5101:6-2-37 Notices of enrollment, continued enrollment, or provider change denial for the managed care plan controlled substances and member management program.

As directed in this rule, a managed care plan (MCP), as defined in rule 5101:3-26-01 of the Administrative Code, shall send a written notice to an affected individual and any authorized representative of the individual on file with the MCP for proposed enrollment, continued enrollment, or provider change denial for the controlled substances and member management program (CSMM), as defined in rule 5101:3-26-01 of the Administrative Code. A copy of the written notice shall also be sent to the bureau of managed care, Ohio department of job and family services (ODJFS), as directed by the bureau of managed care.

(A) Prior notice of enrollment.

(1) When the MCP intends to enroll an individual in the CSMM program, the MCP must provide written notice no later than fifteen calendar days prior to the effective date of the proposed enrollment.

(2) The notice must contain a clear and understandable statement of the proposed action and the reasons for it, cite the applicable regulations, explain the individual’s right to and the method of obtaining a state hearing, explain the circumstances under which a timely hearing request would delay enrollment in CSMM, and contain the name and telephone number of the person to contact for more information and a telephone number to call about free legal services.

(3) If the individual requests a state hearing to appeal the MCP’s proposed action, and the hearing request is received by either the state or local agency within the fifteen-day prior notice period, the MCP shall not enroll the individual in the CSMM program until the hearing is decided or the appeal is withdrawn or abandoned pursuant to rule 5101:6-5-03 of the Administrative Code.

(4) The “Notice of Proposed Enrollment in the Controlled Substances and Member Management Program By Your Managed Care Plan,” JFS 01704 (7/2008) or its computer-generated equivalent shall be used.

(B) Notice of continued enrollment.

(1) When the MCP determines, at the end of the individual’s CSMM program enrollment period, that the enrollment should be continued, the MCP must provide written notice simultaneously with the determination.

(2) The notice shall contain a clear and understandable statement of the determination for continued enrollment and the reasons for it, cite the applicable regulations, explain the individual’s right to and the method of obtaining a state hearing, and contain the name and telephone number of the person to contact for more information and a telephone number to call about free legal services.

(3) The “Notice of Continued Enrollment in the Controlled Substances and Member Management Program By Your Managed Care Plan,” JFS 01705 (7/2008) or its computer-generated equivalent shall be used.

(1) When the MCP denies a CSMM member’s request for a change of designated provider(s) for controlled substances within the MCP’s provider panel as defined in rule 5101:3-26-01 of the Administrative Code, the MCP must provide written notice simultaneously with the denial.

(2) The notice shall contain a clear and understandable statement of the denial of a provider change and the reasons for it, cite the applicable regulations, explain the individual’s right to and the method of obtaining a state hearing, and contain the name and telephone number of the person to contact for more information and a telephone number to call about free legal services.

(3) The “Notice of Denial of Designated Provider Change in the Controlled Substances and Member Management Program By Your Managed Care Plan,” JFS 01706 (7/2008) or its computer-generated equivalent shall be used.

Effective: 05/01/2009

R.C. 119.032 review dates: 05/01/2014

Promulgated Under: 119.03

Statutory Authority: 5101.35, 5111.02, 5111.17

Rule Amplifies: 5101.35, 5111.16, 5111.17, 5111.172