5160-58-01.1 MyCare Ohio plans: application of general managed care rules.

(A) MyCare Ohio plans must comply with all of the requirements applicable to managed care plans (MCPs) in the following rules:

(1) Rule 5160-26-05 of the Administrative Code;

(2) Rule 5160-26- 05.1 of the Administrative Code;

(3) Rule 5160-26-06 of the Administrative Code;

(4) Rule 5160-26- 08.3 of the Administrative Code;

(5) Rule 5160-26-09 of the Administrative Code;

(6) Rule 5160-26- 09.1 of the Administrative Code;

(7) Rule 5160-26-10 of the Administrative Code; and

(8) Rule 5160-26-11 of the Administrative Code.

(B) MyCare Ohio plans must comply with all of the requirements applicable to managed care plans in rule 5160-26- 03.1 of the Administrative Code, with the following revisions:

(1) In paragraph (B)(3)(d), the references to rule 5160-26- 08.4 of the Administrative Code should be replaced by a reference to rule 5160-58- 08.4 of the Administrative Code .

(2) The phrase "seventy-two hours" replaces the phrase "three working days" in paragraph (B)(3)(f).

(3) In paragraph (B)(3)(g), the reference to paragraph (C) of rule 5160-26- 08.4 of the Administrative Code should be replaced by a reference to paragraph (C) of rule 5160-58- 08.4 of the Administrative Code .

(4) The following language replaces all of paragraph (B)(3)(h) for MyCare Ohio plans: "Prior authorization decisions for covered outpatient drugs as defined in 42 U.S.C. 1396r-8(k)(2) ( as in effect January 1, 2017) must be made within the timeframes specified in 42 C.F.R. 423.568(b) (October 1, 2016) for standard decisions and 42 C.F.R. 423.572(a) (October 1, 2016) for expedited decisions. When an emergency situation exists, a seventy-two hour supply of the covered outpatient drug that was prescribed must be authorized. If the plan is unable to obtain the information needed to make the prior authorization decision within seventy-two hours, the decision timeframe has expired and the MCP must give notice to the member as specified in paragraph (C) of rule 5160-58- 08.4 of the Administrative Code."

(5) Only the first sentence in paragraph (B)(5) applies to MyCare Ohio plans.

(C) For all rules listed in paragraphs (A) and (B) of this rule, the following provisions apply to the MyCare Ohio program described in Chapter 5160-58 of the Administrative Code:

(1) All cross-references to rule 5160-26-01 of the Administrative Code are replaced by cross-references to rule 5160-58-01 of the Administrative Code .

(2) All cross-references to rule 5160-26-02 of the Administrative Code are replaced by cross-references to rule 5160-58-02 of the Administrative Code .

(3) All cross-references to rule 5160-26- 02.1 of the Administrative Code are replaced by cross-references to rule 5160-58- 02.1 of the Administrative Code .

(4) All cross-references to rule 5160-26-03 of the Administrative Code are replaced by cross-references to rule 5160-58-03 of the Administrative Code .

(5) All cross-references to rule 5160-26- 08.4 of the Administrative Code are replaced by cross-references to rule 5160-58- 08.4 of the Administrative Code.

(D) The following rules in Chapter 5160-26 of the Administrative Code do not apply to MyCare Ohio, as they are replaced by corresponding rules in Chapter 5160-58 of the Administrative Code:

(1) Rule 5160-26-02 of the Administrative Code

(2) Rule 5160-26- 02.1 of the Administrative Code

(3) Rule 5160-26-03 of the Administrative Code, and

(4) Rule 5160-26- 08.4 of the Administrative Code.

(E) When an MCP holds provider agreements with the Ohio department of medicaid (ODM) for the MyCare Ohio and medicaid managed care programs, ODM may apply all of the applicable provisions in Chapter 5160-26 of the Administrative Code separately to each of the contracts.

Cite as Ohio Admin. Code 5160-58-01.1

Effective: 7/1/2017
Five Year Review (FYR) Dates: 04/14/2017 and 07/01/2022
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5166.02, 5167.02
Rule Amplifies: 5164.02, 5166.02, 5167.02
Prior Effective Dates: 3/1/2014