5101:3-26-02.1 Managed health care programs: termination 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 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.

(b) The member's permanent place of residence is moved outside the MCP membership service area.

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

(d) An MCP member is placed in a residential facility for the treatment of behavioral or developmental health issues and ODM 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 ODM approval, termination is effective the last day of the month preceding placement.

(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 ODM, termination is effective the last day of the month prior to incarceration.

(f) A member is found by ODM 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 ODM, membership termination is effective the last day of the month preceding placement in the ICF-MR facility.

(g) A member is placed in a nursing facility (NF):

(i) Prior to the membership effective date and the member remains in the NF on the membership effective date. Following MCP notification to ODM, the membership termination is effective the last day of the month preceding placement in the NF. When this occurs, the MCP must submit required documentation which includes, but is not limited to, a copy of the approved level of care (LOC) obtained pursuant to division 5101:3 of the Administrative Code and a copy of the NF admission form or other proof of NF admission.

(ii) After the membership effective date, and the member remains authorized by the MCP for NF services past the last day of the second calendar month following the month of NF admission. Following MCP notification to ODM, membership termination is effective the last day of the second calendar month following the month of NF admission. When this occurs, the MCP must submit required documentation which includes, but is not limited to, a copy of the approved level of care (LOC) obtained pursuant to division 5101:3 of the Administrative Code and a copy of the NF admission form or other proof of NF admission.

(h) A member is enrolled in a home and community-based waiver program administered by ODM, Ohio department of aging (ODA), or Ohio department of developmental disabilities (ODODD). 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.

(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 ODM, membership termination is effective the last day of the month preceding the transfer.

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

(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.

(l) A member has third party coverage and ODM determines, following MCP, member, or other public agency notification to ODM 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 ODM but in no event shall the termination date be later than the last day of the month in which ODM approves the termination.

(m) The provider agreement between ODM and the MCP is terminated or ODM 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 ODM fails to notify the MCP of a member's termination from an MCP, ODM shall 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 shall 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 ODM provides the MCP with documentation of the member's termination.

(6) ODM shall 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) From the date of enrollment through 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)(2) to (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 shall document via the consumer contact record (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 oral 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 ODM that the change or termination is effective. ODM shall 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 ODM or its designee at least annually. ODM shall 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 MCP 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 ODM, continued membership in the MCP would be harmful to the interests of the member.

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

(c) ODM shall review all requests for just cause within seven working days of receipt. ODM may request documentation as necessary from both the member and the MCP. ODM shall make a decision within forty-five days from the date ODM receives the just cause request. ODM 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 ODM fails to make the determination within this timeframe, the just cause request is considered approved.

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

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

(f) In the case of members who lose medicaid eligibility prior to ODM action to change or terminate membership for just cause, ODM 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 ODM 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 the member's 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 ODM-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 terminated, notwithstanding the date of ODM approval of the termination request. Inpatient facility services must be provided in accordance with paragraphs (D)(3) and (D)(4) of rule 5101:3-26-02 of the Administrative Code.

(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 ODM approves the MCP's request for termination, ODM shall:

(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 ODM-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 MCP must provide medicaid-covered services to a terminated member(s) through the last day of the month in which the MCP membership is terminated, with the exception of inpatient facility services that must be provided in accordance with paragraphs (D)(3) and (D)(4) of rule 5101:3-26-02 of the Administrative Code.

Effective: 07/01/2013
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), 5/8/89, 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, 1/1/08, 8/26/08 (Emer), 10/9/08, 7/1/09, 2/1/10, 8/1/10