5101:3-26-02 Managed health care programs: eligibility, membership, and automatic renewal of membership.

(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 purpose of this rule, 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, and is:

(a) Found eligible for covered families and children (CFC) medicaid in accordance with Chapter 5101:1-40 of the Administrative Code, and paragraphs (B)(2) to (B)(4) of this rule do not apply; and

(b) Found eligible for aged, blind, or disabled (ABD) medicaid in accordance with Chapter 5101:1-39 of the Administrative Code, and paragraphs (B)(2), (B)(4), and (B)(5) of this rule do not apply.

(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; and

(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.

(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) Eligible individuals for ABD 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.

(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 MCP enrollment:

(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 CFC 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.

(d) Eligible individuals for CFC, including newborns, who are added and authorized 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.

(e) 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.

(f) The MCEC shall 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 oral authorization of MCP membership was given and the date of the authorization.

(g) The MCEC shall complete MCP enrollment requests and assignments as described in paragraph (C)(5)(c) of this rule. The MCEC shall place enrollment information on the CCR and forward the CCR to the MCP.

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

(i) ODJFS shall confirm the eligible individual’s MCP membership to the MCP via an ODJFS-produced roster of new members, continuing members, and terminating members.

(j) The MCP shall not be required to provide coverage until MCP membership is confirmed via an ODJFS-produced roster except as provided in paragraph (C)(6) 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) and (C)(6) 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 eligible individuals specified in paragraph (B)(1) of this rule, ODJFS shall confirm the eligibility of each eligible individual as prescribed in paragraph (C)(3)(i) 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; and

(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.

(i) An eligible assistance group that 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 shall 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 paragraphs (B)(3) and (B)(4) 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.

(6) Newborn notification and membership.

(a) The MCP must notify ODJFS, or its designee, as directed by ODJFS of the birth of any newborn whose mother is enrolled in an MCP .

(b) Newborns born to mothers enrolled in an MCP are enrolled in an MCP from their date of birth through the end of the month of the child’s first birthday unless the newborn is a case addition due to the mother’s eligibility for ABD medicaid as described in paragraph (B)(1)(b) of this rule. Enrollment and disenrollment of newborns shall be in accordance with Chapter 5101:3-26 of the Administrative Code.

(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)(6) of this rule.

(2) 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 paragraphs (D)(3) and (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)(2)(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)(2)(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)(2)(j) of this rule is admitted to an inpatient facility after his or her MCP membership is terminated, and remains an inpatient on the effective date of automatic renewal of MCP membership, the provisions of paragraphs (D)(2)(a) to (D)(2)(c) and paragraphs (D)(2)(f) to (D)(2)(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)(2)(a) to (D)(2)(c) and paragraphs (D)(2)(f) to (D)(2)(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.

(3) The coverage responsibilities listed in paragraph (D)(4) of this rule shall apply to a member who meets the following criteria:

(a) The member’s current MCP membership is changed or terminated for any reason, including, but not limited to, any of the reasons set forth in rule 5101:3-26-02.1 of the Administrative Code, except for the reason specified in paragraph (C)(2)(a) of rule 5101:3-26-02.1 of the Administrative Code; and

(b) The member is admitted to an inpatient facility prior to the effective date of the MCP change or termination; and

(4) The following coverage responsibilities shall apply to a member who meets the criteria listed in paragraph (D)(3) of this rule:

(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 changed or terminated, and shall remain responsible for all inpatient facility charges through the date of discharge. For retroactive disenrollments authorized by ODJFS, where the date of inpatient admission is prior to the last day of MCP coverage, the disenrolling MCP is responsible for inpatient facility charges through the date of discharge.

(b) The disenrolling MCP shall receive capitation through the end of the month in which membership is changed or terminated regardless of the length of the inpatient stay. Additional capitation payments will not be made by ODJFS regardless of the length of the inpatient stay.

(c) If the member will be enrolling in a new MCP, the disenrolling MCP shall notify the enrolling MCP of the inpatient status of the member following verification of the change or termination 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 or termination in MCP enrollment including the name of the enrolling MCP, if applicable, 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) If the member will be enrolling in a new MCP, 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) If the member will be enrolling in a new MCP, the enrolling MCP shall receive capitation beginning with the effective date of MCP membership.

(g) If the member will be enrolling in a new MCP, then upon notification of the inpatient status of the new member as specified in paragraph (D)(4)(c) 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 and ancillary charges related to the inpatient stay beginning with the effective date of MCP membership.

(h) If the member will be enrolling in a new MCP, and 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: 08/01/2011

R.C. 119.032 review dates: 07/01/2014

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, 1/1/08, 8/26/08 (Emer), 10/9/08, 7/1/09