5160-26-02 Managed health care program: eligibility and enrollment.

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

(B) Eligibility.

(1) Except as specified in paragraphs (B)(2) and (B)(3)(b) of this rule, in mandatory service areas as permitted by 42 C.F.R. 438.52 (October 1, 2015), an individual must be enrolled in a managed care plan (MCP) if he or she has been determined medicaid eligible in accordance with rules 5160:1-3-01 to 5160:1-5-02.4 of the Administrative Code.

(2) Effective January 1, 2017, managed care enrollment is mandatory for the following individuals:

(a) Children receiving Title IV-E federal foster care maintenance through an agreement between the local children services board and the foster care provider;

(b) Children receiving Title IV-E adoption assistance through an agreement between the local children services board and the adoptive parent;

(c) Children in foster care or other out-of-home placement by the local children services board; and

(d) Children 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 July 1, 2016) and is defined by the state in terms of either program participation or special health care needs.

(3) Medicaid eligible individuals may voluntarily choose to enroll in an MCP if they are:

(a) Indians who are members of federally recognized tribes; or

(b) Effective January 1, 2017, individuals with intellectual disabilities who have a level of care that meets the criteria specified in rule 5123: 2-8-01 of the Administrative Code and receive services through a 1915(c) home and community based services (HCBS) waiver.

(4) Except for individuals receiving medicaid in the adult extension category under section 1902(a)(10)(A)(i)(VIII) of the Social Security Act 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) (as in effect July 1, 2016) and individuals who meet criteria in paragraph (B)(3)(b) of this rule, medicaid eligible individuals described in paragraph (B)(1) of this rule are excluded from MCP enrollment if any of the following is met:

(a) Institutionalized in a nursing facility; or

(b) Receiving medicaid services through an intermediate care facility for individuals with intellectual disabilities (ICF-IID); or

(c) Receiving medicaid services through a medicaid waiver component, as defined in section 5166.02 of the Revised Code; or

(d) Dually eligible and enrolled in both the medicaid and medicare programs.

(5) Individuals who are inmates of public institutions as defined in 42 C.F.R. 435.1010 (October 1, 2015) are excluded from MCP enrollment unless otherwise specified by the Ohio department of medicaid (ODM).

(6) Medicaid eligible individuals are excluded from MCP enrollment when prohibited under a federally approved state plan or state law.

(7) 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, 2015).

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

(c) If an MCP member loses managed care eligibility and is disenrolled from the MCP, and subsequently regains eligibility, his or her enrollment in the same MCP may be re-instated back to the date eligibility was regained, in accordance with procedures established by the ODM.

(d) ODM shall confirm the eligible individual's MCP enrollment via the ODM-produced HIPAA compliant 834 daily and monthly enrollment files of new members, continuing members, and terminating members.

(e) The MCP shall not be required to provide coverage until MCP enrollment is confirmed via the ODM-produced HIPAA compliant 834 daily and monthly enrollment files 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 requirements 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) of this rule, ODM shall confirm eligibility as prescribed in paragraph (C)(1)(d) 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 are required to enroll in an MCP following receipt of a notification of mandatory enrollment (NME) issued by ODM .

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

(i) An individual that does not make an MCP choice following issuance of an NME by ODM 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 enrollment history, whenever available, or at the discretion of ODM.

(3) Newborn notification and enrollment.

(a) The MCP must notify ODM's 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 at least the end of the month of the child's first birthday, or until such time that the MCP is notified of the child's disenrollment via the ODM-produced HIPAA compliant 834 daily or monthly enrollment files.

(D) Commencement of coverage.

(1) Coverage of MCP members will be effective on the first day of the calendar month specified on the ODM-produced HIPAA compliant 834 daily and monthly enrollment files to the MCP, except as specified in paragraph (C)(3) of this rule.

(2) When an eligible individual is admitted to an inpatient facility prior to the effective date of MCP enrollment and remains in an inpatient facility on the enrollment effective date, the following responsibilities apply:

(a) The admitting medicaid payer, either fee-for-service (FFS) or the admitting MCP, is responsible for all inpatient facility charges, pursuant to rule 5160-2-07.11 of the Administrative Code, through the date of discharge.

(b) The enrolling MCP is responsible for all other medically necessary medicaid covered services including professional services related to the inpatient stay, beginning on the enrollment effective date.

Replaces: 5160-26-02

Effective: 8/1/2016
Five Year Review (FYR) Dates: 08/01/2021
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 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, 4/1/15