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