Chapter 5101:3-26 Managed Care Plan

As used in Chapter 5101:3-26 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 medicaid 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 medicaid 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 when an adult is incapacitated.

(C) “Assignment” means the process as described in rule 5101:3-26-02 of the Administrative Code by which the MCEC, ODJFS, or other ODJFS-approved entity selects an MCP for eligible individuals in service areas where MCP selection is required.

(D) “Assistance group” means a group of consumers receiving benefits together under a specific category of assistance.

(E) “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 the MCEC or ODJFS.

(F) “Automatic termination” means the process as described in rule 5101:3-26-02.1 of the Administrative Code by which a member’s managed care membership is terminated not at the request of the member or the MCP, but for reasons described in that rule.

(G) “CAP” means corrective action plan.

(H) “Care treatment plan” is the treatment plan developed by the managed care plan for the member.

(I) “Case” means one or more assistance groups living in the same household.

(J) “Case management” means activities performed on behalf of members which include services described in paragraph (A)(8) of rule 5101:3-26-03.1 of the Administrative Code.

(K) “CCR” means the consumer contact record. The CCR contains demographic health-related information provided by an eligible individual, managed care member, or ODJFS that is utilized by the MCEC to process membership transactions.

(L) “CDJFS” means a county department of job and family services.

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

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

(O) “CMS” means the centers for medicare and medicaid services.

(P) “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 as outlined in rule 5101:3-1-03 of the Administrative Code. For medicaid-covered services rendered by Title V programs, the MCP shall be the primary payer.

(Q) “Covered services” means those medical services set forth in rule 5101:3-26-03 of the Administrative Code or a subset of those medical services.

(R) “DBA” means doing business as, in accordance with ODI’s designation.

(S) “DEA” means drug enforcement administration.

(T) “Eligible individual” means any medicaid consumer who is a legal resident of the managed care service area and is in one of the categories specified in the MCP’s provider agreement with ODJFS.

(U) “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.

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

(W) “EQRO” means external quality review organization.

(X) “Family planning services” means those services and supplies provided in accordance with rule 5101:3-4-07 of the Administrative Code.

(Y) “FQHC ” means a federally qualified health center as defined in rule 5101:3-28-01 of the Administrative Code.

(Z) “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 himself, 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.

(AA) “Healthchek,” otherwise known as the early and periodic screening, diagnosis, and treatment (EPSDT) program, is a program of comprehensive preventive health services available to medicaid consumers from birth through twenty years of age. The program is designed to maintain health by providing early intervention to discover and treat health problems.

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

(CC) “Hospital” means an institution located at a single site which is engaged primarily in providing 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 which is operated by the United States government or the Ohio department of mental health.

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

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

(FF) “Intermediate care facility for the mentally retarded (ICF-MR)” means a long-term care facility, or part of a facility, for the mentally retarded/developmentally disabled, currently certified by the Ohio department of health as being in compliance with the ICF-MR standards and medicaid conditions of participation.

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

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

(II) “Managed care enrollment center (MCEC)” means an organization or individual under contract with or designated by ODJFS to provide managed care information and selection services to eligible individuals.

(JJ) “MCP (managed care plan),” otherwise known as plan, means a HIC licensed in the state of Ohio that enters into a provider agreement with ODJFS in the managed health care program pursuant to rule 5101:3-26-04 of the Administrative Code. For the purpose of this chapter, MCP does not include entities approved to operate as a PACE site, as defined in paragraph (BBB) of this rule.

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

(LL) “Medically necessary,” otherwise known as medical necessity, as used in this chapter is the same as defined in paragraph (A) of rule 5101:3-1-01 of the Administrative Code.

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

(NN) “Member,” otherwise known as enrollee, means a medicaid consumer who has selected MCP membership or has been assigned to an MCP for the purpose of receiving health care services.

(OO) “MFCU (medicaid fraud control unit)” means a state or federal governmental agency charged with the investigation and prosecution of fraud and related offenses within medicaid.

(PP) “MR/DD” means mental retardation or developmental disabilities.

(QQ) “Nursing facility (NF)” means any long-term care facility (excluding intermediate care facilities for the mentally retarded/developmentally disabled), or part of a facility, currently certified by the Ohio department of health as being in compliance with the nursing facility standards and medicaid conditions of participation.

(RR) “ODA” means the Ohio department of aging.

(SS) “ODADAS” means the Ohio department of alcohol and drug addiction services.

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

(UU) “ODJFS” means the Ohio department of job and family services.

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

(WW) “ODJFS-approved entity” means any entity other than the CDJFS which is under contract with or designated by ODJFS to perform the functions set forth in rules 5101:3-26-02 and 5101:3-26-02.1 of the Administrative Code.

(XX) “ODMH” means the Ohio department of mental health.

(YY) “ODMR/DD” means the Ohio department of mental retardation and developmental disabilities.

(ZZ) “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.

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

(BBB) “PACE” means the program of all inclusive care for the elderly. The PACE program integrates the provision of acute and long-term care across settings for frail older adults who have been determined to require at least an intermediate level of care as defined in rule 5101:3-3-06 of the Administrative Code.

(CCC) “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 5101:3-26-03.1 of the Administrative Code. Acceptable specialty types include family/general practice, internal medicine, pediatrics, and obstetrics/gynecology (OB/GYNs).

(DDD) “Pending member,” otherwise known as pending enrollee, means an eligible individual who has selected or been assigned to an MCP but whose MCP membership is not yet effective.

(EEE) “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 to improve or resolve the member’s condition.

(FFF) “Premium” means the monthly payment amount per member to which the MCP is entitled as compensation for performing its obligations in accordance with Chapter 5101:3-26 of the Administrative Code and/or the provider agreement with ODJFS.

(GGG) “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, and any amendments thereto.

(HHH) “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.

(III) “Provider agreement” means a formal agreement between ODJFS and an MCP for the provision of medically necessary services to medicaid consumers who are enrolled in the MCP.

(JJJ) “Provider panel,” otherwise known as “panel”, means an MCP’s providers as specified in paragraph (A)(3) of rule 5101:3-26-05 of the Administrative Code.

(KKK) “QAPI” means a quality assessment and performance improvement program as described in rule 5101:3-26-07.1 of the Administrative Code.

(LLL) “Qualified family planning provider (QFPP)” means any public or nonprofit health care provider that complies with federal Title X guidelines/standards, and receives either Title X funding or family planning funding from the Ohio department of health.

(MMM) “Quality indicators” means measurable variables relating to a specified clinical or health services delivery area which are reviewed over a period of time to monitor the process or outcome of care delivered in that area.

(NNN) “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 provider agreement.

(OOO) “RHC” means a rural health clinic as defined in rule 5101:3-16-01 of the Administrative Code.

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

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

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

(SSS) “State cut-off” means the eighth state working day prior to the end of a calendar month.

(TTT) “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 provider agreement with ODJFS.

(UUU) “Termination” means the process by which an individual’s managed care membership is terminated. Terminations may be automatic, member-initiated, or plan-initiated as described in rule 5101:3-26-02.1 of the Administrative Code.

(VVV) “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 provider agreement with ODJFS.

(WWW) “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 a state plan.

(XXX) “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.

(YYY) “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.

Effective: 01/01/2008

R.C. 119.032 review dates: 07/01/2009

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.16, 5111.17

Rule Amplifies: 5111.01, 5111.02, 5111.16, 5111.17

Prior Effective Dates: 4/1/85, 2/1/89 (Emer), 2/15/89 (Emer), 4/23/89, 5/15/89 (Emer), 5/1/92, 7/31/92 (Emer), 10/25/92, 5/1/93, 11/1/94, 7/1/96, 7/1/97 (Emer), 9/27/97, 5/14/99, 7/1/00, 7/1/01, 7/1/02, 7/1/03, 7/1/04, 10/31/05, 6/1/06, 1/1/07, 7/1/07

(A) For the purpose of this rule, authorized representative means an individual eighteen years of age or older who stands in the place of the consumer. The authorized representative may act on behalf of individuals inside or outside of the household in which the authorized representative lives. For the purposes of rules 5101:3-26-02 and 5101:3-26-02.1 of the Administrative Code, the authorized representative may be the primary information person of the household, another member of the same assistance group, a custodial parent, or a person designated by custodial parent.

(B) Eligibility.

(1) For the purpose of this rule, an eligible individual is a medicaid consumer who is either subject to mandatory MCP membership, or has the option to select MCP membership. The eligible categories of assistance for MCP membership are as follows:

(a) Covered families and children (CFC) category of assistance as described in rule 5101:1-40-01 of the Administrative Code, with the exception of individuals in the groups specified in paragraphs (B)(2) to (B)(4) of this rule.

(b) Aged, blind, and disabled (ABD) category of assistance as described in division (A)(2) of section 5111.01 of the Revised Code, with the exception of individuals specified in paragraphs (B)(2), (B)(4) and (B)(5) of this rule.

(2) Individuals who are dually eligible under both the medicaid and medicare programs are excluded from medicaid MCP membership.

(3) The following individuals are not required to enroll in an MCP:

(a) Children under nineteen years of age and eligible for supplemental security income (SSI);

(b) Children under nineteen years of age and receiving Title IV-E federal foster care maintenance through an agreement between the local children services board and the foster care provider;

(c) Children under nineteen years of age and receiving Title IV-E adoption assistance through an agreement between the local children services board and the adoptive parent;

(d) Children under nineteen years of age and in foster care or other out-of-home placement;

(e) Children under nineteen years of age and receiving services through the Ohio department of health’s bureau for children with medical handicaps (BCMH) or any other family-centered, community-based, coordinated care system that receives grant funds under Section 501(a)(1)(D) of Title V of the Social Security Act, and is defined by the state in terms of either program participation or special health care needs; and

(4) Indians who are members of federally recognized tribes are not required to enroll in an MCP, except as permitted under 42 C.F.R. 438.50(d)(2).

(5) Individuals who belong to the ABD category of assistance described in paragraph (B)(1)(b) of this rule are excluded from MCP membership if they are:

(a) Under twenty-one years of age;

(b) Institutionalized;

(c) Eligible for medicaid by spending down their income or resources to a level that meets the medicaid program’s financial eligibility requirements; or

(d) Individuals receiving medicaid services through a medicaid waiver component, as defined in section 5111.85 of the Revised Code.

(6) Individuals are eligible for MCP membership in the manner prescribed in this rule if ODJFS has a provider agreement with an MCP in the eligible individual’s service area.

(7) Nothing in this rule shall be construed to limit or in any way jeopardize an eligible individual’s basic medicaid eligibility or eligibility for other non-medicaid benefits to which he or she may be entitled.

(C) Selection of MCP membership.

(1) A managed care enrollment center (MCEC) shall assist the eligible individual or authorized representative of any eligible assistance group requesting help in selecting an MCP or other healthcare option.

(2) The ODJFS, MCEC or other ODJFS-approved entity must accept and process initial MCP membership selection transactions on behalf of eligible individuals in accordance with paragraph (C)(3) of this rule:

(3) The following applies to membership selection:

(a) MCP membership must occur without regard to an eligible individual’s race, color, religion, gender, sexual orientation, age, disability, national origin, veteran’s status, ancestry, health status or need for health services. The MCP will not use any discriminatory policy or practice in accordance with 42 C.F.R. 438.6(d)(4).

(b) MCP membership for the CFC category of assistance as described in paragraph (B)(1)(a) of this rule must occur at the assistance group level. Except for individuals described in paragraphs (B)(3) and (B)(4) of this rule, all eligible individuals in the CFC assistance group must be enrolled in the same MCP.

(c) Eligible individuals or the authorized representative requesting MCP membership may change their choice up to the ninth working day from the end of the month in which the choice is made. Eligible individuals or the authorized representative must be informed of this provision when requesting MCP membership.

(d) Except as specified in paragraph (C)(3)(g) of this rule, newborn children whose mothers are MCP members at the time of birth are deemed eligible for medicaid and treated as an MCP member effective on the date of birth:

(i) The MCP must utilize the CDJFS-designated written format to inform the CDJFS of a birth to a member.

(ii) Within five working days of a birth, or immediately upon learning of the birth, the MCP must provide written notification to the appropriate CDJFS, forward a copy of such notice to the ODJFS, and notify the mother in writing of the need to apply to the CDJFS as soon as possible to have the newborn added to the assistance group to ensure ongoing MCP membership.

(iii) If the MCP has not received confirmation by ODJFS of a newborn’s MCP membership within ninety days of the date of birth, the MCP must send an additional written notification to the CDJFS, ODJFS, and the mother. If at the end of one hundred twenty days from the date of birth no confirmation has been received, the MCP must again send written notification to the CDJFS, ODJFS, and the mother.

(iv) Notwithstanding the addition of the newborn to the assistance group by the CDJFS, the MCP must provide covered services to the newborn through the last day of the month in which the newborn reaches one hundred twenty days of age unless the provisions of paragraph (C) or (D) of rule 5101:3-26-02.1 of the Administrative Code apply.

(e) In the case of newborns added by the CDJFS to the assistance group of a mother who is an MCP member ODJFS will provide retrospective premium back to the first day of the month of the child’s birth provided that:

(i) The MCP has notified the CDJFS, ODJFS and the mother as described in paragraphs (C)(3)(d)(i) to (C)(3)(d)(iii) of this rule; and

(ii) ODJFS has not paid claims under fee-for-service for the newborn. In the event that fee-for-service claims have been paid, the newborn will be covered under medicaid fee-for-service for the month(s) in question.

(f) In the case of newborns as described in paragraph (C)(3)(d)(iv) of this rule, ODJFS will provide premium payments to the MCP up to the end of the month in which the newborn reaches one hundred twenty days of age.

(g) Newborns whose mothers are MCP members due to their eligibility in the aged, blind, and disabled category of assistance as described in paragraph (B)(1)(b) of this rule, are not eligible for MCP membership from their date of birth.

(h) Newborns or other eligible individuals who are automatically added to the assistance group after the assistance group’s initial MCP membership effective date will be enrolled in the same MCP as the rest of the assistance group.

(i) The MCP must accept eligible individuals who request MCP membership, and honor without restriction, the PCP selected when available, except as otherwise provided in this rule.

(j) In the event that an MCP member loses medicaid eligibility and is automatically terminated from the MCP but within a period of sixty days or less regains medicaid eligibility, membership in the same MCP shall automatically be renewed.

(k) The MCEC will document via the CCR all information provided by the eligible individual or the authorized representative of each eligible assistance group requesting MCP membership. The MCEC shall document via the CCR that verbal authorization of MCP membership was given and the date of the authorization.

(l) MCP membership requests and assignments as described in paragraph (C)(5)(c) of this rule, and received by the MCEC will be processed utilizing only information contained on the CCR. Following processing by the MCEC a copy of the CCR will be forwarded to the MCP.

(m) ODJFS will confirm the eligible individual’s MCP membership to the MCP via an ODJFS-produced roster of new members, continuing members, and terminating members on or before the fifth day prior to the end of the calendar month preceding commencement of coverage.

(n) The MCP will not be required to provide coverage until MCP membership is confirmed via an ODJFS-produced roster except as provided in paragraph (C)(3)(d) of this rule or upon mutual agreement between ODJFS and the MCP.

(4) ODJFS may designate that MCP membership is voluntary in any service area.

(5) In addition to the provisions of paragraphs (C)(1) to (C)(3) of this rule, the following applies to membership in service areas designated as mandatory by ODJFS.

(a) Except as specified in paragraphs (B)(2) to (B)(5) of this rule, MCP membership is required for eligible individuals who are residents of service areas designated as mandatory by ODJFS.

(b) When a service area is initially designated by ODJFS as mandatory for one of the categories of assistance specified in paragraph (B)(1) of this rule, the eligibility of each eligible individual in the designated category of assistance is confirmed by ODJFS as prescribed in paragraph (C)(3)(m) of this rule. Upon the confirmation of eligibility:

(i) Eligible individuals residing in the service area who are currently MCP members are deemed participants in the mandatory program.

(ii) All other eligible individuals residing in the mandatory service area may request MCP membership at any time but must select an MCP following receipt of a notification of mandatory selection (NMS) issued by ODJFS.

(c) MCP membership selection procedures for the mandatory program:

(i) An eligible assistance group which does not make a choice following issuance of an NMS by ODJFS and one additional notice will be assigned to an MCP by ODJFS, the MCEC, or other ODJFS-approved entity.

(ii) ODJFS or the MCEC will assign the assistance group to an MCP based on prior medicaid fee-for-service and/or MCP membership history, whenever available, or at the discretion of ODJFS.

(iii) In the event that an eligible assistance group does not identify to the MCEC those individuals who are not required to enroll in an MCP because they meet the criteria as specified in (B)(3) of this rule, such individuals shall be enrolled in the same MCP as the rest of the assistance group until such time as the assistance group notifies the MCEC.

(D) Commencement of coverage.

(1) Coverage of MCP members will be effective at the beginning of the first day of the calendar month following the confirmation of the eligible individual’s effective date of MCP membership via an ODJFS-produced roster to the MCP, except as identified in paragraph (C)(3)(d) of this rule.

(2) In no event shall an MCP notify a pending member about coverage until MCP membership is confirmed by ODJFS as specified in paragraph (C)(3)(m) of this rule.

(3) An MCP may request deferment of coverage for a new member admitted to an inpatient facility prior to the effective date of managed care coverage who remains an inpatient on the effective date of coverage in accordance with the following:

(a) The new member must be enrolling in the MCP from medicaid fee-for-service. In the event the member is transferring membership from one MCP to another, the provisions of paragraph (D)(4) of this rule apply.

(b) The MCP must submit deferment requests to ODJFS in writing with required documentation, as specified in paragraph (D)(3)(d) of this rule, no later than six months from the assistance group member’s original effective date with the MCP or the last automatic MCP renewal date, if applicable.

(c) MCPs coverage and responsibility for payment of medicaid-covered services to a new MCP member may be deferred following MCP notification of the new member’s inpatient admission to ODJFS as specified in paragraph (D)(3)(b) of this rule and subject to approval by ODJFS.

(d) Documentation includes but is not limited to a copy of the inpatient admission form or other proof of inpatient admission and discharge, as approved by ODJFS, along with the MCP’s written request for deferral of the new member’s effective date of MCP membership.

(e) In the event that a previous MCP member subject to automatic renewal of MCP membership as specified in paragraph (C)(3)(j) of this rule is admitted to an inpatient facility after their MCP membership is terminated, and remains an inpatient on the effective date of automatic renewal of MCP membership, the provisions of paragraphs (D)(3)(a) to (D)(3)(c) and paragraphs (D)(3)(f) to (D)(3)(i) of this rule apply.

(f) In the event a new assistance group member, other than a newborn, is admitted to an inpatient facility prior to, and remains an inpatient on, the effective date of MCP membership, the provisions of paragraphs (D)(3)(a) to (D)(3)(c) and paragraphs (D)(3)(f) to (D)(3)(i) of this rule apply.

(g) The MCP is responsible for the provision of all medicaid-covered services for all other MCP members of the same assistance group as specified in paragraph (D)(1) of this rule.

(h) The MCP’s liability for all medicaid- covered services for the deferred MCP member begins the first day of the month following the deferred MCP member’s date of discharge from the hospital.

(i) Premium payments for the MCP will be adjusted to reconcile the period of MCP membership deferral.

(4) In the event an MCP member who requests to change from his or her current MCP to another MCP is admitted to an inpatient facility prior to the effective date of the MCP change and remains an inpatient on the effective date of the new MCP membership, the following coverage responsibilities shall apply:

(a) The disenrolling MCP shall remain responsible for providing all medically necessary Medicaid covered services through the last day of the month in which the membership is terminated, and shall remain responsible for all inpatient facility charges though the date of discharge.

(b) The disenrolling MCP shall receive capitation through the end of the month in which membership is terminated regardless of the length of the inpatient stay.

(c) The disenrolling MCP shall notify the enrolling MCP of the inpatient status of the member following verification of the change by the MCEC via the consumer contact record and the disenrollment by ODJFS via the monthly member roster.

(d) The disenrolling MCP shall notify the inpatient facility of the change in MCP enrollment including the name of the enrolling MCP following verification of the disenrollment by ODJFS via the monthly membership roster, but advise the inpatient facility that the disenrolling MCP shall remain responsible for the inpatient facility charges through the date of discharge.

(e) The enrolling MCP shall assume responsibility for all medically necessary Medicaid covered services including professional and ancillary services related to the inpatient stay beginning with the effective date of membership in the MCP, except for the inpatient facility charges.

(f) The enrolling MCP shall receive capitation beginning with the effective date of MCP membership.

(g) Upon notification of the inpatient status of the new member as specified in paragraph (D)(4)(d) of this rule, the enrolling MCP shall contact the inpatient facility to verify responsibility for all services following discharge for the member, and to assure that discharge plans are arranged through the MCP’s panel. The enrolling MCP shall also verify the MCP’s responsibility for all professional charges related to the inpatient stay beginning with the effective date of MCP membership.

(h) If the enrolling MCP fails to contact the inpatient facility prior to discharge, the enrolling MCP must honor discharge arrangements until such time that the MCP can transition the member to the MCP’s participating providers.

Effective: 01/01/2008

R.C. 119.032 review dates: 07/01/2009

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.16, 5111.17

Rule Amplifies: 5111.01, 5111.02, 5111.16, 5111.17

Prior Effective Dates: 4/1/85, 2/15/89 (Emer), 5/18/89, 5/1/92, 5/1/93, 11/1/94, 7/1/96, 7/1/97 (Emer), 9/27/97, 12/10/99, 7/1/00, 7/1/01, 7/1/02, 7/1/03, 7/1/04, 10/31/05, 6/1/06, 1/1/07, 7/1/07

(A) For the purpose of this rule, authorized representative means an individual eighteen years of age or older who stands in the place of the consumer. The authorized representative may act on behalf of individuals inside or outside of the household in which the authorized representative lives. For the purposes of rules 5101:3-26-02 and 5101:3-26-02.1 of the Administrative Code, the authorized representative may be the primary information person of the household, another member of the same assistance group, a custodial parent, or a person designated by a custodial parent.

(B) Termination of MCP membership occurs through one of the following:

(1) Automatic termination occurs due to a change in MCP member medicaid eligibility, residence, or other circumstance, as set forth in paragraph (C) of this rule.

(2) Member-initiated termination occurs as set forth in paragraph (D) of this rule.

(3) MCP-initiated termination occurs as set forth in paragraph (E) of this rule.

(C) The following applies to all automatic terminations of MCP membership in voluntary and mandatory service areas:

(1) Automatic termination occurs at the individual level.

(2) Automatic termination occurs for one of the following reasons:

(a) The member becomes ineligible for medicaid; or

(b) The member’s permanent place of residence is moved outside the MCP membership service area; or

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

(d) An MCP member is placed in a residential facility for the treatment of behavioral or developmental health issues and ODJFS determines following investigation, that ongoing receipt of health care through the MCP may not be in the best interest of the member or meet the rules of MCP enrollment. Upon ODJFS approval, termination is effective the last day of the month preceding placement; or

(e) A member is incarcerated for either more than fifteen working days or is incarcerated and has accessed non-emergent medical care. When this occurs and following MCP, CDJFS, or other public agency notification to ODJFS, termination is effective the last day of the month prior to incarceration; or

(f) A 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 the ICF-MR facility; or

(g) A member is placed in a NF and remains in the NF past the last day of the calendar month following the month of NF admission. When this occurs and following MCP notification to ODJFS using required documentation, membership termination is effective the last day of the second calendar month the member resides in the NF. Required documentation includes but is not limited to a copy of the approved level of care (LOC) obtained pursuant to Chapter 5101:3 of the Administrative Code and a copy of the NF admission form or other proof of NF admission; or

(h) A member is enrolled in a home and community-based waiver program administered by ODJFS, ODA, or ODMR-DD. When this occurs, termination is effective no later than the last day of the month preceding enrollment in the home and community-based waiver program; or

(i) A minor MCP member’s custody has been legally transferred from the legal parent or guardian to another entity. When this occurs, following appropriate notification to ODJFS, membership termination is effective the last day of the month preceding the transfer; or

(j) A member becomes ineligible in an MCP medicaid-eligible category; or

(k) A member’s eligibility changes from either the ABD category of assistance as described in paragraph (B)(1)(b) of rule 5101:3-26-02 of the Administrative Code to the CFC category of assistance as described in paragraph (B)(1)(a) of rule 5101:3-26-02 of the Administrative Code or from the CFC category of assistance as described in paragraph (B)(1)(a) of rule 5101:3-26-02 of the Administrative Code to the ABD category of assistance as described in paragraph (B)(1)(b) of rule 5101:3-26-02 of the Administrative Code; or

(l) A member has third party coverage and ODJFS determines, following MCP, member, or other public agency notification to ODJFS and based on the type of coverage and the existence of conflicts between provider panels and access requirements, that continuing MCP membership may not be in the best interest of the member. When this occurs the effective date of termination shall be determined by ODJFS but in no event shall the termination date be later than the last day of the month in which ODJFS approves the termination; or

(m) The provider agreement between ODJFS and the MCP is terminated or ODJFS takes action as specified in paragraphs (G) and (H) of rule 5101:3-26-10 of the Administrative Code.

(3) Automatic terminations of MCP membership do not require completion of a CCR.

(4) Except as specified in paragraphs (C)(2)(c) to (C)(2)(i) of this rule, automatic membership termination will be effective at the end of the last day of the month in which the change in eligibility, residence, or other circumstance occurred.

(5) If ODJFS fails to notify the MCP of a member’s termination from an MCP, ODJFS will continue to pay the MCP the monthly premium rate with respect to such member, subject to the provisions of rule 5101:3-26-09 of the Administrative Code. The MCP will remain liable for the provision of covered services as set forth in rule 5101:3-26-03 of the Administrative Code, until such time as ODJFS provides the MCP with documentation of the member’s termination.

(6) ODJFS will recover from the MCP any premium paid for retroactive membership termination occurring as a result of paragraphs (C)(2)(c) to (C)(2)(i) of this rule.

(7) In the event that an MCP member loses medicaid eligibility during an annual open enrollment period resulting in the temporary inability to change managed care plans, the member may request to change managed care plans within thirty days following automatic renewal of MCP membership.

(D) The following applies to MCP member-initiated change requests or terminations:

(1) MCP member-initiated change requests or terminations must occur at the assistance group level except as provided in paragraph (B)(1)(b) of rule 5101:3-26-02 of the Administrative Code and paragraphs (D)(2)(d) and (D)(9)(e) of this rule. All individuals within an assistance group must be terminated at the same time.

(2) MCP member-initiated change requests in mandatory service areas or MCP member-initiated terminations in voluntary service areas may occur:

(a) During the initial three months of MCP membership; or

(b) During an open enrollment month for the member’s service area as described in paragraph (D)(8) of this rule; or

(c) If the just cause request meets one of the reasons for just cause as specified in paragraph (D)(9)(a) of this rule; or

(d) Upon notification to the MCEC if the member meets the criteria as specified in paragraphs (B)(3) and (B)(4) of rule 5101:3-26-02 of the Administrative Code, MCP membership is terminated in mandatory and voluntary counties.

(3) When requesting MCP member-initiated change requests in mandatory service areas, members must select membership in another participating MCP except as specified in paragraph (D)(2)(d) of this rule.

(4) When requesting MCP member-initiated terminations in voluntary service areas, members will be returned to medicaid fee-for-service or may select membership in another participating MCP, if available.

(5) The MCEC will document via the CCR all information provided by the member or authorized representative of each eligible assistance group requesting termination. The MCEC shall document via the CCR that verbal authorization was given and the date of the authorization.

(6) MCP member-initiated terminations in voluntary service areas, and MCP member-initiated change requests in mandatory service areas, will be effective the last day of the calendar month or the succeeding calendar month, subject to state cut-off.

(7) MCPs must:

(a) Provide information on MCP membership change or termination options, including reasons for just cause requests as described in paragraph (D)(9)(a) of this rule, to eligible individuals and members as required in rules 5101:3-26-08 and 5101:3-26-08.2 of the Administrative Code.

(b) Continue to recognize the MCP identification card and not request its return from the member until the MCP receives documentation from ODJFS that the change or termination is effective. ODJFS will continue to pay the MCP the monthly premium until the change or termination is effective.

(8) Open enrollment months will be designated for each voluntary and mandatory service area by ODJFS or its designee at least annually. ODJFS will notify each assistance group by mail at least sixty days prior to the designated open enrollment month of the opportunity to change or terminate MCP membership and where to obtain further information. During open enrollment months, consumers not in their initial three months of membership as described in paragraph (D)(2)(a) of this rule or meeting the criteria described in paragraphs (D)(2)(c) and (D)(2)(d) of this rule will be limited to only a one month time period to change MCPs.

(9) MCP members or authorized representatives may request to change or terminate MCP membership for just cause when the members’ or authorized representatives’ contacts to the MCPs are unsuccessful in identifying providers of services that would alleviate the members’ need to make a just cause request.

(a) Changing MCPs in mandatory service areas or terminating managed care membership in voluntary service areas for just cause includes the following:

(i) The member moves out of the MCP’s service area and a non-emergency service must be provided out of the service area before the effective date of the member’s automatic termination as described in paragraph (C)(2)(b) of this rule;

(ii) The MCP does not, for moral or religious objections, cover the service the member seeks;

(iii) The member needs related services to be performed at the same time; not all related services are available within the MCP network, and the member’s PCP or another provider determines that receiving services separately would subject the member to unnecessary risk;

(iv) Poor quality of care and the services are not available from another provider within the MCP’s network;

(v) Lack of access to medically necessary medicaid-covered services or lack of access to the type of providers experienced in dealing with the member’s health care needs;

(vi) The PCP selected by a member leaves the MCP’s panel and was the only available and accessible PCP speaking the primary language of the member, and another PCP speaking the language is available and accessible in another MCP in the member’s service area; and

(vii) A situation in which, as determined by ODJFS, continued membership in the MCP would be harmful to the interests of the member.

(b) Requests for just cause must be made directly to ODJFS or other ODJFS-approved entity verbally or in writing.

(c) All requests for just cause will be reviewed by ODJFS within seven working days of receipt. ODJFS may request documentation as necessary from both the member and the MCP. A decision will be made within ten working days of receipt of all necessary documentation. ODJFS may establish retroactive termination dates and/or recover premium payments as determined necessary and appropriate. Regardless of the procedures followed, the effective date of an approved just cause request must be no later than the first day of the second month following the month in which the member requests change or termination. If ODJFS fails to make the determination within this timeframe, the just cause request is considered approved.

(d) If the just cause request is not approved, ODJFS shall notify the member or the authorized representative of their right to a state hearing.

(e) Requests for just cause may be processed at the individual level or the assistance group level as ODJFS determines necessary and appropriate.

(f) In the case of members who lose medicaid eligibility prior to ODJFS action to change or terminate membership for just cause, ODJFS shall assure that the member’s MCP membership is not automatically renewed if eligibility for medicaid is reauthorized.

(10) All MCP member-initiated changes or terminations must be voluntary. No member may be encouraged by an MCP to change or terminate due to an adverse 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. No policy or practice that has the effect of discrimination on the basis of race, color, or national origin shall be used.

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

(1) In the following instances, the MCP may submit a request to ODJFS for the termination of a member:

(a) Fraudulent behavior by the member; or

(b) Uncooperative or disruptive behavior by the member or someone acting on their behalf to the extent that such behavior seriously impairs the MCP’s ability to provide services to either the member or other MCP members.

(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) There are no state hearing rights for a member(s) terminated from an MCP pursuant to paragraph (E)(1) of this rule.

(5) The MCP must provide medicaid-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.

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

(a) Termination must occur at the assistance group level with all members returning to the fee-for-service medicaid program, if eligible.

(b) If ODJFS approves the MCP’s request for termination, ODJFS will:

(i) Notify the member(s) or authorized representative, in writing, of the impending MCP-initiated termination of all members within the assistance group; and

(ii) Notify in writing the member(s) or authorized representative, the MCP, or other ODJFS-approved entity and the MCEC, when applicable, of the decision to terminate all members within the assistance group, and initiate the process for returning the individuals to the fee-for-service medicaid program.

(F) The following applies to the coverage of services for any member who is an inpatient on the date an MCP membership termination becomes effective.

(1) MCPs shall remain liable for the provision of covered services for a member who is an inpatient on the date a member-initiated or MCP-initiated termination becomes effective. The MCP shall remain liable for the provision of covered services through the last day of the month in which the member is discharged, unless notified otherwise by ODJFS. The MCP is not responsible for the provision of covered services for other members of the assistance group that were disenrolled from the MCP.

(2) If the termination was automatic as defined in paragraphs (C)(2)(a) to (C)(2)(c) of this rule, the MCP is only responsible for the coverage of services related to the member’s inpatient stay through the date of discharge.

(3) If the termination was automatic as defined in paragraphs (C)(2)(d) to (C)(2)(m) of this rule, the MCP is only responsible for the coverage of services related to the inpatient stay through the date of MCP membership termination.

(4) If the termination is initiated by the member or MCP as defined in this rule, the MCP will receive premium through the last day of the month of discharge if the inpatient stay is documented by the MCP to ODJFS. Such documentation must include a copy of the inpatient facility admission/discharge form or other items as requested by ODJFS.

(5) An MCP must submit a notification of an inpatient admission and corresponding documentation to ODJFS, as specified in paragraph (F)(4) of this rule, no later than six months after the assistance group member’s original MCP membership termination date.

Effective: 01/01/2008

R.C. 119.032 review dates: 07/01/2009

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.16, 5111.17

Rule Amplifies: 5111.01, 5111.02, 5111.16, 5111.17

Prior Effective Dates: 4/1/85, 2/15/89 (Emer), 5/8/89, 5/18/89, 10/9/89, 11/1/89 (Emer), 2/1/90, 2/15/90, 5/1/92, 5/1/93, 11/1/94, 7/1/96, 7/1/97 (Emer), 9/27/97, 12/10/99, 7/1/00, 11/6/00, 7/1/01, 7/1/02, 7/1/03, 7/1/04, 10/31/05, 6/1/06, 7/1/07

(A) Except as provided in this rule, managed care plans (MCPs) must ensure that members have access to all medically-necessary services covered by medicaid. 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 5101:3-26-05.1 of the Administrative Code; and

(4) If a member is unable to obtain medically-necessary services offered by medicaid 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) MCPs must cover annual physical examinations for adults.

(D) At the request of the member, MCPs must provide for a second opinion from a qualified health care professional within the panel. If such a qualified health care professional is not available within the MCP’s panel, the MCP must arrange for the member to obtain a second opinion outside the panel, at no cost to the member.

(E) MCPs must assure that emergency care services as defined in rule 5101:3-26-01 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:

(1) MCPs may not deny payment for treatment obtained when a member had an emergency medical condition, including cases in which the absence of immediate medical attention would not have resulted in the outcomes specified in paragraph (U) of rule 5101:3-26-01 of the Administrative Code.

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

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

(4) MCPs must cover medicaid-covered 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.

(5) 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.

(6) 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, regardless of whether or not that provider has a medicaid provider agreement with ODJFS pursuant to Title XIX of the Social Security Act. An MCP must cover emergency services as defined in paragraph (V) of rule 5101:3-26-01 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 paragraph (U) of rule 5101:3-26-01 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. 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.

(7) 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.

(8) A member who has had an emergency medical condition may not be held liable for payment of any subsequent screening and treatment needed to diagnose the specific condition or stabilize the member.

(F) 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 as described in paragraph (E)(6) of this rule. 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.

(G) MCPs must assure that post-stabilization care services as defined in rule 5101:3-26-01 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. 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.

(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 (G)(3) of this rule is met.

(3) The MCP’s financial responsibility for post stabilization care services it has not 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;

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

(d) The member is discharged.

(H) Exclusions, limitations and clarifications.

(1) When an MCP member is placed in a nursing facility (NF), MCPs are responsible for payment for NF services as described in rule 5101:3-3-02.3 of the Administrative Code, and payment for all covered 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. MCP members remaining in a NF after this period will be disenrolled in accordance with paragraph (C) of rule 5101:3-26-02.1 of the Administrative Code.

(2) MCPs are not responsible for payment of services provided to a member that has been enrolled in a home and community-based waiver program administered by ODJFS, the Ohio department of aging (ODA), or the Ohio department of mental retardation and developmental disabilities (ODMR/DD). MCP members enrolled in a waiver program will be disenrolled in accordance with paragraph (C)(2)(h) of rule 5101:3-26-02.1 of the Administrative Code.

(3) MCPs are not responsible for payment of habilitation services as described in 42 U.S.C. 1396n(c)(5) (2002).

(4) MCP members are permitted to self-refer to all community mental health centers and the Ohio department of alcohol and drug addiction services (ODADAS)-certified medicaid providers. MCPs must ensure access to medicaid-covered behavioral health services for members who are unable to timely access services or unwilling to access services through community providers.

(5) MCP members are permitted to self-refer to family planning services provided by any qualified family planning provider (QFPP). The MCP is responsible for payment of claims for family planning services delivered by QFPPs not contracting with the MCP at the lesser of one hundred per cent of the Ohio medicaid program fee-for-service reimbursement rate or billed charges, in effect for the date of service.

(6) MCPs must permit members to self-refer to any women’s health specialist within the MCP’s panel for covered care necessary to provide women’s routine and preventative health care services. This is in addition to the member’s designated PCP if that PCP is not a women’s health specialist.

(7) MCPs must ensure access to covered services provided by all federally qualified health centers (FQHCs) and rural health clinics (RHCs).

(8) Where available, MCPs must ensure access to covered services provided by a certified nurse practitioner.

(9) ODJFS may approve an MCP’s members to be referred to certain MCP non-contracting hospitals, as specified in rule 5101:3-26-11 of the Administrative Code, for medicaid-covered non-emergency hospital services. When ODJFS permits such authorization, ODJFS will notify the MCP and the MCP non-contracting hospital of the terms and conditions, including the duration, of the approval and the MCP must reimburse the MCP non-contracting hospital at one hundred per cent of the current Ohio medicaid program fee-for-service reimbursement rate in effect for the date of service for all medicaid-covered non-emergency hospital services delivered by the MCP non-contracting hospital. ODJFS will base its determination of when an MCP’s members can be referred to MCP non-contracting hospitals pursuant to the following:

(a) The MCP’s submission of a written request to ODJFS for the approval to refer members to a hospital that has declined to contract with the MCP. The request must document the MCP’s contracting efforts and why the MCP believes it will be necessary for members to be referred to this particular hospital; and

(b) ODJFS consultation with the MCP non-contracting hospital to determine the basis for the hospital’s decision to decline to contract with the MCP, including but not limited to whether the MCP’s contracting efforts were unreasonable and/or that contracting with the MCP would have adversely impacted the hospital’s business.

(10) Paragraph (H)(9) of this rule is not applicable when an MCP and an MCP non-contracting hospital have mutually agreed to that hospital providing non-emergency hospital services to an MCP’s members. MCPs must ensure that such arrangements comply with paragraph (A)(9) of rule 5101:3-26-05 of the Administrative Code.

(11) MCPs must provide all early and periodic screening, diagnosis and treatment (EPSDT) services, also known as healthchek services, in accordance with the periodicity schedule identified in Chapter 5101:3-14 of the Administrative Code, to eligible individuals and assure that services are delivered and monitored as follows:

(a) Healthchek exams must include those components specified in Chapter 5101:3-14 of the Administrative Code. All components of exams must be documented and included in the medical record of each healthchek eligible member and made available for the ODJFS annual external quality review.

(b) The MCP or its contracting provider must notify members of the appropriate healthchek exam intervals as specified in Chapter 5101:3-14 of the Administrative Code.

(c) Healthchek exams are to be completed within ninety days of the initial effective date of membership for those children found to have a possible ongoing condition likely to require case management services.

(I) Out-of-country coverage

MCPs are not required to cover services provided to members outside the United States.

Effective: 01/01/2008

R.C. 119.032 review dates: 10/16/2007 and 01/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.16, 5111.17, 5111.162

Rule Amplifies: 5111.01, 5111.02, 5111.16, 5111.17, 5111.021, 5111.162

Prior Effective Dates: 4/1/85, 5/2/85, 10/1/87, 2/15/89 (Emer), 5/8/89, 11/1/89 (Emer), 5/1/92, 5/1/93, 11/1/94, 7/1/96, 7/1/97 (Emer), 9/27/97, 5/14/99, 12/10/99, 7/1/00, 7/1/01, 7/1/02, 7/1/03, 1/1/06, 6/1/06, 1/1/07, 7/1/07

(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. If such a qualified health care professional is not available within the MCP’s panel, the MCP must arrange for the member to obtain a second opinion outside the panel, at no cost to the member.

(4) Care coordination with ODJFS-designated providers.

(a) MCPs are required to share specific information with ODJFS-designated providers such as ODMH community mental health centers, ODADAS-certified medicaid providers, FQHCs/RHCs, and QFPPs. Such information includes, but is not limited to, the MCP’s contact information, prior authorization procedures and a list of panel laboratories and pharmacies.

(b) Upon request, MCPs must provide information to ODJFS to document the non-contracting providers identified by the MCP under paragraph (A)(4)(a) of this rule and the information the MCP provided to each provider.

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

(6) MCPs must provide a centralized twenty-four-hour toll-free call-in system which is available nationwide.

(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 twenty-four-hour toll-free call-in system for advice or direction concerning emergency and/or after-hours services.

(b) A log for the twenty-four-hour toll-free 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.

(7) 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 utilization management 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 5101:3-26-05.1 of the Administrative Code. MCPs may not impose conditions around the coverage of a medically necessary medicaid-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 5101:6-2-35, 5101:3-26-08.4 and 5101:3-26-08.5 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)(7)(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 5101:3-26-03.1 4 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 timeframe 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)(7)(c)(v) and (A)(7)(c)(vi) of this rule constitute a denial, and the MCPs must give notice to the member as specified in paragraph (B)(2)(d) of rule 5101:3-26-08.4 of the Administrative Code.

(viii) Pursuant to Section 1927(d)(5) of the Social Security Act, prior authorization decisions for covered outpatient drugs as defined in 42 U.S.C. 1396r-8(k)(2) (2002) 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 obtain the information needed to make the prior-authorization decision within seventy-two hours, the decision timeframe has expired and the MCP must give notice to the member as specified in paragraph (B)(2)(d) of rule 5101:3-26-08.4 of the Administrative Code. All other pharmacy prior authorization decisions must be made by no later than the end of the second working day following receipt of the request, or as expeditiously as the member’s condition warrants.

(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.

(8) 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 their 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 care treatment plans; and

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

Effective: 01/01/2008

R.C. 119.032 review dates: 10/16/2007 and 01/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.16, 5111.17

Rule Amplifies: 5111.01, 5111.02, 5111.16, 5111.17

Prior Effective Dates: 4/1/85, 5/2/85, 10/1/87, 2/15/89 (Emer), 5/8/89, 11/1/89 (Emer), 2/1/90, 5/1/92, 5/1/93, 11/1/94, 7/1/96, 7/1/97 (Emer), 9/27/97, 12/10/99, 7/1/00, 7/1/01, 7/1/03, 6/1/06

(A) ODJFS will operate separate procurement processes in accordance with 45 C.F.R. 92.36 for prospective MCPs to enter into provider agreements to serve eligible medicaid individuals. ODJFS may conduct separate procurements or otherwise consider applications if deemed necessary to provide services to special populations or for any other purpose necessary to achieve program objectives.

(B) ODJFS will issue a notice(s) to inform prospective MCPs and others of the procurement process.

(C) ODJFS may determine a maximum number of MCPs in any service area provided that reasonable access to participating providers is assured.

(D) ODJFS will not enter into a provider agreement with a prospective MCP or amend a provider agreement with an MCP to serve eligible medicaid individuals unless the MCP meets all applicable program requirements.

(E) To participate in managed care programs, prospective MCPs who are found by ODJFS to meet all applicable program requirements will be required to enter into a provider agreement.

(F) If an MCP is terminated from the medicaid and/or medicare program or not renewed as a participating provider in the medicaid program, whether as a result of the MCP’s initiative or ODJFS action, ODJFS retains the right not to consider that prospective MCP for a provider agreement for a period of two years from the date of the termination or nonrenewal.

Effective: 06/01/2006

R.C. 119.032 review dates: 07/01/2009

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.16, 5111.17

Rule Amplifies: 5111.01, 5111.02, 5111.16, 5111.17

Prior Effective Dates: 5/2/85, 10/1/87, 5/1/92, 5/1/93, 11/1/94, 7/1/96, 7/1/97 (Emer), 9/27/97, 12/10/99, 7/1/01, 7/1/02, 7/1/03, 7/1/04, 10/31/05

(A) Obligations.

(1) Managed care plans (MCPs) must provide or arrange for the delivery of covered health care services and must assure that all the requirements of Chapter 5101:3-26 of the Administrative Code, the MCP provider 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 and 42 C.F.R. 434.6 and 438.6, as applicable.

(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 and 42 C.F.R. 434.6 and 438.6, as applicable. 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 grievances and appeals as specified in rule 5101:3-26-08.4 of the Administrative Code, and all member complaints reported to the Ohio department of job and family services (ODJFS) and forwarded to the MCP, to identify any deficiencies or areas for improvement. Upon request, 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) All subcontracts must fulfill the requirements of 42 C.F.R. 434.6 and 438.6 that are appropriate to the service or activity delegated under the subcontract.

(7) 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 5101:3-26 of the Administrative Code and the MCP provider agreement.

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

(9) 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. For medicaid-covered non-emergency hospital services outlined in paragraph (H)(9) of rule 5101:3-26-03 of the Administrative Code, the compensation amount is identified in paragraph (C) of rule 5101:3-26-11 of the Administrative Code.

(B) Notification.

(1) Notwithstanding paragraph (D)(13) of this rule, an MCP must notify ODJFS of the addition or deletion of subcontractors on an ongoing basis, and must follow the time restrictions contained in paragraphs (B)(2), (B)(3), (B)(5), and (B)(6) of this rule unless the explanation of extenuating circumstances is accepted by ODJFS.

(2) When any provider of the designated provider types are to be added to the MCP’s provider panel, the MCP must submit evidence of the following within thirty days of the execution of the subcontract for prior approval of the provider’s addition to the panel:

(a) A copy of the subcontractor’s current licensure if ODJFS provides notification that it cannot verify current licensure;

(b) ODJFS may require a copy of the dated and fully-executed medicaid addendum as specified in paragraph (D) of this rule or, for all new subcontracting hospitals, federally qualified health centers (FQHCs), and rural health clinics (RHCs), a copy of the complete subcontract, including the medicaid addendum; and

(c) The subcontractor’s medicaid provider number or provider reporting number, as applicable.

(3) When any program requirement is to be delegated as specified in paragraph (A)(4) of this rule, the MCP must submit a copy of the dated and fully-executed medicaid addendum or amendment as applicable within thirty calendar days of the execution of the subcontract or subcontract amendment for prior approval of the delegation.

(4) Upon ODJFS approval of the provider and/or delegated entity, MCPs must provide the subcontractor with a copy of the fully-executed subcontract and specification of the ODJFS approval date.

(5) 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 MCP must:

(a) If the subcontractor is a hospital or primary care provider (PCP):

(i) Inform ODJFS of the deletion of the subcontractor fifty-five calendar days prior to the expiration, nonrenewal, or termination of said subcontract;

(ii) If the MCP receives or issues less than fifty-five days notice, inform ODJFS within one working day of its awareness of this information.

(iii) If the deletion is a PCP, include the number of members that will be affected by the change.

(b) Deletion of any other subcontractors referenced in paragraph (A)(3) of this rule must be reported to ODJFS no later than thirty calendar days prior to the expiration, nonrenewal, or termination of the subcontract. If the MCP receives or issues less than thirty days notice, the MCP must inform ODJFS within one working day of their awareness of this information.

(c) If the subcontractor involved is a PCP, the MCP must notify, in writing, 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. A copy of this member notification must be submitted to ODJFS along with the MCP’s notification of provider deletion.

(d) When the subcontractor is a hospital, the MCP must notify all members in the service area, in writing, 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, as specified in paragraph (D)(35) of this rule, 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 deletion. 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.

(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 adversely impacts additional members and/or providers.

(v) Copies of the member and provider notifications must be submitted to ODJFS along with the MCP’s notification of the hospital deletion.

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

(f) Regardless of the member notification timeframes 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.

(6) 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 take the following steps:

(a) Inform ODJFS fifty-five calendar days prior to the expiration, nonrenewal, or termination of the subcontract. If the MCP receives or issues less than fifty-five days notice, the MCP must inform ODJFS within one working day of its awareness of this information.

(b) In situations that may adversely impact members and/or providers, notify members and/or providers of the impending expiration, nonrenewal, or termination of the subcontract.

(7) In order to assure availability of services and qualifications of providers, ODJFS may require submission of documentation in accordance with paragraph (B) of this rule regardless of whether the MCP subcontracts directly for services or does so through another entity.

(8) MCPs must submit to ODJFS within thirty calendar days of execution, any amendment to a subcontract with a hospital, FQHC or RHC.

(9) In the event that an MCP’s medicaid managed care program participation in a service area 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.

(C) Provider qualifications.

(1) MCPs must ensure that subcontractors that have medicaid provider agreements are in good standing and must ensure that all 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 provider 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 individual 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 cannot 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’ 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 .

(D) Subcontracts.

MCP subcontracts must include a medicaid addendum that has been prior-approved by ODJFS. All addendums must contain the following elements:

(1) An agreement by the subcontractor to comply with the applicable provisions for record keeping and auditing in accordance with Chapter 5101:3-26 of the Administrative Code.

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

(3) Specification of the services to be provided.

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

(a) ODJFS will notify the MCP and the MCP shall notify the subcontractor of any changes in applicable state or federal law, regulations, waiver, or contractual obligation of the MCP;

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

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

(5) 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.

(6) 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.

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

(8) 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.

(9) An agreement by the subcontractor to not hold liable ODJFS and members in the event that the MCP cannot or will not pay for covered services performed by the subcontractor pursuant to the subcontract with the exception that:

(a) FQHCS and RHCs may be reimbursed by ODJFS in the event of MCP insolvency pursuant to Section 1902(bb) of the Social Security Act, or

(b) The subcontractor may bill the member when the MCP has denied prior authorization or referral for the services and the following conditions are met:

(i) The member was notified by the subcontractor of the financial liability in advance of service delivery;

(ii) The notification by the subcontractor was in writing, specific to the service being rendered, and clearly states 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) The notification is dated and signed by the member.

(10) An agreement by the subcontractor that with the exception of any member co-payments the MCP has elected to implement in accordance with rule 5101:3-26-12 of the Administrative Code, the MCP’s payment constitutes payment in full for any covered service and that the subcontractor will not charge the member or ODJFS any co-payment, cost sharing, down-payment, or similar charge, refundable or otherwise. This agreement does not prohibit nursing facilities (NFs) from collecting patient liability payments from members as specified in rule 5101:1-39-24 of the Administrative Code or FQHCs and RHCs from submitting claims for supplemental payments to ODJFS as specified in rules 5101:3-28-07 and 5101:3-16-05 of the Administrative Code.

(a) MCP shall notify the subcontractor whether the MCP has elected to implement any member co-payments and if applicable under what circumstances member co-payment amounts will be imposed in accordance with rule 5101:3-26-12 of the Administrative Code; and

(b) Subcontractor agrees that member notifications regarding any applicable co-payment amounts must be carried out in accordance with rule 5101:3-26-12 of the Administrative Code.

(11) 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 subcontractor and all employees of the subcontractor have not been excluded from participating in federally funded health care programs.

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

(13) A stipulation that the MCP give the subcontractor at least sixty days prior notice for the nonrenewal or termination of the subcontract except in cases where an adverse finding by a regulatory agency or health or safety risks dictate that the subcontract be terminated sooner.

(14) A stipulation that the subcontractor may nonrenew or terminate the subcontract if:

(a) The subcontractor gives the MCP at least sixty days prior notice for the nonrenewal or termination of the subcontract. The effective date for any subcontractor’s nonrenewal or termination must be the last day of the month; or

(b) ODJFS has proposed action in accordance with paragraph (G) of rule 5101:3-26-10 of the Administrative Code, regardless of whether this action is appealed. The subcontractor’s termination or nonrenewal notice must be received by the MCP within fifteen working days prior to the end of the month in which the subcontractor is proposing termination or nonrenewal. If the notice is not received by this date, the subcontractor must agree to extend the termination or nonrenewal date to the last day of the subsequent month.

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

(16) The subcontractor’s agreement to make the medical records for medicaid eligible individuals available for transfer to new providers at no cost to the individual.

(17) 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.

(18) A requirement securing cooperation with the MCP’s quality assessment and performance improvement (QAPI) program in all its provider subcontracts and employment agreements for physician and nonphysician providers.

(19) An agreement by the subcontractor and MCP that:

(a) The MCP shall disseminate written policies in accordance with the requirements of 42 U.S.C. Section 1396a(a)(68) and section 5111.101 of the Revised Code, regarding the reporting of false claims and whistleblower protections for employees who make such a report, and including the MCP’s policies and procedures for detecting and preventing fraud, waste, and abuse; and

(b) The subcontractor agrees to abide by the MCP’s written policies related to the requirements of 42 U.S.C. Section 1396a(a)(68) and section 5111.101 of the Revised Code, including the MCP’s policies and procedures for detecting and preventing fraud, waste, and abuse.

(20) A specification that hospitals and other subcontractors must allow the MCP access to all member medical records for a period of not less than six years 5101:3-26-05 11 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 5101:3-26-06 of the Administrative Code.

(21) A specification, appearing above the signature(s), on the signature page in all PCP subcontracts stating the maximum number of MCP members that each PCP can serve at each practice site for that MCP.

(22) A specification that the subcontractor must cooperate with the ODJFS external quality review identified in rule 5101:3-26-07 of the Administrative Code.

(23) A specification that the subcontractor must be bound by the same standards of confidentiality that apply to ODJFS and the state of Ohio as described in rule 5101:1-1-03 of the Administrative Code, including standards for unauthorized uses of or disclosures of PHI.

(24) A specification that any third party administrator (TPA) must include the elements of paragraph (D) of this rule in its subcontracts and ensure that its subcontractors will forward information to ODJFS as requested.

(25) A specification that home health subcontractors must meet the eligible provider requirements specified in Chapter 5101:3-12 of the Administrative Code and comply with the requirements for home care dependent adults as specified in section 121.36 of the Revised Code.

(26) A specification that PCPs must participate in the care coordination requirements outlined in rule 5101:3-26-03.1 of the Administrative Code.

(27) 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.

(28) A specification that the MCP agrees to fulfill the subcontractor’s responsibility to mail or personally deliver notice of the member’s right to request a state hearing whenever the subcontractor bills a member due to the MCP’s denial of payment of a service, as specified in rule 5101:3-26-08.4 of the Administrative Code, utilizing the procedures and forms as specified in rule 5101:6-2-35 of the Administrative Code.

(29) The subcontractor’s agreement to contact the twenty-four hour post-stabilization services phone line designated by the MCP to request authorization to provide post-stabilization services in accordance with paragraph (G) of rule 5101:3-26-03 of the Administrative Code.

(30) A specification that the MCP may not prohibit, or otherwise restrict a subcontractor acting within the lawful scope of practice, from advising or advocating on behalf of a member who is his or her patient for the following:

(a) The member’s health status, medical care, or treatment options, including any alternative treatment that may be self-administered;

(b) Any information the member needs in order to decide among all relevant treatment options;

(c) The risks, benefits, and consequences of treatment versus non-treatment; and

(d) The member’s right to participate in decisions regarding his or her health care, including the right to refuse treatment, and to express preferences about future treatment decisions.

(31) A stipulation that th