Chapter 5160-26 Managed Care Plan

5160-26-01 Managed health care programs: definitions.

As used in Chapter 5160-26 of the Administrative Code:

(A) "Abuse" means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes consumer practices that result in unnecessary cost to the medicaid program.

(B) "Advance directive" means written instructions such as a living will or durable power of attorney for health care relating to the provision of health care when an adult is incapacitated.

(C) "Assistance group" means a group of consumers receiving benefits together under a specific category of assistance.

(D) "Authorized representative" has the same meaning as in rule 5160:1-1- 55.1 of the Administrative Code.

(E) "Care plan" means a written document developed by the managed care plan for a member receiving care management services. The care plan is based on the assessment and includes measureable goals, interventions and outcomes with completion timeframes that address the member's clinical and non-clinical needs.

(F) "Care management" means activities performed on behalf of members that include services described in rule 5160-26- 03.1 of the Administrative Code.

(G) "CCR" means the consumer contact record. The CCR contains demographic health-related information provided by an eligible individual, managed care member, or ODM that is utilized by the medicaid consumer hotline to process membership transactions.

(H) "CDJFS" means a county department of job and family services.

(I) "C.F.R." means the Code of Federal Regulations, as amended, unless otherwise specified.

(J) "CLIA" means the clinical laboratory improvement amendments regulated by CMS under 42 C.F.R. part 493 ( October 1, 2013), laboratory requirements.

(K) "CMS" means the centers for medicare and medicaid services.

(L) "COB (coordination of benefits)" means a procedure establishing the order in which health care entities pay their claims.

(M) "COB claim" means any claim that meets the definition of a third party claim as established in this rule.

(N) "Covered services" means those medical services set forth in rule 5160-26-03 of the Administrative Code or a subset of those medical services.

(O) "CSP" means coordinated services program as defined in rule 5160-20-01 of the Administrative Code.

(P) "DBA" means doing business as, in accordance with ODI's designation.

(Q) "DEA" means drug enforcement administration.

(R) "Eligible individual" means any medicaid consumer who is a legal resident of the managed care service area and is in one of the categories specified in the MCP's provider agreement with ODM.

(S) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the following: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.

(T) "Emergency services" means covered inpatient services, outpatient services, or medical transportation that are provided by a qualified provider and are needed to evaluate, treat, or stabilize an emergency medical condition . As used in this chapter, providers of emergency services also include physicians or other health care professionals or health care facilities not under employment or under contractual arrangement with an MCP.

(U) "EOB (explanation of benefits)," otherwise known as "EOP (explanation of payment)," or "RA (remittance advice)," means the information sent to providers and/or members by any other third party payer, or managed care plan (MCP), to explain the adjudication of a claim.

(V) "FQHC " means a federally qualified health center as defined in rule 5160-28-01 of the Administrative Code.

(W) "Fraud" means any intentional deception or misrepresentation made by an individual or entity with the knowledge that the deception could result in some unauthorized benefit to the individual, the entity, or some other person. This includes any act that constitutes fraud under applicable federal or state law. Member fraud means the altering of information or documents in order to fraudulently receive unauthorized benefits or to knowingly permit others to use the member's identification card to obtain services or supplies.

(X) "Healthchek," services otherwise known as early and periodic screening, diagnosis, and treatment (EPSDT) services, are comprehensive preventive health services available to medicaid consumers from birth through twenty years of age.

(Y) "HIC" means a "health insuring corporation" as defined in section 1751.01 of the Revised Code.

(Z) "Hospital" means an institution located at a single site that is engaged primarily in providing to inpatients, by or under the supervision of an organized medical staff of physicians licensed under Chapter 4731. of the Revised Code, diagnostic services and therapeutic services for medical diagnosis and treatment or rehabilitation of injured, disabled, or sick persons. "Hospital" does not mean an institution that is operated by the United States government or the Ohio department of mental health and addiction services.

(AA) "Hospital services" means those inpatient and outpatient services that are generally and customarily provided by hospitals.

(BB) "Inpatient facility" means an acute or general hospital.

(CC) "Intermediate care facility for individuals with intellectual disabilities (ICF/IID)" has the same meaning as in rule 5123:2-7-01 of the Administrative Code.

(DD) "LEP" means limited-English proficiency.

(EE) "LRP" means limited-reading proficiency.

(FF) "Medicaid consumer hotline" means an organization or individual under contract with or designated by ODM to provide medicaid managed care information and enrollment services to eligible individuals.

(GG) "MCP (managed care plan)," otherwise known as "plan," means a HIC licensed in the state of Ohio that enters into a provider agreement with ODM in the managed health care program . For the purpose of this chapter, MCP does not include entities approved to operate as a PACE site, as defined in paragraph (VV) of this rule.

(HH) "Medicaid" means medical assistance as defined in section 5162.01 of the Revised Code.

(II) "Medically necessary," otherwise known as "medical necessity," as used in this chapter is the same as defined in rule 5160-1-01 of the Administrative Code.

(JJ) "Medicare" means the federally financed medical assistance program defined in 42 U.S.C. 1395 ( as in effect December 1, 2014).

(KK) "Member," otherwise known as "enrollee," means a medicaid consumer who has selected MCP membership or has been assigned to an MCP for the purpose of receiving health care services.

(LL) "MFCU (medicaid fraud control unit)" means an identifiable entity of state or federal government charged with the investigation and prosecution of fraud and related offenses within medicaid.

(MM) "MHAS" means the Ohio department of mental health and addiction services.

(NN) "NF (nursing facility)" has the same meaning as in section 5165.01 of the Revised Code.

(OO) "ODA" means the Ohio department of aging.

(PP) "ODI" means the Ohio department of insurance.

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

(RR) "ODM approval" means written approval by ODM and does not constitute approval by any other state or federal agency.

(SS) "ODODD" means the Ohio department of developmental disabilities.

(TT) "Oral interpretation services" means services provided to a limited-reading proficient eligible individual or member to ensure that he or she receives MCP information in a format and manner that is easily understood by the eligible individual or member

(UU) "Oral translation services" means services provided to a limited-English proficient eligible individual or member to ensure that he or she receives MCP information translated into the primary language of the eligible individual or member.

(VV) "PACE" has the same meaning as in rule 5160-36-01 of the Administrative Code.

(WW) "PCP (primary care provider)" means an individual physician (M.D. or D.O.), a physician group practice, an advanced practice registered nurse as defined in section 4723.01 of the Revised Code, an advanced practice nurse group practice within an acceptable specialty, or a physician assistant who meets the requirements of rule 5160-4-03 of the Administrative Code contracting with an MCP to provide services as specified in rule 5160-26- 03.1 of the Administrative Code. Acceptable PCP specialty types include family/general practice, internal medicine, pediatrics, and obstetrics/gynecology (OB/GYNs).

(XX) "Pending member," otherwise known as "pending enrollee," means an eligible individual who has selected or been assigned to an MCP but whose MCP membership is not yet effective.

(YY) "PHI (protected health information)" means information received from or on behalf of ODM that meets the definition of PHI as defined by 45 C.F.R. 160.103 ( October 1, 2013).

(ZZ) "Post-stabilization care services" means covered services related to an emergency medical condition that a treating provider views as medically necessary after an emergency medical condition has been stabilized in order to maintain the stabilized condition, or under the circumstances described in 42 C.F.R. 422.113 ( October 1, 2013) to improve or resolve the member's condition.

(AAA) "Premium" means the monthly payment amount per member to which the MCP is entitled as compensation for performing its obligations in accordance with Chapter 5160-26 of the Administrative Code and/or the provider agreement with ODM.

(BBB) "Provider" means a hospital, health care facility, physician, dentist, pharmacy, or otherwise licensed or certified appropriate individual or entity that is authorized to or may be entitled to reimbursement for health care services rendered to an MCP's member.

(CCC) "Provider agreement" means a formal agreement between ODM and an MCP for the provision of medically necessary services to medicaid consumers who are enrolled in the MCP.

(DDD) "Provider panel," otherwise known as "panel," means the MCP's contracted providers available to the MCP's general membership.

(EEE) "QFPP (qualified family planning provider)" means any public or nonprofit health care provider that complies with guidelines/standards set forth in 42 U.S.C. 300 ( as in effect December 1, 2014), and receives either Title X funding or family planning funding from the Ohio department of health.

(FFF) "Risk" or "underwriting risk" means the possibility that an MCP may incur a loss because the cost of providing services may exceed the payments made by ODM to the contractor for services covered under the provider agreement.

(GGG) "RHC" means a rural health clinic as defined in rule 5160-16-01 of the Administrative Code.

(HHH) "Self-referral" means the process by which an MCP member may access certain services without prior approval from the PCP or the MCP.

(III) "Service area" means the geographic area specified in the MCP's provider agreement.

(JJJ) "SFY (state fiscal year)" means the period July first through June thirtieth, corresponding to the state of Ohio's fiscal year.

(KKK) "State cut-off" means the eighth state working day prior to the end of a calendar month.

(LLL) "Subcontract" means a written contract between an MCP and a third party, including the MCP's parent company or any subsidiary corporation owned by the MCP's parent company, or between the third party and a fourth party, or between any subsequent parties, to perform a specific part of the obligations specified under the MCP's provider agreement with ODM.

(MMM) "Subcontractor" means any party that has entered into a subcontract to perform a specific part of the obligations specified under the MCP's provider agreement with ODM.

(NNN) "Third party benefit" means any health care service(s) available to members through any medical insurance policy or through some other resource that covers medical benefits and the payment for those services is either completely the obligation of the TPP or in part the obligation of the member, the TPP, and/or the MCP.

(OOO) "Third party claim" means any claim submitted to the MCP for reimbursement after all TPPs have met their payment obligations. In addition, the following will be considered third party claims by the MCP:

(1) Any claim received by the MCP that shows no prior payment by a TPP, but the MCP's records indicate that the member has third party benefits.

(2) Any claim received by the MCP that shows no prior payment by a TPP, but the provider's records indicate that the member has third party benefits.

(PPP) "TP (third party)" is as defined in section 5160.35 of the Revised Code.

(QQQ) "TPA (third party administrator)" means any entity utilized in accordance with the provisions of this chapter to manage or administer a portion of services in fulfillment of the provider agreement with ODM.

(RRR) "TPL (third party liability)" means the payment obligations of the TPP for health care services rendered to a member when the member also has third party benefits as described in paragraph (NNN) of this rule.

(SSS) "TPP (third party payer)" means an individual, an entity, or a program responsible for adjudicating and paying claims for third party benefits rendered to an eligible member.

(TTT) "Title V," otherwise known as the "program for medically handicapped children," means the program established under sections 3701.021 to 3701.0210 of the Revised Code.

(UUU) "Title X services" means services and supplies allowed under 42 U.S.C. 300 ( as in effect December 1, 2014), and provided by a qualified family planning provider.

(VVV) "Tort action," otherwise known as "subrogation," means the right of ODM to recover payment received from a third party payer who may be liable for the cost of medical services and care arising out of an injury, disease, or disability to the member.

(WWW) "United States" means the fifty states, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.

Effective: 2/1/2015
Five Year Review (FYR) Dates: 10/30/2014 and 02/01/2020
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5164.02, 5167.03, 5167.10, 5167.13
Prior Effective Dates: 4/1/85, 2/1/89 (Emer), 2/15/89 (Emer), 4/23/89, 5/15/89 (Emer), 5/1/92, 7/31/92 (Emer), 10/25/92, 5/1/93, 11/1/94, 7/1/96, 7/1/97 (Emer), 9/27/97, 5/14/99, 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, 9/15/08, 7/1/09, 1/1/2012, 7/1/13

5160-26-02 Managed health care programs: eligibility, membership, and automatic renewal of membership.

(A) This rule does not apply to "MyCare Ohio" plans as defined in rule 5160-58-01 of the Administrative Code. The eligibility, membership, and automatic renewal provisions for "MyCare Ohio" plans are described in rule 5160-58-02 of the Administrative Code.

(B) Eligibility.

(1) In mandatory service areas as permitted by 42 CFR 438.52 (October 1, 2013), an individual must be enrolled in an MCP if he or she meets the following criteria and paragraphs (B)(2) to (B)(5) of this rule do not apply:

(a) Eligible for covered families and children (CFC) medicaid in accordance with Chapter 5160:1-4 of the Administrative Code or modified adjusted gross income (MAGI)-based medicaid eligibility in accordance with division 5160:1 of the Administrative Code; or

(b) Eligible for aged, blind, or disabled (ABD) medicaid in accordance with Chapter 5160:1-3 of the Administrative Code.

(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;

(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, 42 U.S.C. 701(a)(1)(D) (as in effect December 1, 2014) and is defined by the state in terms of either program participation or special health care needs ;and

(e) Indians who are members of federally recognized tribes.

(4) 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 5166.02 of the Revised Code.

(5) Individuals are excluded from MCP membership when excluded under a federally approved state plan or state law from MCP enrollment.

(6) 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) Enrollment.

(1) The following applies to enrollment in an MCP:

(a) The MCP must accept eligible individuals without regard to 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 in accordance with 42 C.F.R. 438.6(d) ( October 1, 2013).

(b) The MCP must accept eligible individuals who request MCP membership without restriction.

(c) The MCP must accept PCP(s) selected by the member when available, except as otherwise provided in this rule.

(d) 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 re-instated.

(e) 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.

(f) 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) (3) of this rule or upon mutual agreement between ODM and the MCP.

(2) Should a service area change from voluntary to mandatory, the notice rights in this rule must be followed.

(a) 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)(1)(e) 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.

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

(i) An individual 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 medicaid consumer hotline, or other ODM-approved entity.

(ii) ODM or the medicaid consumer hotline shall assign the individual to an MCP based on prior medicaid fee-for-service or MCP membership history, whenever available, or at the discretion of ODM.

(3) 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, in accordance with the enrollment and disenrollment criteria specified in Chapter 5160-26 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) (3) 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 5160-2- 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 5160-26- 02.1 of the Administrative Code, except if the member becomes ineligible for medicaid; 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 medicaid consumer hotline 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: 4/1/2015
Five Year Review (FYR) Dates: 10/30/2014 and 04/01/2020
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5164.02, 5167.03, 5167.10
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, 7/1/13

5160-26-02.1 Managed health care programs: termination of membership.

(A) This rule does not apply to "MyCare Ohio" plans as defined in rule 5160-58-01 of the Administrative Code. Termination of membership provisions for "MyCare Ohio" plans are described in rule 5160-58- 02.1 of the Administrative Code.

ODM will terminate a member from membership in a managed care plan (MCP) for any of the following reasons:

(1) The member becomes ineligible for medicaid. When this occurs, termination of MCP membership takes effect at the end of the last day of the month in which the member became ineligible.

(2) The member's permanent place of residence is moved outside the MCP membership service area. When this occurs, termination of MCP membership takes effect at the end of the last day of the month in which the member moved from the service area.

(3) The member dies, in which case the period of MCP membership ends on the date of death.

(4) The member is placed in a residential facility for the treatment of behavioral or developmental health issues and the Ohio department of medicaid (ODM) determines that ongoing receipt of health care through the MCP may not be in the best interest of the member or meet the rules of MCP enrollment. Upon ODM approval, termination of MCP membership is effective the last day of the month preceding placement.

(5) The member is incarcerated for either more than fifteen working days or is incarcerated and has accessed non-emergent medical care. When this occurs and after ODM receives notification from the member's MCP, a county department of job and family services (CDJFS), or other public agency, termination of MCP membership takes effect the last day of the month prior to incarceration.

(6) The member is found by ODM to meet the criteria for an intermediate care facility for individuals with intellectual disabilities (ICF-IID) level of care and is then placed in an ICF-IID facility. Following MCP notification to ODM and approval by ODM, termination of MCP membership takes effect on the last day of the month preceding placement in the ICF-IID facility.

(7) The member is enrolling in the MCP from medicaid fee-for-service, is placed in a nursing facility (NF) prior to the membership effective date and remains in the NF on the membership effective date. Following MCP notification to ODM and approval by ODM, termination of MCP membership is effective the last day of the month preceding placement in the NF. The MCP must submit required documentation which includes, but is not limited to, a copy of the approved level of care (LOC) obtained pursuant to agency 5160 of the Administrative Code and a copy of the NF admission form or other proof of NF admission. The provisions in this paragraph do not apply to individuals who reside in a NF and remain eligible for MCP enrollment pursuant to a federally approved state plan.

(8) The member is authorized by the MCP for NF services in accordance with the criteria for NF coverage described in rule 5160-26-03 of the Administrative Code. Following MCP notification to ODM and approval by ODM, membership termination is effective the last day of the second calendar month following the month of NF admission. The MCP must submit required documentation which includes, but is not limited to, a copy of the approved level of care (LOC) obtained pursuant to agency 5160 of the Administrative Code and a copy of the NF admission form or other proof of NF admission. The provisions in this paragraph do not apply to individuals who reside in a NF and remain eligible for MCP enrollment pursuant to a federally approved state plan.

(9) The member is enrolled in a home and community-based waiver program administered by ODM, the Ohio department of aging (ODA), or the Ohio department of developmental disabilities (ODODD). When this occurs, termination of MCP membership is effective no later than the last day of the month preceding enrollment in the home and community-based waiver program.

(10) The member is a minor, and his or her custody has been legally transferred from the legal parent or guardian to another entity. When this occurs, following appropriate notification to ODM, termination of MCP membership is effective the last day of the month preceding the transfer.

(11) The member has third party coverage and ODM determines that continuing MCP membership may not be in the best interest of the member. This determination may be based on the type of coverage the member has, the existence of conflicts between provider panels, or access requirements. When this occurs, the effective date of termination of MCP membership shall be determined by ODM but in no event shall the termination date be later than the last day of the month in which ODM approves the termination.

(12) The provider agreement between ODM and the MCP is terminated.

(13) The member is not eligible for enrollment in the MCP for one of the reasons set forth in rule 5160-26-02 of the Administrative Code.

(B) All of the following apply when membership in an MCP is terminated for any of the reasons set forth in paragraph (A) of this rule:

(1) Such terminations may occur either in a mandatory or voluntary service area.

(2) All such terminations occur at the individual level.

(3) Such terminations do not require completion of a consumer contact record (CCR).

(4) If ODM fails to notify the MCP of a member's termination from an MCP, ODM shall continue to pay the MCP the applicable monthly premium rate for the member, subject to the provisions of rule 5160-26-09 of the Administrative Code. The MCP shall remain liable for the provision of covered services as set forth in rule 5160-26-03 of the Administrative Code, until such time as ODM provides the MCP with documentation of the member's termination.

(5) ODM shall recover from the MCP any premium paid for retroactive membership termination occurring as a result of paragraph (A) of this rule.

(6) A member may lose medicaid eligibility during an annual open enrollment period, and thus become temporarily unable to change to a different MCP. If the member then regains medicaid eligibility, he or she may request to change plans within thirty days following reenrollment in the MCP.

(C) Member-initiated terminations

(1) An MCP member may request a different MCP in a mandatory service area as follows:

(a) From the date of enrollment through the initial three months of MCP membership;

(b) During an open enrollment month for the member's service area as described in paragraph (E) of this rule; or

(c) At any time, if the just cause request meets one of the reasons for just cause as specified in paragraph (C)(3)(e) of this rule;

(2) An MCP member may request a different MCP if available or be returned to medicaid fee-for-service in a voluntary service area as follows:

(a) From the date of enrollment through the initial three months of MCP membership;

(b) During an open enrollment month for the member's service area as described in paragraph (E) of this rule; or

(c) At any time, if the just cause request meets one of the reasons for just cause as specified in paragraph (C)(3)(e) of this rule;

(3) The following provisions apply when a member either requests a different plan in a mandatory service area or requests disenrollment in a voluntary service area:

(a) The request may be made by the member, or by the member's authorized representative, as defined in rule 5160-26-01 of the Administrative Code.

(b) All member-initiated changes or terminations must be voluntary. MCPs are not permitted to encourage members to change or terminate enrollment due to a member's age, gender, sexual orientation, disability, national origin, race, color, religion, military status, ancestry, genetic information, health status or need for health services. MCPs may not use a policy or practice that has the effect of discrimination on the basis of the criteria listed in this rule.

(c) If a member requests disenrollment because he or she is a member of a federally-recognized tribe, as described in 42 CFR 438.50(d)(2) (October 1, 2013), the member will be disenrolled after the member notifies the consumer hotline.

(d) Disenrollment will take effect on the last day of the calendar month or the succeeding calendar month, subject to state cut-off.

(e) In accordance with 42 C.F.R. 438.56(d)(2) (October 1, 2013), a change or termination of MCP membership may be permitted for any of the following just cause reasons:

(i) The member moves out of the MCP's service area and a non-emergency service must be provided out of the service area before the effective date of the member's termination as described in paragraph (A)(2) of this rule;

(ii) The MCP does not, for moral or religious objections, cover the service the member seeks;

(iii) The member needs related services to be performed at the same time; not all related services are available within the MCP network, and the member's PCP or another provider determines that receiving services separately would subject the member to unnecessary risk;

(iv) The member has experienced poor quality of care and the services are not available from another provider within the MCP's network;

(v) The member cannot access medically necessary medicaid-covered services or cannot access the type of providers experienced in dealing with the member's health care needs;

(vi) The PCP selected by a member leaves the MCP's panel and was the only available and accessible PCP speaking the primary language of the member, and another PCP speaking the language is available and accessible in another MCP in the member's service area; and

(vii) ODM determines that continued membership in the MCP would be harmful to the interests of the member.

(f) The following provisions apply when a member seeks a change or termination in MCP membership for just cause:

(i) The member or an authorized representative must contact the MCP to identify providers of services before seeking a determination of just cause from ODM.

(ii) The member may make the request for just cause directly to ODM or an ODM-approved entity, either orally or in writing.

(iii) ODM shall review all requests for just cause within seven working days of receipt. ODM may request documentation as necessary from both the member and the MCP. ODM shall make a decision within forty-five days from the date ODM receives the just cause request. If ODM fails to make the determination within this timeframe, the just cause request is considered approved.

(iv) ODM may establish retroactive termination dates and recover premium payments as determined necessary and appropriate.

(v) Regardless of the procedures followed, the effective date of an approved just cause request must be no later than the first day of the second month following the month in which the member requests change or termination.

(vi) If the just cause request is not approved, ODM shall notify the member or the authorized representative of the member's right to a state hearing.

(vii) Requests for just cause may be processed at the individual level or case level as ODM determines necessary and appropriate.

(viii) If a member submits a request to change or terminate membership for just cause, and the member loses medicaid eligibility prior to action by ODM on the request, ODM shall assure that the member's MCP membership is not automatically renewed if eligibility for medicaid is reauthorized.

(D) The following provisions apply when a termination in MCP membership is initiated by an MCP:

(1) An MCP may submit a request to ODM for the termination of a member for the following reasons:

(a) Fraudulent behavior by the member; or

(b) Uncooperative or disruptive behavior by the member or someone acting on the member's behalf to the extent that such behavior seriously impairs the MCP's ability to provide services to either the member or other MCP members.

(2) The MCP may not request termination due to the member's age, gender, sexual orientation, disability, national origin, race, color, religion, military status, genetic information, ancestry, health status or need for health services.

(3) The MCP must provide medicaid-covered services to a terminated member(s) through the last day of the month in which the MCP membership is terminated, notwithstanding the date of ODM approval of the termination request. Inpatient facility services must be provided in accordance with rule 5160-26-02 of the Administrative Code.

(4) If ODM approves the MCP's request for termination, ODM shall notify in writing the member, the authorized representative, the medicaid consumer hotline and the MCP.

(E) Open enrollment

Open enrollment months will occur at least annually. At least sixty days prior to the designated open enrollment month, ODM will notify eligible individuals by mail of the opportunity to change or terminate MCP membership and will explain where to obtain further information.

Replaces: 5160-26- 02.1

Effective: 7/2/2015
Five Year Review (FYR) Dates: 07/02/2020
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5164.02, 5167.03, 5167.10
Prior Effective Dates: 4/1/85, 2/15/89 (Emer), 5/8/89, 5/18/89, 10/9/89, 11/1/89 (Emer), 2/1/90, 2/15/90, 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, 11/6/00, 7/1/01, 7/1/02, 7/1/03, 7/1/04, 10/31/05, 6/1/06, 7/1/07, 1/1/08, 8/26/08 (Emer), 10/9/08, 7/1/09, 2/1/10, 8/1/10, 7/1/13

5160-26-03 Managed health care programs: covered services.

(A) Except as provided in this rule, managed care plans (MCPs) must ensure that members have access to all medically-necessary services covered by medicaid. Specific coverage provisions for "MyCare Ohio" plans as defined in rule 5160-58-01 are described in Chapter 5160-58 of the Administrative Code. The MCP must ensure that:

(1) Services are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished;

(2) The amount, duration, or scope of a required service is not arbitrarily denied or reduced solely because of the diagnosis, type of illness, or condition;

(3) Coverage decisions are based on the coverage and medical necessity criteria published in agency 5160 of the Administrative Code and practice guidelines specified in rule 5160-26- 05.1 of the Administrative Code; and

(4) If a member is unable to obtain medically-necessary services offered by medicaid from a MCP panel provider, the MCP must adequately and timely cover the services out of panel, until the MCP is able to provide the services from a panel provider.

(B) MCPs may place appropriate limits on a service;

(1) On the basis of medical necessity; or

(2) For the purposes of utilization control, provided the services furnished can be reasonably expected to achieve their purpose as specified in paragraph (A)(1) of this rule.

(C) MCPs must cover annual physical examinations for adults.

(D) At the request of the member, MCPs must provide for a second opinion from a qualified health care professional within the panel. If such a qualified health care professional is not available within the MCP's panel, the MCP must arrange for the member to obtain a second opinion outside the panel, at no cost to the member.

(E) MCPs must assure that emergency services as defined in rule 5160-26-01 of the Administrative Code are provided and covered twenty-four hours a day, seven days a week. At a minimum, such services must be provided and reimbursed in accordance with the following:

(1) MCPs may not deny payment for treatment obtained when a member had an emergency medical condition, as defined in rule 5160-26-01 of the Administrative Code.

(2) MCPs cannot limit what constitutes an emergency medical condition on the basis of lists of diagnoses or symptoms.

(3) MCPs must cover all emergency services without requiring prior authorization.

(4) MCPs must cover medicaid-covered services related to the member's emergency medical condition when the member is instructed to go to an emergency facility by a representative of the MCP including but not limited to the member's PCP or the MCP's twenty-four-hour toll-free call-in-system.

(5) MCPs cannot deny payment of emergency services based on the treating provider, hospital, or fiscal representative not notifying the member's PCP of the visit.

(6) For the purposes of this paragraph, "non-contracting provider of emergency services" means any person, institution, or entity who does not contract with the MCP but provides emergency services to an MCP member, regardless of whether or not that provider has a medicaid provider agreement with ODM. An MCP must cover emergency services as defined in rule 5160-26-01 of the Administrative Code when the services are delivered by a non-contracting provider of emergency services and claims for these services cannot be denied regardless of whether the services meet an emergency medical condition as defined in rule 5160-26-01 of the Administrative Code. Such services must be reimbursed by the MCP at the lesser of billed charges or one hundred per cent of the Ohio medicaid program reimbursement rate (less any payments for indirect costs of medical education and direct costs of graduate medical education that is included in the Ohio medicaid program reimbursement rate) in effect for the date of service. If an inpatient admission results, the MCP is required to reimburse at this rate only until the member can be transferred to a provider designated by the MCP. Pursuant to section 5167.10 of the Revised Code, the MCP shall not compensate a hospital for inpatient capital costs in an amount that exceeds the maximum rate established by ODM.

(7) MCPs must adhere to the judgment of the attending provider when requesting a member's transfer to another facility or discharge. MCPs may establish arrangements with hospitals whereby the MCP may designate one of its contracting providers to assume the attending provider's responsibilities to stabilize, treat and transfer the member.

(8) A member who has had an emergency medical condition may not be held liable for payment of any subsequent screening and treatment needed to diagnose the specific condition or stabilize the member.

(F) MCPs must establish, in writing, the process and procedures for the submission of claims for services delivered by non-contracting providers, including non-contracting providers of emergency services as described in paragraph (E)(6) of this rule. Such information must be made available to non-contracting providers, including non-contracting providers of emergency services, on request. MCPs may not establish claims filing and processing procedures for non-contracting providers, including non-contracting providers of emergency services, that are more stringent than those established for their contracting providers.

(G) MCPs must assure that post-stabilization care services as defined in rule 5160-26-01 of the Administrative Code are provided and covered twenty-four hours a day, seven days a week.

(1) The MCP must designate a telephone line to receive provider requests for coverage of post-stabilization care services. The line must be available twenty-four hours a day. MCPs must document that the telephone number and process for obtaining authorization has been provided to each emergency facility in the service area. The MCP must maintain a record of any request for coverage of post-stabilization care services that is denied including, at a minimum, the time of the provider's request and the time that the MCP communicated the decision in writing to the provider.

(2) At a minimum, post-stabilization care services must be provided and reimbursed in accordance with the following:

(a) MCPs must cover services obtained within or outside the MCP's panel that are pre-approved in writing to the requesting provider by a plan provider or other MCP representative.

(b) MCPs must cover services obtained within or outside the MCP's panel that are not pre-approved by a plan provider or other MCP representative but are administered to maintain the member's stabilized condition within one hour of a request to the MCP for preapproval of further post-stabilization care services.

(c) MCPs must cover services obtained within or outside the MCP's panel that are not pre-approved by a plan provider or other MCP representative but are administered to maintain, improve or resolve the member's stabilized condition if:

(i) The MCP fails to respond within one hour to a provider request for authorization to provide such services.

(ii) The MCP cannot be contacted.

(iii) The MCP's representative and treating provider cannot reach an agreement concerning the member's care and a plan provider is not available for consultation. In this situation, the MCP must give the treating provider the opportunity to consult with a plan provider and the treating provider may continue with care until a plan provider is reached or one of the criteria specified in paragraph (G)(3) of this rule is met.

(3) The MCP's financial responsibility for post stabilization care services it has not pre-approved ends when:

(a) A plan provider with privileges at the treating hospital assumes responsibility for the member's care;

(b) A plan provider assumes responsibility for the member's care through transfer;

(c) An MCP representative and the treating provider reach an agreement concerning the member's care; or

(d) The member is discharged.

(H) Exclusions, limitations and clarifications.

(1) When an MCP member is placed in a nursing facility (NF) , the MCP is responsible for payment of medically necessary NF services as described in rule 5160-3- 02.3 of the Administrative Code. Except for populations for whom enrollment in an MCP does not specifically exclude NF residence, as documented in any federally approved state plan amendment (SPA), the member may be disenrolled upon request to ODM by the MCP in accordance with 5160-26- 02.1 of the Administrative Code if all of the following are met:

(a) The MCP has authorized NF services for no less than the month of NF admission and for one complete consecutive calendar month thereafter;

(b) For the entire period in (a) above, the member has remained in the NF without any admission to an inpatient hospital or long-term acute care (LTAC) facility;

(c) The member's discharge plan documents that NF discharge is not expected in the foreseeable future and the member has a need for long-term NF care ;

(d) For the entire period in paragraph (H)(1)(a) of this rule, the member is not using hospice services; and

(e) ODM has approved the request.

(2) MCPs are not responsible for payment of services provided to a member that has been enrolled in a home and community-based waiver program administered by ODM, the Ohio department of aging (ODA), or the Ohio department of developmental disabilities (ODODD). MCP members enrolled in waiver programs will be disenrolled in accordance with 5160-26- 02.1 of the Administrative Code.

(3) MCP members are permitted to self-refer to mental health services and substance abuse services offered through the Ohio department of mental health and addiction services (MHA) community mental health centers and MHA-certified medicaid providers. MCPs must ensure access to medicaid-covered behavioral health services for members who are unable to timely access services or unwilling to access services through community providers.

(4) MCP members are permitted to self-refer to Title X services provided by any qualified family planning provider (QFPP). The MCP is responsible for payment of claims for Title X services delivered by QFPPs not contracting with the MCP at the lesser of one hundred per cent of the Ohio medicaid program fee-for-service reimbursement rate or billed charges, in effect for the date of service.

(5) MCPs must permit members to self-refer to any women's health specialist within the MCP's panel for covered care necessary to provide women's routine and preventative health care services. This is in addition to the member's designated PCP if that PCP is not a women's health specialist.

(6) MCPs must ensure access to covered services provided by all federally qualified health centers (FQHCs) and rural health clinics (RHCs).

(7) Where available, MCPs must ensure access to covered services provided by a certified nurse practitioner.

(8) ODM may approve an MCP's members to be referred to certain MCP non-contracting hospitals, as specified in rule 5160-26-11 of the Administrative Code, for medicaid-covered non-emergency hospital services. When ODM permits such authorization, ODM will notify the MCP and the MCP non-contracting hospital of the terms and conditions, including the duration, of the approval and the MCP must reimburse the MCP non-contracting hospital at one hundred per cent of the current Ohio medicaid program fee-for-service reimbursement rate in effect for the date of service for all medicaid-covered non-emergency hospital services delivered by the MCP non-contracting hospital. ODM will base its determination of when an MCP's members can be referred to MCP non-contracting hospitals pursuant to the following:

(a) The MCP's submission of a written request to ODM for the approval to refer members to a hospital that has declined to contract with the MCP. The request must document the MCP's contracting efforts and why the MCP believes it will be necessary for members to be referred to this particular hospital; and

(b) ODM consultation with the MCP non-contracting hospital to determine the basis for the hospital's decision to decline to contract with the MCP, including but not limited to whether the MCP's contracting efforts were unreasonable and/or that contracting with the MCP would have adversely impacted the hospital's business.

(9) Paragraph (H) (8) of this rule is not applicable when an MCP and an MCP non-contracting hospital have mutually agreed to that hospital providing non-emergency hospital services to an MCP's members. The MCP must ensure that such arrangements comply with 5160-26-05 of the Administrative Code.

(10) MCPs are not responsible for payment of services provided through medicaid school program (MSP) providers pursuant to Chapter 5160-35 of the Administrative Code. MCPs must ensure access to medicaid-covered services for members who are unable to timely access services or unwilling to access services through MSP providers.

(11) MCPs are responsible for providing respite services to eligible members, as described in this paragraph. "Respite services" are services that provide short-term, temporary relief to the informal unpaid caregiver of an individual under the age of twenty-one in order to support and preserve the primary caregiving relationship. The service provides general supervision of the child, and meal preparation and hands-on assistance with personal care that are incidental to supervision of the child during the period of service delivery. Respite services can be provided on a planned or emergency basis and shall only be furnished in the child's home. The provider must be awake during the provision of respite services and the services shall not be provided overnight.

(a) To be eligible for respite services, the member must meet all of the following criteria:

(i) The member must reside with his or her informal, unpaid primary caregiver in a home or an apartment that is not owned, leased or controlled by a provider of any health-related treatment or support services.

(ii) The member must not be residing in foster care.

(iii) The member must be under the age of twenty-one and determined eligible for social security income for children with disabilities or supplemental security disability income .

(iv) The member must be enrolled in the MCP's care management program.

(v) The member must be determined by the MCP to meet an institutional level of care as set forth in rules 5160-3-07 and 5160-3-08 of the Administrative Code.

(vi) The member must require skilled nursing or skilled rehabilitation services at least once per week.

(vii) The member must have received at least fourteen hours per week of home health aide services for at least six consecutive months immediately preceding the date respite services are requested.

(viii) The MCP must have determined that the child's primary caregiver has a need for temporary relief from the care of the child as a result of the child's long term services and support needs/disabilities, or in order to prevent the provision of institution or out-of-home placement.

(b) Respite services are limited to no more than twenty-four hours per month and no more than two hundred fifty hours per calendar year.

(c) Respite services must be provided by individuals employed by enrolled medicaid providers that are either medicare-certified home health agencies pursuant to Chapter 3701-60 of the Administrative Code, or otherwise-accredited agencies (i.e., accredited by the "Joint Commission", the "Community Health Accreditation Program", or the "Accreditation Commission for Health Care") as that term is defined in rule 5160-45-01 of the Administrative Code.

(i) Before commencing service delivery, the provider agency employee must:

(a) Obtain a certificate of completion of either a competency evaluation program or training and competency evaluation program approved or conducted by the Ohio department of health under Section 3721.31 of the Revised Code, or the medicare competency evaluation program for home health aides as specified in 42 CFR 484.36 ( October 1, 2013), and

(b) Obtain and maintain first aid certification from a class that is not solely internet-based and that includes hands-on training by a certified first aid instructor and a successful return demonstration of what was learned in the course.

(ii) After commencing service delivery, the provider agency employee must:

(a) Maintain evidence of completion of twelve hours of in-service continuing education within a twelve-month period, excluding agency and program-specific orientation, and

(b) Receive supervision from an Ohio-licensed RN and meet any other additional supervisory requirements pursuant to the agency's certification or accreditation.

(d) Respite services must not be delivered by the child's legally responsible family member or foster caregiver.

(12) MCPs must provide all early and periodic screening, diagnosis and treatment (EPSDT) services, also known as healthchek services, in accordance with the periodicity schedule identified in Chapter 5160-14 of the Administrative Code, to eligible individuals and assure that services are delivered and monitored as follows:

(a) Healthchek exams must include those components specified in Chapter 5160-14 of the Administrative Code. All components of exams must be documented and included in the medical record of each healthchek eligible member and made available for the ODM annual external quality review.

(b) The MCP or its contracting provider must notify members of the appropriate healthchek exam intervals as specified in Chapter 5160-14 of the Administrative Code.

(c) Healthchek exams are to be completed within ninety days of the initial effective date of membership for those children found to have a possible ongoing condition likely to require care management services.

(I) Out-of-country coverage

MCPs are not required to cover services provided to members outside the United States.

Effective: 7/2/2015
Five Year Review (FYR) Dates: 07/01/2018
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5167.03, 5167.20, 5167.201, 5167.10, 5167.12
Prior Effective Dates: 4/1/85, 5/2/85, 10/1/87, 2/15/89 (Emer), 5/8/89, 11/1/89 (Emer), 5/1/92, 5/1/93, 11/1/94, 7/1/96, 7/1/97 (Emer), 9/27/97, 5/14/99, 12/10/99, 7/1/00, 7/1/01, 7/1/02, 7/1/03, 1/1/06, 6/1/06, 1/1/07, 7/1/07, 1/1/08, 9/15/08, 2/1/10, 10/1/11, 7/1/13, 1/1/14

5160-26-03.1 Managed health care programs: care coordination.

(A) Managed care plan (MCP) care coordination responsibilities.

(1) MCPs must ensure that each member has a primary care provider (PCP) who will serve as an ongoing source of primary care and assist with care coordination appropriate to the member's needs. The care coordination responsibilities of a PCP are set forth in paragraph (B) of this rule.

(2) MCPs must ensure that PCPs are in compliance with the following triage requirements:

(a) Members with emergency care needs must be triaged and treated immediately on presentation at the PCP site;

(b) Members with persistent symptoms must be treated no later than the end of the following working day after their initial contact with the PCP site; and

(c) Members with requests for routine care must be seen within six weeks.

(3) At the request of the member, MCPs must provide for a second opinion from a qualified health care professional within the MCP's panel. If such a qualified health care professional is not available within the MCP's panel, the MCP must arrange for the member to obtain a second opinion outside the panel, at no cost to the member.

(4) Care coordination with ODM-designated providers.

(a) MCPs are required to share specific information with ODM-designated non-panel providers . Such information includes, but is not limited to, the MCP's contact information, prior authorization procedures, and a list of panel laboratories and pharmacies.

(b) Upon request, MCPs must provide information to ODM to document the non-contracting providers identified by the MCP under paragraph (A)(4)(a) of this rule and the information the MCP provided to each provider.

(5) MCPs that require referrals to specialists must ensure that information on referral approvals and denials is made available to ODM upon request.

(6) MCPs must provide a centralized toll-free call-in system that is available nationwide twenty-four hours a day, seven days a week.

(a) The call-in system must be staffed by trained medical professionals who will provide members with medical advice and direct members to the appropriate care setting. Such system must also provide information to members and/or providers as necessary to assure access, including, but not limited to, membership status. MCPs may not require members to contact their PCP or any other entity prior to contacting the twenty-four-hour toll-free call-in system for advice or direction concerning emergency and/or after-hours services.

(b) A log for the twenty-four-hour toll-free call-in system must be maintained, and accessible, by the MCP and must include at a minimum:

(i) Identification of the member;

(ii) Date and time of call;

(iii) Member's question, concern, or presenting problem;

(iv) Disposition of call;

(v) PCP or other provider if contacted by MCP; and

(vi) Name and title of person taking the call.

(c) The twenty-four-hour toll-free call-in system must have services available to assist:

(i) Hearing impaired members; and

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

(7) The MCP must have a utilization management (UM) program with clearly defined structures and processes designed to maximize the effectiveness of the care provided to the member. MCPs must ensure that decisions rendered through the UM program are based on medical necessity.

(a) The UM program must be based on written policies and procedures that include, at a minimum, the following:

(i) The specification of the information sources used to make determinations of medical necessity;

(ii) The criteria, based on sound clinical evidence, to make UM decisions and the specific procedures for appropriately applying the criteria;

(iii) A specification that written utilization management criteria will be made available to both contracting and non-contracting providers; and

(iv) A description of how the MCP will monitor the impact of the UM program to detect and correct potential under- and over-utilization.

(b) The MCP's UM program must also assure and document the following:

(i) An annual review and update of the UM program.

(ii) The involvement of a designated senior physician in the UM program.

(iii) The use of appropriate qualified licensed health professionals to assess the clinical information used to support UM decisions.

(iv) The use of board-certified consultants to assist in making medical necessity determinations, as necessary.

(v) That UM decisions are consistent with clinical practice guidelines as specified in paragraph (B) of rule 5101:3-26-05.1 of the Administrative Code. MCPs may not impose conditions around the coverage of a medically necessary medicaid-covered service unless they are supported by such clinical practice guidelines.

(vi) The reason for each denial of a service, based on sound clinical evidence.

(vii) That compensation by the MCP to individuals or entities that conduct UM activities does not offer incentives to deny, limit, or discontinue medically necessary services to any member.

(c) MCPs must process requests for initial and continuing authorizations of services from their providers and members. MCPs must have written policies and procedures to process requests and, upon request, the MCP's policies and procedures must be made available for review by ODM. The MCP's written policies and procedures for initial and continuing authorizations of services must also be made available to contracting and non-contracting providers upon request. The MCPs must assure and document the following occurs when processing requests for initial and continuing authorizations of services:

(i) Consistent application of review criteria for authorization decisions.

(ii) Consultation with the requesting provider, when necessary.

(iii) That any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested, be made by a health care professional who has appropriate clinical expertise in treating the member's condition or disease.

(iv) That a written notice will be sent to the member and the requesting provider of any decision to reduce, suspend, terminate, or deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice to the member must meet the requirements of rules 5101:6-2-35, 5101:3-26-08.4, and 5101:3-26- 08.5 of the Administrative Code.

(v) For standard authorization decisions, the MCP must provide notice to the provider and member as expeditiously as the member's health condition requires but no later than fourteen calendar days following receipt of the request for service, except as specified in paragraph (A)(7)(c)(viii) of this rule. If requested by the member, provider, or MCP, standard authorization decisions may be extended up to fourteen additional calendar days. If requested by the MCP, the MCP must submit to ODM for prior-approval, documentation as to how the extension is in the member's interest. If ODM approves the MCP's extension request, the MCP must give the member written notice of the reason for the decision to extend the time frame and inform the member of the right to file a grievance if he or she disagrees with that decision. The MCP must carry out its determination as expeditiously as the member's health condition requires and no later than the date the extension expires.

(vi) If a provider indicates or the MCP determines that following the standard authorization timeframe could seriously jeopardize the member's life or health or ability to attain, maintain, or regain maximum function, the MCP must make an expedited authorization decision and provide notice of the authorization decision as expeditiously as the member's health condition requires but no later than three working days after receipt of the request for service. If requested by the member or MCP, expedited authorization decisions may be extended up to fourteen additional calendar days. If requested by the MCP, the MCP must submit to ODM for prior-approval, documentation as to how the extension is in the member's interest. If ODM approves the MCP's extension request, the MCP must give the member written notice of the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if he or she disagrees with that decision. The MCP must carry out its determination as expeditiously as the member's health condition requires and no later than the date the extension expires.

(vii) Service authorization decisions not reached within the timeframes specified in paragraphs (A)(7)(c)(v) and (A)(7)(c)(vi) of this rule constitute a denial, and the MCPs must give notice to the member as specified in paragraph (B)(2)(d) of rule 5101:3-26-08.4 of the Administrative Code.

(viii) Prior authorization decisions for covered outpatient drugs as defined in 42 U.S.C. 1396r - 8(k)(2) ( May 1, 2013) must be made by telephone or other telecommunication device within twenty-four hours of the initial request. When an emergency situation exists, a seventy-two hour supply of the covered outpatient drug that was prescribed must be authorized. If the MCP is unable to obtain the information needed to make the prior-authorization decision within seventy-two hours, the decision timeframe has expired and the MCP must give notice to the member as specified in paragraph (B)(2)(d) of rule 5101:3-26-08.4 of the Administrative Code. All other pharmacy prior authorization decisions must be made by no later than the end of the second working day following receipt of the request, or as expeditiously as the member's condition warrants.

(ix) MCPs must maintain and submit as directed by ODM, a record of all authorization requests, including standard and expedited authorization requests and any extensions granted. MCP records must include member identifying information, service requested, date initial request received, any extension requests, decision made, date of decision, date of member notice, and basis for denial, if applicable.

(d) MCPs must implement the ODM-required emergency department diversion program for frequent users.

(e) Pursuant to section 5111.172 of the Revised Code, MCPs may, subject to ODM prior approval, implement strategies for the management of drug utilization. At a minimum, MCPs must implement a coordinated services program (CSP) as described in rule 5101:3-20-01 of the Administrative Code. MCPs must provide members with a notice of their right to a state hearing in accordance with rules 5101:3-26-08.5 and 5101:6-2-40 of the Administrative Code before enrolling or continuing the enrollment of a member in CSP. If a member requests a state hearing regarding CSP enrollment within the fifteen day prior notice period set forth in rule 5101:6-4-01 of the Administrative Code, an MCP shall enroll the member into CSP no sooner than the hearing decision mail date. If a member requests a timely hearing regarding continued enrollment in CSP, CSP enrollment shall continue until the hearing decision is rendered. MCPs must also provide care management services to any member enrolled in CSP.

(f) MCPs may develop other utilization management programs subject to ODM prior approval.

(8) MCPs must provide care management (CM) services to coordinate and monitor treatment rendered to members with specific diagnoses or who require high-cost or extensive services.

(a) MCPs must notify all members of the CM services they may be eligible to receive.

(b) The MCP's CM program must include and document the following, at a minimum:

(i) Identification of members who potentially meet the criteria for care management;

(ii) Assessment of the member to determine the need for care management;

(iii) Assignment of the member to a risk stratification level;

(iv) Notification to the member and his or her PCP of the member's enrollment in the MCP's care management program;

(v) Development, implementation, and ongoing monitoring of a care plan for members in care management; and

(vi) Assignment of an accountable point of contact.

(c) MCPs must report care management program-related data to ODM, as required.

(B) PCP care coordination responsibilities include at a minimum the following:

(1) Assisting with coordination of the member's overall care, as appropriate for the member;

(2) Serving as the ongoing source of primary and preventive care;

(3) Recommending referrals to specialists, as required;

(4) Triaging members as described in paragraph (A)(2) of this rule;

(5) Participating in the development of care plans as described in paragraph (A)(8) of this rule; and

(6) Notifying the MCP of members who may benefit from care management.

Effective: 10/01/2013
R.C. 119.032 review dates: 07/16/2013 and 10/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02, 5111.16, 5111.17, 5111.085
Rule Amplifies: 5111.01, 5111.16, 5111.17, 5111.172, 5111.179
Prior Effective Dates: 4/1/85, 5/2/85, 10/1/87, 2/15/89 (Emer), 5/8/89, 11/1/89 (Emer), 2/1/90, 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, 6/1/06, 1/1/08, 9/15/08, 7/1/09, 8/1/10 , 01/01/12

5160-26-04 [Rescinded] Managed health care programs: procurement and plan selection.

Effective: 2/1/2015
Five Year Review (FYR) Dates: 10/30/2014
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5167.03, 5167.10
Prior Effective Dates: 5/2/85, 10/1/87, 5/1/92, 5/1/93, 11/1/94, 7/1/96, 7/1/97 (Emer), 9/27/97, 12/10/99, 7/1/01, 7/1/02, 7/1/03, 7/1/04, 10/31/05, 6/1/06

5160-26-05 Managed health care programs: provider panel and subcontracting requirements.

(A) Subcontracts.

(1) For the purposes of this rule, delegated entity means a subcontractor that has been provided the authority by the MCP to conduct any of the following functions or related services or both: claims processing, network development, care coordination, quality management and improvement, care management, member materials distribution and fulfillment, interpreter services, reinsurance, fraud and abuse identification, benefit management, utilization management, credentialing and recredentialing, or any other program function that may affect a member's safety, welfare or access to medicaid covered services. In the event of inconsistency or ambiguity and upon the MCP's request of a determination from ODM, ODM will make the final determination of program functions or related services that may affect a member's safety, welfare or access to medicaid covered services.

(2) An MCP must provide or arrange for the delivery of covered health care services described in rule 5160-26-03 either through the use of employees or through subcontracts . Subcontractors include the MCP's parent company or its subsidiaries. All subcontracts must be in writing and in accordance with paragraph (D) of this rule and 42 C.F.R. 434.6 and 438.6(October 1, 2013) . The MCP's execution of a subcontract with a subcontractor does not terminate the MCP's legal responsibility to ODM to assure that all of the MCP's activities and obligations are performed in accordance with Chapter 5160-26 or Chapter 5160-58 of the Administrative Code, as applicable, or both, the MCP provider agreement, and all applicable federal, state, and local regulations.

(3) The MCP must do all of the following for any delegated entity:

(a) Evaluate the entity prior to executing a subcontract to assure that the entity is capable of performing the delegated activity in accordance with all applicable program requirements and provide a copy of the evaluation summary to ODM upon request.

(b) Provide the delegated entity with all information, materials, and documentation the entity will need to meet the delegated program requirement(s).

(c) Require the delegated entity to submit a report to the MCP, at least monthly, summarizing the status of the delegated activity, and including at a minimum:

(i) A copy of any required reports or logs maintained by the delegated entity; and

(ii) Identification of any problems, concerns or potential compliance issues that may exist.

(d) Monitor the entity's performance on an ongoing basis, including a review of the report referenced in paragraph (A) (3)(c) of this rule, all relevant member grievances and appeals as specified in rule 5160-26- 08.4 of the Administrative Code, and all member complaints reported to the Ohio department of medicaid ( ODM) and forwarded to the MCP, to identify any deficiencies or areas for improvement. If requested to do so, the MCP must also provide documentation of the MCP's monitoring efforts and its findings to ODM.

(e) Submit an annual assessment of the delegated entity's performance with meeting the delegated program requirements throughout the year to ODM as directed by ODM.

(f) Include in the subcontract between the MCP and the delegated entity the sanctions that will be imposed for inadequate performance. The sanctions must specify the MCP's authority to require corrective action for any deficiencies or areas for improvement identified and provide for the revocation of the delegation if the MCP or ODM determines that the delegation is not in the best interest of the enrollees.

(g) Include in the subcontract between the MCP and the delegated entity the sanctions that will be imposed for unauthorized uses or disclosures of protected health information (PHI).

(h) Include in the subcontract between the MCP and the delegated entity that, unless otherwise specified by ODM, all information required to be submitted to ODM must be submitted directly by the MCP.

(4) For subcontracts that the MCP believes to be short-term, one-time, or for infrequent activities, the MCP may request that ODM exempt them from the reporting, monitoring and assessment requirements specified in paragraphs (A) (3)(c) and (A) (3)(e) of this rule.

(5) Subcontracts may not include language that conflicts with the specifications identified in paragraphs (C) and (D) of this rule.

(6) For a provider that does not have an executed subcontract with the MCP, the MCP must establish a mutually agreed upon compensation amount for the authorized service and notify the provider of the applicable provisions of paragraph (D) of this rule. For medicaid-covered non-emergency hospital services outlined in rule 5160-26-03 of the Administrative Code, the compensation amount is identified in rule 5160-26-11 of the Administrative Code.

(B) Notification.

(1) Notwithstanding paragraph (D)(13) of this rule, an MCP must notify ODM of the addition or deletion of subcontractors on an ongoing basis, and must follow the time restrictions contained in this paragraph unless the explanation of extenuating circumstances is accepted by ODM.

(2) At the direction of ODM, the MCP must submit evidence of the following:

(a) A copy of the subcontractor's current licensure ;

(b) Copies of written agreements with the subcontractor, including but not limited to subcontracts, amendments and the medicaid addendum as specified in paragraph (D) of this rule;

(c) Notification to ODM of any hospital subcontract for which a date of termination is specified; and

(d) The subcontractor's medicaid provider number or provider reporting number, as applicable.

(3) When any program function is to be delegated as specified in paragraph (A) (3) of this rule, the MCP must submit a copy of the dated and fully executed medicaid addendum or amendment as applicable thirty calendar days prior to the effective date of the subcontract or subcontract amendment for ODM's prior approval of the delegation. Delegation of the program function or related services may not take effect without prior approval by ODM.

(4) Upon ODM approval of the delegated entity, the MCP must provide the delegated entity with a copy of the fully executed subcontract and specification of the ODM approval date.

(5) The MCP shall inform ODM of the expiration, nonrenewal, or termination of any subcontractor fifty-five calendar days prior to the expiration, nonrenewal or termination of the subcontract in a manner and format directed by ODM. If the MCP receives less than fifty-five calendar days notice from the subcontractor, the MCP must inform ODM within one working day of its awareness of this information. The MCP must also comply with the following:

(a) If the subcontractor is a hospital:

(i) Forty-five calendar days prior to the effective date of the expiration, nonrenewal or termination of the hospital's subcontract, the MCP shall notify in writing all providers who have admitting privileges at the hospital of the impending expiration, nonrenewal, or termination of the subcontract and the last date the hospital will provide services to members under the MCP subcontract. If the MCP receives less than forty-five calendar days notice from the hospital, the MCP shall send the notice within one working day of becoming aware of the expiration, nonrenewal, or termination of the subcontract.

(ii) Forty-five calendar days prior to the effective date of the expiration, nonrenewal, or termination of the hospital's subcontract, the MCP shall notify in writing all members in the service area, or in an area authorized by ODM, of the impending expiration, nonrenewal, or termination of the hospital's subcontract. If the MCP receives less than forty-five calendar days notice from the subcontractor, the MCP shall send the notice within one working day of becoming aware of the expiration, nonrenewal, or termination of the subcontract.

(iii) The MCP shall submit a template for member and provider notifications to ODM along with the MCP's notification to ODM of the impending expiration, nonrenewal, or termination of the hospital's subcontract. The notifications shall comply with the following:

(a) The form and content of the member notice must be prior-approved by ODM and contain an ODM designated toll-free telephone number that members can call for information and assistance.

(b) The form and content of the provider notice must be prior-approved by ODM.

(iv) ODM may require the MCP to notify additional members or providers if the impending expiration, nonrenewal, or termination of the hospital's subcontract adversely impacts additional members or providers.

(b) If the subcontractor is a primary care provider (PCP):

(i) The MCP shall include the number of members that will be affected by the change in the notice to ODM; and

(ii) The MCP shall notify in writing all the members who use or are assigned to the subcontractor as a PCP at least forty-five calendar days prior to the effective date of the change. If the MCP receives less than forty-five calendar days prior notice from the PCP, the MCP shall issue the notification within one working day of the MCP becoming aware of the expiration, nonrenewal, or termination of PCP's subcontract. The form of the notice and its content must be prior-approved by ODM and must contain, at a minimum, all of the following information:

(a) The PCP's name and last date the PCP is available to provide care to the MCP's members;

(b) Information regarding how members can select a different PCP; and

(c) An MCP telephone number members can call for further information or assistance.

(6) ODM may require the MCP to notify members or providers for the expiration, nonrenewal, or termination of certain other provider subcontracts that may adversely impact the MCP's members.

(7) In order to assure availability of services and qualifications of providers, ODM may require submission of documentation in accordance with paragraph (B) of this rule regardless of whether the MCP subcontracts directly for services or does so through another entity.

(8) In the event that an MCP's medicaid managed care program participation in a service area is terminated, the MCP must provide written notification to its affected subcontractors at least forty-five calendar days prior to the termination date, unless otherwise specified by ODM.

(C) Provider qualifications.

(1) The MCP must ensure that none of its employees or subcontractors are sanctioned or excluded from providing medicaid or medicare services. At a minimum, monthly, the MCP shall utilize available resources for identifying sanctioned providers, including, but not limited to, the following:

(a) The federal office of inspector general provider exclusion list;

(b) The ODM excluded provider web page; and

(c) The discipline pages of the applicable state boards that license providers or an alternative data resource, such as the national practitioner databank, that is as complete and accurate as the discipline pages of the applicable state boards.

(2) An MCP may not discriminate in regard to the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable state law, solely on the basis of that license or certification. If an MCP declines to include individual or groups of providers in its network, it must give the affected providers written notice of the reasons for its decision. This paragraph may not be construed to:

(a) Require the MCP to contract with providers beyond the number necessary to meet the needs of its members;

(b) Preclude the MCP from using different reimbursement amounts for different specialties or for different practitioners in the same specialty; or

(c) Preclude the MCP from establishing measures that are designed to maintain quality of services and control costs and are consistent with its responsibilities to members.

(3) The MCP must have written policies and procedures for the selection and retention of providers that prohibit discrimination against particular providers that serve high-risk populations or specialize in conditions that require costly treatment.

(4) When initially credentialing and recredentialing providers in connection with policies, contracts, and agreements providing basic health care services, the MCP must utilize the standardized credentialing form and process as prescribed by the Ohio department of insurance under sections 3963.05 and 3963.06 of the Revised Code. Upon ODM's request, the MCPmust demonstrate to ODM the record keeping associated with maintaining this documentation.

(5) If any MCP delegates the credentialing or recredentialing of subcontractors to another entity, the MCP must retain the authority to approve, suspend, or terminate any subcontractors.

(D) Subcontracts.

All subcontracts must include a medicaid addendum that has been approved by ODM. The medicaid addendum must include the following elements, appropriate to the service being rendered or delegated function(s), as specified by ODM:

(1) An agreement by the subcontractor to comply with the applicable provisions for record keeping and auditing in accordance with Chapter 5160-26 of the Administrative Code.

(2) Specification of the medicaid population and service area(s) to be served, pursuant to the MCP's provider agreement.

(3) Specification of the services to be provided.

(4) Specification that the subcontract is governed by, and construed in accordance with all applicable laws, regulations, and contractual obligations of the MCP and:

(a) ODM shall notify the MCP and the MCP shall notify the subcontractor of any changes in applicable state or federal law, regulations, waiver, or contractual obligation of the MCP;

(b) The subcontract shall be automatically amended to conform to such changes without the necessity for written execution; and

(c) The MCP shall notify the subcontractor of all applicable contractual obligations.

(5) Specification of the beginning date and expiration date of the subcontract, or an automatic renewal clause, as well as the applicable methods of extension, renegotiation, and termination.

(6) Specification of the procedures to be employed upon the ending, nonrenewal, or termination of the subcontract, including an agreement by the subcontractor to promptly supply all records necessary for the settlement of outstanding medical claims.

(7) Full disclosure of the method and amount of compensation or other consideration to be received by the subcontractor from the MCP.

(8) An agreement not to discriminate in the delivery of services based on the member's race, color, religion, gender, genetic information, sexual orientation, age, disability, national origin, military status, ancestry, health status, or need for health services.

(9) An agreement by the subcontractor to not hold liable ODM or members in the event that the MCP cannot or will not pay for services performed by the subcontractor pursuant to the subcontract with the exception that:

(a) Federally qualified health centers (FQHCs) and rural health clinics (RHCs) may be reimbursed by ODM in the event of MCP insolvency

(b) The subcontractor may bill the member when the MCP has denied prior authorization or referral for services and the following conditions are met:

(i) The member was notified by the subcontractor of the financial liability in advance of service delivery.

(ii) The notification by the subcontractor was in writing, specific to the service being rendered, and clearly states that the member is financially responsible for the specific service. A general patient liability statement signed by all patients is not sufficient for this purpose.

(iii) The notification is dated and signed by the member.

(10) An agreement by the subcontractor that with the exception of any member co-payments the MCP has elected to implement in accordance with rule 5160-26-12 of the Administrative Code, the MCP's payment constitutes payment in full for any covered service and that the subcontractor will not charge the member or ODM any co-payment, cost sharing, down-payment, or similar charge, refundable or otherwise. This agreement does not prohibit nursing facilities (NFs) or home and community-based services waiver providers from collecting patient liability payments from members as specified in rule 5160:1-3-24 of the Administrative Code or FQHCs and RHCs from submitting claims for supplemental payments to ODM as specified in Chapter 5160-28 of the Administrative Code. Additionally, the MCP and subcontractor agree to the following:

(a) MCP shall notify the subcontractor whether the MCP has elected to implement any member co-payments and if, applicable, the circumstances in which member co-payment amounts will be imposed in accordance with rule 5160-26-12 of the Administrative Code; and

(b) Subcontractor agrees that member notifications regarding any applicable co-payment amounts must be carried out in accordance with rule 5160-26-12 of the Administrative Code.

(11) A specification that the subcontractor and all employees of the subcontractor are duly registered, licensed or certified under applicable state and federal statutes and regulations to provide the health care services that are the subject of the subcontract, and that subcontractor and all employees of the subcontractor have not been excluded from participating in federally funded health care programs.

(12) An agreement that subcontractors who are currently medicaid providers meet the qualifications specified in paragraph (C) of this rule.

(13) A stipulation that the MCP will give the subcontractor at least sixty-days prior notice for the nonrenewal or termination of the subcontract except in cases where an adverse finding by a regulatory agency or health or safety risks dictate that the subcontract be terminated sooner.

(14) A stipulation that the subcontractor may nonrenew or terminate the subcontract if one of the following occurs:

(a) The subcontractor gives the MCP at least sixtydays prior notice for the nonrenewal or termination of the subcontract. The effective date for any nonrenewal or termination of the subcontract must be the last day of the month.

(b) ODM has proposed action to terminate, nonrenew, deny or amend the MCP's provider agreement in accordance with rule 5160-26-10 of the Administrative Code, regardless of whether this action is appealed. The subcontractor's termination or nonrenewal notice must be received by the MCP within fifteen working days prior to the end of the month in which the subcontractor is proposing termination or nonrenewal. If the notice is not received by this date, the subcontractor must agree to extend the termination or nonrenewal date to the last day of the subsequent month.

(15) The subcontractor's agreement to serve members through the last day the subcontract is in effect.

(16) The subcontractor's agreement to make the medical records for medicaid eligible individuals available for transfer to new providers at no cost to the individual.

(17) A specification that all laboratory testing sites providing services to members must have either a current clinical laboratory improvement amendments (CLIA) certificate of waiver, certificate of accreditation, certificate of compliance, or certificate of registration along with a CLIA identification number.

(18) A requirement securing cooperation with the MCP's quality assessment and performance improvement (QAPI) program in all its provider subcontracts and employment agreements for physician and nonphysician providers.

(19) An agreement by the subcontractor and MCP that:

(a) The MCP shall disseminate written policies in accordance with the requirements of 42 U.S.C. 1396a(a)(68) (as in effect December 1, 2014) and section 5162.15 of the Revised Code, regarding the reporting of false claims and whistleblower protections for employees who make such a report, and including the MCP's policies and procedures for detecting and preventing fraud, waste, and abuse; and

(b) The subcontractor agrees to abide by the MCP's written policies related to the requirements of 42 U.S.C. 1396a(a)(68) (as in effect December 1, 2014) and section 5162.15 of the Revised Code, including the MCP's policies and procedures for detecting and preventing fraud, waste, and abuse.

(20) A specification that hospitals and other subcontractors must allow the MCP access to all member medical records for a period of not less than eight-years from the date of service or until any audit initiated within the eight year period is completed and allow access to all record-keeping, audits, financial records, and medical records to ODM or its designee or other entities as specified in rule 5160-26-06 of the Administrative Code.

(21) A specification, appearing above the signature(s) on the signature page in all PCP subcontracts, stating the maximum number of MCP members that each PCP can serve at each practice site for that MCP.

(22) A specification that the subcontractor must cooperate with the ODM external quality reviews required by 42 C.F.R. 438.358 (October 1, 2013) and on-site audits as deemed necessary based on ODM's periodic analysis of financial, utilization, provider panel and other information.

(23) A specification that the subcontractor must be bound by the same standards of confidentiality that apply to ODM and the state of Ohio as described in rule 5160:1-1- 51.1 of the Administrative Code, including standards for unauthorized uses of or disclosures of PHI.

(24) A specification that any third party administrator (TPA) must include the elements of paragraph (D) of this rule in its subcontracts and ensure that its subcontractors will forward information to ODM as requested.

(25) A specification that home health subcontractors must meet the eligible provider requirements specified in Chapter 5160-12 of the Administrative Code and comply with the requirements for home care dependent adults as specified in section 121.36 of the Revised Code.

(26) A specification that PCPs must participate in the care coordination requirements outlined in rule 5160-26- 03.1 of the Administrative Code.

(27) A specification that the subcontractor in providing health care services to members must identify and where necessary arrange, pursuant to the mutually agreed upon policies and procedures between the MCP and subcontractor, for the following at no cost to the member;

(a) Sign language services; and

(b) Oral interpretation and oral translation services.

(28) A specification that the MCP agrees to fulfill the subcontractor's responsibility to mail or personally deliver notice of the member's right to request a state hearing whenever the subcontractor bills a member due to the MCP's denial of payment of a service, as specified in rules 5160-26- 08.4and 5160-58- 08.4 of the Administrative Code, utilizing the procedures and forms as specified in rule 5101:6-2-35 of the Administrative Code.

(29) The subcontractor's agreement to contact the twenty-four-hour post-stabilization services phone line designated by the MCP to request authorization to provide post-stabilization services in accordance with rule 5160-26-03 of the Administrative Code.

(30) A specification that the MCP may not prohibit or otherwise restrict a subcontractor, acting within the lawful scope of practice, from advising or advocating on behalf of a member who is his or her patient for the following:

(a) The member's health status, medical care, or treatment options, including any alternative treatment that may be self-administered;

(b) Any information the member needs in order to decide among all relevant treatment options;

(c) The risks, benefits, and consequences of treatment versus non-treatment; and

(d) The member's right to participate in decisions regarding his or her health care, including the right to refuse treatment, and to express preferences about future treatment decisions.

(31) A stipulation that the subcontractor must not identify the addressee as a medicaid consumer on the outside of the envelope when contacting members by mail.

(32) An agreement by the subcontractor that members will not be billed for missed appointments.

(33) An agreement that in the performance of the subcontract or in the hiring of any employees for the performance of services under the subcontract, the subcontractor shall not by reason of race, color, religion, gender, genetic information, sexual orientation, age, disability, national origin, military status, health status, or ancestry, discriminate against any citizen of Ohio in the employment of a person qualified and available to perform the services to which the subcontract relates.

(34) An agreement by the subcontractor that it shall not in any manner, discriminate against, intimidate, or retaliate against any employee hired for the performance of services under the subcontract on account of race, color, religion, gender, genetic information, sexual orientation, age, disability, national origin, military status, health status, or ancestry.

(35) Notwithstanding paragraphs (D)(13) and (D)(14) of this rule, in the event of a hospital's proposed nonrenewal or termination of a hospital subcontract, an agreement by the hospital subcontractor to notify in writing all providers who have admitting privileges at the hospital of the impending nonrenewal or termination of the subcontract and the last date the hospital will provide services to members under the MCP contract. The subcontracting hospital must send this notice to the providers with admitting privileges at least forty-five calendar days prior to the effective date of the nonrenewal or termination of the hospital subcontract. If the subcontractor issues less than forty-five days prior notice to the MCP, the notice to providers with admitting privileges must be sent within one working day of the subcontractor issuing notice of nonrenewal or termination of the subcontract.

(36) An agreement by the subcontractor to supply, upon request, the business transaction information required under 42 C.F.R. 455.105(October 1, 2013).

(37) An agreement by the subcontractor to release to the MCP, ODM or ODM designee any information necessary for the MCP to perform any of its obligations under the ODM provider agreement, including but not limited to compliance with reporting and quality assurance requirements.

(38) An agreement by the subcontractor that its applicable facilities and records will be open to inspection by the MCP, ODM or its designee, or other entities as specified in rule 5160-26-06 of the Administrative Code.

(39) An agreement by the subcontractor that if the base contract with the MCP provides for assignment to another entity, no assignment, in whole or in part, shall take effect without sixty days prior notice to the MCP.

(40) An agreement by the subcontractor to immediately forward any information regarding a member appeal or grievance as defined in rule 5160-26- 08.4 or 5160-58- 08.4 of the Administrative Code to the MCP for processing.

(41) A specification that if the subcontractor has been delegated decision-making authority to reduce, suspend, deny or terminate services to a member, the MCP must ensure compliance with the state hearing notification requirements specified in rule 5101:6-2-35 of the Administrative Code.

(42) A specification that the subcontractor not providing direct health care services agrees to provide a report to the MCP, on at least a monthly basis, summarizing the status of the work in support of the program requirement, including a copy of any required reports or logs maintained by the subcontractor, the submission dates for any required documentation sent to MCP, and indicating any problems, concerns or potential compliance issues that may exist.

(E) In lieu of including a medicaid addendum as required by paragraph (D) of this rule, an MCP may permit a benefit manager that assists in the administration of health care services including pharmaceutical, dental, vision and behavioral health services on behalf of the MCP's members, to include elements (D)(1) to (D)(38) in subcontracts with entities that provide for the direct provision of health care services to the MCP members. The MCP must receive written evidence that the benefit manager complied with this paragraph and has informed the entities of the obligation to provide services to the MCP's members.

Effective: 7/2/2015
Five Year Review (FYR) Dates: 04/15/2015 and 07/02/2020
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03 , 5162.20, 5164.02, 5167.03 , 5167.02 , 5167.10
Prior Effective Dates: 4/1/85, 10/1/87, 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, 10/27/00, 7/20/01, 7/1/02, 7/1/03, 1/1/06, 6/1/06, 1/1/07, 7/1/07, 1/1/08, 7/1/09, 8/1/11

5160-26-05.1 Managed health care programs: provider services.

(A) MCPs must provide the following written information to their contracting providers:

(1) The MCP's grievance, appeal and state fair hearing procedures and time frames, including:

(a) The member's right to file grievances and appeals and the requirements and time frames for filing;

(b) The MCP's toll-free telephone number to file oral grievances and appeals;

(c) The member's right to a state fair hearing, the requirements and time frames for requesting a hearing, and representation rules at a hearing;

(d) The availability of assistance from the MCP in filing any of these actions;

(e) The member's right to request continuation of benefits during an appeal or a state hearing and specification that at the discretion of ODM the member may be liable for the cost of any such continued benefits; and

(f) The provider's rights to participate in these processes on behalf of the provider's patients and to challenge the failure of the MCP to cover a specific service.

(2) The MCP's requirements regarding the submission and processing of prior authorization requests including:

(a) A list of the benefits, if any, that require prior authorization approval from the MCP;

(b) The process and format to be used in submitting such requests;

(c) The time frames in which the MCP must respond to such requests;

(d) Pursuant to the provisions of paragraph (A)(1) of this rule, how the provider will be notified of the MCP's decision regarding such requests; and

(e) Pursuant to the provisions of paragraph (A)(1) of this rule, the procedures to be followed in appealing the MCP's denial of a prior authorization request.

(3) The MCP's requirements regarding the submission and processing of requests for specialist referrals including:

(a) A list of the provider types, if any, that require prior authorization approval from the MCP;

(b) The process and format to be used in submitting such requests;

(c) How the provider will be notified of the MCP's decision regarding such requests; and

(d) The procedures to be followed in appealing the MCP's denial of such requests.

(4) The MCP's documentation, legibility, confidentiality, maintenance and access standards for member medical records; including a member's right to amend or correct his or her medical record as specified in 45 C.F.R. 164.526( October 1, 2013).

(5) The MCP's process and requirements for the submission of claims and the appeal of denied claims.

(6) The MCP's process and standards for the recredentialing of providers.

(7) The MCP's policies and procedures regarding what action the MCP may take in response to occurrences of undelivered, inappropriate or substandard health care services, including the reporting of serious deficiencies to the appropriate authorities.

(8) A description of the MCP's care coordination and care management programs, and the role of the provider in those programs, including:

(a) The MCP's criteria for determining which members might benefit from care management;

(b) The provider's responsibility in identifying members who may meet the MCP's care management criteria; and

(c) The process for the provider to follow in notifying the MCP when such members are identified.

(9) The MCP's requirements and expectations for PCPs, including triage requirements.

(10) The mutually agreed upon policies and procedures between the MCP and provider that explain the provider's obligation to provide oral translation, oral interpretation, and sign language services to the MCP's members including:

(a) The provider's responsibility to identify those members who may require such assistance;

(b) The process the provider is to follow in arranging for such services to be provided;

(c) Information that members will not be liable for the costs of such services; and

(d) Specification of whether the MCP or the provider will be financially responsible for the costs of providing these services.

(11) The procedures that providers are to follow in notifying the MCP of changes in their practice, including at a minimum:

(a) Address and phone numbers;

(b) Providers included in the practice;

(c) Acceptance of new patients; and

(d) Standard office hours.

(12) Specification of what service utilization and provider performance data the MCP will make available to providers.

(13) Specification of the healthchek components to be provided to eligible members as specified in Chapter 5160-14 of the Administrative Code.

(B) MCPs must adopt practice guidelines and disseminate the guidelines to all affected providers, and upon request to members and pending members. These guidelines must:

(1) Be based on valid and reliable clinical evidence or a consensus of health care professionals in the particular field;

(2) Consider the needs of the MCP's members;

(3) Be adopted in consultation with contracting health care professionals; and

(4) Be reviewed and updated periodically, as appropriate.

(C) MCPs must have staff specifically responsible for resolving individual provider issues, including, but not limited to, problems with claims payment, prior authorizations and referrals. MCPs must provide written information to their contracting providers detailing how to contact these designated staff.

Effective: 7/2/2015
Five Year Review (FYR) Dates: 04/15/2015 and 07/02/2020
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5164.02 , 5167.03, 5167.10
Prior Effective Dates: 4/1/85, 10/1/87, 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, 10/27/00, 7/20/01, 7/1/02, 7/1/03, 1/1/06, 6/1/06, 1/1/07, 7/1/07, 1/1/08, 9/15/08, 7/1/2013

5160-26-06 Managed health care programs: program integrity - fraud and abuse, audits, reporting, and record retention.

(A) Each MCP must have administrative and management arrangements or procedures, including a mandatory compliance plan, to guard against fraud and abuse.

(1) These arrangements or procedures must include the implementation of sound business practices which support appropriate access to and appropriate payment for quality services and must include the following:

(a) Written policies, procedures, and standards of conduct that articulate the MCP's commitment to comply with all applicable federal and state standards, including the prevention, identification, investigation, correction, and reporting of fraud and abuse;

(b) Designation of a compliance officer and a compliance committee that are accountable to senior management;

(c) Effective training and education for the compliance officer and the MCP's employees;

(d) Effective lines of communication between the compliance officer and the MCP's employees. To ensure effective communication, the MCP must organize resources to respond to complaints of fraud and abuse and have established procedures to process these complaints;

(e) Education of providers and delegated entities about fraud and abuse;

(f) Enforcement of MCP standards through well-publicized disciplinary guidelines;

(g) Provision for internal monitoring and auditing, including procedures to monitor service patterns of providers and subcontractors;

(h) Establishment and/or modification of internal MCP controls to ensure the proper submission and payment of claims;

(i) Provision for prompt response to detected offenses, and for development of corrective action initiatives relating to the MCP's contract; and

(j) Prompt reporting of all instances of fraud and abuse to ODM and member fraud to the CDJFS.

(2) These arrangements or procedures must be made available to ODM upon request.

(3) The MCP must annually submit to ODM a report that summarizes the MCP's fraud and abuse activities for the previous year and identifies any proposed changes to the MCP's fraud and abuse program for the coming year.

(B) ODM or its designee, the state auditor's office, the state attorney general's office, the MFCU and the U.S. department of health and human services may evaluate or audit a contracting MCP's performance for the purpose of determining compliance with the requirements of Chapter 5160-26 of the Administrative Code, fraud and abuse statutes, applicable state and federal regulations or requirements under federal waiver authority.

(C) ODM or its designee may conduct on-site audits and reviews as deemed necessary based on periodic analysis of financial, utilization, provider panel, and other information.

(D) The MCP must submit required reports and additional information, as requested by ODM, as related to its duties and obligations and where needed to assure operation in accordance with all state and federal regulations or requirements.

(E) If the MCP fails to submit any ODM-requested materials, as specified in paragraph (D) of this rule, without cause as determined by ODM, on or before the due date, ODM may impose any or all of the sanctions listed in rule 5160-26-10 of the Administrative Code.

(F) Record retention.

The MCP and its subcontractors shall retain and safeguard all hard copy or electronic records originated or prepared in connection with the MCP's performance of its obligations under the provider agreement, including but not limited to working papers or information related to the preparation of reports, medical records, progress notes, charges, journals, ledgers, and fiscal reports, in accordance with applicable sections of the federal regulations, the Revised Code, and the Administrative Code. Records stored electronically must be produced at the MCP's expense, upon request, in the format specified by state or federal authorities. All such records must be maintained for a minimum of eight years from the renewal, amendment or termination date of the provider agreement, or in the event that the MCP has been notified that state or federal authorities have commenced an audit or investigation of the provider agreement, until such time as the matter under audit or investigation has been resolved. For the initial three years of the retention period, the MCP and its subcontractors must store the records in a manner and place that provides readily available access.

Effective: 2/1/2015
Five Year Review (FYR) Dates: 10/30/2014 and 02/01/2020
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03 , 5164.02 , 5164.70 , 5167.03 , 5167.10
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, 7/1/13

5160-26-07 [Rescinded] Managed health care programs: annual external quality review survey.

Effective: 2/1/2015
Five Year Review (FYR) Dates: 10/30/2014
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5164.02, 5167.03, 5167.10
Prior Effective Dates: 4/1/85, 5/2/85, 10/1/87, 2/15/89 (Emer), 5/8/89, 11/1/89 (Emer), 2/1/90, 5/1/92, 5/1/93, 11/1/94, 7/1/96, 7/1/97 (Emer), 9/27/97, 7/1/01, 7/1/02, 7/1/03, 7/1/04, 10/31/05, 6/1/06, 1/1/07, 1/1/08, 9/15/08

5160-26-07.1 [Rescinded] Managed health care programs: Quality assessment and performance improvement program (QAPI).

Effective: 2/1/2015
Five Year Review (FYR) Dates: 10/30/2014
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5164.02, 5167.10
Prior Effective Dates: 4/1/85, 5/2/85, 10/1/87, 2/15/89 (Emer), 5/8/89, 11/1/89 (Emer), 2/1/90, 5/1/92, 5/1/93, 11/1/94, 7/1/96, 7/1/97 (Emer), 9/27/97, 7/1/00, 7/1/01, 7/1/03

5160-26-08 Managed health care programs: marketing.

(A) Marketing means any communication from an MCP to an eligible individual who is not a member of that MCP that can reasonably be interpreted as intended to influence the individual to select membership in that MCP, or to not select membership in or to terminate membership from another MCP.

(B) MCPs:

(1) Must ensure that representatives, as well as materials and plans, represent the MCP in an honest and forthright manner, and do not make statements which are inaccurate, misleading, confusing or otherwise misrepresentative, or which defraud the eligible individuals or ODM.

(2) Must ensure that no marketing activity directed specifically toward the medicaid population begins prior to approval by ODM.

(3) Are prohibited from engaging directly or indirectly in cold-call marketing activities including, but not limited to, door-to-door or telephone contact. Cold-call marketing means any unsolicited personal contact by the MCP with an eligible individual for the purpose of marketing as defined in paragraph (A) of this rule.

(4) Must receive prior approval from any event or location where the MCP plans to provide information to eligible individuals.

(5) Are prohibited from offering material or financial gain, including but not limited to, the offering of any other insurance, to an eligible individual as an inducement to select MCP membership.

(6) Are prohibited from offering inducements to CDJFS or medicaid consumer hotline staff or to others who may influence an individual's decision to select MCP membership.

(7) Are allowed to offer nominal gifts prior-approved by ODM to an eligible individual as long as these gifts are offered whether or not the individual selects membership in the MCP.

(8) May reference member incentive/appreciation items, as specified in rule 5160-26- 08.2 of the Administrative Code, in marketing presentations and materials; however, such member items must not be made available to non-members.

(9) Must ensure that marketing representatives represent the MCP in an honest and forthright manner, and do not make statements which are inaccurate, misleading, confusing, or otherwise misrepresentative, or which defraud the eligible individuals or ODM.

(10) Are prohibited from making one-on-one marketing presentations in any setting unless requested by the eligible individual.

(C) MCPs must comply with the following requirements:

(1) Only ODM-approved MCP marketing representatives may make a marketing presentation as outlined in paragraph (F) (6)(e) of this rule to an eligible individual or in any way advise or recommend to an eligible individual that he or she select MCP membership in a particular MCP. As provided in Chapter 1751. and section 3905.01 of the Revised Code, and rule 3901-1-10 of the Administrative Code, all non-licensed agents, including providers, are prohibited from advising or recommending to an eligible individual that he or she select MCP membership in a particular MCP as this would constitute the unlicensed practice of marketing.

(2) MCP informational displays do not require the presence of a marketing representative if no marketing presentation will be made.

(D) Marketing materials are materials produced in any medium by or on behalf of an MCP and which can reasonably be interpreted as intended to market to eligible individuals. All new and revised materials, including materials used for marketing presentations, must be prior approved by ODM. MCPs must include with each marketing submission an attestation that the material is accurate and does not mislead, confuse or defraud the eligible individuals or ODM. Marketing materials must comply with the following requirements:

(1) All MCP marketing materials must be available in a manner and format that may be easily understood.

(2) Written materials developed to promote membership selection in an MCP must be available in:

(a) The prevalent non-English languages of eligible individuals in the service area.

(b) Alternative formats in an appropriate manner that takes into consideration the special needs of eligible individuals including but not limited to visually-limited and LRP eligible individuals.

(3) Oral interpretation and oral translation services must be available for the review of marketing materials at no cost to eligible individuals.

(4) The mailing and distribution of all MCP marketing materials must be prior-approved by ODM and may contain no information or text on the outside of the mailing that identifies the addressee as a medicaid consumer. Marketing materials must be distributed to the MCP's entire service area.

(5) ODM or its designee may, at an MCP's request, mail MCP marketing materials to eligible individuals. Postage and handling for each mailing will be charged to the requesting MCP. The MCP address must not be used as the return address in mailings to eligible individuals processed by ODM.

(6) An MCP must have a solicitation brochure available to eligible individuals which contains, at a minimum:

(a) Identification of the medicaid consumers eligible for the MCP's coverage.

(b) Information that the MCP's identification card replaces the member's monthly medicaid health card.

(c) A statement that all medically-necessary medicaid-covered services, including healthchek (EPSDT) services, will be available to all members.

(d) A description of any additional services available to all members.

(e) Information that membership selection in a particular MCP is voluntary, that a decision to select MCP membership or to not select MCP membership in the MCP will not affect eligibility for medicaid or other public assistance benefits, and that individuals may change MCPs under certain circumstances.

(f) Information on how the individual can request or access additional MCP information or services, including clarification on how this information can be requested or accessed through:

(i) Sign language, oral interpretation and oral translation services at no cost to the eligible individual;

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

(iii) Written information in alternative formats.

(g) Information clearly identifying corporate or parent company identity when a trade name or DBA is used for the medicaid product.

(h) A statement that this brochure contains only a summary of the relevant information and that more details, including at a minimum a list of providers and any physician incentive plans the MCP operates, will be provided upon request.

(i) Information that an individual must choose a PCP from the MCP's provider panel and that the PCP will coordinate the member's health care.

(j) Information that a member may change PCPs at least monthly.

(k) A statement that all medically-necessary health care services must be obtained in or through the MCP's providers except emergency care, behavioral health services provided through facilities and medicaid providers certified by the Ohio department of mental health and addiction services and any other services or provider types designated by ODM.

(l) A description of how to access emergency services including information that access to emergency services is available within and outside the service area.

(m) A description of the MCP's policies regarding access to providers outside the service area.

(n) Information on member-initiated termination options in accordance with rule 5160-26- 02.1 of the Administrative Code.

(o) Information on the procedures an eligible individual must follow to select MCP membership in an MCP including any applicable ODM selection requirements.

(p) If applicable, information on any member co-payments the MCP has elected to implement in accordance with rule 5160-26-12 of the Administrative Code.

(E) An MCP must submit an annual marketing plan to ODM that includes all planned activities for promoting membership in or increasing awareness of the MCP. The marketing plan submission must include an attestation by the MCP that the plan is accurate and does not mislead, confuse, or defraud the eligible individuals or ODM.

(F) An MCP that utilizes marketing representatives for marketing presentations requested by eligible individuals must comply with the following:

(1) All marketing representatives must be employees of the MCP. A copy of the representative's job description(s) must be submitted to ODM.

(2) Marketing representatives must be trained and duly licensed by ODI to perform such activities.

(3) The MCP must develop and submit to ODM for priorapproval a marketing representative training program. This training program must include, at a minimum:

(a) A training curriculum that includes at a minimum:

(i) A full review of the MCP's solicitation brochure, provider directory and all other marketing materials including all video, audio, electronic and print materials.

(ii) An overview of applicable public assistance benefits, designed to familiarize and impart a working knowledge of these programs.

(iii) The MCP's process for providing sign language, oral interpretation and oral translation services to an eligible individual to whom a marketing presentation is being made, including a review of the MCP's written marketing materials.

(iv) Instruction on acceptable and appropriate marketing tactics, including a requirement that the marketing representatives may not discriminate on the basis of age, gender, sexual orientation, disability, race, color, religion, national origin, military status, genetic information, ancestry, health status, or the need for health services.

(v) An overview of the ramifications to the MCP and/or the marketing representatives if ODM rules are violated.

(vi) Review of the MCP's code of conduct or ethics.

(b) Methods that the MCP will utilize to determine initial and ongoing competency with the training curriculum.

(4) Any revisions to the ODM-approved training program must be submitted to ODM for review and prior approval.

(5) No more than fifty per cent of each marketing representative's total annual compensation, including salary, benefits, and bonuses may be paid on a commission basis. For the purpose of this rule, any performance-based compensation would be considered a form of commission. The MCP must make available for inspection, upon request by ODM, the compensation package(s) for marketing representatives as its assurance of compliance with this requirement.

(6) Any MCP staff person providing information on the MCP or making marketing presentations to an eligible individual(s) must comply with the following:

(a) The MCP staff person must not discriminate on the basis of age, gender, sexual orientation, race, color, religion, national origin, military status, ancestry, disability, genetic information, health status, or the need for health services.

(b) No MCP staff person may ask eligible individual(s) questions related to health status or the need for health services.

(c) The MCP staff person must visibly wear or display an identification tag and offer a business card when speaking to an eligible individual(s) and provide information which ensures that the staff person is not mistaken for a medicaid consumer hotline, federal, state or county employee.

(d) The MCP staff person must inform eligible individuals that the following MCP information or services are available and how the eligible individual can access the information or services:

(i) Sign language, oral interpretation, and oral translation services at no cost to the member;

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

(iii) Written information in alternative formats.

(e) For the purposes of this rule, a marketing presentation is defined as a one-on-one interaction between an MCP's marketing representative and an eligible individual(s). MCP marketing representatives must offer the ODM-approved solicitation brochure to the eligible individual(s) at the time of the marketing presentation and must provide, at a minimum:

(i) An explanation of the importance of reviewing the information in the ODM-approved solicitation brochure, how the individual can receive additional information about the MCP prior to making an MCP membership selection, and the process for contacting ODM to select an MCP.

(ii) Information that membership in the particular MCP is voluntary and that a decision to select or not select the MCP will not affect eligibility for medicaid or other public assistance benefits.

(iii) Information that each member must choose a PCP and must access providers and services as directed in the MCP's member handbook and provider directory.

(iv) Information that all medically-necessary medicaid-covered services, as well as any additional services provided by the MCP, will be available to all members.

(G) Upon request, MCPs must provide eligible individuals with a provider directory which has been approved by ODM.

(H) Alleged marketing violations.

(1) The MCP must immediately notify ODM in writing of its discovery of an alleged or suspected marketing violation.

(2) ODM will forward information pertaining to alleged marketing violations to the Ohio department of insurance and the medicaid fraud control unit as appropriate.

Effective: 2/1/2015
Five Year Review (FYR) Dates: 10/30/2014 and 02/01/2020
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5164.02, 5167.03, 5167.10
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, 7/1/00, 7/1/01, 7/1/02, 7/1/03, 7/1/04, 10/31/05, 6/1/06, 7/1/07, 1/1/08

5160-26-08.1 [Rescinded] Managed health care programs: information and enrollment services.

Effective: 3/6/2015
Five Year Review (FYR) Dates: 10/30/2014
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5164.02, 5167.03, 5167.10
Prior Effective Dates: 2/15/89 (Emer), 5/8/89, 5/18/89, 5/1/93, 11/1/94, 7/1/96, 7/1/97 (Emer), 9/27/97, 7/1/01, 7/1/02, 7/1/03, 7/1/04, 10/31/05

5160-26-08.2 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 5160-26- 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 ODM office of civil rights any complaints of discrimination on the basis of race, color, religion, gender, sexual orientation, age, disability, national origin, military status, genetic information, 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. The MCP must ensure that these services are provided at no cost to the eligible individual or member. The MCP must designate a staff person to coordinate and document the provision of these services.

(3) In the event the consumer contact record (CCR) does not identify a member-selected primary care provider (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 ODM;

(b) Notify each member of the name of his or her PCP prior to the effective date of coverage and pursuant to the provisions of rule 5160-26-02 of the Administrative Code;

(c) Simultaneously notify each member 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 ODM.

(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 5160-26- 05.1 of the Administrative Code.

(3) At a minimum, the MCP must provide the following materials to each member or assistance group, as applicable. The MCP 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 each member's medicaid management information system billing number;

(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 5160-26- 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 ODM.

(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 each member at a minimum of:

(i) The new member materials issued by the MCP, what action the member should take if he or she has 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 a member believes he or she meets this criteria and does not want to be an MCP member;

(v) The need and time frame for a member to contact the MCP if the member has a health care condition that the MCP should be aware of in order to most appropriately manage or transition the member's 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 5160-26- 08.3 of the Administrative Code and any member responsibilities specified by the MCP. With the exception of any priorauthorization requirements the MCP describes 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 priorauthorization 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 rule 5160-26-03 of the Administrative Code;

(iii) FQHC ,RHC and certified nurse practitioner services as specified in rule 5160-26-03 of the Administrative Code; and

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

(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) An explanation of the terms "emergency medical condition," "emergency services," and "post-stabilization services," as defined in rule 5160-26-01 of the Administrative Code;

(ii) A statement that prior authorization is not required for emergency services;

(iii) An explanation regarding the availability of the 911telephone system or its local equivalent;

(iv) A statement that members have a right to use any hospital or other appropriate setting for emergency services; and

(v) An explanation of the post-stabilization care services requirements specified in rule 5160-26-03 of the Administrative Code.

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

(e) Identification of the categories of 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 through the providers in the MCP's provider network except for emergency care, behavioral health services provided through facilities and medicaid providers certified by the Ohio department of mental health and addiction services,and any other services or provider types designated by ODM.

(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, early and periodic screening, diagnosis and treatment) 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 rule 5160-26- 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 or outside the service area for non-emergency after-hours services.

(l) Information on member-initiated termination options in accordance with rule 5160-26- 02.1 of the Administrative Code.

(m) An explanation of automatic renewal of MCP membership in accordance with rule 5160-26-02 of the Administrative Code.

(n) The procedure for members to file an appeal, a grievance, or a state hearing request as specified in rule 5160-26- 08.4 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, military status, ancestry, genetic information, 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 ODM, and how members can contact ODM, 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 rule 5160-26- 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 5160-26-12 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) (October 1, 2013).

(5) If a member's MCP membership is automatically renewed as specified in rule 5160-26-02 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, the MCP must determine the predominant health care needs of its medicaid members and provide health education materials as indicated by these assessments. The MCP must provide ODM 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: 2/1/2015
Five Year Review (FYR) Dates: 10/30/2014 and 02/01/2020
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03 , 5164.02 , 5167.03 , 5167.10 , 5167.13
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, 1/1/12

5160-26-08.3 Managed health care programs: member rights.

(A) MCPs must develop and implement written policies that ensure that members have and are informed of the following rights:

(1) To receive all services that the MCP is required to provide pursuant to the terms of their provider agreement with ODM.

(2) To be treated with respect and with due consideration for their dignity and privacy.

(3) To be ensured of confidential handling of information concerning their diagnoses, treatments, prognoses, and medical and social history.

(4) To be provided information about their health. Such information should also be made available to the individual legally authorized by the member to have such information or the person to be notified in the event of an emergency when concern for a member's health makes it inadvisable to give him/her such information.

(5) To be given the opportunity to participate in decisions involving their health care .

(6) To receive information on available treatment options and alternatives, presented in a manner appropriate to the member's condition and ability to understand.

(7) To maintain auditory and visual privacy during all health care examinations or treatment visits.

(8) To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.

(9) To request and receive a copy of their medical records, and to be able to request that their medical records be amended or corrected.

(10) To be afforded the opportunity to approve or refuse the release of information except when release is required by law.

(11) To be afforded the opportunity to refuse treatment or therapy. Members who refuse treatment or therapy will be counseled relative to the consequences of their decision, and documentation will be entered into the medical record accordingly.

(12) To be afforded the opportunity to file grievances, appeals, or state hearings pursuant to the provisions of rule 5160-26- 08.4 of the Administrative Code.

(13) To be provided written member information from the MCP :

(a) At no cost to the member,

(b) In the prevalent non-English languages of members in the MCP's service area, and

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

(14) To receive necessary oral interpretation and oral translation services at no cost .

(15) To receive necessary services of sign language assistance at no cost.

(16) To be informed of specific student practitioner roles and the right to refuse student care.

(17) To refuse to participate in experimental research.

(18) To formulate advance directives and to file any complaints concerning noncompliance with advance directives with the Ohio department of health.

(19) To change PCPs no less often than monthly. The MCP must mail written confirmation to the member of his or her new PCP selection prior to or on the effective date of the change.

(20) To appeal to or file 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.

(21) To appeal to or file directly with the ODM office of civil rights any complaints of discrimination on the basis of race, color, religion, gender, sexual orientation, age, disability, national origin, military status, genetic information, ancestry, health status or need for health services in the receipt of health services.

(22) To be free to exercise their rights and to be assured that exercising their rights does not adversely affect the way the MCP, the MCP's providers, or ODM treats the member.

(23) To be assured that the MCP must comply with all applicable federal and state laws and other laws regarding privacy and confidentiality.

(24) To choose his or her health professional to the extent possible and appropriate.

(25) For female members, to obtain direct access to a woman's health specialist within the network for covered care necessary to provide women's routine and preventive health care services. This is in addition to a member's designated PCP if the PCP is not a woman's health specialist.

(26) To be provided a second opinion from a qualified health care professional within the MCP's panel. If such a qualified health care professional is not available within the MCP's panel, the MCP must arrange for a second opinion outside the network, at no cost to the member.

(27) To receive information on their MCP.

(B) MCPs must advise members via the member handbook of the member rights specified in paragraph (A) of this rule.

Effective: 2/1/2015
Five Year Review (FYR) Dates: 07/01/2018
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5164.02, 5167.03, 5167.10
Prior Effective Dates: 4/1/85, 5/2/85, 10/1/87, 2/15/89 (Emer), 5/8/89, 11/1/89 (Emer), 2/1/90, 5/1/92, 5/1/93, 11/1/94, 7/1/96, 7/1/97 (Emer), 9/27/97, 7/1/00, 7/1/01, 7/1/03, 1/1/08, 1/1/13

5160-26-08.4 Managed health care programs: MCP grievance system.

This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code. Provisions regarding appeals and grievances for MyCare Ohio are described in Chapter 5160-58 of the Administrative Code.

(A) Definitions.

For the purposes of this rule the following terms are defined as:

(1) An "action" is the MCP's

(a) Denial or limited authorization of a requested service, including the type or level of service;

(b) Reduction, suspension, or termination of services prior to the member receiving the services previously authorized by the MCP;

(c) Denial, in whole or part, of payment for a service;

(d) Failure to provide services in a timely manner as specified in rule 5160-26- 03.1 of the Administrative Code; or

(e) Failure to act within the resolution timeframes specified in this rule.

(2) An "appeal" is the request for an MCP's review of an action.

(3) A "grievance" is an expression of dissatisfaction with any aspect of the MCP's or provider's operation, provision of health care services, activities, or behaviors, other than an MCP's action as defined in paragraph (A)(1) of this rule.

(4) "Resolution" means a final decision is made by the MCP and the decision is communicated to the member.

(5) "Notice of action (NOA)" is the written notice an MCP must provide to members when an MCP action has occurred or will occur.

(B) Each MCP must have written policies and procedures for an appeal and grievance system for members, in compliance with the requirements of this rule. The policies and procedures must be made available for review by ODM, and must include the following:

(1) A process by which members may file grievances with the MCP, in compliance with paragraph (H) of this rule;

(2) A process by which members may file appeals with the MCP, in compliance with paragraphs (C) to (G) of this rule; and

(3) A process by which members may access the state's hearing system through the Ohio department of job and family services (ODJFS) in compliance with paragraph (I) of this rule.

(C) Notice of action (NOA) by an MCP.

(1) When an MCP action has occurred or will occur, the MCP must provide the affected member(s) with a written NOA.

(2) The NOA must meet the language and format requirements for member materials specified in rule 5160-26- 08.2 of the Administrative Code and explain:

(a) The action the MCP has taken or intends to take;

(b) The reasons for the action;

(c) The member's or authorized representative's right to file an appeal to the MCP;

(d) If applicable, the member's right to request a state hearing through the state's hearing system;

(e) Procedures for exercising the member's rights to appeal or grieve the action;

(f) Circumstances under which expedited resolution is available and how to request it;

(g) If applicable, the member's right to have benefits continue pending the resolution of the appeal, how to request that benefits be continued, and the circumstances under which the member may be required to pay for the cost of these services;

(h) The date that the notice is being issued;

(i) Oral interpretation is available for any language;

(j) Written translation is available in prevalent languages as applicable;

(k) Written alternative formats may be available as needed; and

(l) How to access the MCP's interpretation and translation services as well as alternative formats that can be provided by the MCP.

(3) An MCP must give members a written NOA within the following timeframes:

(a) For a decision to deny or limit authorization of a requested service, including the type or level of service, the MCP must issue an NOA simultaneously with the MCP's decision.

(b) For reduction, suspension, or termination of services prior to the member receiving the services previously authorized by the MCP, the MCP must give notice fifteen calendar days before the date of action except:

(i) If probable recipient fraud has been verified, the MCP must give notice five calendar days before the date of action.

(ii) Under the circumstances set forth in 42 C.F.R. 431.213 ( October 1, 2013), the MCP must give notice on or before the date of action.

(c) For denial of payment for a noncovered service, MCPs must give notice simultaneously with the MCP's action to deny the claim, in whole or part, for a service that is not covered by medicaid, including a service that was determined through the MCP's prior authorization process as not medically necessary.

(d) For untimely prior authorization, appeal or grievance resolution, the MCP must give notice simultaneously with the MCP becoming aware of the action. A service authorization decision not reached within the timeframes specified in rule 5160-26- 03.1 of the Administrative Code constitutes a denial and is thus considered to be an adverse action. Notice must be given on the date that the authorization decision timeframe expires.

(D) Standard appeal to an MCP.

(1) A member, provider, or a member's authorized representative may file an appeal orally or in writing within ninety days from the date on the NOA. The ninety day period begins on the day after the mailing date of the NOA. An oral filing must be followed with a written appeal. The MCP must:

(a) Assist members that file an oral appeal by immediately converting an oral filing to a written record;

(b) Ensure that oral filings are treated as appeals to establish the earliest possible filing date for the appeal; and

(c) Consider the date of the oral filing as the filing date if the member follows the oral filing with a written appeal.

(2) Any provider acting on the member's behalf must have the member's written consent to file an appeal. The MCP must begin processing the appeal pending receipt of the written consent.

(3) The MCP must acknowledge receipt of each appeal to the individual filing the appeal. At a minimum, acknowledgment must be made in the same manner that the appeal was filed. If an appeal is filed in writing, written acknowledgment must be made by the MCP within three working days of the receipt of the appeal.

(4) The MCP must provide members a reasonable opportunity to present evidence and allegations of fact or law, in person as well as in writing. The member and/or member's authorized representative must be allowed to examine the case file, including medical records and any other documents and records, before and during the appeals process.

(5) The MCP must consider the member, member's authorized representative, or estate representative of a deceased member as parties to the appeal.

(6) The MCP must review and resolve each appeal as expeditiously as the member's health condition requires, but the resolution timeframe must not exceed fifteen calendar days from the receipt of the appeal unless the resolution timeframe is extended as outlined in paragraph (F) of this rule.

(7) The MCP must provide written notice to the member, and to the member's authorized representative if applicable, of the resolution including, at a minimum, the decision and date of the resolution.

(8) For appeal decisions not resolved wholly in the member's favor, the written notice to the member must also include information regarding:

(a) Oral interpretation that is available for any language;

(b) Written translation that is available in prevalent languages as applicable;

(c) Written alternative formats that may be available as needed;

(d) How to access the MCP's interpretation and translation services as well as alternative formats that can be provided by the MCP;

(e) The right to request a state hearing through the state's hearing system; and

(f) How to request a state hearing; and if applicable:

(i) The right to continue to receive benefits pending a state hearing,

(ii) How to request the continuation of benefits; and

(iii) If the MCP action is upheld at the state hearing that the member may be liable for the cost of any continued benefits.

(9) For appeals decided in favor of the member, the MCP must:

(a) Authorize or provide the disputed services promptly and as expeditiously as the member's health condition requires if the services were not furnished while the appeal was pending.

(b) Pay for the disputed services if the member received the services while the appeal was pending.

(E) Expedited appeals to an MCP.

(1) Each MCP must establish and maintain an expedited review process to resolve appeals when the MCP determines, or the provider indicates in making the request on the member's behalf or supporting the member's request, that taking the time for a standard resolution could seriously jeopardize the member's life or health or ability to attain, maintain, or regain maximum function.

(2) In utilizing an expedited appeal process, the MCP must comply with the standard appeal process specified in paragraph (D) of this rule, except the MCP must:

(a) Not require that an oral filing be followed with a written, signed appeal ;

(b) Make a determination within one working day of the appeal request whether to expedite the appeal resolution ;

(c) Make reasonable efforts to provide prompt oral notification to the member of the decision to expedite or not expedite the appeal resolution ;

(d) Inform the member of the limited time available for the member to present evidence and allegations of fact or law in person or in writing ;

(e) Resolve the appeal as expeditiously as the member's health condition requires but the resolution timeframe must not exceed three working days from the date the MCP received the appeal unless the resolution timeframe is extended as outlined in paragraph (F) of this rule ;

(f) Make reasonable efforts to provide oral notice of the appeal resolution in addition to the required written notification ;

(g) Ensure that punitive action is not taken against a provider who requests an expedited resolution or supports a member's appeal ; and

(h) Notify ODM within one working day of any appeal that meets the criteria for expedited resolution as specified by ODM.

(3) If the MCP denies the request for expedited resolution of an appeal the MCP must:

(a) Transfer the appeal to the standard resolution timeframe of fifteen calendar days from the date the appeal was received unless the resolution timeframe is extended as outlined in paragraph (F) of this rule;

(b) Provide the member written notice of the denial to expedite the resolution within two calendar days of the receipt of the appeal, including information that the member can grieve the decision.

(F) Appeal resolution extensions.

(1) A member may request that the MCP extend the timeframe to resolve a standard or expedited appeal up to fourteen calendar days.

(2) An MCP may request that the timeframe to resolve a standard or expedited appeal be extended up to fourteen calendar days. The MCP must seek such an extension from ODM prior to the expiration of the regular appeal resolution timeframe and its request must be supported bydocumentation that the extension is in the member's best interest . If ODM approves the extension, the MCP must immediately give the member written notice of the reason for the extension and the date by which a decision must be made.

(3) The MCP must maintain documentation of any extension request.

(G) Continuation of benefits for an appeal to the MCP.

(1) The MCP must continue a member's benefits when an appeal has been filed if the following conditions are met:

(a) The member or authorized representative files the appeal on or before the later of the following:

(i) Within fifteen working days of the MCP mailing the NOA; or

(ii) The intended effective date of the MCP's proposed action;

(b) The appeal involves the termination, suspension, or reduction of services prior to the member receiving the previously authorized course of treatment;

(c) The services were ordered by an authorized provider;

(d) The authorization period has not expired; and

(e) The member requests the continuation of benefits.

(2) If the MCP continues or reinstates the member's benefits while the appeal is pending, the benefits must be continued until one of the following occurs:

(a) The member withdraws the appeal;

(b) Fifteen calendar days pass following the mailing date of the MCP's notice to the member of an adverse appeal decision unless the member, within the fifteen-day timeframe, requests a state hearing in which case the benefits must be continued as specified in rule 5101:6-4-01 of the Administrative Code;

(c) A state hearing regarding the reduction, suspension or termination of services is decided adverse to the member; or

(d) The initial time period for the authorization expires or the authorization service limits are met.

(3) At the discretion of ODM, the MCP may recover the cost of the continuation of services furnished to the member while the appeal was pending if the final resolution of the appeal upholds the MCP's original action.

(H) Grievances to an MCP.

(1) A member or authorized representative can file a grievance. An authorized representative must have the member's written consent to file a grievance on the member's behalf.

(2) Grievances may be filed only with the MCP, orally or in writing, within ninety calendar days of the date that the member became aware of the issue.

(3) The MCP must acknowledge the receipt of each grievance to the individual filing the grievance. Oral acknowledgment is acceptable . However , if the grievance is filed in writing, written acknowledgment must be made within three working days of receipt of the grievance.

(4) The MCP must review and resolve all grievances as expeditiously as the member's health condition requires. Grievance resolutions including member notification must meet the following timeframes:

(a) Within two working days of receipt if the grievance is regarding access to services.

(b) Within thirty calendar days of receipt for non claims-related grievances except as specified in paragraph (H)(4)(a) of this rule.

(c) Within sixty calendar days of receipt for claims-related grievances.

(5) At a minimum, the MCP must provide oral notification to the member of a grievance resolution. However, if the MCP is unable to speak directly with the member or the resolution includes information that must be confirmed in writing, the resolution must be provided in writing simultaneously with the MCP's decision.

(6) If the MCP's resolution to a grievance is to affirm the denial, reduction, suspension, or termination of a service or billing of a member due to the MCP's denial of payment for that service, the MCP must notify the member of his or her right to request a state hearing as specified in paragraph (I) of this rule, if the member has not previously been notified.

(I) Access to state's hearing system.

(1) The MCP must develop and implement written policies and procedures that ensure the plan's compliance with the state hearing provisions specified in division 5101:6 of the Administrative Code.

(2) Members are not required to exhaust the appeal or grievance process through the MCP in order to access the state's hearing system.

(3) When required by paragraph (C) of this rule and division 5101:6 of the Administrative Code, the MCP must notify members, and any authorized representatives on file with the MCP, of the right to a state hearing. The following requirements apply:

(a) If the MCP denies a request for the authorization of a service, in whole or in part, the MCP must simultaneously complete and mail or personally deliver the "Notice of Denial of Medical Services By Your Managed Care Plan" ( ODM 04043, 7/2014 formerly JFS 04043).

(b) If the MCP decides to reduce, suspend, or terminate services prior to the member receiving the services as authorized by the MCP, the MCP must complete and mail or personally deliver no later than fifteen calendar days prior to the effective date of the proposed reduction, suspension, or termination, the "Notice of Reduction, Suspension or Termination of Medical Services By Your Managed Care Plan" ( ODM 04066, 7/2014 formerly JFS 04066).

(c) If the MCP learns that a member has been billed for services received by the member due to the MCP's denial of payment, and the MCP upholds the denial of payment, the MCP must immediately complete and mail or personally deliver the "Notice of Denial of Payment for Medical Services By Your Managed Care Plan" ( ODM 04046, 7/2014 formerly JFS 04046).

(d) If the MCP proposes enrollment in the coordinated services program (CSP), the MCP must complete and mail or personally deliver no later than fifteen calendar days prior to the effective date of the proposed enrollment, the "Notice of Proposed Enrollment in the Coordinated Services Program (CSP) " ( ODM 01717, 7/2014 formerly JFS 01717).

(e) If the MCP decides to continue enrollment in CSP, the MCP must simultaneously complete and mail or personally deliver the "Notice of Continued Enrollment in the Coordinated Services Program (CSP) " ( ODM 01705, 7/2014 formerly JFS 01705).

(f) If the MCP denies a CSP member's request to change designated provider(s) within the MCP's provider panel, the MCP must simultaneously complete and mail or personally deliver the "Notice of Denial of Designated Provider or Pharmacy in the Coordinated Services Program (CSP) " (, (ODM 01718, 7/2014 formerly JFS 01718 ).

(4) The member or member's authorized representative may request a state hearing within ninety calendar days by contacting the ODJFS bureau of state hearings or local county department of job and family services (CDJFS). The ninety-day period begins on the day after the mailing date on the state hearing form.

(5) There are no state hearing rights for a member(s) terminated from the MCP pursuant to an MCP-initiated membership termination as permitted in rule 5160-26- 02.1 of the Administrative Code.

(6) Following the bureau of state hearings' notification to the MCP that a member has requested a state hearing the MCP must:

(a) Complete the "Appeal Summary for Managed Care Plans" (ODM 01959, 7/2014 formerly JFS 01959) with appropriate attachments, and file it with the bureau of state hearings at least three business days prior to the scheduled hearing date. The appeal summary must provide all facts and documents relevant to the issue, and be sufficient to demonstrate the basis for the MCP's action or decision.

(b) Send a copy of the completed appeal summary to the appellant, the bureau of state hearings, the local agency, and the designated ODM contact.

(c) Continue or reinstate the benefit(s) specified in rule 5101:6-4-01 of the Administrative Code, if the MCP is notified that the member's state hearing request was received within the prior notification period.

(d) Not enroll the individual in the coordinated services program (CSP) if the MCP is notified that the member's state hearing request was received within the prior notification period.

(7) The MCP must participate in the hearing in person or by telephone, on the date indicated on the "State Hearing Scheduling Notice" (JFS 04002, rev. 09/2002) sent to the MCP by the bureau of state hearings.

(8) In addition to the MCP and member, other parties to a state hearing may include an authorized representative of a member, or the representative of the member's estate, if the member is deceased.

(9) The MCP must comply with the state hearing officer's decision provided to the MCP via the "State Hearing Decision" (JFS 04005, rev. 03/2003). If the hearing officer's decision is to sustain the member's appeal, the MCP must complete the "State Hearing Compliance" form (JFS 04068, rev. 05/2001). A copy of the completed form, including applicable documentation, is due by no later than the compliance date specified in the hearing decision to the bureau of state hearings and the designated ODM contact. If applicable, the MCP must:

(a) Authorize or provide the disputed services promptly and as expeditiously as the member's health condition requires.

(b) Pay for the disputed services if the member received the disputed services while the appeal was pending.

(10) The MCP must provide a copy of the state hearing forms referenced in this paragraph to ODM, as directed by ODM.

(11) Upon request, the MCP's state hearing policies and procedures must be made available for review by ODM.

(J) Logging and reporting of appeals and grievances.

(1) The MCP must maintain records of all appeals and grievances including resolutions for a period of eight years and the records must be made available upon request to ODM and the medicaid fraud control unit .

(2) The MCP must identify a key staff person responsible for the logging and reporting of appeals and grievances and assuring that the grievance system is in accordance with this rule.

(3) The MCP is required to submit information regarding appeal and grievance activity as directed by ODM.

(K) Other duties of an MCP regarding appeals and grievances.

(1) The MCP must give members all reasonable assistance in filing an appeal, a grievance, or a state hearing request including but not limited to:

(a) Explaining the MCP's process to be followed in resolving the member's appeal or grievance;

(b) Completing forms and taking other procedural steps as outlined in this rule; and

(c) Providing oral interpreter and oral translation services, sign language assistance, and access to the grievance system through a toll-free number with text telephone yoke (TTY) and interpreter capability.

(2) The MCP must ensure that the individuals who make decisions on appeals and grievances are individuals who:

(a) Were not involved in previous levels of review or decision-making; and

(b) Are health care professionals who have the appropriate clinical expertise in treating the member's condition or disease if deciding any of the following:

(i) An appeal of a denial that is based on lack of medical necessity;

(ii) A grievance regarding the denial of an expedited resolution of an appeal; or

(iii) An appeal or grievance that involves clinical issues.

(3) The procedure to be followed to file an appeal, grievance, or state hearing request must be described in the MCP's member handbook and must include the telephone number(s) for the MCP's toll-free member services hotline, the MCP's mailing address, and a copy of the optional form(s) that members may use to file an appeal or grievance with the MCP. Copies of the form(s) to file an appeal or grievance must also be made available through the MCP's member services program.

(4) Appeals and grievance procedures must include the participation of individuals authorized by the MCP to require corrective action.

(5) The MCP is prohibited from delegating the appeal or grievance process to another entity.

Effective: 3/6/2015
Five Year Review (FYR) Dates: 10/30/2014 and 03/06/2020
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5164.02, 5167.03, 5167.10, 5167. 13
Prior Effective Dates: 7/1/03, 6/1/06, 9/15/08, 7/1/09, 8/1/10, 1/1/12

5160-26-08.5 [Rescinded] Managed health care programs: responsibilities for state hearings.

Effective: 2/1/2015
Five Year Review (FYR) Dates: 10/30/2014
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5164.02, 5167.03, 5167.10, 5167.13
Prior Effective Dates: 7/1/03, 6/1/06, 9/15/08, 7/1/09, 8/1/10

5160-26-09 Managed health care programs: payment and financial responsibility.

(A) Payment.

(1) The Ohio department of medicaid (ODM) will compute managed care plan (MCP) premium rates on an actuarially sound basis. The premium rates do not include any amount for risks assumed under any other existing or any previous agreement or contract. ODM will review the premium rates at least annually and the rate(s) may be modified based on existing actuarial factors and experience.

(2) The MCP will receive a monthly premium payment for each member from ODM.

(3) When an MCP provides or arranges for maternity coverage, ODM will make a separate payment to the MCP for each reimbursable delivery for applicable covered populations described in rule 5160-26-02 of the Administrative Code.

(4) The amounts paid by ODM in accordance with this paragraph represent a full-risk arrangement and the total obligation of ODM to the MCP for the costs of medical care and services provided. Any savings or losses remaining after costs have been deducted from the premium will be wholly retained by the MCP.

(5) Payments made by ODM in accordance with this paragraph will be in effect for the duration of the provider agreement entered into between ODM and the MCP unless restricted in accordance with rule 5160-26-10 of the Administrative Code or the terms of the provider agreement.

(6) ODM may establish financial incentive programs based on performance for MCPs.

(B) Fiscal responsibility requirements.

(1) An MCP must maintain a fiscally-sound operation and meet ODM performance standards.

(2) An MCP must make provisions against the risk of insolvency.

(3) Neither members nor ODM shall be liable for any MCP debts, including those that remain in the event of MCP insolvency or the insolvency of any subcontractors.

(4) An MCP must pay providers in accordance with 42 C.F.R. 447.46(October 1, 2013).

(5) The following requirements apply to an MCP licensed as a health insuring corporation (HIC) by the Ohio department of insurance (ODI):

(a) A copy of the MCP's current license or certificate of authority must be submitted to ODM annually, no later than thirty days after issuance;

(b) Copies of all annual and quarterly financial statements and any revision to such copies must be submitted to ODM. For purposes of this rule, " annual financial statement" is the annual statement of financial condition prescribed by the "National Association of Insurance Commissioners" (NAIC) and required by ODI in accordance with sections 1751.32 and 1751.47 of the Revised Code.

(c) The MCP must submit to ODM a copy of its audited financial statement as compiled by an independent auditor and including the statement of reconciliation with statutory accounting principles as required by ODI in accordance with section 1751.321 of the Revised Code. The statement must be submitted annually to ODM.

(6) The following items must be submitted by each MCP as so indicated:

(a) Cost reports on ODM forms quarterly and annually as directed by ODM. The MCP must adhere to ODM provider agreement and cost report instructions;

(b) Financial disclosure statements to be submitted in conjunction with cost report submissions as specified in paragraph (B)(5)(b) of this rule for MCPs. The MCP must also submit copies of annual financial statements for those entities who have an ownership interest totaling five percent or more in the MCP, or an indirect interest of five percent or more or a combination of direct and indirect interest equal to five percent or more in the MCP; and

(c) MCP physician incentive plan disclosure statements in accordance with 42 C.F.R. 438.6 (October 1, 2013).

(C) Reinsurance requirements.

(1) All MCPs must carry reinsurance coverage from a licensed commercial carrier to protect against catastrophic inpatient-related medical expenses incurred by medicaid members.

(2) To the extent that the risk for such expenses is transferred to a subcontractor, the MCP must provide proof of reinsurance coverage for that subcontractor in accordance with the provisions of this paragraph.

(3) A copy of the fully-executed reinsurance agreement to provide the specified coverage must be submitted to ODM prior to the effective date of the provider agreement. No provider agreement will be signed in the absence of such documentation.

(4) The annual deductible must be specified in the reinsurance agreement and must not exceed the amount specified by ODM.

(5) The reinsurance coverage must remain in force during the term of the provider agreement with ODM and must contain adequate provisions for contract extensions.

(6) The MCP shall provide written notification to ODM when directed by ODM, specifying the dates of admission, diagnoses, and estimates of the total claims incurred for all medicaid members for which reinsurance claims have been submitted.

(7) The MCP must give ODM prior written notice of any proposed changes or modifications in the reinsurance agreements for ODM review and approval. Such notice shall be submitted to ODM thirty days prior to the intended effective date of any proposed change and must include the complete and exact text of the proposed change. The MCP must provide copies of new or modified reinsurance agreements to ODM within thirty days of execution.

(8) In the event of termination of the reinsurance agreement due to insolvency of the MCP or the reinsurance carrier, the MCP will be fully responsible for all pending or unpaid claims.

(9) Any reinsurance agreements which cover expenses to be paid for continued benefits in the event of insolvency must include medicaid members as a covered class.

(10) Reinsurance requirements for partial-risk arrangements may differ from those specified in this paragraph.

Effective: 2/1/2015
Five Year Review (FYR) Dates: 10/30/2014 and 02/01/2020
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5164.02, 5164.70, 5167.03, 5167.10
Prior Effective Dates: 4/1/85, 5/2/85, 10/1/87, 2/15/89 (Emer), 5/8/89, 5/1/92, 5/1/93, 11/1/94, 5/8/95, 7/1/96, 7/1/97 (Emer), 9/27/97, 7/4/98, 7/1/00, 11/18/00, 7/1/01, 7/1/03, 7/1/04, 10/31/05, 6/1/06

5160-26-09.1 Managed health care programs: third party recovery.

(A) Tort

(1) Pursuant to sections 5160.37. and 5160.38 of the Revised Code, ODM maintains all rights of recovery (tort) against the liability of any third party payer (TPP) for the cost of medical services arising out of any accident/incident related to an injury of a member.

(2) Managed care plans (MCPs) are prohibited from accepting any settlement, compromise, judgment, award, or recovery of any action or claim by the member.

(3) MCPs must notify ODM and/or its designated entity within fourteen calendar days of all requests for the release of financial and medical records to a member or the member's representative pursuant to the filing of a tort action. Notification must be made via the "Notification of Third Party (tort) Request For Release" form (JFS 03245, rev. 1/2011) or a method determined by the ODM designated entity, provided ODM has approved the designated entity's method and notified MCPs.

(4) MCPs must submit a summary of financial information to ODM and/or its designated entity within thirty calendar days of receiving an original authorization to release a financial claim statement letter from ODM pursuant to a tort action. MCPs must use the "Tort Summary Statement for ODJFS" form (JFS 03246, rev. 1/2011) or a method determined by the ODM designated entity, provided ODM has approved the designated entity's method and notified MCPs. Upon request, the MCPs must provide ODM and/or its designated entity with true copies of medical claims.

(B) Fraud and abuse recovery

(1) Except as set forth in paragraph (B)(2) of this rule, ODM assigns to MCPs its rights of recovery against any TPP for the costs arising out of provider fraud or abuse as defined by rule 5160-26-01 of the Administrative Code related to each member during periods of membership in the MCP.

(2) MCPs must promptly report to ODM all cases of suspected fraud or abuse, in the manner specified by ODM. If an MCP fails to properly report a case of suspected fraud or abuse before the suspected fraud or abuse is identified by the state of Ohio, its designees, the United States or private parties acting on behalf of the United States, any portion of the fraud or abuse recovered by the state of Ohio or designees shall be retained by the state of Ohio or its designees.

(C) Coordination of benefits (COB)

(1) ODM assigns its right to third party resources (coordination of benefits) to contracted MCPs for services rendered to each member during periods of membership.

(2) MCPs must act to provide coordination of benefits if a member has third party resources available for the payment of medical expenses for medically necessary medicaid-covered services. Such expenses will be paid in accordance with this rule and sections 5160.37 and 5160.38 of the Revised Code.

(3) The MCP is the payer of last resort when a member has third party resources available for payment of medical expenses for medicaid-covered services, except for the following resources in which the MCP is the primary payer:.

(a) Resources provided through the children with medical handicaps program under sections 3701.021 to 3701.0210 of the Revised Code, as specified in rule 5160-1-03 of the Administrative Code.

(b) Resources that are exempt from primary payer status under federal medicaid law, 42 U.S.C. 1396 (August 19, 2013).

(c) Resources provided through the state sponsored program awarding reparations to victims of crime, as set forth in sections 2743.51 to 2743.72 of the Revised Code.

(d) Resources available for prenatal care for pregnant women, or preventive pediatric services pursuant to 42 CFR 433.139 (August 14, 2013).

(4) MCPs will take reasonable measures to ascertain and verify any third party resources that are available to the member. When an MCP denies a claim due to third party liability (TPL), the MCP must timely share appropriate and available information regarding the third party resources to the provider for the purposes of coordination of benefits, including, but not limited to, the following information:

(a) Insurance company name;

(b) Insurance company billing address for claims;

(c) Member's group number;

(d) Member's policy number; and

(e) Policy holder name.

(5) MCPs must require providers who are submitting TPL claims to the MCPs to request information regarding third party benefit(s) from the member or his/her authorized representative. If the member or the member's authorized representative specifies that the member has no third party benefit(s), or the provider is unable to determine that the member has third party benefit(s), the MCP must permit the provider to submit a claim to the MCP. If, as a result of requesting the information, the provider determines that third party liability exists, the MCP must allow the provider to submit a claim for reimbursement if he/she first takes reasonable measures to obtain third party payment(s) as set forth in paragraph (C)(6) of this rule.

(6) The MCP must be the last payer to receive and adjudicate the claim, except for those exemptions listed in paragraph (C)(3) of this rule. The MCP must require providers to take reasonable measures to obtain all third party payments and file claims with all TPPs prior to billing the MCP. MCPs must permit providers who have taken reasonable measures to obtain all third party payments, but who have not received payment from a TPP, or have taken reasonable measures and received partial payment, to submit a claim to the MCP requesting reimbursement for the rendered service(s).

(a) MCPs must process claims when the provider has complied with one or more of the following reasonable measures:

(i) The provider first submits a claim to the TPP for the rendered service(s) and does not receive a remittance advice or other communication from the TPP within ninety days after the submission date. MCPs may require providers to document the claim and date of the claim submission to the TPP.

(ii) The provider has retained and/or submitted at least one of the following types of documentation that indicates a valid reason for non-payment for the service(s) that is not related to provider error:

(a) Documentation from the TPP;

(b) Documentation from the TPP's automated eligibility and claim verification system;

(c) Documentation from the TPP's member benefits reference guide/manual; or

(d) Any other information and/or documentation from the TPP that there is no third party benefit coverage for the rendered service(s).

(iii) The provider submitted a claim to the TPP and received a partial payment along with a remittance advice documenting the allocation of the charges.

(b) Valid reasons for non-payment from a third party payer to the provider for a third party benefit claim include, but are not limited to, the following:

(i) The service(s) is not covered under the member's third party benefits.

(ii) The member does not have third party benefits through the TPP for the date of service.

(iii) All of the provider's billed charges or the TPP's approved rate was applied, in whole or in part, to the member's third party benefit deductible amount, coinsurance and/or co-payment for the TPP. The provider may then submit a secondary claim to the MCP showing the appropriate amount received from the TPP.

(iv) The member has not met any required waiting periods, or residency requirements for his/her third party benefits, or was non-compliant with the TPP's requirements in order to maintain coverage.

(v) The member is a dependent of the individual with third party benefits, but the benefits do not cover the individual's dependents.

(vi) The member has reached the lifetime benefit maximum for the medical service or third party benefits being billed to the third party payer.

(vii) The TPP is disputing or contesting its liability to pay the claim or cover the service.

(7) If the provider receives payment from the TPP after the MCP has made payment, the MCP must require the provider to repay the MCP any amount overpaid by the MCP. The MCP must not allow the provider to reimburse any overpaid amounts to the member.

(8) MCPs must make available to providers information on how to submit a claim that will have a zero paid amount in the third party field on the claim.

(9) MCP reimbursement for third party claims will not exceed the MCP allowed amount for the service, less all third party payments for the service.

(10) An MCP's timely filing limits for provider claims shall be at least ninety days from the date of the remittance advice that indicates adjudication or adjustment of the third party claim by the TPP.

(11) MCPs must ensure that providers do not hold liable or bill members in the event that the MCP cannot or will not pay for covered services unless all of the specifications set forth in rule 5160-26-05 and rule 5160-26-11 of the Administrative Code are met. The provider may not collect and/or bill the member for any difference between the MCP payment and the provider's charge or request the member to share in the cost through a deductible, coinsurance, co-payment, or other similar charge, other than MCP co-payments as permitted in rule 5160-26-12 of the Administrative Code.

Effective: 01/01/2014
R.C. 119.032 review dates: 10/15/2013 and 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5167.03, 5167.10
Prior Effective Dates: 11/1/94, 7/1/97 (Emer), 9/27/97, 7/1/01, 7/1/03, 6/1/06, 7/1/07, 9/15/08, 8/1/2011

5160-26-10 Managed health care programs: sanctions and provider agreement actions.

(A) If the MCP fails to fulfill its duties and obligations under 42 C.F.R. Part 438 (October 1, 2013), 42 U.S.C. 1396b(m) (as in effect January 1, 2015), 42 U.S.C. 1396u-2 (as in effect January 1, 2015), Chapter 5160-26 or 5160-58 of the Administrative Code, or the MCP provider agreement, ODM will provide timely written notification to the MCP identifying the violations or deficiencies, and may impose corrective actions or any of the following sanctions in addition to or instead of any actions or sanctions specified in the provider agreement:

(1) ODM may require corrective action plans (CAPs) in accordance with the following:

(a) If requested by ODM, the MCP must submit, within the specified time frame, a proposed CAP for each cited violation or deficiency.

(b) The CAP must contain the proposed correction date, describe the manner in which each violation or deficiency will be resolved, and address all items specified in the ODM notification.

(c) The CAP must be reviewed and approved by ODM.

(d) Following the approval of the CAP, ODM will monitor the correction process until all violations or deficiencies are corrected to the satisfaction of ODM.

(e) If the MCP fails to submit an approvable CAP within the ODM-specified time frames, ODM may impose an ODM-developed CAP, sanctions, or both.

(f) If ODM has already determined the specific action that must be implemented by the MCP, ODM may require the MCP to comply with an ODM-developed or directed CAP.

(g) Failure by the MCP to successfully complete the correction process and correct the violations or deficiencies to the satisfaction of ODM may lead to the imposition of any or all of the sanctions listed in paragraph (A)(2) of this rule.

(2) Sanctions that may be imposed on MCPs by ODM include but are not limited to the following:

(a) Suspension of the enrollment of MCP members.

(b) Disenrollment of the MCP's members.

(c) Prohibition or reduction of the MCP's voluntary assignments.

(d) Prohibition or reduction of the MCP's involuntary assignments.

(e) Granting MCP members the right to terminate without cause and notifying the affected members of their right to disenroll.

(f) Retention by ODM of the MCP's premium payments or a portion thereof until the violations or deficiencies are corrected.

(g) Imposition of financial sanctions.

(B) ODM will select sanction(s) specified in paragraph (A)(2) of this rule based on a pattern of repeated violations or deficiencies, the severity of the cited violations or deficiencies, the failure of the MCP to meet the requirements of an approved CAP, or all these factors.

(C) The sanctions in paragraph (A)(2) of this rule are subject to reconsideration by ODM as specified in Chapter 5160-70 of the Administrative Code, with the exception that the involuntary assignments referenced in paragraph (A)(2)(d) of this rule are not subject to reconsideration.

(D) Regardless of any other sanction that may be imposed, ODM may impose temporary management on any MCP that has repeatedly failed to meet substantive requirements in 42 U.S.C. 1396b(m) (as in effect January 1, 2015), 42 U.S.C. 1396 u-2 (as in effect January 1, 2015) or 42 C.F.R. Part 438 subpart I (October 1, 2013). Such temporary management shall be imposed in accordance with the following:

(1) The MCP must pay the costs of a temporary manager for performing the duties of a temporary manager as determined by ODM.

(2) The MCP is solely responsible for any costs or liabilities incurred on behalf of the MCP when temporary management is imposed by ODM.

(3) The imposition of temporary management is not subject to the appeals process provided under Chapter 119. of the Revised Code; however, the MCP may request that the director for the medicaid program reconsider this action. ODM will not delay imposition of temporary management to provide reconsideration prior to imposing this sanction.

(4) Unless the director for the medicaid program determines through the reconsideration process that temporary management should not have been imposed, the temporary management will remain in place until such time as ODM determines that the MCP can ensure that the sanctioned behavior will not recur.

(5) Regardless of the imposition of temporary management, the MCP retains the right to appeal any proposed termination or nonrenewal of its provider agreement under Chapter 119. of the Revised Code. The MCP also retains the right to initiate the sale of the MCP or its assets.

(6) If temporary management is imposed, ODM will notify the MCP's members that such action has occurred and inform them that they therefore have the right to terminate their membership in the MCP without cause. Termination of the MCP's membership without cause is not subject to the appeals process provided under Chapter 119. of the Revised Code; however, the MCP may request that the director for the medicaid program reconsider this action. ODM will not delay the notification to the MCP's membership to provide reconsideration prior to imposing this sanction.

(E) ODM will provide an MCP with written notice before imposing any sanction. The notice will describe any reconsideration or appeal rights that are available to the MCP.

(F) Regardless of whether ODM imposes a sanction, MCPs shall initiate corrective action for any MCP program violations or deficiencies as soon as they are identified by either the MCP or ODM.

(G) The following provisions apply in the event ODM decides to terminate, nonrenew, deny or amend the MCP's provider agreement.

(1) ODM may terminate, nonrenew, deny or amend the MCP's provider agreement if at any time ODM determines that continuation or assumption of a provider agreement is not in the best interest of recipients or the state of Ohio. For the purposes of this rule, an amendment to an MCP's provider agreement is defined as and limited to the elimination of one or more service areas included in that MCP's current agreement. The phrase "not in the best interest" includes, but is not limited to, the following:

(a) The MCP's delivery system does not assure adequate access to services for its members.

(b) The MCP's delivery system does not assure the availability of all services covered under the provider agreement.

(c) The MCP fails to provide all medically-necessary covered services.

(d) The MCP fails to provide proper assurances of financial solvency.

(e) The number of members enrolled by the MCP in a service area is not sufficient to ensure the effective or efficient delivery of services to members.

(f) The MCP fails to comply with any of the following:

(i) Chapter 5160-26 or 5160-58 of the Administrative Code or both;

(ii) The provider agreement;

(iii) The applicable requirements in 42 U.S.C. 1396b(m) (as in effect January 1, 2015) or 42 U.S.C. 1396u-2 (as in effect January 1, 2015);

(iv) 42 C.F.R. Part 438 (October 1, 2013).

(2) If ODM has proposed termination, nonrenewal, denial, or amendment of a provider agreement, ODM may notify the MCP's members of this proposed action and inform the members of their right to immediately disenroll from the MCP without cause.

(3) If ODM determines that the termination, nonrenewal, or denial of a provider agreement is warranted:

(a) ODM will provide notice, at a minimum, forty-five days prior to the effective date of the proposed action;

(b) The action will be in accordance with and subject to Chapter 5160-70 of the Administrative Code; and

(c) The action will be effective at the end of the last day of a calendar month.

(4) If ODM determines that the amendment of a provider agreement is warranted, the proposed action is subject to reconsideration pursuant to Chapter 5160-70 of the Administrative Code.

(5) Notwithstanding the preceding paragraphs of this rule, ODM may terminate an MCP's provider agreement effective on the last day of the calendar month in which any of the following occur:

(a) The determination by ODM that the loss or reduction of federal or state funding has reduced funding to a level which is insufficient to maintain the activities or services agreed to in the provider agreement;

(b) The exclusion from participation of the MCP in a program administered under Title XVIII, XIX, or XX of the Social Security Act due to criminal conviction or the imposition of civil monetary penalties in accordance with 42 C.F.R. Part 455 subpart B (October 1, 2013), 42 C.F.R. Part 1002 subpart A (October 1, 2013), and rule 5160-1- 17.3 of the Administrative Code;

(c) The suspension, revocation or nonrenewal of ODM's authority to operate the program under the state plan or waivers of certain federal regulations granted by CMS or congress;

(d) The suspension, revocation or nonrenewal of the MCP's certificate of authority or license.

(e) The exclusion of the MCP from participation in accordance with 42 C.F.R. 438.808 (October 1, 2013).

(6) MCPs whose provider agreements are amended, terminated, denied or nonrenewed are required to fulfill all duties and obligations under Chapter 5160-26 or 5160-58 or both of the Administrative Code and the provider agreement.

Replaces: 5160-26-10

Effective: 7/2/2015
Five Year Review (FYR) Dates: 07/02/2020
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5164.02, 5167.03, 5167.10
Prior Effective Dates: 5/2/85, 10/1/87, 2/15/89 (Emer), 5/8/89, 5/1/92, 5/1/93, 11/1/94, 7/1/97 (Emer), 9/27/97, 12/10/99, 7/1/01, 7/1/03, 7/1/04, 10/31/05, 1/1/08, 8/26/08 (Emer), 10/9/08

5160-26-11 Managed health care programs: managed care plan non-contracting providers.

(A) For the purposes of this rule, the following terms are defined as follows:

(1) "Managed care plan (MCP) non-contracting provider" means any provider with a medicaid provider agreement with ODM who does not contract with the MCP but delivers health care services to that MCP's member(s), as described in paragraphs (C) and (D) of this rule.

(2) "Managed care plan (MCP) non-contracting provider of emergency services" means any person, institution, or entity that does not contract with the MCP but provides emergency services to an MCP member, regardless of whether or not that provider has a medicaid provider agreement with the Ohio department of medicaid (ODM).

(B) MCP non-contracting providers of emergency services must accept as payment in full from the MCP the lesser of billed charges or one hundred per cent of the Ohio medicaid program reimbursement rate (less any payments for indirect costs of medical education and direct costs of graduate medical education that is included in the Ohio medicaid program reimbursement rate) in effect for the date of service. Pursuant to section 5167.10 of the Revised Code, the MCP shall not compensate a hospital for inpatient capital costs in an amount that exceeds the maximum rate established by ODM.

(C) When ODM has approved an MCP's members to be referred to an MCP non-contracting hospital pursuant to rule 5160-26-03 of the Administrative Code, the MCP non-contracting hospital must provide the service for which the referral was authorized and must accept as payment in full from the MCP one hundred per cent of the current Ohio medicaid program reimbursement rate in effect for the date of service. Pursuant to section 5167.10 of the Revised Code, the MCP shall not compensate a hospital for inpatient capital costs in an amount that exceeds the maximum rate established by ODM. MCP non-contracting hospitals are exempted from this provision when:

(1) The hospital is located in a county in which eligible individuals were required to enroll in an MCP prior to January 1, 2006;

(2) The hospital is contracted with at least one MCP serving the eligible individuals specified in paragraph (C)(1) of this rule prior to January 1, 2006; and

(3) The hospital remains contracted with at least one MCP serving eligible individuals who are required to enroll in MCPs in the service area where the hospital is located.

(D) MCP non-contracting qualified family planning providers (QFPPs) must accept as payment in full from the MCP the lesser of one hundred per cent of the Ohio medicaid program reimbursement rate or billed charges, in effect for the date of service.

(E) An MCP non-contracting provider may not bill an MCP member unless all of the following conditions are met:

(1) The member was notified by the provider of the financial liability in advance of service delivery.

(2) The notification by the provider was in writing, specific to the service being rendered, and clearly states that the recipient is financially responsible for the specific service. A general patient liability statement signed by all patients is not sufficient for this purpose.

(3) The notification is dated and signed by the member.

(4) The reason the service is not covered by the MCP is specified and is one of the following:

(a) The service is a benefit exclusion;

(b) The provider is not contracted with the MCP and the MCP has denied approval for the provider to provide the service because the service is available from a contracted provider, at no cost to the member; or

(c) The provider is not contracted with the MCP and has not requested approval to provide the service.

(F) An MCP non-contracting provider may not bill an MCP member for a missed appointment.

(G) MCP non-contracting providers, including MCP non-contracting providers of emergency services, must contact the twenty-four hour post-stabilization services phone line designated by the MCP to request authorization to provide post-stabilization services in accordance with rule 5160-26-03 of the Administrative Code.

(H) MCP non-contracting providers, including MCP non-contracting providers of emergency services, must allow the MCP, ODM, and ODM's designee access to all enrollee medical records for a period not less than eight years from the date of service or until any audit initiated within the eight year period is completed. Access must include copies of the medical record(s) at no cost for the purpose of activities related to the annual external quality review specified by 42.C.F.R. 438.358 (October 1, 2013)

(I) When an MCP elects to impose member co-payments in accordance with rule 5160-26-12 of the Administrative Code, applicable co-payments shall also apply to services rendered by MCP non-contracting providers. When an MCP has not elected to impose co-payments in accordance with rule 5160-26-12 of the Administrative Code, MCP non-contracting providers are not permitted to impose co-payments on MCP members.

Effective: 2/1/2015
Five Year Review (FYR) Dates: 07/01/2018
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5164.02, 5167.03, 5167.10, 5167.20, 5167.201
Prior Effective Dates: 7/20/01, 7/1/03, 1/1/06, 6/1/06, 1/1/07, 1/1/08, 7/1/13

5160-26-12 Managed health care programs: member co-payments.

(A) Managed care plans (MCPs) may elect to implement a member co-payment program pursuant to section 5162.20 of the Revised Code for dental services, vision services, non-emergency emergency department services, or prescription drugs as provided for in this rule. MCPs must receive prior approval from the Ohio department of medicaid ( ODM) before notifying members that a co-payment program will be implemented. This rule does not apply to "MyCare Ohio" plans pursuant to Chapter 5160-58 of the Administrative Code.

(B) MCPs that elect to implement member co-payment amounts must:

(1) Exclude the populations and services set forth in paragraph (C) of this rule;

(2) Not deny services to members as specified in paragraph (D) of this rule;

(3) Not impose co-payment amounts in excess of the maximum amounts specified in 42 C.F.R. 447.54(October 1, 2013);

(4) Specify in provider subcontracts governed by rule 5160-26-05 of the Administrative Code the circumstances under which member co-payment amounts can be requested. For MCPs that elect to implement a co-payment program, no provider can waive a member's obligation to pay the provider a co-payment except as described in paragraph (G) of this rule;

(5) Ensure that the member is not billed for any difference between the MCP's payment and the provider's charge or request that the member share in the cost through co-payment or other similar charge, other than medicaid co-payments as defined in this rule;

(6) Ensure that member co-payment amounts are requested by providers in accordance with this rule; and

(7) Ensure that no provider or drug manufacturer, including the manufacturer's representative, employee, independent contractor, or agent shall pay any co-payment on behalf of the member.

(C) Exclusions to the member co-payment program for dental, vision, non-emergency emergency department services, and prescription medications include the following:

(1) Children. Members who are under the age of twenty-one are excluded from medicaid co-payment obligations.

(2) Pregnant women. With the exception of routine eye examinations and the dispensation of eyeglasses during a member's pregnancy or post-partum period, all services provided to pregnant women during their pregnancy and the post-partum period are excluded from a medicaid co-payment obligation. The post-partum period is the period that begins on the last day of pregnancy and extends through the end of the month in which the sixty-day period following termination of pregnancy ends.

(3) Institutionalized members. Services or medications provided to members who reside in a nursing facility (NF) or intermediate care facility for individuals with intellectual disabilities (ICF/IID) are excluded from medicaid co-payment obligations.

(4) Emergency. An MCP shall not impose a co-payment obligation for emergency services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily part or organ.

(5) Family planning (pregnancy prevention or contraceptive management). An MCP shall not impose a medicaid co-payment obligation on any service identified by ODM as a pregnancy prevention/contraceptive management service in accordance with rule 5160-21-02 and the appendix to rule 5160-9-12 of the Administrative Code and provided to an individual of child-bearing age.

(6) Hospice. Members receiving services for hospice care are excluded from medicaid co-payment obligation.

(7) Medicare cross-over claims. Medicare cross-over claims defined in accordance with rule 5160-1-05 of the Administrative Code will not be subject to medicaid co-payment obligations.

(8) Medications administered to a member during a medical encounter provided in a hospital, clinic, office or other facility, when the medication is part of the evaluation and treatment of the condition, are not subject to a member co-payment.

(D) No provider may deny services to a member who is eligible for services due to the member's inability to pay the member co-payment. Members who are unable to pay their member co-payment may declare their inability to pay for services or medication and receive their services or medications without paying their member co-payment amount. This provision does not relieve the member from the obligation to pay a member co-payment or prohibit the provider from attempting to collect an unpaid member co-payment. If it is the routine business practice of the provider to refuse service to any individual who owes an outstanding debt to the provider, the provider may consider an unpaid medicaid co-payment as an outstanding debt and may refuse service to a member who owes the provider an outstanding debt. If the provider intends to refuse service to a member who owes the provider an outstanding debt, the provider shall notify the individual of the provider's intent to refuse services. In such situations, MCPs must still ensure that the member has access to needed services.

(E) MCPs may elect to impose member co-payments as follows:

(1) For dental services, the member co-payment amount may not exceed the amount set forth in Chapter 5160-5 of the Administrative Code. Services provided to a member on the same date of service by the same provider are subject to only one co-payment.

(2) For non-emergency emergency department services, the member co-payment amount must not exceed the amount set forth in Chapter 5160-2 of the Administrative Code. For purposes of this rule, the hospital provider shall determine if services rendered are non-emergency emergency department services and will report, through claim submission, the applicable co-payment to the MCP in accordance with medicaid hospital billing instructions.

(3) For vision services, the member co-payment amounts must not exceed the amounts set forth in Chapter 5160-6 of the Administrative Code.

(4) For pharmacy services, the member co-payment amounts must not exceed the amounts set forth in Chapter 5160-9 of the Administrative Code.

(F) Prescriptions for medications are subject to the applicable member co-payment for medications if they are given to a member during a medical encounter provided in the emergency department or other hospital setting, clinic, office, or other facility as a result of the evaluation and treatment of the condition, regardless of whether they are filled at a pharmacy located at the facility or at an outside location.

(G) If an MCP has implemented a member co-payment program for non-emergency emergency department services, as described in paragraph (E)(2) of this rule, a hospital may take action to collect a co-payment by providing, at the time services are rendered to a managed care member, notice that a co-payment may be owed. If the hospital provides the notice and chooses not to take further action to pursue collection of the co-payment, the prohibition against waiving co-payments, as described in paragraph (B)(4) of this rule, does not apply.

(H) If an MCP elects not to impose a co-payment amount for dental services, vision services, non-emergency emergency department services or prescription drugs and the MCP reimburses contracting or non-contracting providers for these services using the medicaid provider reimbursement rate, the MCP must not reduce its provider payments by the applicable co-payment amount set forth in this rule.

Effective: 2/1/2015
Five Year Review (FYR) Dates: 10/01/2016
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5162.20 , 5164.02 , 5167.03 , 5167.10 , 5167.12
Prior Effective Dates: 1/1/06, 6/1/06, 1/1/07, 7/1/09, 2/1/10, 10/1/11