Chapter 5160-20 Coordinated Services Program

5160-20-01 Coordinated services program.

(A) Definitions.

(1) "Coordinated services program" (CSP) means a program that requires an individual to obtain certain services from a designated provider.

(2) "Department" means the Ohio department of medicaid (ODM) or its designee.

(3) "Designated provider" means a hospital, health care facility, physician, dentist, pharmacy, or otherwise licensed or certified single provider or provider entity that is authorized to and is not excluded from receiving reimbursement for health care services rendered to an individual. The designated provider is selected in accordance with paragraph (E) of this rule to serve as the primary provider of non-emergency services for an individual enrolled in CSP.

(4) "Individual" is defined in rule 5160:1-1-01 of the Administrative Code.

(5) "Managed care plan" (MCP) is defined in rule 5160-26-01 of the Administrative Code.

(6) "Medical necessity" is defined in rule 5160-1-01 of the Administrative Code.

(B) CSP provides continuity of medical care and protection of health and safety to individuals by avoiding duplication of services, inappropriate or unnecessary utilization of medical services, and excessive utilization of prescription medications. An individual 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.

(C) An individual enrolled in CSP is eligible for all medically necessary services covered by medicaid. An individual enrolled in CSP must obtain medically necessary medicaid covered services from designated providers related to the reason for enrollment, as indicated by benefit utilization patterns.

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

(1) Initial enrollment.

(a) An individual 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 twenty-four months from the effective date of enrollment.

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

(2) Continued enrollment.

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

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

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

(3) Disenrollment.

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

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

(E) Initial assignment or changing a designated provider.

(1) Initial assignment.

(a) An individual enrolled in CSP may request a designated provider within thirty days of the mailing date on the initial enrollment notification. If approved by the department, this provider will serve as the individual's designated provider. The designated provider must be contracted with the department, unless otherwise permitted by the department.

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

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

(ii) The individual's selected designated provider is denied by the department; or

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

(2) Changing a designated provider.

(a) An individual may request to change, or the department may require an alternative selection of a designated provider under the following circumstances:

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

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

(B) Of relocation or incapacity of an individual;

(C) The designated provider is no longer an eligible provider;

(D) The designated provider chooses to not, or no longer, provide services to the individual; or

(E) The individual 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 individual require a designated provider with a different specialty.

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

Replaces: 5160-20-01

Effective: 1/1/2017
Five Year Review (FYR) Dates: 01/01/2022
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5164.758
Rule Amplifies: 5164.02, 5164.758
Prior Effective Dates: 12/1/83, 4/1/86, 7/1/87, 2/1/90, 4/1/92, 11/1/97, 1/1/08, 1/1/12