5101:3-26-10 Managed health care programs: sanctions and provider agreement actions.

(A) If the MCP fails to fulfill its duties and obligations under Chapter 5101:3-26 of the Administrative Code and/or the MCP provider agreement, ODJFS will provide timely written notification to the MCP identifying the violations/deficiencies, and may impose any of the following sanctions in addition to or instead of any sanctions specified in the provider agreement:

(1) Corrective action in accordance with the following:

(a) If requested by ODJFS, the MCP must submit, within the specified time frame, a proposed CAP for each cited violation/deficiency.

(b) The CAP must contain the proposed correction date, describe the manner in which each violation/deficiency will be resolved, and address all items specified in the ODJFS notification.

(c) The CAP must be reviewed and approved by ODJFS.

(d) Following the approval of the CAP, ODJFS will monitor the correction process until all violations/deficiencies are corrected to the satisfaction of ODJFS.

(e) Failure to submit an approvable CAP within the ODJFS-specified time frames may result in the imposition of an ODJFS-developed CAP and/or additional sanctions.

(f) If ODJFS has already determined the specific action which must be implemented by the MCP, ODJFS may require the MCP to comply with an ODJFS-developed or directed CAP.

(g) Failure to successfully complete the correction process and correct the violations/deficiencies to the satisfaction of ODJFS may lead to the imposition of any or all of the sanctions listed in paragraphs (A)(2) to (A)(5) of this rule.

(2) Suspension of further membership except MCP automatic renewals, and MCP newborns and case additions.

(3) ODJFS notification to the MCP's members that they may terminate from the MCP without cause.

(4) Reduction of the premium rate.

(5) Retention of premium payments or a portion thereof by ODJFS until violations/deficiencies are corrected.

(B) Sanction selection will be determined based on a pattern of repeated violations/deficiencies, the severity of cited violations/deficiencies, and/or the failure of the MCP to meet the requirements of an approved CAP.

(C) Sanctions in paragraphs (A)(2) to (A)(5) of this rule are subject to reconsideration as specified in paragraph (B) of rule 5101:3-1-57 of the Administrative Code, with the exception of the sanction in paragraph (A)(3) of this rule when such notification occurs in conjunction with action taken under paragraph (D) of this rule.

(D) Regardless of any other sanction that may be imposed, ODJFS shall appoint a temporary manager for any MCP that has repeatedly failed to meet substantive requirements in section 1903(m) or section 1932 of the Social Security Act or 42 C.F.R. Part 438 subpart I. Such temporary management shall be imposed in accordance with the following:

(1) The MCP must pay the costs of a temporary manager for performing the duties of a temporary manager, as determined by ODJFS.

(2) Any costs or liabilities incurred on behalf of an MCP by a temporary manager shall be paid by the MCP and the MCP shall be solely responsible for such costs or liabilities.

(3) The imposition of temporary management is not subject to the appeals process provided under Chapter 119. of the Revised Code but the MCP may request that the deputy director for the medicaid program reconsider this action. ODJFS will not delay imposition of temporary management to provide reconsideration prior to imposing this sanction.

(4) Unless the deputy director for the medicaid program determines through the reconsideration process that temporary management should not have been imposed, the temporary management will remain in place until such time as ODJFS determines that the MCP can ensure that the sanctioned behavior will not recur.

(5) Regardless of the imposition of temporary management, the MCP retains the right to appeal any proposed termination or nonrenewal of their provider agreement under Chapter 119. of the Revised Code. The MCP also retains the right to initiate the sale of the MCP or its assets.

(6) If temporary management is imposed, ODJFS will notify the MCP's members that such action has occurred and inform them that they therefore have the right to terminate their membership in the MCP without cause.

(E) ODJFS will provide an MCP with written notice before imposing any sanction. The notice will include specification of any reconsideration or appeal rights that are available to the MCP.

(F) Regardless of whether ODJFS imposes a sanction, MCPs are to initiate corrective action for any MCP program violations/deficiencies as soon as they are identified by either the MCP or ODJFS.

(G) ODJFS may terminate, nonrenew, deny or amend a provider agreement if at any time ODJFS determines that continuation or assumption of a provider agreement is not in the best interest of recipients or the state of Ohio. For the purposes of this rule, an amendment to an MCP's provider agreement is defined as and limited to the elimination of one or more service areas included in that MCP's current agreement. For MCPs, the phrase "not in the best interest" includes, but is not limited to, the following:

(1) The MCP's delivery system does not assure adequate access to services for their members.

(2) The MCP's delivery system does not assure the availability of all services covered under the provider agreement.

(3) The MCP fails to provide all medically-necessary covered services.

(4) The MCP fails to provide proper assurances of financial solvency.

(5) The MCP fails to comply with the provisions of:

(a) Chapter 5101:3-26 of the Administrative Code;

(b) The provider agreement;

(c) The applicable requirements in sections 1932 and 1903(m) of the Social Security Act; and/or

(d) 42 C.F.R. Part 438.

(H) If ODJFS has proposed termination, nonrenewal, denial, or amendment of a provider agreement pursuant to paragraph (I)(2) of this rule, ODJFS may notify the MCP's members of this proposed action and inform the members of their right to immediately disenroll from the MCP without cause. If ODJFS has proposed termination, nonrenewal, denial, or amendment of a provider agreement and access to medically-necessary covered services is jeopardized, ODJFS may propose membership termination of all the MCP's members. This proposed action would be subject to appeal by the MCP and reconsideration by the deputy director for the medicaid program. If the proposed action is not appealed or if upheld by the deputy director upon appeal, the membership termination would occur at the earliest possible effective date.

(I) If ODJFS determines that the termination, nonrenewal, denial or amendment of a provider agreement is warranted:

(1) Notification will be given, at a minimum, forty-five days prior to the effective date of the proposed action, in accordance with Chapter 5101:6-50 of the Administrative Code;

(2) The action will be in accordance with and subject to Chapter 5101:6-50 and rule 5101:3-1-57 of the Administrative Code; and

(3) All such actions will be effective at the end of the last day of a calendar month.

(J) Notwithstanding the preceding paragraphs of this rule, provider agreements may be terminated effective on the last day of the calendar month in which any of the following occur:

(1) The determination by ODJFS that the loss or reduction of federal or state funding has reduced funding to a level which is insufficient to maintain the activities or services agreed to in the provider agreement; or

(2) The exclusion from participation of the MCP in a program administered under Title XVIII, XIX, or XX of the Social Security Act due to criminal conviction or the imposition of civil monetary penalties in accordance with 42 C.F.R. Part 455 subpart B, 42 C.F.R. Part 1002 subpart A, and rule 5101:3-1-17.3 of the Administrative Code; or

(3) The suspension, revocation or nonrenewal of ODJFS' authority to operate the program under waivers of certain federal regulations granted by CMS or congress; or

(4) The suspension, revocation or nonrenewal of the MCP's certificate of authority or license.

(5) The entity is excluded from participation in accordance with 42 C.F.R. 438.808 .

(K) MCPs whose provider agreements are amended, terminated or nonrenewed are required to fulfill all duties and obligations under Chapter 5101:3-26 of the Administrative Code and/or the provider agreement.

Effective: 10/09/2008
R.C. 119.032 review dates: 04/14/2009 and 04/01/2014
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: 5/2/85, 10/1/87, 2/15/89 (Emer), 5/8/89, 5/1/92, 5/1/93, 11/1/94, 7/1/97 (Emer), 9/27/97, 12/10/99, 7/1/01, 7/1/03, 7/1/04, 10/31/05, 1/1/08, 8/26/08 (Emer)