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 receiving Title IV-E federal foster care maintenance through an agreement between the local children services board and the foster care provider;

(b) 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;

(c) Children under nineteen years of age and in foster care or other out-of-home placement; and

(d) 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) (May 1, 2013).

(5) Eligible individuals for ABD described in paragraph (B)(1)(b) of this rule are excluded from MCP membership if they are:

(a) Institutionalized;

(b) Eligible for medicaid by spending down their income or resources to a level that meets the medicaid program's financial eligibility requirements; or

(c) Individuals receiving medicaid services through a medicaid waiver component, as defined in section 5111.85 of the Revised Code.

(6) Individuals are excluded from MCP membership when excluded under state law from participating in the care management system pursuant to section 5111.16 of the Revised Code.

(7) Individuals are eligible for MCP membership in the manner prescribed in this rule if ODM has a provider agreement with an MCP(s) in the eligible individual's service area.

(8) 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.

(C) MCP enrollment.

(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 ODM, MCEC, or other ODM-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, military status, genetic information, ancestry, health status or need for health services. The MCP will not use any discriminatory policy or practice as specified in 42 C.F.R. 438.6(d)(4) (May 1, 2013).

(b) Except for individuals described in paragraphs (B)(3) and (B)(4) of this rule, all eligible individuals in the CFC assistance group will be enrolled in the same MCP.

(c) MCP membership for ABD as described in paragraph (B)(1)(b) of this rule must occur at the individual level.

(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(s) 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) ODM shall confirm the eligible individual's MCP membership to the MCP via an ODM-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 ODM-produced roster except as provided in paragraph (C)(6) of this rule or upon mutual agreement between ODM and the MCP.

(4) ODM 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 ODM.

(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 ODM.

(b) When a service area is initially designated by ODM as mandatory for eligible individuals specified in paragraph (B)(1) of this rule, ODM 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 ODM.

(c) MCP membership selection procedures for the mandatory program:

(i) An eligible assistance group that does not make a choice following issuance of an NMS by ODM and one additional notice will be assigned to an MCP by ODM, the MCEC, or other ODM-approved entity.

(ii) ODM 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 ODM.

(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 ODM, or its designee, as directed by ODM 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 ODM-produced roster to the MCP, except as identified in paragraph (C)(6) of this rule.

(2) The following coverage responsibilities shall apply 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 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. Medicaid fee-for-service shall remain responsible for the inpatient facility charges through the date of discharge pursuant to rule 5101:3-2-07.11 of the Administrative Code.

(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

(c) The member remains an inpatient in an inpatient facility after the date that membership in the current MCP ends.

(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 ODM, 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 ODM 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 ODM 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 ODM 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: 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), 5/18/89, 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, 8/1/11