Chapter 5160-20 Primary Alternative Care and Treatment Program

5160-20-01 Coordinated services program.

(A) Definitions.

(1) "Coordinated services program" (CSP) means a program that requires a medicaid consumer to obtain certain services from a designated provider and/or pharmacy.

(2) "Department" means the Ohio department of job and family services (ODJFS) or its designee.

(3) "Designated pharmacy" means a pharmacy participating in the Ohio medicaid program, or with an Ohio medicaid managed care plan (MCP), that has been selected in accordance with paragraph (E) of this rule to serve as the sole provider of pharmacy services to medicaid consumers enrolled in CSP.

(4) "Designated provider" means a doctor of medicine or osteopathy or an advanced practice nurse participating in the Ohio medicaid program, or with an Ohio medicaid MCP, selected in accordance with paragraph (E) of this rule to serve as the primary provider of non-emergency physician services to medicaid consumers enrolled in CSP.

(5) "Managed care plan" (MCP) is defined in rule 5101:3-26-01 of the Administrative Code.

(6) "Medical necessity" is defined in rule 5101:3-1-01 of the Administrative Code.

(B) A consumer may be enrolled in CSP if a review of his or her utilization demonstrates a pattern of receiving services at a frequency or in an amount that exceeds medical necessity. Reasons for enrollment may include the use of multiple pharmacies, multiple controlled substances, multiple visits to emergency rooms, a high volume of prescriptions or visits to medical professionals, previous enrollment in CSP or recommendations from medical professionals indicating that the consumer has demonstrated fraudulent or abusive patterns of medical service utilization.

(C) A consumer enrolled in CSP is eligible for all services covered by medicaid as defined in division 5101:3 of the Administrative Code. All covered services except for pharmacy services, if a designated pharmacy is assigned to the consumer, and physician services, if a designated provider of physician services is assigned to the consumer may be obtained from providers pursuant to division 5101:3 of the Administrative Code. A consumer enrolled in CSP must obtain covered physician and/or pharmacy services from designated providers and/or pharmacies, except for emergency services and services received by referral from the designated provider.

(D) Initial enrollment, continued enrollment and disenrollment procedures.

(1) Initial enrollment.

(a) A consumer proposed for enrollment in CSP will receive a notice of enrollment, including the effective date of enrollment, from the department in accordance with rule 5101:6-2-40 of the Administrative Code.

(b) Initial CSP enrollment will be for eighteen months from the effective date of enrollment.

(c) If a consumer enrolled in CSP becomes ineligible for medicaid, then resumes eligibility for medicaid within the initial enrollment period, the consumer will be reinstated into CSP until the initial enrollment period is exhausted.

(2) Continued enrollment.

(a) If after the initial eighteen-month enrollment period the department determines a consumer's service utilization still supports the reasons for enrollment described in paragraph (B) of this rule, the consumer will continue to be enrolled in CSP for an additional eighteen-month period.

(b) The department will notify the consumer of the continued enrollment in accordance with rule 5101:6-2-40 of the Administrative Code.

(c) If a consumer enrolled in CSP becomes ineligible for medicaid, then resumes eligibility for medicaid within a continued enrollment period, the consumer will be reinstated into CSP until the continued enrollment period is exhausted.

(3) Disenrollment.

(a) If the department determines a consumer's service utilization no longer supports the reasons for enrollment described in paragraph (B) of this rule, the consumer will be disenrolled.

(b) If a consumer enrolled in CSP enters a long-term care facility or hospice program, the consumer will be disenrolled from CSP. If the consumer is subsequently discharged from the long-term care facility or hospice program during the CSP enrollment period, the department may reinstate the consumer into CSP.

(E) Assigning or changing a designated provider or pharmacy.

(1) Initial assignment.

(a) A consumer enrolled in CSP may request a designated provider and/or pharmacy within thirty days of the mailing date on the initial enrollment notification. If approved by the department, this provider and/or pharmacy will serve as the consumer's designated provider or pharmacy.

(b) The department will select a designated provider or pharmacy for the consumer for any of the following reasons:

(i) The consumer does not select a designated provider or pharmacy within thirty days of the mailing date on the initial enrollment notification;

(ii) The consumer's selected designated provider or pharmacy is not approved by the department; or

(iii) The selected designated provider or pharmacy is unwilling or unable to accept the consumer.

(2) Changing a designated provider or pharmacy.

(a) A consumer may request, or the department may require, a change from one designated provider and/or pharmacy to another only under one of the circumstances set forth in paragraph (E)(2)(a)(i) or (E)(2)(a)(ii) of this rule:

(i) The designated provider's office or pharmacy is no longer accessible to the consumer because:

(a) Of relocation or closing of the designated provider's office;

(b) Of relocation or closing of the designated pharmacy;

(c) Of relocation or incapacity of a consumer;

(d) The designated provider or pharmacy is no longer an eligible provider;

(e) The designated provider or pharmacy chooses to not, or no longer, provide services to the consumer; or

(f)The consumer transfers from the fee-for-service program to an MCP, from an MCP to the fee-for-service program or from one MCP to another.

(ii) The medical needs of the consumer require a designated provider with a different specialty.

(b) If the department denies the consumer's request to change the designated provider and/or pharmacy, the department shall notify the consumer in accordance with rule 5101:6-2-40 of the Administrative Code.

Replaces: 5101:3-20-01, 5101:3-20-02, 5101:3-20-03

Effective: 01/01/2012
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.085
Rule Amplifies: 5111.02 , 5111.085
Prior Effective Dates: 12/1/83, 4/1/86, 7/1/87, 2/1/90, 4/1/92, 11/1/97, 1/1/08