5160-58-02 MyCare Ohio plans: eligibility and enrollment.

(A) Eligibility.

(1) Except as specified in paragraph (A)(2) of this rule, in mandatory service areas as permitted by 42 C.F.R. 438.52 (October 1, 2016), an individual must be enrolled in a MyCare Ohio plan (also known as "plan") if he or she meets all of the following criteria:

(a) Age eighteen or older at the time of enrollment in the plan;

(b) Eligible for medicare parts A, B and D, and full benefits under the medicaid program; and

(c) Reside in a plan demonstration county in Ohio. A list of demonstration counties, and the plans available in those counties, is available at http://medicaid. ohio.gov.

(2) Indians who are members of federally recognized tribes may voluntarily choose to enroll in a plan.

(3) The following individuals are not eligible for enrollment in a plan:

(a) Individuals enrolled in the program of all -inclusive care for the elderly (PACE);

(b) Individuals who have other third party creditable health care coverage, except medicare coverage as authorized by 42 U.S.C. 1395 ( January 1, 2017);

(c) Individuals who are inmates of public institutions as defined in 42 C.F.R. 435.1010 (October 1, 2016);

(d) Individuals with intellectual disabilities who have a level of care that meets the criteria specified in rule 5123:2-8-01 of the Administrative Code and receive services through a home and community-based services (HCBS) waiver administered by the Ohio department of developmental disabilities (DODD); and

(e) Individuals with intellectual disabilities who receive services through an intermediate care facility for individuals with intellectual disabilities (ICF-IID).

(4) Individuals are eligible for plan enrollment in the manner prescribed in this rule if the Ohio department of medicaid (ODM) has a provider agreement with the plan applicable to the eligible individual's county of residence.

(5) Nothing in this rule shall be construed to limit or in any way jeopardize an eligible individual's basic medicaid eligibility or eligibility for medicare or other non-medicaid benefits to which he or she may be entitled.

(B) MyCare Ohio plan enrollment.

(1) The following applies to plan enrollment:

(a) The plan must accept eligible individuals without regard to race, color, religion, gender, sexual orientation, age, disability, national origin, veteran's status, military status, genetic information, ancestry, ethnicity, mental ability, behavior, mental or physical disability, use of services, claims experience, appeals, medical history, evidence of insurability, geographic location within the service area, health status or need for health services. The plan will not use any discriminatory policy or practice in accordance with 42 C.F.R. 438.3(d) (October 1, 2016).

(b) The plan must accept eligible individuals who request plan membership without restriction.

(c) If a plan member loses managed care eligibility and is disenrolled from the plan, and subsequently regains eligibility, his or her membership in the same plan shall be re-instated back to the date eligibility was regained in accordance with procedures established by ODM.

(d) The plan must cover all members designated by ODM in an ODM-produced Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant 834 daily or monthly enrollment file of new members, continuing members, and terminating members.

(e) The plan shall not be required to provide medicaid coverage to an individual until the individual's membership in the plan is confirmed via an ODM-produced HIPAA compliant 834 daily or monthly enrollment file or upon mutual agreement between ODM and the plan.

(2) Should a service area change from voluntary to mandatory, the notice rights in this rule must be followed.

(a) When a service area is initially designated by ODM as mandatory for eligible individuals specified in paragraph (A)(1) of this rule, ODM shall confirm the eligibility of each individual as prescribed in paragraph (A)(1) of this rule. Upon the confirmation of eligibility:

(i) Eligible individuals residing in the service area who are currently plan members are deemed participants in the mandatory program; and

(ii) All other eligible individuals residing in the mandatory service area may request plan membership at any time but must select a plan following receipt of a notification of mandatory enrollment (NME) issued by ODM.

(b) MyCare Ohio plan membership selection procedures for the mandatory program:

(i) A newly eligible individual who does not make a choice following issuance of a NME by ODM and one additional notice,will be assigned to a plan by ODM, the medicaid consumer hotline, or other ODM-approved entity.

(ii) ODM or the medicaid consumer hotline shall assign the individual to a plan based on prior medicaid fee-for-service or plan membership history, whenever available, or at the discretion of ODM.

(C) Commencement of coverage.

Coverage of plan members will be effective on the first day of the calendar month specified on the ODM-produced HIPAA compliant 834 daily or monthly enrollment file to the plan.

Cite as Ohio Admin. Code 5160-58-02

Effective: 1/1/2017
Five Year Review (FYR) Dates: 10/14/2016 and 01/01/2022
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, 8/1/2016