Ohio Administrative Code Search

...(A) The medicaid provider incentive program (MPIP) is Ohio's program implementing section 4201 of the American Recovery and Reinvestment Act of 2009 (ARRA), Pub. L. No. 111-5, and the published regulations in 42 C.F.R. Part 495. Certain medicaid eligible professionals and hospitals are eligible to participate in MPIP. Funding for this program ends in 2021. (B) An eligible professional partic...

...(A) Program integrity. (1) MPIP legal notice. (a) All eligible professionals and eligible hospitals submitting an application to receive an MPIP payment are required to sign the MPIP legal notice before confirming and submitting their application. (b) All program applicants are bound by the requirements of the MPIP legal notice. (2) Eligible professional and eligible hospital MPIP applications...

...(A) The definitions set forth in rule 5160-26-01 of the Administrative Code apply to the MyCare Ohio rules set forth in Chapter 5160-58 of the Administrative Code. (B) In addition to the definitions set forth in rule 5160-26-01 of the Administrative Code, the following definitions apply to Chapter 5160-58 of the Administrative Code: (1) "Assessment" means a comprehensive evaluation of an individ...

...(A) The definitions set forth in rule 5160-26-01 of the Administrative Code apply to the MyCare Ohio rules set forth in Chapter 5160-58 of the Administrative Code. (B) In addition to the definitions set forth in rule 5160-26-01 of the Administrative Code, the following definitions apply to Chapter 5160-58 of the Administrative Code: (1) "Assessment" means a comprehensive evaluation of an individ...

...(A) The definitions set forth in rule 5160-26-01 of the Administrative Code apply to the MyCare Ohio rules set forth in Chapter 5160-58 of the Administrative Code. (B) In addition to the definitions set forth in rule 5160-26-01 of the Administrative Code, the following definitions apply to Chapter 5160-58 of the Administrative Code: (1) "Assessment" means a comprehensive evaluation of an individ...

...(A) The general definitions set forth in rule 5160-26-01 of the Administrative Code regarding managed care entities (MCEs) apply to the MyCare Ohio rules set forth in Chapter 5160-58 of the Administrative Code. (B) In addition to the definitions set forth in rule 5160-26-01 of the Administrative Code, the following definitions apply to Chapter 5160-58 of the Administrative Code: (1) "Assessment"...

...(A) MyCare Ohio plans must comply with all of the requirements applicable to managed care plans (MCPs) in the following rules: (1) Rule 5160-26-05 of the Administrative Code; (2) Rule 5160-26-05.1 of the Administrative Code; (3) Rule 5160-26-06 of the Administrative Code; (4) Rule 5160-26-08.3 of the Administrative Code; (5) Rule 5160-26-09 of the Administrative Code; (6) Rule 5160-2...

...(A) Eligibility. (1) Except as specified in paragraph (A)(2) of this rule, in mandatory service areas as permitted by 42 C.F.R. 438.52 (October 1, 2016), an individual must be enrolled in a MyCare Ohio plan (also known as "plan") if he or she meets all of the following criteria: (a) Age eighteen or older at the time of enrollment in the plan; (b) Eligible for medicare parts A, B and D, and full benefits under the ...

...(A) Eligibility. (1) Except as specified in paragraph (A)(2) 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 a MyCare Ohio plan (MCOP) if he or she meets all of the following criteria: (a) Age eighteen or older at the time of enrollment in the MCOP; (b) Eligible for medicare parts A, B and D, and full benefits under ...

...(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) Member care coordination. (1) All MyCare Ohio members are assigned a care coordinator to assist with management of their care and navigation of services in accordance with 42 CFR 422.101, as applicable. MyCare Ohio members who are not receiving long-term care services through the MyCare Ohio waiver or in a nursing facility may choose not to participate in care coordination. (a) Care coordinator outreach frequen...