Lawriter - OAC - 5160-20-01 Coordinated services program.

5160-20-01 Coordinated services program.

(A) Definitions.

(1) "Abuse potential drug" as used in the appendix to this rule, means any drug that contains substances which have a potential for abuse because of depressant or stimulant effects on the central nervous system or hallucinogenic effects. Abuse potential drugs include any drug that is reportable to Ohio automated rx reporting system (OARRS) as defined in rules 4729-37-02 and 4729-37-12 of the Administrative Code, in addition to non-controlled drugs including muscle relaxants.

(2) "Assigned 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 assigned provider is selected in accordance with paragraph (F) of this rule to serve as the primary provider of non-emergency services for an individual enrolled in the coordinated services program (CSP).

(3) "Coordinated services program" (CSP) means a program that requires an individual to obtain services related to the reason for enrollment from an assigned provider. An individual enrolled in CSP is eligible for all medically necessary services covered by medicaid.

(4) "Fraud" for the purpose of this rule, includes but is not limited to, forged prescriptions, possession and use of multiple medicaid cards, card loaning, and sharing of drugs or other supplies obtained through medicaid.

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

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

(B) CSP provides continuity of medical care and helps to ensure the health and safety of individuals by avoiding duplication of services, inappropriate or unnecessary utilization of medical services, fraud and excessive use of prescribed drugs.

(C) An individual enrolled in CSP must obtain medically necessary medicaid covered services of the type related to the reason for enrollment from an assigned provider.

(D) CSP enrollment criteria.

(1) The enrollment criteria found in the appendix to this rule are based upon ninety days of utilization data. An individual who meets three or more of the criteria in the appendix to this rule shall be enrolled in CSP; or

(2) An individual shall be enrolled in CSP when a review of his or her utilization demonstrates a pattern of receiving services at a high frequency as determined by the Ohio department of medicaid or its designee (hereafter referred to as ODM).

(3) ODM may, at its discretion, choose to apply additional criteria to identify individuals for CSP enrollment when utilization of services appears to exceed, or appears not to follow, nationally recognized treatment standards.

(4) An individual may be excluded from CSP enrollment when he or she:

(a) Has a current diagnosis of cancer and is actively receiving chemotherapy or radiation treatment;

(b) Resides in a long-term care facility; or

(c) Receives hospice services.

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

(1) Initial enrollment.

(a) An individual proposed for enrollment in CSP will receive the "Notice of Proposed Enrollment in the Coordinated Services Program (CSP)" (ODM 01717, 6/2018), including the effective date of enrollment, from ODM in accordance with division 5101:6 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, ODM determines an individual's service utilization continues to support the reasons for enrollment described in paragraph (D) of this rule, the individual will continue to be enrolled in CSP for up to an additional twenty-four months.

(b) ODM will notify the individual of the continued enrollment by issuing the "Notice of Continued Enrollment in the Coordinated Services Program (CSP)" (ODM 01705, 6/2018) in accordance with division 5101:6 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 ODM determines an individual's service utilization no longer supports the reasons for enrollment described in paragraph (D) of this rule, the individual may be disenrolled.

(b) If an individual enrolled in CSP meets any of the criteria described in paragraph (D)(4) of this rule, the individual will be disenrolled from CSP. If the individual is subsequently discharged from the long-term care facility, hospice program or no longer receives treatment for a cancer diagnosis during the CSP enrollment period, ODM may reinstate the individual into CSP.

(F) Initial assignment or changing an assigned provider.

(1) Initial provider assignment.

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

(b) ODM will select an assigned provider for the individual for any of the following reasons:

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

(ii) The individual's selected assigned provider is denied by ODM; or

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

(2) Changing an assigned provider.

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

(i) The assigned provider's office is no longer accessible to the individual for any of the following reasons:

(a) The assigned provider's office has relocated or closed;

(b) The individual has moved or is unable to travel to the provider;

(c) The assigned provider is no longer an eligible provider;

(d) The assigned provider chooses not to 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 assignment of a provider with a different specialty.

(b) If the department denies the individual's request to change the assigned provider, the department shall notify the individual by issuing the "Notice of Denial of Assigned Provider or Pharmacy in the Coordinated Services Program (CSP)" (ODM 01718, 6/2018) in accordance with division 5101:6 of the Administrative Code.

Replaces: 5160-20-01

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Effective: 1/1/2019
Five Year Review (FYR) Dates: 01/01/2024
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5164.758
Rule Amplifies: 5164.02, 5164.758
Prior Effective Dates: 12/01/1983, 04/01/1986, 07/01/1987, 02/01/1990, 04/01/1992, 11/01/1997, 01/01/2008, 01/01/2012, 01/01/2017, 01/01/2018