5101:3-26-08.2 Managed health care programs: member services.

(A) MCP member services program.

(1) Each MCP must establish and operate a member services toll-free telephone number. This telephone line must have services available to assist:

(a) Hearing-impaired members; and

(b) LEP members in the primary language of the member.

(2) The member services program must, at a minimum, assist MCP members, and, as applicable, eligible individuals seeking information about MCP membership, with the following:

(a) Accessing medicaid-covered services;

(b) Obtaining or understanding information on the MCP's policies and procedures;

(c) Understanding the requirements and benefits of the plan;

(d) Resolution of concerns, questions, and problems;

(e) Filing of grievances and appeals as specified in rule 5101:3-26-08.4 of the Administrative Code;

(f) Obtaining information on state hearing rights;

(g) Appealing to or filing directly with the United States department of health and human services office of civil rights any complaints of discrimination on the basis of race, color, national origin, age, or disability in the receipt of health services;

(h) Appealing to or filing directly with the ODJFS office of civil rights any complaints of discrimination on the basis of race, color, religion, gender, sexual orientation, age, disability, national origin, veteran's status, ancestry, health status, or need for health services in the receipt of health services; and

(i) Accessing sign language, oral interpretation, and oral translation services. MCPs must ensure that these services are provided at no cost to the eligible individual or member. MCPs must designate a staff person, to coordinate and document the provision of these services.

(3) In the event the CCR does not identify a member-selected PCP for each assistance group member, or if the member-selected PCP is not available, the MCP must:

(a) Select a PCP for each member prior to the effective date of coverage based on the PCP assignment methodology prior-approved by ODJFS;

(b) Notify members of the name of their PCP prior to the effective date of coverage and pursuant to the provisions of paragraphs (D)(1) and (D)(2) of rule 5101:3-26-02 of the Administrative Code;

(c) Simultaneously notify members with an MCP-selected PCP of the ability within the first month of initial MCP membership to change the MCP-selected PCP effective on the date of contact with the MCP; and

(d) Explain that PCP change requests after the initial month of MCP membership shall be processed according to the procedures outlined in the MCP member handbook.

(B) MCP member materials.

(1) The MCP must develop and disseminate member materials, including at a minimum member materials specified in paragraph (B)(3) of this rule. All MCP member materials, including but not limited to those used for member education, member appreciation and member incentive programs, and changes thereto must be prior-approved in writing by ODJFS.

(2) Member materials must be:

(a) Provided in a manner and format that may be easily understood.

(b) Printed in the prevalent non-English languages of members in the MCP's service area.

(c) Available in alternative formats in an appropriate manner that takes into consideration the special needs of members including but not limited to visually-limited and LRP members.

(d) Consistent with the practice guidelines specified in paragraph (B) of rule 5101:3-26-05.1 of the Administrative Code.

(3) At a minimum, MCPs must provide the following materials to each member or assistance group, as applicable: MCPs must provide the materials specified in paragraphs (B)(3)(a) and (B)(3)(c) of this rule by no later than the effective date of coverage and the materials specified in paragraphs (B)(3)(b) and (B)(3)(d) of this rule prior to the effective date of coverage.

(a) The MCP's member handbook as specified in paragraph (B)(4) of this rule.

(b) An MCP identification card bearing unique features, clearly listing:

(i) The MCP's name as stated in its article of incorporation and any other trade or DBA name used;

(ii) The name(s) of the member(s) enrolled in the MCP and their medicaid management information system billing number(s);

(iii) The MCP's emergency procedures, which must be consistent with those approved in the member handbook, including the toll-free call-in system phone numbers as specified in paragraph (A)(6) of rule 5101:3-26-03.1 of the Administrative Code;

(iv) The MCP's toll-free member services number(s) as specified in paragraph (A)(1) of this rule;

(v) The name(s) and telephone number(s) of the PCP(s) assigned to the member(s);

(vi) Information on how to obtain the current eligibility status for the member(s); and

(vii) Coordinated services program (CSP) information as specified by ODJFS.

(c) Information concerning a member's right to formulate, at the member's option, advance directives including a description of applicable state law.

(d) A letter informing members at a minimum of:

(i) The new member materials issued by the MCP, what action members are to take if they have not yet received those materials, and how to access the MCP's provider directory;

(ii) How to access MCP-provided transportation services;

(iii) How to change primary care providers;

(iv) The population groups that are not required to select MCP membership and what action to take if members believe they meet this criteria and do not want to be an MCP member;

(v) The need and time frame for members to contact the MCP if members have a health care condition that the MCP should be aware of in order to most appropriately manage/transition the members' care; and

(vi) The need and how to access information on medications that require prior authorization.

(4) The MCP's member handbook must be clearly labeled as such and include, at a minimum:

(a) The rights of members that include at a minimum, all rights found in rule 5101:3-26-08.3 of the Administrative Code and any member responsibilities specified by the MCP. With the exception of any prior-authorization requirements the MCP stipulates in the member handbook, the MCP cannot establish any member responsibility that would preclude the MCP's coverage of a medicaid-covered service.

(b) Information regarding services that are excluded from MCP coverage and the services and benefits that are available at or through the MCP, and how to obtain them, including at a minimum:

(i) All services and benefits requiring prior-authorization or referral by the MCP or the member's PCP;

(ii) Self-referral services, including at a minimum Title X services, and women's routine and preventative health care services provided by a woman's health specialist as specified in paragraphs (H)(5) and (H)(6) of rule 5101:3-26-03 of the Administrative Code;

(iii) FQHC/RHC and certified nurse practitioner services as specified in paragraphs (H)(7) and (H)(8) of rule 5101:3-26-03 of the Administrative Code; and

(iv) If applicable, any pharmacy utilization management strategies prior-approved by ODJFS.

(c) Information that emergency services are available to the member, the procedures for accessing emergency services, and directives as to the appropriate utilization, including at a minimum:

(i) Explanation of emergency medical condition, emergency services, and post-stabilization services as defined in rule 5101:3-26-01 of the Administrative Code;

(ii) Prior authorization is not required for emergency services;

(iii) The availability of the 911-telephone system or its local equivalent;

(iv) Members have a right to use any hospital or other appropriate setting for emergency services; and

(v) The post-stabilization care services requirements specified in paragraph (G) of rule 5101:3-26-03 of the Administrative Code.

(d) The procedure for members to express their recommendations for change to the MCP's staff.

(e) Identification of the medicaid consumers eligible for MCP membership.

(f) Information stating that the MCP's identification card replaces the member's monthly medicaid health card, how often the card is issued, and how to use it.

(g) A statement that medically necessary health care services must be obtained in or through the MCP facilities and/or providers except emergency care, behavioral health services provided through the ODMH or at ODADAS-certified facilities that are medicaid providers, and any other services or provider types designated by ODJFS.

(h) Information on the member's responsibility to select a PCP from the MCP provider directory, how to change PCPs including the ability to change PCPs no less often than monthly, the MCP's procedures for processing PCP change requests after the initial month of MCP membership, and how the MCP will provide written confirmation to the member of any new PCP selection prior to or on the effective date of the change.

(i) A description of the healthchek (EPSDT) program, including who is eligible and how to obtain healthchek (EPSDT) services through the MCP.

(j) Information on the additional services available to all members including at a minimum care management services as specified in paragraph (A)(8) of rule 5101:3-26-03.1 of the Administrative Code and the member services toll-free call-in system.

(k) A description of the MCP's policies regarding access to providers outside the service area for non-emergency services and if applicable access to providers within and/or outside the service area for non-emergency after-hours services.

(l) Information on member-initiated termination options in accordance with paragraph (D) of rule 5101:3-26-02.1 of the Administrative Code.

(m) An explanation of automatic renewal of MCP membership in accordance with paragraph (C)(3) (h) of rule 5101:3-26-02 of the Administrative Code.

(n) The procedure for members to file an appeal, a grievance, or a state hearing request as specified in rules 5101:3-26-08.4 and 5101:3-26-08.5 of the Administrative Code.

(o) Information about MCP-initiated terminations.

(p) The issuance date of the member handbook.

(q) A statement that the MCP may not discriminate on the basis of race, color, religion, gender, sexual orientation, age, disability, national origin, veteran's status, ancestry, health status, or need for health services in the receipt of health services.

(r) An explanation of subrogation and coordination of benefits.

(s) A clear identification of corporate or parent identity when a trade name or DBA is used for the medicaid product.

(t) Information on the procedures for members to access behavioral health services.

(u) Information on the MCP's policies respecting the implementation of the member's rights regarding advance directives, including a statement of any limitation regarding the implementation of advance directives as a matter of conscience.

(v) Information stating that the MCP provides covered services to members through a provider agreement with ODJFS, and how members can contact ODJFS, by mail or by telephone, if they so desire.

(w) The toll-free call-in system phone numbers specified in paragraph (A)(1) of this rule and paragraph (A)(6) of rule 5101:3-26-03.1 of the Administrative Code.

(x) A statement that additional information is available from the MCP upon request including, at a minimum, the structure and operation of the MCP and any physician incentive plans that the MCP operates.

(y) Information on how the member can request or access additional MCP information or services including, at a minimum:

(i) Oral interpretation and oral translation services;

(ii) Written information in the prevalent non-English languages of members in the MCP's service area; and

(iii) Written information in alternative formats.

(z) If applicable, detailed information on any member co-payments the MCP has elected to implement in accordance with rule 5101:3-26-12 of the Administrative Code.

(aa) Information on how members can access the MCP's provider directory.

(bb) The standard and expedited state hearing resolution time frames as outlined in 42 C.F.R.431.244(f).

(5) If a member's MCP membership is automatically renewed as specified in paragraph (C)(3) (h) of rule 5101:3-26-02 of the Administrative Code, the MCP must issue an identification card as specified in paragraph (B)(3) of this rule prior to the new effective date of coverage. Additionally, in the event the member handbook has been revised since the initial MCP membership date of the member's assistance group, the MCP must issue a new member handbook to the member.

(6) At least annually, MCPs must determine the predominant health care needs of their medicaid members and provide health education materials as indicated by these assessments. MCPs must provide ODJFS a summary of the results of the health care needs assessment and a list of the materials distributed to members as a result of the assessment.

(7) No information or text that identifies the addressee as a medicaid recipient may appear on the outside of any MCP or MCP subcontractor mailing.

Effective: 01/01/2012
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, 2/15/89 (Emer), 5/8/89, 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, 7/1/03, 7/1/04, 10/31/05, 6/1/06, 1/1/08, 9/15/08, 7/1/09, 8/1/10