFS following verification that the full premium payment for the initial month of membership has been received on the member’s behalf.

(3) CBI coverage through an MCP will be effective prospectively, at the beginning of the first day of the calendar month after all of the following occur:

(a) Determination of CBI program eligibility by ODJFS;

(b) Receipt of the applicant’s full premium payment by ODJFS; and

(c) Confirmation of the applicant’s effective date of coverage via an ODJFS-produced monthly roster provided to the MCP prior to the individual’s effective date of coverage.

(4) The MCP must accept individuals who are approved by ODJFS and have paid their premium, and honor, without restriction, the PCP selected when available.

(5) The MCP shall be responsible for the provision of all CBI program-covered services for member(s) beginning with the first day of membership, including inpatient hospital services and related charges.

Replaces: 5101:3-25-02

Effective: 06/30/2008

R.C. 119.032 review dates: 06/30/2013

Promulgated Under: 119.03

Statutory Authority: 5101.5215

Rule Amplifies: 5101.5211, 5101.5212, 5101.5213, 5101.5214, 5101.5215, 5101.5216

Prior Effective Dates: 4/1/08

(A) Automatic termination of MCP membership will occur as a result of any of the following:

(1) The member does not meet the eligibility requirements specified in rule 5101:1-42-30 of the Administrative Code. When this occurs, membership termination will be effective the last day of the month in which the member fails to meet the eligibility requirements;

(2) The member dies, in which case the period of MCP membership ends on the date of death;

(3) The member is found by ODJFS to meet the criteria for an ICF-MR level of care and is then placed in an ICF-MR facility. When this occurs and following MCP notification to ODJFS, membership termination is effective the last day of the month preceding placement in an ICF-MR facility;

(4) The member receives medicaid. When this occurs, membership termination will be effective the last day of the month prior to receiving medicaid coverage; or

(5) The grant agreement between ODJFS and the MCP is terminated. In this situation, membership termination will be effective the last day of the month in which the grant agreement termination occurs.

(B) ODJFS will recover from the MCP any capitation paid for retroactive membership termination occurring as a result of applicable situations set forth in paragraph (A) of this rule.

(C) If ODJFS fails to notify the MCP of a member’s termination from an MCP, ODJFS will continue to pay the MCP the monthly capitation rate with respect to such member, subject to the provisions of rule 5101:3-25-09 of the Administrative Code. The MCP will remain liable for the provision of covered services as set forth in rule 5101:3-25-03 of the Administrative Code, until such time as ODJFS provides the MCP with documentation of the member’s termination.

(D) The following applies to the coverage of services for any MCP member who is an inpatient on the date membership termination becomes effective: Additional capitation payments will not be made by ODJFS and the MCP shall remain liable for the provision of covered services for a member who is an inpatient on the date termination becomes effective. The continuation of coverage shall terminate at the earliest occurrence of any of the following:

(1) The member’s discharge from a hospital;

(2) The determination by the member’s attending physician that inpatient care is no longer medically necessary for the member; or

(3) The effective date of any new coverage including medicaid or other creditable coverage.

(E) The following applies to all MCP-initiated membership terminations:

(1) The MCP may submit a request to ODJFS for an MCP-initiated membership termination of a member if the enrollee or enrollee’s parent or legal guardian has performed an act or practice that constitutes fraud or intentional misrepresentation of material fact under the terms of the coverage and if the cancellation or nonrenewal is not based, either directly or indirectly, on any health status-related factor in relation to the enrollee.

(2) All proposed MCP-initiated terminations of members must contain ODJFS-specified documentation.

(3) The MCP may not request termination due to a change in the member’s health status or need for health services, age, gender, sexual orientation, disability, national origin, race, color, religion, veteran’s status, or ancestry.

(4) The MCP must provide covered services to a terminated member(s) through the last day of the month in which the MCP membership is effective, notwithstanding the date of ODJFS approval of the termination request. Coverage of inpatient services will continue in accordance with paragraph (D) of this rule.

(5) For MCP-initiated termination of MCP membership:

(a) Termination may occur at the family group level or the individual member level.

(b) If ODJFS approves the MCP’s request for termination, ODJFS will notify the member, the member’s parent or legal guardian, and the MCP, in writing, of the decision to terminate the member or all members within the family group.

Replaces: 5101:3-25-02.1

Effective: 06/30/2008

R.C. 119.032 review dates: 06/30/2013

Promulgated Under: 119.03

Statutory Authority: 5101.5215

Rule Amplifies: 5101.5211, 5101.5212, 5101.5213, 5101.5214, 5101.5215, 5101.5216

Prior Effective Dates: 4/1/08

(A) Except as provided in this rule, MCPs must ensure that members have access to covered services outlined in paragraph (C) of this rule. The list of covered services is subject to change. The MCP must ensure that:

(1) Services are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished;

(2) The amount, duration, or scope of a required service is not arbitrarily denied or reduced solely because of the diagnosis, type of illness, or condition;

(3) Coverage decisions are based on the practice guidelines specified in paragraph

(B) of rule 5101:3-25-05.1 of the Administrative Code; and

(4) If a member is unable to obtain medically necessary covered services from a MCP panel provider, the MCP must adequately and timely cover the services out of panel, until the MCP is able to provide the services from a panel provider.

(B) MCPs may place appropriate limits on a service:

(1) On the basis of medical necessity; or

(2) For the purposes of utilization control, provided the services furnished can be reasonably expected to achieve their purpose as specified in paragraph (A)(1) of this rule.

(C) Covered services.

(1) Inpatient and outpatient hospital services.

(2) Emergency room services.

MCPs must assure that emergency care services as defined in rule 5101:3-25-01 of the Administrative Code are provided and covered twenty-four hours a day, seven days a week. At a minimum, such services must be provided and reimbursed in accordance with the following:

(a) MCPs may not deny payment for treatment obtained when a member had an emergency medical condition.

(b) MCPs cannot limit what constitutes an emergency medical condition on the basis of lists of diagnoses or symptoms.

(c) MCPs must cover all emergency services without requiring prior authorization.

(d) MCPs must cover emergency services related to the member’s emergency medical condition when the member is instructed to go to an emergency facility by a representative of the MCP including, but not limited to, the member’s PCP or the MCP’s twenty-four-hour toll-free call-in system.

(e) MCPs cannot deny payment of emergency services based on the treating provider, hospital, or fiscal representative not notifying the member’s PCP of the visit.

(f) For the purposes of this paragraph, “non-contracting provider of emergency services” means any person, institution, or entity who does not contract with the MCP but provides emergency services to an MCP member. An MCP must cover emergency services as defined in rule 5101:3-25-01 of the Administrative Code when the services are delivered by a non-contracting provider of emergency services and claims for these services cannot be denied regardless of whether the services meet an emergency medical condition as defined in rule 5101:3-25-01 of the Administrative Code. Such services must be reimbursed by the MCP at the lesser of billed charges or one hundred per cent of the Ohio medicaid program fee-for-service reimbursement rate (less any payments for indirect costs of medical education and direct costs of graduate medical education that is included in the Ohio medicaid program fee-for-service reimbursement rate) in effect for the date of service. The reimbursement amount must exclude applicable member cost-sharing amounts as specified in rule 5101:3-25-12 of the Administrative Code. If an inpatient admission results, the MCP is required to reimburse at this rate only until the member can be transferred to a provider designated by the MCP.

(g) MCPs must adhere to the judgment of the attending provider when requesting a member’s transfer to another facility or discharge. MCPs may establish arrangements with hospitals whereby the MCP may designate one of its contracting providers to assume the attending provider’s responsibilities to stabilize, treat, and transfer the member.

(h) A member who has had an emergency medical condition may not be held liable for payment, minus any applicable member cost-sharing amounts, for any subsequent screening and treatment needed to diagnose the specific condition or stabilize the member.

(3) Urgent care services are covered for urgent medical conditions where care is medically necessary and immediately required because of unforeseen illness, injury or condition, and it is not reasonable, given the circumstances, to delay care in order to obtain services from the member’s PCP.

(4) Physical, occupational, and speech therapy services are limited to twenty visits per therapy, per rolling twelve month period.

(5) Office visits/consultations.

(6) Prescription drugs based on a restricted formulary prior-approved by ODJFS.

(7) Mental health and substance abuse services provided in a general hospital.

(8) Mental health and substance abuse services provided in an outpatient setting.

(9) Durable medical equipment, medical supplies, home health, laboratory, and radiology services.

(10) Ambulance services for emergency care.

(11) Case management services.

(12) Immunizations.

(13) Well-child care services.

(14) Short-term nursing facility (NF) stays. When an MCP member is placed in a NF, MCPs are responsible for NF services until the last day of the month following the month of the member’s NF admission, for a period not to exceed sixty-two calendar days per rolling twelve month period.

(15) Coverage for all organ transplant services, except kidney transplants, is contingent upon review and recommendation by the Ohio solid organ transplant consortium. Coverage for bone marrow transplants and hematapoietic stem cell transplants is contingent upon review and recommendation by the Ohio hematapoietic stem cell transplant consortium.

(D) MCPs must establish, in writing, the process and procedures for the submission of claims for services delivered by non-contracting providers, including non-contracting providers of emergency services. Such information must be made available to non-contracting providers, including non-contracting providers of emergency services, on request. MCPs may not establish claims filing and processing procedures for non-contracting providers, including non-contracting providers of emergency services, that are more stringent than those established for their contracting providers.

(E) MCPs must assure that post-stabilization care services as defined in rule 5101:3-25-01 of the Administrative Code are provided and covered twenty-four hours a day, seven days a week.

(1) The MCP must designate a telephone line to receive provider requests for coverage of post-stabilization care services. The line must be available twenty-four hours a day, seven days a week. MCPs must document that the telephone number and process for obtaining authorization has been provided to each emergency facility in the service area. The MCP must maintain a record of any request for coverage of post-stabilization care services that is denied including, at a minimum, the time of the provider’s request and the time that the MCP communicated the decision in writing to the provider.

(2) At a minimum, post-stabilization care services must be provided and reimbursed in accordance with the following:

(a) MCPs must cover services obtained within or outside the MCP’s panel that are pre-approved in writing to the requesting provider by a plan provider or other MCP representative.

(b) MCPs must cover services obtained within or outside the MCP’s panel that are not pre-approved by a plan provider or other MCP representative but are administered to maintain the member’s stabilized condition within one hour of a request to the MCP for preapproval of further post-stabilization care services.

(c) MCPs must cover services obtained within or outside the MCP’s panel that are not pre-approved by a plan provider or other MCP representative but are administered to maintain, improve, or resolve the member’s stabilized condition if:

(i) The MCP fails to respond within one hour to a provider request for authorization to provide such services;

(ii) The MCP cannot be contacted; or

(iii) The MCP’s representative and treating provider cannot reach an agreement concerning the member’s care and a plan provider is not available for consultation. In this situation, the MCP must give the treating provider the opportunity to consult with a plan provider and the treating provider may continue with care until a plan provider is reached or one of the criteria specified in paragraph (E)(3) of this rule is met.

(3) The MCP’s financial responsibility for post-stabilization care services that have not been pre-approved ends when:

(a) A plan provider with privileges at the treating hospital assumes responsibility for the member’s care;

(b) A plan provider assumes responsibility for the member’s care through transfer to another facility;

(c) A MCP representative and the treating provider reach an agreement concerning the member’s care; or

(d) The member is discharged.

(F) Exclusions, limitations, and clarifications.

(1) MCPs must permit members to self-refer to any women’s health specialist within the MCP’s panel for covered obstetric and gynecological services without obtaining a referral from the enrollee’s PCP.

(2) The following services are excluded from MCP coverage:

(a) Abortions, except as permitted under section 5101.56 of the Revised Code;

(b) Acupuncture, acupressure, acupuncture therapy, and other forms of alternative treatment, except when performed by a participating physician as a form of anesthesia in connection with covered surgery;

(c) Any service in connection with, or required by, a procedure or benefit not covered by the MCP;

(d) Behavioral health services given for the treatment of organic conditions, including chronic organic brain syndrome, mental retardation, autism, pervasive developmental disorders, and learning disabilities;

(e) Biofeedback, except as specifically approved by the MCP;

(f) Canceled office visits or missed appointments;

(g) Chiropractic services;

(h) Cosmetic surgery or surgical procedures for the purpose of changing the appearance of any part of the body to improve appearance or self-esteem, except when deemed medically necessary due to medical complications/conditions;

(i) Court-ordered services and services required by court order as a condition of parole or probation, unless medically necessary and provided by the MCP’s participating providers;

(j) Custodial or non-skilled care;

(k) Dental services;

(l) Educational services, special education, remedial education or job training. The MCP does not cover evaluation or treatment of learning disabilities, minimal brain dysfunction, developmental and learning disorders, behavioral therapy, or cognitive rehabilitation;

(m) Examinations for employment, licensing, school, camp, sports, insurance, adoptions, or other non-medically necessary reasons;

(n) Expenses that are the legal responsibility of a third party payer;

(o) Experimental services and procedures, including drugs and equipment, unless covered by the MCP;

(p) Habilitation services, as described in 42 U.S.C. 1396n(c)(5) (December 3, 2004);

(q) Hypnotherapy, except when approved in advance by the MCP;

(r) ICF-MR services, when an enrollee is found by ODJFS to meet the criteria for an ICF-MR level of care;

(s) Immunizations related to travel or work;

(t) Infertility services for males or females;

(u) Membership costs for health clubs, weight loss clinics, and similar programs;

(v) Non-emergent transportation services, including ambulette services;

(w) Paternity testing;

(x) Personal comfort or convenience items, including services and supplies that are not directly related to medical care, such as guest meals and accommodations, barber services, telephone charges, radio and television rentals, homemaker services, travel expenses, take-home supplies, and other similar items and services;

(y) Private duty nursing;

(z) Religious, marital, and sex counseling, including related services and treatment;

(aa) Residential facility room and board, and treatment;

(bb) Reversal of voluntary sterilizations, including related follow-up care;

(cc) Services for the treatment of obesity, unless deemed medically necessary;

(dd) Services or supplies that are not medically necessary;

(ee) Services provided to members outside the United States;

(ff) Services to find cause of death (autopsy);

(gg) Transsexual surgery, sex change, or transformation;

(hh) Treatment of injuries sustained while committing a felony;

(ii) Vision services; and

(jj) Voluntary sterilizations.

Replaces: 5101:3-25-03

Effective: 06/30/2008

R.C. 119.032 review dates: 06/30/2013

Promulgated Under: 119.03

Statutory Authority: 5101.5215

Rule Amplifies: 5101.5211, 5101.5212, 5101.5213, 5101.5214, 5101.5215, 5101.5216

Prior Effective Dates: 4/1/08

(A) MCP care coordination responsibilities.

(1) MCPs must ensure that each member has a PCP who will serve as an ongoing source of primary care and assist with care coordination appropriate to the member’s needs.

(2) MCPs must ensure that PCPs are in compliance with the following triage requirements:

(a) Members with emergency care needs must be triaged and treated immediately on presentation at the PCP site;

(b) Members with persistent symptoms must be treated no later than the end of the following working day after their initial contact with the PCP site; and

(c) Members with requests for routine care must be seen within six weeks.

(3) At the request of the member, MCPs must provide for a second opinion from a qualified health care professional within the MCP’s panel.

(4) MCPs that require referrals to specialists must ensure that information on referral approvals and denials is made available to ODJFS upon request.

(5) MCPs must provide a centralized toll-free call-in system that is available nationwide, twenty-four-hours a day, seven days a week.

(a) The call-in system must be staffed by trained medical professionals who will provide members with medical advice and direct members to the appropriate care setting. Such system must also provide information to members and/or providers as necessary to assure access, including, but not limited to, membership status. MCPs may not require members to contact their PCP or any other entity prior to contacting the call-in system for advice or direction concerning emergency and/or after-hours services.

(b) A log for the call-in system must be maintained, and accessible, by the MCP and must include at a minimum:

(i) Identification of the member;

(ii) Date and time of call;

(iii) Member’s question, concern, or presenting problem;

(iv) Disposition of call;

(v) PCP or other provider if contacted by MCP; and

(vi) Name and title of person taking the call.

(c) The twenty-four-hour toll-free call-in system must have services available to assist:

(i) Hearing impaired members; and

(ii) LEP members in the primary language of the member.

(6) The MCP must have a utilization management (UM) program with clearly defined structures and processes designed to maximize the effectiveness of the care provided to the member. MCPs must ensure that decisions rendered through the UM program are based on medical necessity.

(a) The UM program must be based on written policies and procedures that include, at a minimum, the following:

(i) The specification of the information sources used to make determinations of medical necessity;

(ii) The criteria, based on sound clinical evidence, to make UM decisions and the specific procedures for appropriately applying the criteria;

(iii) A specification that written UM criteria will be made available to both contracting and non-contracting providers;

(iv) A description of how the MCP will monitor the impact of the UM program to detect and correct potential under- and over-utilization.

(b) The MCP’s UM program must also assure and document the following:

(i) An annual review and update of the UM program;

(ii) The involvement of a designated senior physician in the UM program;

(iii) The use of appropriate qualified licensed health professionals to assess the clinical information used to support UM decisions;

(iv) The use of board-certified consultants to assist in making medical necessity determinations, as necessary;

(v) That UM decisions are consistent with clinical practice guidelines as specified in paragraph (B) of rule 5101:3-25-05.1 of the Administrative Code. MCPs may not impose conditions around the coverage of a medically necessary covered service unless they are supported by such clinical practice guidelines;

(vi) The reason for each denial of a service, based on sound clinical evidence; and

(vii) That compensation by the MCP to individuals or entities that conduct UM activities does not offer incentives to deny, limit, or discontinue medically necessary services to any member.

(c) MCPs must process requests for initial and continuing authorizations of services from their providers and members. MCPs must have written policies and procedures to process requests and, upon request, the MCP’s policies and procedures must be made available for review by ODJFS. The MCP’s written policies and procedures for initial and continuing authorizations of services must also be made available to contracting and non-contracting providers upon request. The MCPs must assure and document the following occurs when processing requests for initial and continuing authorizations of services:

(i) Consistent application of review criteria for authorization decisions.

(ii) Consultation with the requesting provider, when necessary.

(iii) That any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested, be made by a health care professional who has appropriate clinical expertise in treating the member’s condition or disease.

(iv) That a written notice will be sent to the member and the requesting provider of any decision to reduce, suspend, terminate, or deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice to the member must meet the requirements of rules 5101:3-25-08.4 and 5101:3-25-08.5 of the Administrative Code.

(v) For standard authorization decisions, the MCP must provide notice to the provider and member as expeditiously as the member’s health condition requires but no later than fourteen calendar days following receipt of the request for service, except as specified in paragraph (A)(6)(c)(viii) of this rule. If requested by the member, provider, or MCP, standard authorization decisions may be extended up to fourteen additional calendar days. If requested by the MCP, the MCP must submit to ODJFS for prior-approval, documentation as to how the extension is in the member’s interest. If ODJFS approves the MCP’s extension request, the MCP must give the member written notice of the reason for the decision to extend the time frame and inform the member of the right to file a grievance if he or she disagrees with that decision. The MCP must carry out its determination as expeditiously as the member’s health condition requires and no later than the date the extension expires.

(vi) If a provider indicates or the MCP determines that following the standard authorization time frame could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function, the MCP must make an expedited authorization decision and provide notice of the authorization decision as expeditiously as the member’s health condition requires but no later than three working days after receipt of the request for service. If requested by the member or MCP, expedited authorization decisions may be extended up to fourteen additional calendar days. If requested by the MCP, the MCP must submit to ODJFS for prior-approval, documentation as to how the extension is in the member’s interest. If ODJFS approves the MCP’s extension request, the MCP must give the member written notice of the reason for the decision to extend the time frame and inform the member of the right to file a grievance if he or she disagrees with that decision. The MCP must carry out its determination as expeditiously as the member’s health condition requires and no later than the date the extension expires.

(vii) Service authorization decisions not reached within the time frames specified in paragraphs (A)(6)(c)(v) and (A)(6)(c)(vi) of this rule are deemed approved by the MCP.

(viii) Prior authorization decisions for covered outpatient drugs must be made by telephone or other telecommunication device within twenty-four hours of the initial request. When an emergency situation exists, a seventy-two hour supply of the covered outpatient drug that was prescribed must be dispensed. If the MCP is unable to make the prior-authorization decision within the required time frame, authorization for the requested drug is deemed approved.

(ix) MCPs must maintain a record of all authorization requests, including standard and expedited authorization requests and any extensions granted. MCP records must include member identifying information, service requested, date initial request received, any extension requests, decision made, date of decision, date of member notice, and basis for denial, if applicable.

(d) MCPs must implement the ODJFS-required emergency department diversion program for frequent users and may develop other utilization management programs subject to prior approval by ODJFS.

(7) MCPs must provide case management (CM) services to coordinate and monitor treatment rendered to members with specific diagnoses or who require high-cost or extensive services.

(a) MCPs must notify all members of the CM services they may be eligible to receive.

(b) The MCP’s CM program must include and document the following, at a minimum:

(i) Screening and identification of members who potentially meet the criteria for case management;

(ii) Assessment of the member’s health condition to confirm the results of the screening and determine the need for case management;

(iii) Notification to the member and his or her PCP of the member’s enrollment in the MCP’s case management program; and

(iv) Development and implementation of a care treatment plan for members in case management.

(c) MCPs must report case management program-related data to ODJFS, as required.

(B) PCP care coordination responsibilities include at a minimum the following:

(1) Assisting with coordination of the member’s overall care, as appropriate for the member;

(2) Serving as the ongoing source of primary and preventive care;

(3) Recommending referrals to specialists, as required;

(4) Triaging members as described in paragraph (A)(2) of this rule;

(5) Participating in the development of case management treatment plans; and

(6) Notifying the MCP of members who may benefit from case management.

Replaces: 5101:3-25-03.1

Effective: 06/30/2008

R.C. 119.032 review dates: 06/30/2013

Promulgated Under: 119.03

Statutory Authority: 5101.5215

Rule Amplifies: 5101.5211, 5101.5212, 5101.5213, 5101.5214, 5101.5215, 5101.5216

Prior Effective Dates: 4/1/08

(A) Obligations.

(1) MCPs must provide or arrange for the delivery of covered health care services and must assure that all the requirements of Chapter 5101:3-25 of the Administrative Code, the MCP grant agreement, and all applicable federal, state, and local regulations are met.

(2) For the purposes of this rule, the following terms are defined as follows:

(a) “Subcontractor” means providers and delegated entities contracted with the MCP and providers employed by the MCP.

(b) “Fully executed” means that the legal written agreement between an MCP and its subcontractors includes dated signatures by both parties. These signatures must be by persons legally authorized to represent those parties, including each signee’s formal title.

(3) For the direct provision of health care services, MCPs must meet the obligations specified in paragraph (A)(1) of this rule either through employment or through current fully executed subcontracts with providers. All subcontracts must be in writing and in accordance with paragraph (D) of this rule.

(4) For delegated entities used to meet any program requirement, other than the direct provision of health care services, MCPs must meet the obligations specified in paragraph (A)(1) of this rule by entering into fully executed subcontracts. All subcontracts must be in writing and in accordance with paragraph (D) of this rule. In addition, MCPs must do all of the following:

(a) Evaluate the entity prior to executing a subcontract to assure that the entity is capable of performing the delegated activity in accordance with all applicable program requirements and provide a copy of the evaluation summary to ODJFS upon request.

(b) Provide the delegated entity with all information, materials, and documentation the entity will need to meet the delegated program requirement(s).

(c) Require the delegated entity to submit a report to the MCP, at least monthly, summarizing the status of the delegated activity, and including at a minimum:

(i) A copy of any required reports or logs maintained by the delegated entity; and

(ii) Identification of any problems, concerns, or potential compliance issues that may exist.

(d) Monitor the entity’s performance on an ongoing basis, including a review of the report referenced in paragraph (A)(4)(c) of this rule, all relevant member grievance system documentation, and all member complaints reported to the ODJFS and forwarded to the MCP, to identify any deficiencies or areas for improvement. Upon request, the MCP must provide documentation of the MCP’s monitoring efforts and its findings to ODJFS.

(e) Submit an annual assessment of the delegated entity’s performance with meeting the delegated program requirements throughout the year to ODJFS within thirty calendar days of the assessment.

(f) Include in the contract between the MCP and the delegated entity the sanctions that will be imposed for inadequate performance. The sanctions must specify the MCP’s authority to require corrective action for any deficiencies or areas of improvement identified and provide for the revocation of the delegation if the MCP or ODJFS determines that the delegation is not in the best interest of the enrollees.

(g) Include in the contract between the MCP and the delegated entity the sanctions that will be imposed for unauthorized uses or disclosures of protected health information (PHI).

(h) Include in the contract between the MCP and the delegated entity that, unless otherwise specified by ODJFS, all information required to be submitted to ODJFS must be submitted directly by the MCP.

(5) For subcontracts that the MCP believes to be short-term, one-time, or infrequent activities, the MCP may request that ODJFS exempt them from the reporting, monitoring and assessment requirements specified in paragraphs (A)(4)(c) and (A)(4)(e) of this rule.

(6) The MCP’s execution of a subcontract with a provider or delegated entity does not terminate the MCP’s legal responsibility to ODJFS to assure that all of the MCP’s activities and obligations are performed in accordance with Chapter 5101:3-25 of the Administrative Code and the MCP grant agreement.

(7) MCP-executed subcontracts may not include language that conflicts with the specifications identified in paragraphs (C) and (D) of this rule.

(8) MCPs that authorize the delivery of services from a provider who does not have an executed subcontract with the MCP must ensure that they have a mutually agreed upon compensation amount for the authorized service and notify the provider of the applicable provisions of paragraph (D) of this rule.

(9) MCPs terminating participation of a contracted provider must meet applicable provisions of applicable state and federal regulations.

(10) MCPs must include provisions in their provider manual, or other applicable provider notices/materials, that clearly state the rights and responsibilities of the MCP, and of the contracted providers and health care facilities, with respect to administrative policies and programs, including, but not limited to, payment systems, utilization management, quality assurance, assessment, and improvement programs, credentialing, confidentiality requirements, any applicable federal or state programs, and procedures for the resolution of disputes between the provider and MCP.

(B) Notification.

(1) When providers are to be added or deleted from the MCP’s provider panel, the MCP must submit documentation to ODJFS as requested.

(2) When any program requirement is to be delegated as specified in paragraph (A)(4) of this rule, the MCP must submit documentation to ODJFS as requested.

(3) In the event any of the providers of the designated types are to be deleted from the MCP’s provider panel due to the expiration, nonrenewal, or termination of said subcontract, the following must occur:

(a) If the subcontractor involved is a PCP, the MCP must notify, in writing by mail, all members who use the subcontractor as a PCP.

(i) The form of the notice and its content must be prior-approved by ODJFS and must contain, at a minimum, all of the following information:

(a) The PCP’s name and last date the PCP is available to provide care to the MCP’s members;

(b) The name, location, telephone number, and effective date of the member’s new PCP as selected by the MCP;

(c) Information regarding how members can select a different PCP; and

(d) An MCP telephone number members can call for further information and/or assistance.

(ii) This notice must be sent at least forty-five calendar days prior to the effective date of the deletion to members who use the subcontractor as a PCP. If the MCP receives less than forty-five days prior notice, this notice must be issued within one working day of the MCP becoming aware of the PCP’s deletion.

(b) When the subcontractor is a hospital, the MCP must notify all members in the service area, in writing by mail, of the impending expiration, nonrenewal, or termination of the subcontract and the last date the subcontractor will provide services to members under the MCP contract.

If the subcontract is expiring or the MCP is initiating the nonrenewal or termination of the subcontract, the MCP must notify all providers who have admitting privileges at the hospital of the impending expiration, nonrenewal, or termination of the subcontract and the last date the subcontractor will provide services to members under the MCP subcontract.

If the subcontractor is initiating the nonrenewal or termination of the subcontract, the subcontractor must notify all providers who have admitting privileges at the hospital of the impending nonrenewal or termination of the subcontract and the last date the subcontractor will provide services to members under the MCP subcontract.

(i) These notices must be sent to the members and providers who have admitting privileges at the hospital at least forty-five calendar days prior to the effective date of the hospital’s deletion from the MCP’s provider panel. If the MCP receives/issues less than forty-five days prior notice, these notices must be sent within one working day of the MCP becoming aware of the hospital’s deletion from the MCP’s provider panel.

(ii) The form and content of the member notice must be prior-approved by ODJFS and contain an ODJFS designated toll-free telephone number that members can call for information and assistance.

(iii) When issued by the MCP, the form and content of the provider notice must be prior-approved by ODJFS.

(iv) Notification to additional members and/or providers may also be required if the hospital’s deletion from the MCP’s provider panel adversely impacts additional members and/or providers.

(c) Regardless of the member notification time frames specified in this paragraph, the MCP must make a good faith effort to give written notice of termination of a contracted provider, within fifteen calendar days after receipt or issuance of the termination notice, to each member who received his or her primary care from, or was seen on a regular basis by, the terminated provider.

(4) Member and/or provider notification may also be required for certain other provider deletions from the MCP’s panel that may adversely impact the MCP’s members.

(5) In the event of the expiration, nonrenewal, or termination of the subcontract with a delegated entity, as specified in paragraph (A)(4) of this rule, the MCP must notify members and/or providers of the impending expiration, nonrenewal, or termination of the subcontract in situations that may adversely impact members and/or providers.

(6) In order to assure availability of services and qualifications of providers, ODJFS may require submission of documentation regardless of whether the MCP subcontracts directly for services or does so through another entity.

(7) MCPs must submit to ODJFS within thirty calendar days of execution, any subcontract and/or amendment to a subcontract with a hospital.

(8) In the event that the MCP’s statewide managed care program participation is terminated, the MCP must provide written notification to its affected subcontractors at least forty-five calendar days prior to the termination date, unless otherwise specified by ODJFS.

(9) MCPs must require participating providers to notify them, in writing, of the provider’s intent to limit and/or close their panel and/or treat covered members only, at least sixty days prior to the date of this change.

(10) An MCP shall notify members and participating providers of the circumstances and applicable member cost-sharing amounts that will be imposed in accordance with rule 5101:3-25-12 of the Administrative Code.

(C) Provider qualifications.

(1) MCPs must ensure that subcontractors are not sanctioned/excluded from providing medicaid or medicare services. MCPs shall utilize available resources for identifying sanctioned providers, including, but not limited to, the federal office of inspector general provider exclusion list; the national practitioner data bank; the ODJFS excluded provider web page; and the discipline pages of the applicable state boards that license providers. ODJFS will provide notification to MCPs of sanctions ODJFS imposes during the term of the grant agreement.

(2) An MCP may not discriminate in regard to the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable state law, solely on the basis of that license or certification. If an MCP declines to include individuals or groups of providers in its network, it must give the affected providers written notice of the reasons for its decision. This paragraph may not be construed to:

(a) Require the MCP to contract with providers beyond the number necessary to meet the needs of its members;

(b) Preclude the MCP from using different reimbursement amounts for different specialties or for different practitioners in the same specialty; or

(c) Preclude the MCP from establishing measures that are designated to maintain quality of services and control costs and are consistent with its responsibilities to members.

(3) MCPs must have written policies and procedures for the selection and retention of providers that do not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment.

(4) When initially credentialing and recredentialing providers in connection with policies, contracts, and agreements providing basic health care services, MCPs must utilize the standardized credentialing form and process as prescribed by the Ohio department of insurance under section 1753.03 of the Revised Code. Upon ODJFS’s request, MCPs must demonstrate the record keeping associated with maintaining this documentation.

(5) If any MCP delegates the credentialing/recredentialing of subcontractors to another entity, the MCP must retain the authority to approve, suspend, or terminate any subcontractors.

(6) MCPs must ensure that home health subcontractors are medicare-certified and comply with the requirements for home care dependent adults as specified in section 121.36 of the Revised Code.

(D) Subcontracts.

MCP subcontracts or other provider materials, as long as the material(s) are referenced in the subcontract in such a manner as to obligate the provider to comply, must include the following elements and be in accordance with applicable federal and state regulations:

(1) An agreement by the subcontractor to comply with the applicable provisions for record keeping and auditing in accordance with Chapter 5101:3-25 of the Administrative Code, and any other applicable federal and state laws.

(2) Specification of the population and service area to be served.

(3) Specification that the subcontract is governed by, and construed in accordance with all applicable laws, regulations, and contractual obligations of the MCP and:

(a) The subcontract shall be automatically amended to conform to such changes without the necessity for written execution; and

(b) The MCP shall notify the subcontractor of all applicable contractual obligations.

(4) Specification of the terms of the subcontract, including the beginning date and expiration date, or automatic renewal clause, as well as the applicable methods of extension, renegotiation, and termination.

(5) Specification of the procedures to be employed upon the ending, nonrenewal, or termination of the subcontract, including the agreement to promptly supply all records necessary for the settlement of outstanding medical claims.

(6) Full disclosure of the method and amount of compensation or other consideration to be received by the subcontractor from the MCP.

(7) An agreement not to discriminate in the delivery of services based on the member’s race, color, religion, gender, sexual orientation, age, disability, national origin, veteran’s status, ancestry, health status, or need for health services.

(8) A provision requiring the provider to observe, protect, and promote the rights of members as patients.

(9) The MCP must include a provision in provider materials specifying the language in this paragraph. Upon renewal or amendment of the subcontract, the MCP must include an agreement by the subcontractor to not hold ODJFS or members liable in the event the MCP cannot or will not pay for covered services performed by the subcontractor pursuant to the subcontract, including an agreement that:

(a) In no event, including, but not limited to, nonpayment by the MCP, insolvency of the MCP, or breach of the subcontract, shall the subcontractor bill, charge, collect a deposit from, seek remuneration or reimbursement from, or have any recourse against, members for health care services provided pursuant to the subcontract. This does not prohibit the subcontractor from collecting co-insurance, deductibles, or copayments as specifically provided in the member handbook, or fees for uncovered health care services delivered on a fee-for-service basis to members, nor from any recourse against the MCP or its successor.

(b) To bill a member for a non-covered or non-medically necessary health care service , the subcontractor must:

(i) Notify the member of the financial liability in advance of the service delivery;

(ii) Provide the notification to the member in writing, specific to the service being rendered, and clearly state that the member is financially responsible for the specific service. A general patient liability statement signed by all patients is not sufficient for this purpose; and

(iii) Ensure the notification is dated and signed by the member.

(10) An agreement by the subcontractor that, with the exception of applicable member cost-sharing obligations in accordance with rule 5101:3-25-12 of the Administrative Code, the MCP’s payment constitutes payment in full for any covered service and the subcontractor will not charge the member any other cost sharing, down payment, or similar charge, refundable or otherwise.

(a) The MCP shall notify the subcontractor of member cost-sharing obligations in accordance with rule 5101:3-25-12 of the Administrative Code.

(b) The subcontractor agrees that member notifications regarding applicable member cost-sharing amounts must be carried out in accordance with rule 5101:3-25-12 of the Administrative Code.

(11) Provisions requiring the provider or health care facility to continue to provide covered health care services to members in the event of the MCP’s insolvency or discontinuance of operations. The provisions shall require the provider or health care facility to continue to provide covered health care services to members as needed to complete any medically necessary procedures commenced but unfinished at the time of the health MCP’s insolvency or discontinuance of operations. The completion of a medically necessary procedure shall include the rendering of all covered health care services that constitute medically necessary follow-up care for that procedure. If a member is receiving necessary inpatient care at a hospital, the provisions may limit the required provision of covered health care services relating to that inpatient care in accordance with division (D)(3) of section 1751.11 of the Revised Code, and may also limit such required provision of covered health care services to the period ending thirty days after the MCP’s insolvency or discontinuance of operations.

The provisions required by this paragraph shall not require any provider or health care facility to continue to provide any covered health care service after the occurrence of any of the following:

(a) The end of the thirty-day period following the entry of a liquidation order under Chapter 3903. of the Revised Code;

(b) The end of the member’s period of coverage for a contractual prepayment or premium; or

(c) A liquidator effects a transfer of the MCP’s obligations under the contract under division (A)(8) of section 3903.21 of the Revised Code.

(12) A specification that the subcontractor and all employees of the subcontractor are duly registered, licensed, or certified under applicable state and federal statutes and regulations to provide the health care services that are the subject of the subcontract, and that the subcontractor and all employees of the subcontractor have not been excluded from participating in federally funded health care programs.

(13) An agreement that subcontractors who are currently providers meet the qualifications specified in paragraph (C) of this rule.

(14) A stipulation that either the MCP or subcontractor may terminate its subcontract for cause or without cause.

(a) In the event of termination for cause, the subcontract shall terminate upon receipt of written notice from the terminating party. Cause shall mean:

(i) Failure of the MCP to maintain license or certifications required to operate in conformity with the subcontract; or, failure of the provider to maintain licenses required to perform provider’s duties under the subcontract, or to comply with applicable laws, regulations, or MCP requirements;

(ii) Habitual neglect or continued failure by either the MCP or subcontractor to perform its duties under the subcontract that affects the quality of care being delivered to the member;

(iii) Material breach of the terms of the subcontract by the subcontractor or MCP provided the party causing the breach fails to cure such breach within thirty days of receipt of notice of breach; and

(iv) Any material misrepresentation or falsification of any information submitted by the subcontractor to the MCP including, but not limited to, billing information or information set forth in any credentialing or recredentialing materials.

(b) In the event of termination without cause, notice must be given ninety days prior to the effective date of the termination.

(15) The subcontractor’s agreement to serve members through the last day the subcontract is in effect.

(16) A specification that all laboratory testing sites providing services to members must have either a current clinical laboratory improvement amendments (CLIA) certificate of waiver, certificate of accreditation, certificate of compliance, or certificate of registration along with a CLIA identification number.

(17) A specification that hospitals and other subcontractors must allow the MCP access to all member records for a period of not less than six years from the date of service or until any audit initiated within the six-year period is completed and allow access to all record-keeping, audits, financial records, and medical records to ODJFS or its designee or other entities as specified in paragraph (F) of rule 5101:3-25-06 of the Administrative Code and any other applicable federal and state laws.

(18) A specification that the subcontractor is bound by federal and state standards of confidentiality that apply to ODJFS and the state of Ohio, including standards for unauthorized uses of or disclosures of PHI.

(19) A specification regarding any activities to be performed by the subcontractor that relate to third party liability requirements.

(20) A specification that the subcontractor in providing health care services to members must identify and where indicated arrange, pursuant to the mutually agreed upon policies and procedures between the MCP and subcontractor, for the following at no cost to the member;

(a) Sign language services; and

(b) Oral interpretation and oral translation services.

(21) A provision clearly stating the rights and responsibilities of the MCP, and of the contracted providers and health care facilities, with respect to administrative policies and programs, including, but not limited to, payment systems, utilization management, quality assurance, assessment, and improvement programs, credentialing, confidentiality requirements, and any applicable federal or state programs.

(22) A specification that home health subcontractors must be medicare-certified and comply with the requirements for home care dependent adults as specified in section 121.36 of the Revised Code.

(23) A specification that PCPs must participate in the care coordination requirements outlined in rule 5101:3-25-03.1 of the Administrative Code.

(24) A provision regarding the availability and confidentiality of those health records maintained by providers to monitor and evaluate the quality of care, to conduct evaluations and audits, and to determine on a concurrent or retrospective basis the necessity of and appropriateness of health care services provided to enrollees. The provision shall include terms requiring the provider or health care facility to make these health records available to appropriate state and federal authorities involved in assessing the quality of care or in investigating the grievances or complaints of enrollees, and requiring the provider to comply with applicable state and federal laws related to the confidentiality of medical or health records.

(25) A provision setting forth procedures for the resolution of disputes arising out of the contract.

(26) A provision requiring the provider to maintain adequate professional liability and malpractice insurance. The provision shall also require the provider to notify the MCP not more than ten days after the provider’s or health care facility’s receipt of notice of any reduction or cancellation of such coverage.

Replaces: 5101:3-25-05

Effective: 06/30/2008

R.C. 119.032 review dates: 06/30/2013

Promulgated Under: 119.03

Statutory Authority: 5101.5215

Rule Amplifies: 5101.5211, 5101.5212, 5101.5213, 5101.5214, 5101.5215, 5101.5216

Prior Effective Dates: 4/1/08

5101:3-25-05.1 Children’s buy-in program: provider services.

(A) MCPs must provide the following written information to their contracting providers:

(1) The MCP’s grievance, appeal, and reconsideration procedures and time frames, as defined by ODJFS.

(2) The MCP’s requirements regarding the submission and processing of prior authorization requests including:

(a) A list of the benefits, if any, that require prior authorization approval from the MCP;

(b) The process and format to be used in submitting such requests;

(c) The time frames in which the MCP must respond to such requests;

(d) How the provider will be notified of the MCP’s decision regarding grievance, appeal, and reconsideration requests; and

(e) The procedures to be followed in appealing the MCP’s denial of a prior authorization request.

(3) The MCP’s requirements regarding the submission and processing of requests for specialist referrals including:

(a) A list of the provider types, if any, that require a referral from the MCP or PCP;

(b) The process and format to be used in submitting such requests;

(c) How the provider will be notified of the MCP’s decision regarding such requests; and

(d) The procedures to be followed in appealing the MCP’s denial of such requests.

(4) The MCP’s documentation, legibility, confidentiality, maintenance, and access standards for member medical records, including a member’s right to amend or correct his or her medical record as specified in 45 C.F.R. 164.526 (April 14, 2001).

(5) The MCP’s process and requirements for the submission of claims and the appeal of denied claims.

(6) The MCP’s process and standards for the recredentialing of providers.

(7) The MCP’s policies and procedures regarding what action the MCP may take in response to occurrences of undelivered, inappropriate, or substandard health care services, including the reporting of serious deficiencies to the appropriate authorities.

(8) A description of the MCP’s care coordination and case management programs, and the role of the provider in those programs, including:

(a) The MCP’s criteria for determining which members might benefit from case management;

(b) The provider’s responsibility in identifying members who may meet the MCP’s case management criteria; and

(c) The process for the provider to follow in notifying the MCP when such members are identified.

(9) The MCP’s requirements and expectations for PCPs, including triage requirements.

(10) The mutually agreed upon policies and procedures between the MCP and provider that explain the provider’s obligation to provide oral translation, oral interpretation, and sign language services to the MCP’s members including:

(a) The provider’s responsibility to identify those members who may require such assistance;

(b) The process the provider is to follow in arranging for such services to be provided;

(c) Information that members will not be liable for the costs of such services; and

(d) Specification of whether the MCP or the provider will be financially responsible for the costs of providing these services.

(11) The procedures that providers are to follow in notifying the MCP of changes in their practice, including at a minimum:

(a) Address and phone numbers;

(b) Providers included in the practice;

(c) Acceptance of new patients; and

(d) Standard office hours.

(12) Specification of what service utilization and provider performance data the MCP will make available to providers.

(B) MCPs must adopt practice guidelines and provide written copies to all affected providers. These guidelines must:

(1) Be based on valid and reliable clinical evidence or a consensus of health care professionals in the particular field;

(2) Consider the needs of the MCP’s members;

(3) Be adopted in consultation with contracting health care professionals; and

(4) Be reviewed and updated periodically, as appropriate.

(C) MCPs must have staff specifically responsible for resolving individual provider issues, including, but not limited to, problems with claims payment, prior authorizations and referrals. MCPs must provide written information to their contracting providers detailing how to contact these designated staff.

Replaces: 5101:3-25-05.1

Effective: 06/30/2008

R.C. 119.032 review dates: 06/30/2013

Promulgated Under: 119.03

Statutory Authority: 5101.5215

Rule Amplifies: 5101.5211, 5101.5212, 5101.5213, 5101.5214, 5101.5215, 5101.5216

Prior Effective Dates: 4/1/08

(A) MCPs must have administrative and management arrangements or procedures, including a mandatory compliance plan, designed to guard against fraud and abuse.

(1) These arrangements or procedures must include the implementation of sound business practices that support appropriate access to and appropriate payment for quality services and must include the following:

(a) Written policies, procedures, and standards of conduct that articulate the MCP’s commitment to comply with all applicable federal and state standards, including the prevention, identification, investigation, correction, and reporting of fraud and abuse;

(b) Designation of a compliance officer and a compliance committee that are accountable to senior management;

(c) Effective training and education for the compliance officer and the MCP’s employees;

(d) Effective lines of communication between the compliance officer and the MCP’s employees. To ensure effective communication, the MCP must organize resources to respond to complaints of fraud and abuse and have established procedures to process these complaints;

(e) Education of providers and delegated entities about fraud and abuse;

(f) Enforcement of MCP standards through well-publicized disciplinary guidelines;

(g) Provision for internal monitoring and auditing, including procedures to monitor service patterns of providers and subcontractors;

(h) Establishment and/or modification of internal MCP controls to ensure the proper submission and payment of claims;

(i) Provision for prompt response to detected offenses, and for development of corrective action initiatives relating to the MCP’s contract; and

(j) Prompt reporting of all instances of fraud and abuse to ODJFS.

(2) These arrangements or procedures must be made available to ODJFS upon request.

(3) MCPs must annually submit to ODJFS a report that summarizes the MCP’s fraud and abuse activities for the previous year and that identifies any proposed changes to the MCP’s fraud and abuse program for the coming year.

(B) ODJFS or its designee, the state auditor’s office, and the state attorney general’s office will evaluate or audit a contracting MCP’s performance for the purpose of determining compliance with the requirements of this chapter as well as applicable state and federal requirements.

(C) ODJFS or its designee may conduct on-site audits and reviews as deemed necessary based on periodic analysis of financial, utilization, provider panel, and other information.

(D) The MCP must submit required reports and additional information, as requested by ODJFS, as related to its duties and obligations and where needed to assure operation in accordance with all state and federal regulations or requirements.

(E) Failure of the MCP to submit any ODJFS-requested materials, as specified in paragraph (D) of this rule, without cause as determined by ODJFS, on or before the due date, may result in application of any or all of the sanctions listed in rule 5101:3-25-10 of the Administrative Code.

(F) All hard copy or electronic records originated or prepared in connection with the MCP’s performance of its obligations under the grant agreement, including, but not limited to, working papers or information related to the preparation of reports, medical records, progress notes, charges, journals, ledgers, and fiscal reports, will be retained and safeguarded by the MCP and its subcontractors. Records stored electronically must be produced at the MCP’s expense, upon request, in the format specified by ODJFS. All such records must be maintained for a minimum of six years from the renewal, amendment, or termination date of the grant agreement or in the event that the MCP has been notified that state authorities have commenced an audit or investigation of the grant agreement, until such time as the matter under audit or investigation has been resolved.

Replaces: 5101:3-25-06

Effective: 06/30/2008

R.C. 119.032 review dates: 06/30/2013

Promulgated Under: 119.03

Statutory Authority: 5101.5215

Rule Amplifies: 5101.5211, 5101.5212, 5101.5213, 5101.5214, 5101.5215, 5101.5216

Prior Effective Dates: 4/1/08

(A) ODJFS, or its designee, will conduct a review of the quality, outcomes, timeliness of, and access to, services provided by MCPs.

(B) The quality review activities may include, but not be limited to, the following components for MCPs:

(1) A review of the MCP’s administrative quality functions, including internal QAPI activities as described in rule 5101:3-25-07.1 of the Administrative Code;

(2) A performance review and outcome assessment of the MCP’s case management system and other internal administrative programs; and

(3) A member satisfaction survey.

(C) MCPs must timely submit at no cost to ODJFS, data and information, including member medical records, as requested by ODJFS, or its designee, for the quality reviews.

(D) MCPs must develop and implement CAPs or quality improvement directives that are prior-approved by ODJFS and that address deficiencies cited by ODJFS or its designee.

Replaces: 5101:3-25-07

Effective: 06/30/2008

R.C. 119.032 review dates: 06/30/2013

Promulgated Under: 119.03

Statutory Authority: 5101.5215

Rule Amplifies: 5101.5211, 5101.5212, 5101.5213, 5101.5214, 5101.5215, 5101.5216

Prior Effective Dates: 4/1/08

(A) Each MCP must have an ongoing QAPI program that is annually prior-approved by ODJFS.

(B) As part of the QAPI program, the MCP must, at a minimum:

(1) Have in effect mechanisms to detect both under-utilization and over-utilization of services.

(2) Have in effect mechanisms to assess the quality and appropriateness of care furnished to members with special health care needs.

(3) Establish appropriate administrative oversight arrangements and accountability for the QAPI program. The MCP must be able to document, upon request, that such arrangements include:

(a) The assignment of a senior official responsible for the QAPI program;

(b) Provision for and a record of ongoing communication and coordination between the area that oversees the QAPI program and relevant functional areas of the organization; and

(c) Assurance that the medical director is involved in all clinically related projects and that all staff responsible for QAPI implementation have education, experience, and training appropriate to their position.

(4) Maintain and monitor a network of appropriate providers that is supported by written agreements and is sufficient to provide adequate access to all services under the contract.

(5) Ensure coordination and continuity of care by implementing mechanisms to identify members with special health care needs and that each member has an ongoing source of primary care appropriate to his/her needs and a person or entity designated as responsible for coordinating health care services.

(6) Have written policies and procedures for selection and retention of providers.

(7) Adopt clinical practice guidelines based on valid and reliable clinical evidence in consultation with contracting health care professionals, and are reviewed and updated periodically. The application of the guidelines should be used for utilization management, member education, coverage of services, and other areas where the guidelines apply.

Replaces: 5101:3-25-07.1

Effective: 06/30/2008

R.C. 119.032 review dates: 06/30/2013

Promulgated Under: 119.03

Statutory Authority: 5101.5215

Rule Amplifies: 5101.5211, 5101.5212, 5101.5213, 5101.5214, 5101.5215, 5101.5216

Prior Effective Dates: 4/1/08

(A) Definitions. For the purposes of this rule, the following terms are defined as follows:

(1) “Marketing” means any communication from an MCP to an individual who is not a member of that MCP, that can reasonably be interpreted as intended to influence the individual to select membership in that MCP, or to not select membership in or to terminate membership from another MCP.

(2) “Marketing presentation” means a one-on-one interaction between an MCP’s marketing representative and an individual who is not a member of that MCP.

(B) Marketing activities.

(1) MCPs must assure that representatives, as well as materials and plans, represent the MCP in an honest and forthright manner, and do not make statements that are inaccurate, misleading, confusing or otherwise misrepresentative, or that defraud ODJFS or individuals who are not members of that MCP.

(2) MCPs must assure that no marketing activity directed specifically toward the CBI population begins prior to approval by ODJFS.

(3) MCPs are prohibited from engaging directly or indirectly in “cold-call marketing” activities including, but not limited to, door-to-door or telephone contact. Cold-call marketing means any unsolicited personal contact by the MCP with an individual who is not a member of that MCP for the purpose of marketing as defined in paragraph (A) of this rule.

(4) MCPs must receive prior approval for any event or location where the MCP plans to provide information to individuals who are not members of that MCP.

(5) MCPs are prohibited from offering material or financial gain, including, but not limited to, the offering of any other insurance, to an individual who is not a member of that MCP as an inducement to select membership in that MCP.

(6) MCPs are prohibited from offering inducements to ODJFS, including ODJFS-approved entities, or to others who may influence the decision of an individual who is not a member of that MCP to select membership in that MCP.

(7) MCPs are allowed to offer nominal gifts prior-approved by ODJFS to an individual who is not a member of that MCP as long as these gifts are offered whether or not the individual selects membership in that MCP.

(8) MCPs may reference member incentive/appreciation items, as specified in paragraph (B) of rule 5101:3-25-08.2 of the Administrative Code, in marketing presentations and materials; however, such member items must not be made available to non-members.

(C) Marketing presentations.

(1) Only ODJFS-approved MCP marketing representatives may make a marketing presentation as outlined in paragraph (F)(6) of this rule to an individual who is not a member of that MCP or in any way advise or recommend to an individual who is not a member of that MCP that he/she select MCP membership in a particular MCP. As provided in Chapter 1751. and section 3905.01 of the Revised Code, and rule 3901-1-10 of the Administrative Code, all non-licensed agents, including providers, are prohibited from advising or recommending to an individual who is not a member of that MCP that he/she select MCP membership in a particular MCP as this would constitute the unlicensed practice of marketing.

(2) MCPs must assure that marketing representatives represent the MCP in an honest and forthright manner, and do not make statements that are inaccurate, misleading, confusing, or otherwise misrepresentative, or that defraud ODJFS or individuals who are not members of that MCP.

(3) MCPs are prohibited from making one-on-one marketing presentations in any setting unless requested by an individual who is not a member of that MCP.

(4) MCP informational displays do not require the presence of a marketing representative if no marketing presentation will be made.

(D) Marketing materials.

(1) Marketing materials are materials produced in any medium by or on behalf of an MCP and that can reasonably be interpreted as intended to market to individuals who are not members of that MCP. All new and revised materials, including materials used for marketing presentations, must be prior approved by ODJFS. MCPs must include with each marketing submission an attestation that the material is accurate and does not mislead, confuse, or defraud ODJFS or individuals who are not members of that MCP.

(2) All MCP marketing materials must be available in a manner and format that may be easily understood.

(3) Written materials developed to promote membership selection in an MCP must be available in:

(a) The prevalent non-English languages of individuals in the service area who are not members of that MCP.

(b) Alternative formats in an appropriate manner that takes into consideration the special needs of individuals who are not members of that MCP including, but not limited to, visually limited and LRP individuals.

(4) Oral interpretation and oral translation services must be available for the review of marketing materials at no cost to individuals who are not members of that MCP.

(5) The mailing/distribution of all MCP marketing materials must be prior-approved by ODJFS and may contain no information or text on the outside of the mailing that identifies the addressee as a CBI consumer. Marketing materials must be distributed to the MCP’s entire service area.

(6) MCPs must have a solicitation brochure available to individuals who are not members of that MCP that contains, at a minimum:

(a) Description of the eligibility criteria for CBI program coverage.

(b) A description of the MCP’s identification card.

(c) A statement that all CBI-covered services will be available to all members.

(d) A description of any additional services available to all members.

(e) Information on how the individual can request or access additional MCP information or services, including clarification on how this information can be requested or accessed through:

(i) Sign language, oral interpretation, and oral translation services at no cost to an individual who is not a member of that MCP;

(ii) Written information in the prevalent non-English languages of individuals who are not members of that MCP or members in the MCP’s service area; and

(iii) Written information in alternative formats.

(f) Information clearly identifying corporate or parent company identity when a trade name or doing business as (DBA) is used for the CBI product.

(g) A statement that this brochure contains only a summary of the relevant information and that more details about the MCP will be provided upon request.

(h) Information that an individual must choose a PCP from the MCP’s provider panel and that the PCP will coordinate the member’s health care.

(i) Information that a member may change PCPs at least monthly.

(j) A statement that all CBI-covered health care services must be obtained in or through the MCP facilities and/or providers except emergency care.

(k) A description of how to access emergency services, including information that access to emergency services is available within and outside the service area.

(l) A description of the MCP’s policies regarding access to providers outside the service area.

(m) Information on the procedures an individual who is not a member of that MCP must follow to select MCP membership in an MCP, including any applicable ODJFS selection requirements.

(n) Information on member cost-sharing amounts the MCP has implemented in accordance with rule 5101:3-25-12 of the Administrative Code.

(E) Marketing plan.

MCPs must submit an annual marketing plan to ODJFS that includes all planned activities for promoting membership in or increasing awareness of the MCP. The marketing plan submission must include an attestation by the MCP that the plan is accurate and does not mislead, confuse, or defraud ODJFS or individuals who are not members of that MCP.

(F) Marketing representatives.

The following requirements apply to MCPs that utilize marketing representatives for marketing presentations requested by individuals who are not members of that MCP must comply with the following:

(1) All marketing representatives must be employees of the MCP. A copy of the representative’s job description(s) must be submitted to ODJFS.

(2) Marketing representatives must be trained and duly licensed by ODI to perform such activities.

(3) The MCP must develop and submit to ODJFS for prior-approval a marketing representative training program. This training program must include, at a minimum:

(a) A training curriculum that includes at a minimum:

(i) A full review of the MCP’s solicitation brochure, provider directory, and all other marketing materials, including all video, audio, electronic, and print materials.

(ii) An overview of applicable public assistance benefits designed to familiarize and impart a working knowledge of these programs.

(iii) The MCP’s process for providing sign language, oral interpretation, and oral translation services to an individual who is not a member of that MCP to whom a marketing presentation is being made, including a review of the MCP’s written marketing materials.

(iv) Instruction on acceptable and appropriate marketing tactics, including that the marketing representatives may not discriminate on the basis of age, gender, sexual orientation, disability, race, color, religion, national origin, veteran’s status, ancestry, health status, or the need for health services.

(v) An overview of the ramifications to the MCP and/or the marketing representatives if ODJFS rules are violated.

(vi) Review of the MCP’s code of conduct/ethics.

(b) Methods the MCP will utilize to determine initial and ongoing competency with the training curriculum.

(4) Any revisions to the ODJFS-approved training program must be submitted to ODJFS for review and prior approval.

(5) No more than fifty per cent of each marketing representative’s total annual compensation, including salary, benefits, and bonuses may be paid on a commission basis. For the purpose of this rule, any performance-based compensation would be considered a form of commission. The MCP must make available for inspection, upon request by ODJFS, the compensation package(s) for marketing representatives as its assurance of compliance with this requirement.

(6) Any MCP staff providing information on the MCP or making marketing presentations to an individual who is not a member of that MCP must comply with the following:

(a) The MCP must not discriminate on the basis of age, gender, sexual orientation, race, color, religion, national origin, veteran’s status, ancestry, disability, health status, or the need for health services.

(b) The MCP must not ask an individual who is not a member of that MCP questions related to health status or the need for health services.

(c) The MCP staff must visibly wear or display an identification tag and offer a business card when speaking to an individual who is not a member of that MCP and provide information that ensures that the staff is not mistaken for a federal, state or county employee.

(d) The MCP must inform individuals who are not members of that MCP that the following MCP information or services are available and how they can access the information or services:

(i) Sign language, oral interpretation, and oral translation services at no cost to the member;

(ii) Written information in the prevalent non-English languages of individuals who are not members of that MCP or members in the MCP’s service area; and

(iii) Written information in alternative formats.

(e) MCP marketing representatives must offer the ODJFS-approved solicitation brochure to an individual who is not a member of that MCP at the time of the marketing presentation and provide, at a minimum:

(i) An explanation of the importance of reviewing the information in the ODJFS-approved solicitation brochure, how they can receive additional information about the MCP prior to making an MCP membership selection, and the process for contacting ODJFS to select an MCP.

(ii) When more than one MCP is available in the service area, information that membership in a particular MCP is voluntary and that a decision to select or not select the MCP will not affect eligibility for the CBI program.

(iii) Information that each member must choose a PCP and must access providers and services as directed in the MCP’s member handbook and provider directory.

(iv) Information that all CBI-covered services, as well as any additional services provided by the MCP, will be available to all members.

(G) Provider directory. Upon request, MCPs must provide individuals who are not members of that MCP with access to their provider directory.

(H) Alleged marketing violations.

(1) The MCP must immediately notify ODJFS in writing of its discovery of an alleged/suspected marketing violation.

(2) ODJFS will forward information pertaining to alleged marketing violations to ODI as appropriate.

Replaces: 5101:3-25-08

Effective: 06/30/2008

R.C. 119.032 review dates: 06/30/2013

Promulgated Under: 119.03

Statutory Authority: 5101.5215

Rule Amplifies: 5101.5211, 5101.5212, 5101.5213, 5101.5214, 5101.5215, 5101.5216

Prior Effective Dates: 4/1/08

(A) MCP member services program.

(1) Each MCP must establish and operate a member services toll-free telephone number. This telephone line must have services available to assist:

(a) Hearing-impaired members; and

(b) LEP members in the primary language of the member.

(2) The member services program must, at a minimum, assist MCP members and, as applicable, individuals who are not members of that MCP, who are seeking information about MCP membership, with the following:

(a) Accessing covered services;

(b) Obtaining or understanding information on the MCP’s policies and procedures;

(c) Understanding the requirements and benefits of the plan;

(d) Resolution of concerns, questions, and problems;

(e) Filing of grievances, appeals, and reconsiderations as specified in rules 5101:3-25-08.4 and 5101:3-25-08.5 of the Administrative Code; and

(f) Accessing sign language, oral interpretation and oral translation services. MCPs must ensure that these services are provided at no cost to an individual who is not a member of that MCP or to a member. MCPs must designate a staff person, to coordinate and document the provision of these services.

(3) In the event a member-selected PCP is not identified for each member prior to the effective date of coverage, or if the member-selected PCP is not available, the MCP must:

(a) Select a PCP for each member prior to the effective date of coverage based on the PCP assignment methodology prior approved by ODJFS;

(b) Notify members of the name of their PCP prior to the effective date of coverage and pursuant to the provisions of paragraph (D) of rule 5101:3-25-02 of the Administrative Code;

(c) Simultaneously notify members with an MCP-selected PCP of the ability within the first month of initial MCP membership to change the MCP-selected PCP effective on the date of contact with the MCP; and

(d) Explain that PCP change requests after the initial month of MCP membership shall be processed according to the procedures outlined in the MCP member handbook.

(B) MCP member materials.

(1) The MCP must develop and disseminate member materials, including, at a minimum, member materials specified in paragraph (B)(3) of this rule. All MCP member materials, including, but not limited to, those used for member education, member appreciation and member incentive programs, and changes thereto must be prior-approved in writing by ODJFS.

(2) Member materials must be:

(a) Provided in a manner and format that may be easily understood.

(b) Printed in the prevalent non-English languages of members in the MCP’s service area.

(c) Available in alternative formats in an appropriate manner that takes into consideration the special needs of members including but not limited to visually-limited and LRP members.

(d) Consistent with the practice guidelines specified in paragraph (B) of rule 5101:3-25-05.1 of the Administrative Code.

(3) At a minimum, MCPs must provide the following materials to each member or family group, as applicable: MCPs must provide the materials specified in paragraphs (B)(3)(a) and (B)(3)(c) of this rule by no later than the effective date of coverage and the materials specified in paragraphs (B)(3)(b) and (B)(3)(d) of this rule prior to the effective date of coverage.

(a) The MCP’s member handbook as specified in paragraph (B)(4) of this rule.

(b) An MCP identification card bearing unique features, clearly listing:

(i) The MCP’s name as stated in its article of incorporation and any other trade or DBA name used;

(ii) The name(s) of the member(s) enrolled in the MCP and their ODJFS-assigned identification number(s);

(iii) The MCP’s emergency procedures, which must be consistent with those approved in the member handbook, including the toll-free call-in system phone numbers as specified in rule 5101:3-25-03.1 of the Administrative Code;

(iv) The MCP’s toll-free member services number(s) as specified in paragraph (A)(1) of this rule;

(v) The name(s) and telephone number(s) of the PCP assigned to the member(s);

(vi) Information on how to obtain the current eligibility status for the member(s);

(vii) The name of the children’s buy-in program; and

(viii) Applicable co-payment amounts as specified in rule 5101:3-25-12 of the Administrative Code.

(c) Information concerning a member’s right to formulate, at the member’s option, advance directives including a description of applicable state law.

(d) A letter informing members, at a minimum, of:

(i) The new member materials issued by the MCP and what action members are to take if they have not yet received those materials;

(ii) How to access MCP-covered transportation services;

(iii) How to change primary care providers;

(iv) The need and time frame for members to contact the MCP if members have a health care condition that the MCP should be aware of in order to most appropriately manage/transition the members’ care; and

(v) The need and how to access information on medications that require prior authorization.

(4) The MCP’s member handbook must be clearly labeled as such and include, at a minimum:

(a) The rights of members that include at a minimum, all rights found in rule 5101:3-25-08.3 of the Administrative Code and any member responsibilities specified by the MCP. With the exception of any prior-authorization requirements the MCP stipulates in the member handbook, the MCP cannot establish any member responsibility that would preclude the MCP’s coverage of a covered service.

(b) Information regarding services that are excluded from MCP coverage and the services and benefits that are available at or through the MCP, and how to obtain them, including at a minimum:

(i) All services and benefits requiring prior-authorization or referral by the MCP or the member’s PCP;

(ii) Self-referral services for women’s routine and preventative health care services provided by a women’s health specialist as specified in rule 5101:3-25-03 of the Administrative Code.

(iii) If applicable, any pharmacy utilization management strategies prior-approved by ODJFS.

(c) Information that emergency services are available to the member, the procedures for accessing emergency services, and directives as to the appropriate utilization, including at a minimum:

(i) Explanation of emergency medical condition, emergency services, and post-stabilization services as defined in rule 5101:3-25-01 of the Administrative Code;

(ii) Prior authorization is not required for emergency services;

(iii) The availability of the 911-telephone system or its local equivalent;

(iv) Members have a right to use any hospital or other appropriate setting for emergency services; and

(v) The post-stabilization care services requirements specified in rule 5101:3-25-03 of the Administrative Code.

(d) The procedure for members to express their recommendations for change to the MCP’s staff.

(e) Information regarding consumers eligible for MCP membership.

(f) A statement that CBI-covered health care services must be obtained in or through the MCP facilities and/or providers except emergency care, and any other services or provider types designated by ODJFS.

(g) Information on the member’s responsibility to select a PCP from the MCP provider directory, how to change PCPs, including the ability to change PCPs no less often than monthly, the MCP’s procedures for processing PCP change requests after the initial month of MCP membership and how the MCP will provide written confirmation to the member of any new PCP selection prior to or on the effective date of the change.

(h) Information on the additional services available to all members including at a minimum case management services as specified in paragraph (A)(7) of rule 5101:3-25-03.1 of the Administrative Code and the member services toll-free call-in system.

(i) A description of the MCP’s policies regarding access to providers outside the service area for non-emergency services and if applicable access to providers within and/or outside the service area for non-emergency after-hours services.

(j) The procedure for members to file a grievance, appeal, or reconsideration as specified in rules 5101:3-25-08.4 and 5101:3-25-08.5 of the Administrative Code.

(k) The issuance date of the member handbook.

(l) A statement that the MCP may not discriminate on the basis of race, color, religion, gender, sexual orientation, age, disability, national origin, veteran’s status, ancestry, health status, or need for health services in the receipt of health services.

(m) An explanation of subrogation and coordination of benefits.

(n) A clear identification of corporate or parent identity when a trade name or doing business as (DBA) is used.

(o) Information on how to access available community resources for behavioral health services.

(p) Information on the MCP’s policies respecting the implementation of the member’s rights regarding advance directives, including a statement of any limitation regarding the implementation of advance directives as a matter of conscience.

(q) Information stating that the MCP provides covered services to members through a grant agreement with ODJFS, and how members can contact ODJFS by standard mail, by electronic mail, or by telephone, if they so desire.

(r) The toll-free call-in system phone numbers specified in paragraph (A)(1) of this rule and rule 5101:3-25-03.1 of the Administrative Code.

(s) A statement that additional information is available from the MCP upon request.

(t) Information on how the member can request or access additional MCP information or services including, at a minimum:

(i) Oral interpretation and oral translation services;

(ii) Written information in the prevalent non-English languages of members in the MCP’s service area; and

(iii) Written information in alternative formats.

(u) Detailed information on member cost-sharing obligations in accordance with rule 5101:3-25-12 of the Ad