Rule 5160-26-02 | Managed health care program: eligibility and enrollment.
(A) This rule does not apply to "MyCare Ohio" plans as defined in rule 5160-58-01 of the Administrative Code. The eligibility and enrollment provisions for "MyCare Ohio" plans are described in rule 5160-58-02 of the Administrative Code.
(B) Eligibility for managed care organization (MCO) enrollment.
(1) Except as specified in paragraphs (B)(3) to (B)(5) of this rule, in mandatory service areas as permitted by 42 C.F.R. 438.52 (October 1, 2020), an individual must be enrolled in an MCO if he or she has been determined medicaid eligible in accordance with division 5160:1 of the Administrative Code.
(2) MCO enrollment is mandatory for the following individuals:
(a) Children receiving Title IV-E federal foster care maintenance;
(b) Children receiving Title IV-E adoption assistance:
(c) Children in foster care or other out-of-home placement; and
(d) Children receiving services through the Ohio department of health's bureau for children with medical handicaps (BCMH) or any other family-centered, community-based, coordinated care system that receives grant funds under Section 501(a)(1)(D) of Title V of the Social Security Act, 42 U.S.C. 701(a)(1)(D) (as in effect January 1, 2021) and is defined by the state in terms of either program participation or special health care needs.
(3) Medicaid eligible individuals may voluntarily choose to enroll in an MCO if they are:
(a) Indians who are members of federally recognized tribes;
(b) Individuals diagnosed with a developmental disability who have a level of care that meets the criteria specified in rule 5123-8-01 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);
(4) Except for individuals receiving medicaid in the adult extension category under section 1902(a)(10)(A)(i)(VIII) of the Social Security Act 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) (as in effect January 1, 2021), and individuals who meet criteria in paragraph (B)(3)(b) of this rule medicaid eligible individuals are excluded from MCO enrollment if they:
(a) Reside in a nursing facility; or
(b) Receive medicaid services through a medicaid waiver component, as defined in section 5166.02 of the Revised Code.
(5) The following individuals are excluded from MCO enrollment.
(a) Inmates of public institutions as defined in 42 C.F.R. 435.1010 (October 1, 2020) unless otherwise specified by ODM;
(b) Dually eligible individuals enrolled in both the medicaid and medicare programs;
(c) Individuals receiving services in an intermediate care facility for individuals with intellectual disabilities (ICF-IID) or a developmental center as defined in rule 5123-9-30 of the Administrative Code;
(d) Individuals enrolled in the program of all-inclusive care for the elderly (PACE);
(e) Individuals who are determined to be presumptively eligible and receive temporary, time-limited medical assistance as described in rule 5160:1-2-13 of the Administrative Code;
(f) Individuals who receive alien emergency medical assistance in accordance with rule 5160:1-5-06 of the Administrative Code;
(g) Individuals who receive refugee medical assistance in accordance with rule 5160:1-5-05 of the Administrative Code; and
(h) Non-citizen victims of trafficking as set forth in rule 5160:1-5-08 of the Administrative Code.
(6) Nothing in this rule shall be construed to limit or in any way jeopardize an eligible individual's basic medicaid eligibility or eligibility for other non-medicaid benefits to which he or she may be entitled.
(C) Enrollment in an MCO.
(1) The MCO must accept eligible individuals without regard to race, color, religion, gender, gender identity, sexual orientation, age, disability, national origin, military status, genetic information, ancestry, health status or need for health services. The MCO will not use any discriminatory policy or practice in accordance with 42 C.F.R. 438.3(d) (October 1, 2020).
(2) The MCO must accept eligible individuals who request MCO enrollment without restriction.
(3) If an MCO member loses managed care eligibility and is disenrolled from the MCO, and subsequently regains eligibility, his or her enrollment in the same MCO may be reinstated back to the date eligibility was regained in accordance with procedures established by ODM.
(4) ODM shall confirm the eligible individual's MCO enrollment via the ODM-produced Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant 834 daily and monthly enrollment files of new members, continuing members and terminating members.
(5) The MCO shall not be required to provide coverage until MCO enrollment is confirmed via the ODM-produced HIPAA compliant 834 daily or monthly enrollment files except as provided in paragraph (C)(6) of this rule or upon mutual agreement between ODM and the MCO.
(6) Infants born to mothers enrolled in an MCO are enrolled in an MCO from their date of birth through at least the end of the month of the child's first birthday, or until such time that the MCO is notified of the child's disenrollment via the ODM-produced HIPAA compliant 834 daily or monthly enrollment files.
(D) Commencement of coverage.
(1) Coverage of MCO members will be effective on the first day of the calendar month specified on the ODM-produced HIPAA compliant 834 daily and monthly enrollment files to the MCO, except as specified in paragraph (C)(6) of this rule.
(2) When an eligible individual is admitted to an inpatient facility prior to the effective date of MCO enrollment and remains in an inpatient facility on the enrollment effective date, the following responsibilities apply:
(a) The admitting medicaid payer, either fee-for-service or the admitting MCO, is responsible for all inpatient facility charges, pursuant to rule 5160-2-07.11 of the Administrative Code, through the date of discharge.
(b) The enrolling MCO is responsible for all other medically necessary medicaid covered services including professional services related to the inpatient stay, beginning on the enrollment effective date.
Last updated April 8, 2021 at 1:30 PM
Amplifies: 5164.02, 5167.03, 5167.10
Five Year Review Date: 4/4/2026
Prior Effective Dates: 4/1/1985, 2/15/1989 (Emer.), 5/18/1989, 5/1/1992, 5/1/1993, 11/1/1994, 7/1/1996, 7/1/1997 (Emer.), 9/27/1997, 12/10/1999, 7/1/2000, 7/1/2001, 7/1/2002, 7/1/2003, 7/1/2004, 10/31/2005, 6/1/2006, 1/1/2007, 7/1/2007, 1/1/2008, 8/26/2008 (Emer.), 10/9/2008, 7/1/2009, 8/1/2011, 7/1/2013, 4/1/2015, 8/1/2016, 7/1/2017, 1/1/2018, 7/1/2018, 2/14/2019