5101:3-26-01 Managed health care programs: definitions.

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, ODM, or other ODM-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 ODM.

(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 plan" means a written document developed by the managed care plan for a member receiving care management services. The care plan is based on the assessment and includes measureable goals, interventions and outcomes with completion timeframes that address the member's clinical and non-clinical needs.

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

(J) "Care management" means activities performed on behalf of members that 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 ODM 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 CMS under 42 C.F.R. part 493 (May 1, 2013), 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.

(Q) "COB claim" means any claim that meets the definition of a third party claim as established in this rule.

(R) "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.

(S) "CSP" means coordinated services program as defined in rule 5101:3-20-01 of the Administrative Code.

(T) "DBA" means doing business as, in accordance with ODI's designation.

(U) "DEA" means drug enforcement administration.

(V) "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 ODM.

(W) "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.

(X) "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 (W) 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.

(Y) "EOB (explanation of benefits)," otherwise known as "EOP (explanation of payment)," or "RA (remittance advice)," means the information sent to providers and/or members by any other third party payer, or managed care plan (MCP), to explain the adjudication of a claim.

(Z) "EQRO" means external quality review organization.

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

(BB) "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 the individual, 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.

(CC) "Healthchek," services otherwise known as early and periodic screening, diagnosis, and treatment (EPSDT) services, are comprehensive preventive health services available to medicaid consumers from birth through twenty years of age.

(DD) "HIC" means a "health insuring corporation" as defined in section 1751.01 of the Revised Code.

(EE) "Hospital" means an institution located at a single site that 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 that is operated by the United States government or the Ohio department of mental health and addiction services.

(FF) "Hospital services" means those inpatient and outpatient services that are generally and customarily provided by hospitals.

(GG) "Inpatient facility" means an acute or general hospital.

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

(II) "LEP" means limited-English proficiency.

(JJ) "LRP" means limited-reading proficiency.

(KK) "MCEC (managed care enrollment center)" otherwise known as the "Ohio medicaid consumer hotline" means an organization or individual under contract with or designated by ODM to provide managed care information and selection services to eligible individuals.

(LL) "MCP (managed care plan)," otherwise known as "plan," means a HIC licensed in the state of Ohio that enters into a provider agreement with ODM 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 (EEE) of this rule.

(MM) "Medicaid" means medical assistance as defined in section 5111.01 of the Revised Code.

(NN) "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.

(OO) "Medicare" means the federally financed medical assistance program defined in 42 U.S.C. 1395 (April 15, 2013).

(PP) "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.

(QQ) "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.

(RR) "MHA" means the Ohio department of mental health and addiction services.

(SS) "MR/DD" means mental retardation or developmental disabilities.

(TT) "NF (nursing facility)" 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.

(UU) "ODA" means the Ohio department of aging.

(VV) "ODI" means the Ohio department of insurance.

(WW) "ODM" means the Ohio department of medicaid.

(XX) " ODM approval" means written approval by ODM and does not constitute approval by any other state or federal agency.

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

(ZZ) "ODODD" means the Ohio department of developmental disabilities.

(AAA) "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.

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

(CCC) "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.

(DDD) "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).

(EEE) "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.

(FFF) "PHI (protected health information)" means information received from or on behalf of ODM that meets the definition of PHI as defined by 45 C.F.R. 160.103 (May 1, 2013).

(GGG) "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 (May 1, 2013) to improve or resolve the member's condition.

(HHH) "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 ODM.

(III) "Provider" means a hospital, health care facility, physician, dentist, pharmacy, or otherwise licensed, certified, or other appropriate individual or entity, that is authorized to or may be entitled to reimbursement for health care services rendered to an MCP's member.

(JJJ) "Provider agreement" means a formal agreement between ODM and an MCP for the provision of medically necessary services to medicaid consumers who are enrolled in the MCP.

(KKK) "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.

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

(MMM) "QFPP (qualified family planning provider)" means any public or nonprofit health care provider that complies with guidelines/standards set forth in 42 U.S.C. 300 (April 15, 2013), and receives either Title X funding or family planning funding from the Ohio department of health.

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

(OOO) "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 ODM to the contractor for services covered under the provider agreement.

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

(QQQ) "Self-referral" means the process by which an MCP member may access certain services without the PCP's and/or MCP's prior approval.

(RRR) "Service area" means the geographic area specified in the MCP's provider agreement.

(SSS) "SFY (state fiscal year)" means the period July first through June thirtieth, corresponding to the state of Ohio's fiscal year.

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

(UUU) "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 MCP's provider agreement with ODM.

(VVV) "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.

(WWW) "Third party benefit" means any health care service(s) available to members through any medical insurance policy or through some other resource that covers medical benefits and the payment for those services is either completely the obligation of the TPP or in part the obligation of the member, the TPP, and/or the MCP.

(XXX) "Third party claim" means any claim submitted to the MCP for reimbursement after all TPPs have met their payment obligations. In addition, the following will be considered third party claims by the MCP:

(1) Any claim received by the MCP that shows no prior payment by a TPP, but the MCP's records indicate that the member has third party benefits.

(2) Any claim received by the MCP that shows no prior payment by a TPP, but the provider's records indicate that the member has third party benefits.

(YYY) "TP (third party)" is as defined in section 5101.571 of the Revised Code.

(ZZZ) "TPA (third party administrator)" means any entity utilized in accordance with the provisions of this chapter to manage or administer a portion of services in fulfillment of the provider agreement with ODM.

(AAAA) "TPL (third party liability)" means the payment obligations of the TPP for health care services rendered to a member when the member also has third party benefits as described in paragraph (YYY) of this rule.

(BBBB) "TPP (third party payer)" means an individual, an entity, or a program responsible for adjudicating and paying claims for third party benefits rendered to an eligible member.

(CCCC) "Title V," otherwise known as the "program for medically handicapped children," means the program established under sections 3701.021 to 3701.0210 of the Revised Code.

(DDDD) "Title X services" means services and supplies allowed under 42 U.S.C. 300 (April 15, 2013), and provided by a qualified family planning provider.

(EEEE) "Tort action," otherwise known as "subrogation," means the right of ODM 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.

(FFFF) "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: 07/01/2013
R.C. 119.032 review dates: 07/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.16 , 5111.17 , 5111.085
Rule Amplifies: 5111.01 , 5111.02 , 5111.16 , 5111.17 , 5111.179
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, 1/1/08, 9/15/08, 7/1/09, 1/1/2012