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