(A) The purpose of this rule is to explain the requirements of healthchek, Ohio's early and periodic screening, diagnostic and treatment (EPSDT) medicaid benefit for all recipients under twenty-one years of age. A separate healthchek application is not required. All medicaid recipients under twenty-one years of age are entitled to all healthchek services that are medically necessary services.
(B) Definitions. For the purposes of this rule, the following terms have the following meanings:
(1) "CDJFS" means county department of job and family services.
(2) "EPSDT" means early and periodic screening, diagnostic and treatment.
(3) "Healthchek" is Ohio's early and periodic screening, diagnostic and treatment benefit for all recipients under twenty-one years of age.
(4) "Healthchek coordinator" is the staff person or primary liaison within a unit in the CDJFS who is responsible for the implementation of EPSDT/healthchek services.
(5) "Healthchek services" are periodic screening services (including a comprehensive medical exam, vision, dental, and hearing screenings) and such other necessary health care, diagnostic services, treatment, and other measures described in 42 U.S.C. section 1396d(a) (eff. 1/1/2011) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the state plan. Healthchek services are identical to "EPSDT services" as defined at 42 U.S.C. section 1396d(r).
(6) "Healthchek Services Implementation Plan" (HSIP) means the document submitted by a CDJFS describing how it delivers healthchek services to recipients in its county and who in the agency is responsible for ensuring the delivery of healthchek services.
(7) "Managed care plan" (MCP) means a medicaid managed care plan as defined in Chapter 5101:3-26 of the Administrative Code.
(8) "Medically necessary services" has the same meaning as in rule 5101:3-1-01 of the Administrative Code.
(9) "Prior authorization" for a member of a medicaid MCP is the process outlined in Chapter 5101:3-26 of the Administrative Code. For all other recipients, prior authorization is the process outlined in Chapter 5101:3-1 of the Administrative Code.
(10) "Private child placing agency" (PCPA) has the same meaning as in Chapter 5101:2-1 of the Administrative Code.
(11) "Private non-custodial agency" (PNA) has the same meaning as defined in Chapter 5101:2-1 of the Administrative Code (12) "Provider" means "eligible provider" as defined in Chapter 5101:3-1 of the Administrative Code.
(13) "Public children services agency" (PCSA) has the same meaning as in Chapter 5101:2-1 of the Administrative Code.
(14) "Recipient" means an Ohio medicaid recipient under twenty-one years of age.
(15) "Special populations" means recipients who are blind or deaf or who cannot read or understand the English language.
(16) "Substitute caregiver" has the same meaning as in Chapter 5101:2-1 of the Administrative Code.
(17) "Support services" means personal assistance, coordination, referrals, transportation or other services required to be provided by the CDJFS to assist the recipient with accessing healthchek services.
(18) "Title IV-E agency" has the same meaning as in Chapter 5101:2-1 of the Administrative Code.
(C) Informing. County departments of job and family services are responsible for informing recipients in their counties about healthchek. Each CDJFS shall use a combination of written and oral (including telephone calls, office visits, or home visits) methods to effectively inform recipients (or such recipients' parents, guardians or legal custodians, as applicable) in its county about healthchek within sixty days of the eligibility determination and at least once each year thereafter. Appropriate oral and written informing methods are described as followed:
(1) Written informing.
(a) Each CDJFS shall ensure that each recipient (or such recipient's parent, guardian or legal custodian, as applicable) in its county receives JFS 03528 "Healthchek and Pregnancy Related Services Information" (rev. 2/2011) and JFS 08009 "Healthchek - Ohio's EPSDT Services Brochure" (rev. 11/2007) within sixty days after the recipient is determined eligible for medicaid and at least once each year thereafter:
(b) Each CDJFS shall document that each recipient (or such recipient's parent, guardian or legal custodian, as applicable) in its county has received a JFS 03528 and JFS 08009.
(c) If written healthchek information is sent to a recipient (or such recipient's parent, guardian or legal custodian, as applicable) and returned as undeliverable, the CDJFS will make a second attempt to contact the recipient by alternate means. All attempts to contact a recipient (or such recipient's parent, guardian, or legal custodian, as applicable) shall be documented.
(d) Upon the completion of the JFS 03528, the recipient (or such recipient's parent, guardian or legal custodian, as applicable) will be asked to sign the JFS 03528 form to verify understanding of the healthchek services available to the recipient. If the recipient (or such recipient's parent, guardian or legal custodian, as applicable) needs additional information in order to understand healthchek services, the CDJFS shall immediately provide the necessary information.
(e) Each CDJFS shall enter data regarding recipients into electronic information systems, as directed by ODJFS. Such information shall include information from completed JFS 03528 forms.
(f) Each CDJFS shall prominently post JFS 08137 "Healthchek Screenings, Diagnosis, Treatment" (rev. 9/2010) in an area where medicaid applications are accepted and where it can be seen by the maximum number of applicants and recipients.
(g) ODJFS may develop additional written materials containing information about healthchek. Each CDJFS shall distribute such written materials, as directed by ODJFS. All written materials that a CDJFS uses to inform individuals about healthchek shall be submitted to ODJFS for its review and approval. No CDJFS shall use such written materials unless they have been approved by ODJFS.
(h) Each CDJFS shall utilize ODJFS' information systems to monitor the quality of data regarding recipients, monitor the CDJFS' healthchek informing activities, and aid the CDJFS' healthchek informing activities.
(2) Oral informing. Each CDJFS shall ensure that each recipient (or such recipients' parents, guardians, or legal custodians, as applicable), who has a face-to-face meeting or telephone call with CDJFS staff to apply for medicaid, is orally informed about healthchek. The oral informing shall include written informing material distributed to each CDJFS by ODJFS and shall include clear and non-technical language about the following:
(a) The benefits of preventive health care, including without limitation;
(i) Increased well-being;
(ii) Reduced risk to the recipient's health;
(iii) Identification and treatment of health problems early to reduce the possibility of increase in their severity and cost of treatment; and
(iv) Education of the family to allow for optimal health.
(b) The services covered by healthchek and where and how to obtain those services.
(c) That the services covered by healthchek are without cost to recipients.
(d) The recipient's ability to request and schedule dental, vision, and hearing services separately from the healthchek screening visit.
(e) The availability of medically necessary diagnostic and follow-up treatment services, including referrals, for problems discovered during the healthchek screening service.
(f) The prior authorization process, including that:
(i) The prior authorization process, whether fee-for-service or managed care, must be started by the recipient's medicaid provider;
(ii) The prior authorization requirement for some services, products, or procedures applies even if the recipient is under twenty-one years of age;
(iii) The prior authorization process may enable individuals under twenty-one years of age to receive services not available to adults, including services that are limited in number for adults;
(iv) Certain services require prior authorization, which must be requested by a provider and approved by Ohio medicaid before the service is provided; and
(v) The provider of a recipient who is a member of an MCP must submit a prior authorization request to the recipient's MCP.
(g) The CDJFS must explain necessary transportation and scheduling assistance is available to recipients under twenty-one years of age, upon request, in accordance with Chapter 5101:3-15 of the Administrative Code, and the following:
(i) That transportation will be provided to any medicaid reimbursable service;
(ii) How to request transportation and the timeframes for requesting transportation;
(iii) Verification requirements, if any; and
(iv) That for a recipient who is a member of an MCP, transportation is also available through the recipient's MCP.
(3) Informing special populations. Each CDJFS shall use appropriate methods to inform recipients in a special population (or such recipients' parents, guardians, or legal custodians, as applicable) about healthchek. Information provided to special populations shall meet the requirements of paragraphs (C)(2)(a) to (C)(2)(g) of this rule.
(4) Informing pregnant women. A JFS 03528 shall be used to document the informing of pregnant women about healthchek services as outlined in Chapter 5101:1-38 of the Administrative Code. The JFS 03528 shall be used to document informing again upon the birth of the infant.
(5) The CDJFS shall use electronic means to track pregnant women and the births of their infants to accomplish the following:
(a) Identify newborns and the infant's parent, guardian, legal custodian, as applicable, or the PCSA, using the CDJFS' existing records.
(b) Ensure that any infant is added to the assistance group (AG) within thirty days of learning of the birth of the infant;
(c) Inform the infant's parent, guardian, legal custodian, as applicable, of healthchek services within sixty days of the infant's birth;
(d) Contact the infant's parent, guardian, legal custodian, as applicable, to assist in securing an ongoing primary care provider for the newborn;
(e) Coordinate the activity in paragraphs (C)(1) to (C)(3) of this rule with the assistance group's MCP, other agencies, and programs where applicable.
(D) Provision of support services.
(1) The CDJFS will refer the recipient, and/or the recipient's parent, guardian, or legal custodian, as applicable, to entities listed on the JFS 03528 and/or other community services as requested. The CDJFS will ensure:
(a) That referrals are made, as needed, for both medical and other services such as help me grow (HMG); women, infants and children (WIC); maternal and child health clinics; local health departments; head start (HS); child care; clothing and/or other community social services, where applicable.
(b) Coordination between the recipient and the entity where the referral is made.
(c) Coordination between the recipient and the medical provider or MCP.
(d) The recipient enrolled in a MCP (or the recipient's parent, guardian or legal custodian, as applicable) is advised to contact the recipient's MCP for medical care options and/or referrals.
(e) Offering and providing assistance with scheduling medical appointments as requested by the recipient or the recipient's parent, guardian or legal custodian, as applicable.
(2) The CDJFS shall provide recipients with necessary assistance in obtaining transportation to healthchek services as requested by the recipient or the recipient's parent, guardian or legal custodian, as applicable.
(3) Each recipient in a household who requests or is in need of non-medicaid covered medical services as indicated on the JFS 03528 or through other verbal or written communication shall be referred by the CDJFS to community, medical or other social services, as needed, including providers who have expressed a willingness to furnish non-medicaid covered services at little or no expense to the family. Community and medical service requests will be documented and forwarded to the appropriate community provider, medical provider and/or MCP.
(4) Elevated blood lead level services for assisting families of recipients identified as having elevated blood lead levels when notified by the family, provider or the county or city department of health shall be provided by the CDJFS and include:
(a) Referral of the recipient to the Ohio department of health (ODH) for an environmental assessment.
(b) Verification of medicaid eligibility at the time the environmental assessment is conducted and informing the ODH agent of such eligibility, when asked and after receiving proper verification of whom, is requesting the information;
(c) Education of the family about the purpose of the environmental assessment by:
(i) Informing the family of the need to remove the source of lead or removing the recipient from the contaminated environment;
(ii) Explaining the family's responsibility to inform the health department staff who conduct the environmental assessment of places the recipient visits regularly;
(iii) Assisting the family with securing lead-free housing by making any necessary referrals if the source of lead cannot or will not be removed from the environment.
(d) The CDJFS is responsible for maintaining records of environmental assessment recommendations made by the ODH and any action taken as a result of those recommendations. If as a result of CDJFS efforts the family relocates, the CDJFS must inform the ODH of the family's new address.
(e) In geographic areas with Ohio childhood lead poisoning prevention regional resource centers or local arrangements for environmental assessments and follow-up, the requirements of those programs supersede this rule.
(E) Custodial agency responsibility.
(1) The custodial agency of a recipient is responsible for ensuring that healthchek informing requirements are completed as explained in this rule. A custodial agency that has a recipient child placed in a substitute care setting certified by another PCSA, PCPA or PNA, is responsible for complying with this rule.
(2) The PCSA, PCPA and the Title IV-E agency shall inform the substitute caregivers about healthchek services and complete the JFS 03528.
(3) The JFS 03528 shall be submitted by the PSCA, PCPA, or Title IV-E agency to the CDJFS:
(a) After the initial informing process;
(b) When the recipient is moved to a new placement setting; and
(c) After completion of each annual review.
(F) CDJFS healthchek service implementation plan. Each CDJFS shall submit a proposed HSIP to ODJFS within ten business days of a change in director, healthchek coordinator or where the responsibility for healthchek resides in the agency. The proposed HSIP shall include all of the following:
(1) Identification of the CDJFS table of organization, showing where the responsibility for delivery of administrative healthchek support services lies;
(a) The name, title and contact information of the contact person or coordinator for administrative healthchek support services;
(b) A job description of the staff responsible for administration of administrative healthchek support services,
(2) Procedures for coordination of efforts between the CDJFS and the MCPs. The procedures may be in the form of written agreements between the agency and the MCPs and shall include:
(a) Provisions for regularly scheduled meetings to exchange information regarding:
(i) Tracking recipients to ensure they are receiving care and other services as identified as needed;
(ii) Issues recipients may be having in accessing services (such as finding a provider, making appointments, accessing transportation) and identifying remedies to these issues;
(iii) Social support services needed or discovered for recipients (such as housing needs, clothing, increased food needs);
(iv) MCP referrals to other agencies (such as HMG, WIC, and HS) so the healthchek coordinator can follow-up with the family; and
(v) The JFS 03528 or other documentation.
(b) A method for MCPs and the CDJFS to share follow-up and other communication with the recipient (or such recipient's parent, guardian or legal custodian, as applicable) to ensure complete care is delivered.
(3) The CDJFS shall provide a description in the HSIP of the electronic and/or hard-copy methods for ensuring permanent records and documentation are maintained in a case file for each recipient. The case file shall contain the following information, when appropriate:
(a) The agency copy of the signed JFS 03528;
(b) Copies of all correspondence received and sent;
(c) Documentation of agency contacts with recipients (or such recipient's parent, guardian or legal custodian, as applicable) , both attempted and successful;
(d) Documentation of the MCP in which recipients are enrolled, if applicable;
(e) Any communication from or forms provided by the medical provider;
(f) Information received from the other county when a recipient is an inter-county transfer;
(g) Documentation of all support service referrals or requests made by a recipient or on a recipient's behalf, and the CDJFS efforts to fulfill the referrals and/or requests. At a minimum the documentation shall contain:
(i) Steps taken by the CDJFS to assure the requested support services are provided, and whether or not the recipient received the requested support services;
(ii) A copy of all documentation of services requested by a recipient (or such recipient's parents, caretakers, custodians or substitute caregivers, as applicable) and provided or facilitated by the CDJFS.
(iii) Records of transportation requested and provided; and
(iv) Any communication from or forms provided by the medical provider.
(4) The CDJFS shall identify, if applicable, any services or functions required in this rule which are contracted out to other entities. A copy of the contract shall be provided to ODJFS. The CDJFS shall also describe accountability and monitoring measures, along with timeframes when monitoring takes place to ensure the contracted entities are achieving all required functions and that these functions are in accordance with applicable state and federal rules.
(G) Release of information. The CDJFS shall, if necessary, obtain a HIPAA-compliant signed authorization for release of information, form JFS 03397 "Authorization for the Release or Use of Protected Health Information (PHI)" (rev. 7/2003), if and when the CDJFS needs additional medical information from the recipient or the recipient's provider.
(H) Provider recruitment. The CDJFS is required to take steps to recruit and maintain a network of fee-for-service providers of medical, dental, vision, and hearing services that is adequate to meet the screening and treatment needs of the healthchek consumers. The CDJFS may make use of a variety of methods including personal visits, telephone calls, and letters to recruit providers.
(I) Training. Each CDJFS' healthchek coordinator, or such coordinator's designee(s), shall attend annual training and attend any other available healthchek training offered by ODJFS. Recording a training for later viewing does not constitute attendance. Verification of attendance shall consist of documentation roll call and sending an evaluation form to the state e-mail box within three days of the video conference or training for video conferences. Verification of attendance at an on site training shall be documented by the healthchek coordinator or such coordinators' designee(s) by signing the attendance log.
(J) Responsibilities of recipient. A recipient (or the recipient's parent(s), guardian or legal custodian, as applicable) shall:
(1) Complete the JFS 03528;
(2) Return the JFS 03528 to the recipient's healthchek coordinator as soon as it is completed;
(3) As soon as possible, report to the recipient's CDJFS any change in a recipient's address or family or household group; and
(4) Attend scheduled appointments for healthchek services.
R.C. 119.032 review dates: 11/01/2015
Promulgated Under: 111.15
Statutory Authority: 5111.01
Rule Amplifies: 5111.01, 5111.016
Prior Effective Dates: 1/14/83, 3/20/83, 3/21/83, 11/1/85 (Emer), 1/1/86, 1/29/86 (Emer), 1/31/86, 4/1/86 (Emer), 1/1/87, 3/20/87, 9/28/87 (Emer), 12/23/87 (Emer), 3/15/88, 7/1/88 (Emer), 9/1/88, 1/1/89, 10/1/90, 7/1/92, 9/1/93, 6/1/97, 3/18/99 (Emer), 6/17/99, 4/1/01, 12/1/01, 9/19/05, 3/1/06, 10/1/09, 12/31/10