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