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Ohio Laws and Rules
(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