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

(A) ODJFS shall operate procurement processes in accordance with 45 C.F.R. 92.36 for prospective MCPs to enter into provider agreements to serve eligible medicaid individuals. ODJFS may conduct separate procurements or otherwise consider applications if deemed necessary to provide services to special populations or for any other purpose necessary to achieve program objectives.

(B) ODJFS shall issue notice(s) to inform prospective MCPs and others of the procurement process.

(C) ODJFS may determine a maximum number of MCPs in any service area provided that reasonable access to participating providers is assured.

(D) ODJFS shall not enter into a provider agreement with a prospective MCP or amend a provider agreement with an MCP to serve eligible medicaid individuals unless the MCP meets all applicable program requirements.

(E) To participate in managed care programs, prospective MCPs who are found by ODJFS to meet all applicable program requirements will be required to enter into a provider agreement.

(F) If an MCP is terminated from the medicaid and/or medicare program or not renewed as a participating provider in the medicaid program, whether as a result of the MCP's initiative or ODJFS action, ODJFS retains the right not to consider that prospective MCP for a provider agreement for a period of two years from the date of the termination or nonrenewal.

Effective: 07/01/2009
R.C. 119.032 review dates: 04/14/2009 and 07/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.16 , 5111.17
Rule Amplifies: 5111.01 , 5111.02 , 5111.16 , 5111.17
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