5101:3-25-03 Children's buy-in program: covered services.

(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.

(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.

(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;

(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;

(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