Rule 5160:1-2-16 | Medicaid: pregnancy related services (PRS).
(A) The purpose of this rule is to outline the responsibilities of the administrative agency to inform a pregnant woman eligible for medical assistance about the benefits and importance of pregnancy related services (PRS), to make requested or needed referrals to support services, and to provide non-medical support services that promote healthy birth outcomes in accordance with 42 C.F.R. 440.210 (as in effect October 1, 2023).
(B) Definitions.
(1) "Administrative agency," for the purpose of this rule, means the county department of job and family services (CDJFS).
(2) "Individual" for the purpose of this rule, means a pregnant woman eligible for medical assistance, as verified by either self-declaration or medical verification, including during the postpartum period.
(3) ODM 03515 "Pregnancy Related Services Implementation Plan" (PRSIP) means the document submitted by the administrative agency describing how it delivers PRS to pregnant women in its county and identifies which entities are responsible for ensuring the delivery of PRS.
(4) ODM 03528 "Healthchek and Pregnancy Related Services Information Sheet" means the document given to individuals by the administrative agency to meet the informing requirement of this rule.
(5) "Postpartum period," for the purpose of this rule, is the same as defined in rule 5160:1-1-01 of the Administrative Code.
(6) "Pregnancy-related services" (PRS) are those services that are necessary for the health of the pregnant woman and fetus, or that have become necessary as a result of the individual having been pregnant. These include, but are not limited to, prenatal care, delivery, postpartum care, and family planning services.
(7) "PRS coordinator" means the administrative agency employee who is responsible for the execution of the PRSIP.
(8) "Support services" are non-medical services offered or provided by the administrative agency to assist the individual and may include arranging or providing transportation, making medical appointments, accompanying the individual to medical appointments, and making referrals to community and other social services. Support services will be coordinated with the individual's medicaid-contracted managed care organization (MCO), where applicable.
(C) The individual (or the individual's parent(s), guardian, or legal custodian, as applicable) may:
(1) Complete and sign the ODM 03528 to verify understanding of PRS and Healthchek services;
(2) Complete, sign, and return the ODM 03528 to identify the need for services for the individual and/or the individual's children.
(D) Administrative agency responsibilities. The administrative agency shall:
(1) Inform individuals in its county about PRS within sixty days of the eligibility determination. Contact shall be made through either verbal or written forms of communication or a combination of the two described as follows:
(a) Provide the ODM 03528.
(b) Assist individuals with care coordination and referrals as requested via the ODM 10257 "Report of Pregnancy (ROP)" and ODM 10207 "Pregnancy Risk Assessment Communication (PRAF)."
(c) Provide information about:
(i) The benefits and importance of early and continual prenatal and postpartum care.
(ii) The special supplemental food program for women, infants and children (WIC).
(iii) The services covered by PRS as described in Chapter 5160-4 of the Administrative Code.
(iv) The benefits of healthchek services as described in rule 5160-1-14 of the Administrative Code.
(v) Transportation services and scheduling assistance available to individuals, when needed and upon request, in accordance with Chapter 5160-15 of the Administrative Code.
(vi) Availability of transportation services through the individual's MCO. The transportation services shall be provided by the administrative agency if not available from the MCO.
(vii) Transportation services and scheduling assistance available to infants during the first year of life.
(viii) Medical and non-medical support services to include but not limited to:
(a) The "Help Me Grow" (HMG) program;
(b) Maternal, child and family health (MCFH) clinics;
(c) Local health departments;
(d) Social services and other community services;
(e) Child care and head start; and
(f) The program for children and youth with special health care needs.
(ix) Availability of assistance for scheduling medical appointments, as requested by the individual.
(x) A list of medicaid prenatal care providers, when requested, available to the community.
(2) Inform individuals enrolled in an MCO that they should contact the MCO for medical care options and referrals.
(3) Re-inform the individual of the benefits of healthchek services as soon as possible after an infant's birth.
(4) Refer the individual to support services as requested verbally, in writing, or via the ODM 03528 and ensure:
(a) Referrals are made for medical and non-medical support services, as requested.
(b) Coordination between the individual, medical provider, MCO, or other entity where a referral is made.
(c) Transportation assistance is provided to individuals, as requested.
(5) Provide a copy of the ODM 03528 (when applicable) (to the individual's MCO.
(6) Make a second attempt to contact the individual by alternate means when written information about PRS sent to the individual is returned as undeliverable.
(7) Submit a new or amended ODM 03515 to the Ohio department of medicaid (ODM), when there has been a change, including but not limited to, agency address, director, PRS coordinator, or where the responsibility for PRS is located within the agency. The ODM 03515 shall be submitted to ODM within ten business days of a change.
(8) Obtain a Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant signed authorization for release of information, ODM 03397 "Authorization for the Release or Use of Protected Health Information", when additional medical information is needed from the individual.
(9) Maintain a listing of fee-for-service providers who have expressed a willingness to furnish non-medicaid covered services at little or no expense to the individual. It is recognized that the ability of the administrative agency to recruit and maintain an adequate provider network depends on the existence of appropriate providers within a reasonable geographic area.
(10) Maintain documentation in a secure file for each eligible individual. The file shall consist of permanent records, either hard copy or electronically stored, containing the following information, when appropriate:
(a) Copy of the ODM 03528, ODM 10207, ODM 10257, or other referral forms received by the administrative agency;
(b) Copy of correspondence received and sent;
(c) Documentation of agency contact with the individual, both attempted and established;
(d) Documentation of the MCO in which the individual is enrolled;
(e) Information received from another county when the individual is an intercounty transfer;
(f) Documentation of all service requests and steps taken by the administrative agency to connect the individual with the requested services; and
(g) Records of transportation services provided.
(E) Each administrative agency PRS coordinator, or such coordinator's designee(s), shall attend annual and other pertinent trainings offered by ODM. Verification of attendance shall be provided for all trainings and an evaluation form shall be sent to the state email box within three days of completion of the training. Verification of attendance at in-person training shall be documented by the PRS coordinator or such coordinator's designee(s) by signing the attendance log.
Last updated December 13, 2024 at 7:55 AM
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