Ohio Administrative Code Search

...(A) Eligibility. (1) An individual is enrolled in a MyCare Ohio plan (MCOP) if he or she meets all of the following criteria: (a) Age twenty-one or older at the time of enrollment in the MCOP; (b) Eligible for medicare parts A, B, and D, and full benefits under the medicaid program. (2) The following individuals are not eligible for enrollment in an MCOP: (a) Individuals enrolled in the program of all-inclusive ...

...(A) A member will be terminated from enrollment in a MyCare Ohio plan ("plan") for any of the following reasons: (1) The member becomes ineligible for full medicaid or medicare parts A or B or D. Termination of plan enrollment is effective the end of the last day of the month in which the member became ineligible. (2) The member's permanent place of residence is moved outside the plan's service ...

...(A) A member will be terminated from enrollment in a MyCare Ohio plan (MCOP) for any of the following reasons: (1) The member becomes ineligible for full medicaid or medicare parts A or B or D. Termination of MCOP enrollment is effective the end of the last day of the month in which the member became ineligible. (2) The member's permanent place of residence is moved outside the plan's service ar...

...(A) A member will be terminated from enrollment in a MyCare Ohio plan (MCOP) for any of the following reasons: (1) The member becomes ineligible for full medicaid or medicare parts A or B or D. Termination of MCOP enrollment is effective the end of the last day of the month in which the member became ineligible. (2) The member's permanent place of residence is moved outside the plan's service ar...

...(A) Disenrollment from the MyCare Ohio program occurs for the following reasons: (1) The member becomes ineligible for full benefits under the medicaid program or medicare parts A or B or D. Termination of MyCare Ohio plan (MCOP) enrollment is effective the end of the last day of the month in which the member became ineligible. (2) The member's permanent place of residence is moved outside the ...

...(A) To be eligible for enrollment in the MyCare Ohio waiver, a member must meet all of the following requirements: (1) Be enrolled in the MyCare Ohio demonstration at the time of application for the MyCare Ohio waiver; (2) Be determined to have a nursing facility-based level of care (i.e., intermediate or skilled) in accordance with rule 5160-3-08 or 5160-3-09 of the Administrative Code; (3) In...

...(A) To be eligible for enrollment in the MyCare Ohio waiver, a member must meet all of the following requirements: (1) Be enrolled in the MyCare Ohio demonstration at the time of application for the MyCare Ohio waiver; (2) Be determined to have a nursing facility-based level of care (i.e., intermediate or skilled) in accordance with rule 5160-3-08 or 5160-3-09 of the Administrative Code; (3) In...

...(A) To be eligible for enrollment in the MyCare Ohio waiver, a member meets all of the following requirements: (1) Is enrolled in the MyCare Ohio program at the time of application for the MyCare Ohio waiver; (2) Is determined to have a nursing facility-based level of care (i.e., intermediate or skilled) in accordance with rule 5160-3-08 of the Administrative Code; (3) In the absence of the MyCare Ohio waiver, re...

...(A) A MyCare Ohio plan (MCOP) must ensure members have access to all medically-necessary medical, drug, behavioral health, nursing facility and home and community-based services (HCBS) covered by Ohio medicaid. After consideration of verified third party liability including medicare coverage pursuant to rule 5160-26-09.1 of the Administrative Code, the MCOP must ensure: (1) Services are suffi...

...(A) A MyCare Ohio plan (MCOP) must ensure members have access to all medically-necessary medical, drug, behavioral health, nursing facility and home and community-based services (HCBS) covered by Ohio medicaid. After consideration of verified third party liability including medicare coverage pursuant to rule 5160-26-09.1 of the Administrative Code, the MCOP must ensure: (1) Services are suffi...

...(A) A MyCare Ohio plan (MCOP) ensures members have access to all medically-necessary medical, medicaid-covered over the counter drugs, behavioral health, nursing facility and home and community-based services (HCBS) covered by Ohio medicaid. Prescription drug coverage for members is provided under the medicare part d program. After consideration of verified third party liability including medicare coverage pursuant t...

...(A) A MyCare Ohio plan (MCOP) will ensure each member has a primary care provider (PCP) who will serve as an ongoing source of primary care and assist with care coordination appropriate to the member's needs. (1) The MCOP will ensure PCPs are in compliance with the following triage requirements. Members with: (a) Emergency care needs will be triaged and treated immediately on presentation at...

...(A) A MyCare Ohio plan (MCOP) ensures each member has a primary care provider (PCP) who serves as an ongoing source of primary care and assists with care coordination appropriate to the member's needs. (1) The MCOP ensures PCPs are in compliance with the following triage requirements. Members with: (a) Emergency care needs are triaged and treated immediately on presentation at the PCP site; ...

...A member and/or an authorized representative who is acting on behalf of a member (hereinafter "member") who is enrolled in the MyCare Ohio waiver in accordance with rule 5160-58-02.2 of the Administrative Code has choice and control over the arrangement and provision of home and community-based services (HCBS). Members also have choice over the selection and control over the direction of approved waiver ser...

...(A) A member may choose to receive MyCare Ohio waiver services from any combination of providers on the provider panel of the MyCare Ohio plan selected by the member pursuant to paragraph (B) of rule 5160-58-04 of the Administrative Code. (B) A member receiving waiver services from any MyCare Ohio waiver provider will: (1) Participate with the waiver service coordinator in the development of th...

...(A) Definitions. (1) "Adverse benefit determination" is a MyCare Ohio plan (MCOP)'s: (a) Denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit; (b) Reduction, suspension, or termination of services prior to the member receiving the...

...(A) Notice of action (NOA) by a MyCare Ohio plan (MCOP). (1) When an MCOP adverse benefit determination has or will occur, the MCOP shall provide the affected member with a NOA. (2) The NOA shall explain: (a) The adverse benefit determination the MCOP has taken or intends to take; (b) The reasons for the adverse benefit determination, including the right of the member to be provided, upon ...

...(A) Notice of action (NOA) by a MyCare Ohio plan (MCOP). (1) When an MCOP adverse benefit determination has or will occur, the MCOP shall provide the affected member with a NOA. (2) The NOA shall explain: (a) The adverse benefit determination the MCOP has taken or intends to take; (b) The reasons for the adverse benefit determination, including the right of the member to be provided, upon ...

...(A) Grievances and appeals vary depending on the MyCare Ohio enrollment of the member. (1) If the member is enrolled as a dual-benefits member, as defined in rule 5160-58-01 of the Administrative Code, then all grievances and appeals are conducted by the MyCare Ohio plan (MCOP). (2) If the member is enrolled as a medicaid-only member, as defined in rule 5160-58-01 of the Administrative Code, then the grievances and...

...(A) The definitions set forth in rule 5160-26-01 of the Administrative Code, with the exceptions noted in paragraphs (A)(1) and (A)(2) of this rule, apply to the Ohio resilience through integrated systems and excellence (OhioRISE) rules set forth in Chapter 5160-59 of the Administrative Code. Definitions that reference managed care organizations (MCOs) in Chapter 5160-26 of the Administrative Code...

...(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan has to adhere to all of the requirements applicable to managed care organizations (MCOs) or managed care entities (MCEs) in the following rules: (1) Rule 5160-26-05 of the Administrative Code with the exception of paragraphs (B)(4), (B)(5), (D)(21), (D)(25), and (D)(26); (2) Rule 5160-26-05.1 of the Administrat...

...(A) To be eligible for enrollment in the Ohio resilience through integrated systems and excellence (OhioRISE) program, an individual has to meet the criteria for first day eligibility and enrollment in rule 5160-59-02.1 of the Administrative Code or the criteria in paragraphs (A)(1) to (A)(3) and either paragraph (A)(4), (A)(5), (A)(6) or (B) of this rule. (1) Be twenty years of age or younge...

...(A) To be eligible for enrollment in the Ohio resilience through integrated systems and excellence (OhioRISE) program, an individual has to meet the criteria for first day eligibility and enrollment in rule 5160-59-02.1 of the Administrative Code or the criteria in paragraphs (A)(1) to (A)(3) and either paragraph (A)(4), (A)(5), (A)(6) or (B) of this rule. (1) Be twenty years of age or younge...

...(A) To be eligible for enrollment in the Ohio resilience through integrated systems and excellence (OhioRISE) program, an individual has to meet the criteria for first day eligibility and enrollment in rule 5160-59-02.1 of the Administrative Code or the criteria in paragraphs (A)(1) to (A)(3) and either paragraph (A)(4), (A)(5), (A)(6) or (B) of this rule. (1) Be twenty years of age or younge...

...(A) To be eligible for enrollment in the Ohio resilience through integrated systems and excellence (OhioRISE) program, an individual has to meet either the criteria for first day eligibility and enrollment in rule 5160-59-02.1 of the Administrative Code or the criteria in paragraphs (A)(1) to (A)(3) along with either paragraph (A)(4), (A)(5), (A)(6) or (B) of this rule. (1) Be twenty years of ...