Rule 5160-26-02 | Managed care: eligibility and enrollment.
(A) This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 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, 2021), 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) (July 1, 2022) and is defined by the state in terms of either program participation or special health care needs.
(e) Individuals who meet the criteria specified in rule 5160-59-04 of the Administrative Code and receive services through the OhioRISE home and community based services (HCBS) waiver administered by the Ohio department of medicaid (ODM).
(3) Medicaid eligible individuals may voluntarily choose to enroll in an MCO if they are:
(a) Indians who are members of federally recognized tribes; or
(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 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) (July 1, 2022), and individuals who meet the criteria in paragraphs (B)(2)(e) and (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, 2021) 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) Upon implementation of the single pharmacy benefit manager (SPBM), any individual enrolled in an MCO as specified in paragraph (B) of this rule will be mandatorily enrolled in the SPBM.
(D) Enrollment and commencement of coverage in an MCO or the SPBM.
(1) The MCO and the SPBM 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 and the SPBM will not use any discriminatory policy or practice in accordance with 42 C.F.R. 438.3(d) (October 1, 2021).
(2) The MCO and the SPBM must accept eligible individuals who request MCO enrollment without restriction.
(3) If a member loses managed care eligibility and is disenrolled from the MCO and the SPBM, and subsequently regains eligibility, his or her enrollment in the same MCO and the SPBM 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 and SPBM 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 and SPBM shall not be required to provide coverage until MCO or SPBM enrollment is confirmed via the ODM-produced HIPAA compliant 834 daily or monthly enrollment files except as provided in paragraph (D)(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. This does not include infants placed for adoption or legally placed in the custody of an Ohio county public children's serivces agency (PCSA).
(7) Coverage of MCO and SPBM 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 and SPBM, except as specified in paragraph (D) of this rule.
Last updated July 18, 2022 at 8:17 AM
Supplemental Information
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, 4/4/2021