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Rule 5160-26-01 | Managed care: definitions.
As used in Chapter 5160-26 of the Administrative
Code: (A) "Abuse" means provider
practices that are inconsistent with sound fiscal, business, or medical
practices, and result in an unnecessary cost to the medicaid program, or in
reimbursement for services that are not medically necessary or that fail to
meet professionally recognized standards for health care. It also includes
recipient practices that result in unnecessary cost to the medicaid
program. (B) "Advance directive" means
written instructions such as a living will or durable power of attorney for
health care relating to the provision of health care when an adult is
incapacitated. (C) "Adverse benefit
determination" is a managed care entity's (MCE's): (1) 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; (2) Reduction,
suspension, or termination of services prior to the member receiving the
services previously authorized by the MCE; (3) Failure to provide
services in a timely manner as specified in rule 5160-26-03.1 of the
Administrative Code; (4) Failure to act within
the resolution time frames specified in rule 5160-26-08.4 of the Administrative
Code; (5) Denial of a
member's request to dispute a financial liability, including cost sharing,
copayments, premiums, deductibles, coinsurance and other member financial
liabilities, if applicable; or (6) Denial, in whole or
part, of payment for a service. A denial, in whole or in part, of a payment for
a service solely because the claim does not meet the definition of a
"clean claim" as defined in 42 C.F.R. 447.45(b) (October 1, 2021) is
not an adverse benefit determination. (D) "Appeal" is the
member's request for an MCE to review an adverse benefit
determination. (E) "Authorized representative" has the same
meaning as in rule 5160:1-1-01 of the Administrative Code. (F) "Care management system"
means the system established by the Ohio department of medicaid (ODM) in
accordance with section 5167.03 of the Revised Code. (G) "Consumer contact record (CCR)" means the
record containing demographic health-related information provided by an
eligible individual, managed care member, or ODM that is used by the Ohio
medicaid consumer hotline to process membership transactions. (H) "Coordination of benefits (COB)" means a
procedure establishing the order in which health care entities pay their claims
as described in rule 5160-26-09.1 of the Administrative Code. (I) "Covered services" means those medical
services set forth in rule 5160-26-03 of the Administrative Code or a subset of
those medical services. (J) "Eligible individual" means any medicaid
recipient who is a legal resident of the managed care service area and is in
one of the categories specified in rule 5160-26-02 of the Administrative
Code. (K) "Emergency medical condition" means a medical
condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that a prudent layperson, who possesses an average
knowledge of health and medicine, could reasonably expect the absence of
immediate medical attention to result in any of the following: placing the
health of the individual (or, with respect to a pregnant woman, the health of
the woman or her unborn child) in serious jeopardy; serious impairment to
bodily functions; or serious dysfunction of any bodily organ or
part. (L) "Emergency services" means covered inpatient
services, outpatient services, or medical transportation services that are
provided by a qualified provider and are needed to evaluate, treat, or
stabilize an emergency medical condition. As used in this chapter, providers of
emergency services also include physicians or other health care professionals
or health care facilities not under employment or under contractual arrangement
with an MCE. (M) "Explanation of benefits (EOB)," otherwise
known as "explanation of payment (EOP)," or "remittance advice
(RA)," means the information sent to providers and/or members by any other
third party payer, or MCE, to explain the adjudication of a claim. (N) "Federally qualified health center (FQHC)"
has the same meaning as in rule 5160-28-01 of the Administrative
Code. (O) "Fraud" means any intentional deception or
misrepresentation made by an individual or entity with the knowledge that the
deception could result in some unauthorized benefit to the individual, the
entity, or some other person. This includes any act that constitutes fraud
under applicable federal or state law. Member fraud means the altering of
information or documents in order to fraudulently receive unauthorized benefits
or to knowingly permit others to use the member's identification card to
obtain services or supplies. (P) "Grievance" is the member's expression
of dissatisfaction about any matter other than an adverse benefit
determination. Grievances may include, but are not limited to, the quality of
care or services provided, and aspects of interpersonal relationships such as
rudeness of a provider or employee, or failure to respect the member's
rights regardless of whether remedial action is requested. Grievance includes a
member's right to dispute an extension of time proposed by an MCE to make
an authorization decision. (Q) "Healthchek" services, otherwise known as
early and periodic screening, diagnostic, and treatment (EPSDT) services, are
comprehensive preventive health services available to individuals under
twenty-one years of age who are enrolled in medicaid as those services are
described in rule 5160-1-14 of the Administrative Code. (R) "Hospital" means an institution located at a
single site that is engaged primarily in providing to inpatients, by or under
the supervision of an organized medical staff of physicians licensed under
Chapter 4731. of the Revised Code, diagnostic services and therapeutic services
for medical diagnosis and treatment or rehabilitation of injured, disabled, or
sick persons. "Hospital" does not mean an institution that is
operated by the United States government. (S) "Hospital services" means those inpatient and
outpatient services that are generally and customarily provided by
hospitals. (T) "Inpatient facility" means an acute or
general hospital. (U) "Intermediate care facility for individuals with
intellectual disabilities (ICF/IID)" has the same meaning as in section
5124.01 of the Revised Code. (V) "Managed care" means a health care delivery
system operated by the state in accordance with 42 C.F.R. part 438 (October 1,
2021). (W) "Managed care entity (MCE)" means a managed
care organization, the single pharmacy benefit manager, a MyCare Ohio plan as
defined in rule 5160-58-01 of the Administrative Code, and the OhioRISE plan as
defined in rule 5160-59-01 of the Administrative Code. (X) "Managed care organization (MCO)" has the
same definition as in 42 C.F.R 438.2 (October 1, 2021) and is a health insuring
corporation (HIC) licensed in the state of Ohio that enters into a managed care
provider agreement with ODM. (Y) "Medicaid" means medical assistance as
defined in section 5162.01 of the Revised Code. (Z) "Medicaid fraud control unit (MCFU)" means an
identifiable entity of state or federal government charged with the
investigation and prosecution of fraud and related offenses within
medicaid. (AA) "Medically necessary," or "medical
necessity," has the same meaning as in rule 5160-1-01 of the
Administrative Code. (BB) "Medicare" means the federally financed
medical assistance program defined in 42 U.S.C. 1395 (as in effect July 1,
2022). (CC) "Member" means a medicaid recipient who has
selected or been assigned to an MCE for the purpose of receiving health care
services. (DD) "Network
provider" means any provider, group of providers, or entity that has a
network provider contract with the MCE in accordance with rule 5160-26-05 of
the Administrative Code and receives medicaid funding directly or indirectly to
order, refer, or render covered services as a result of the MCE's provider
agreement or contract with ODM. (EE) "Non-contracting provider" means any provider
with an ODM provider agreement who does not contract with an MCE, but delivers
health care services to an MCE's members. (FF) "Non-contracting provider of emergency
services" means any person, institution or entity that does not contract
with an MCE, but provides emergency services to an MCE's members,
regardless of whether that provider has an ODM provider agreement. (GG) "Notice of action (NOA)" is the written
notice an MCE provides to members when an adverse benefit determination has
occurred or will occur. (HH) "Nursing facility" has the same meaning as in
section 5165.01 of the Revised Code. (II) "Ohio medicaid consumer hotline" means the
managed care enrollment broker and customer service agent for individuals
receiving Ohio medicaid services. (JJ) "Oral interpretation services" means services
provided to a limited-reading proficient eligible individual or member to
ensure that he or she receives MCE information in a format and manner that is
easily understood by the eligible individual or member. (KK) "Oral translation services" means services
provided to a limited-English proficient eligible individual or member to
ensure that he or she receives MCE information translated into the primary
language of the eligible individual or member. (LL) "Pending member" means an eligible individual
who has selected or been assigned to an MCE but whose membership in the MCE is
not yet effective. (MM) "Post-stabilization care services" means
covered services related to an emergency medical condition that a treating
provider views as medically necessary after an emergency medical condition has
been stabilized in order to maintain the stabilized condition, or under the
circumstances described in 42 C.F.R. 422.113 (October 1, 2021) to improve or
resolve the member's condition. (NN) "Premium" means the monthly payment amount
per member to which the MCO is entitled as compensation for performing its
obligations in accordance with Chapter 5160-26 of the Administrative Code
and/or the provider agreement with ODM. (OO) "Primary care provider (PCP)" means an
individual physician (M.D. or D.O.), a physician group practice, an advanced
practice registered nurse as defined in section 4723.01 of the Revised Code, an
advanced practice nurse group practice within an acceptable specialty, or a
physician assistant who meets the requirements of rule 5160-4-03 of the
Administrative Code contracting with an MCO to provide services as specified in
rule 5160-26-03.1 of the Administrative Code. Acceptable PCP specialty types
include family/general practice, internal medicine, pediatrics, and
obstetrics/gynecology (OB/GYNs). (PP) "Protected health information (PHI)" means
information received from or on behalf of ODM that meets the definition of PHI
as defined by 45 C.F.R. 160.103 (October 1, 2021). (QQ) "Provider" means a hospital, health care
facility, physician, dentist, pharmacy, or otherwise licensed or certified
appropriate individual or entity that is authorized to or may be entitled to
reimbursement for health care-related services rendered to an MCE's
member. (RR) "Provider agreement" means a formal agreement
between ODM and an MCO for the provision of medically necessary services to
medicaid recipients who are enrolled in the MCO. (SS) "Provider network" or "network,"
means an MCE's contracted providers available to the MCE's
members. (TT) "Qualified family planning provider (QFPP)"
means any public or nonprofit health care provider that complies with
guidelines/standards set forth in 42 U.S.C. 300 (as in effect July 1, 2022),
and receives either Title X funding or family planning funding from the Ohio
department of health. (UU) "Respite services" are services that provide
short-term, temporary relief to the informal unpaid caregiver of a managed care
member in order to support and preserve the primary care giving
relationship. (VV) "Risk" or "underwriting risk" means
the possibility that an MCO may incur a loss because the cost of providing
services may exceed the payments made by ODM to the contractor for services
covered under the provider agreement. (WW) "Rural health clinic (RHC)" has the same
meaning as in rule 5160-28-01 of the Administrative Code. (XX) "Self-referral" means the process by which an
MCO member may access certain services without prior approval from the PCP or
the MCO. (YY) "Service area" means the geographic area
specified in the MCO's provider agreement where the MCO agrees to provide
Medicaid services to members residing in those areas. (ZZ) "Single case
agreement" means a contract with an out-of-network provider to provide
services to an MCE's member on a one-time, individual, or limited basis.
(AAA) "Single pharmacy benefit manager (SPBM)" is a
prepaid ambulatory health plan as defined in 42 C.F.R. 438.2 (October 1, 2021)
and the state pharmacy benefit manager selected under section 5167.24 of the
Revised code which is responsible for processing all pharmacy claims under the
care management system. The SPBM service area is statewide. (BBB) "SPBM contract" means a formal agreement
between ODM and the SPBM for the provision of medically necessary pharmacy
services to medicaid recipients who are enrolled in the SPBM. (CCC) "State cut-off" means the eighth state
working day prior to the end of a calendar month. (DDD) "State
hearing" means the process set forth in 42 C.F.R 431, Subpart E (October
1, 2021) and division 5101:6 of the Administrative Code. (EEE) "Subcontract" means a written contract
between an MCE and a third party, including the MCE's parent company or
any subsidiary corporation owned by the MCE's parent company, or between
the third party and a fourth party, or between any subsequent parties, to
perform a specific part of the obligations specified under the MCO's
provider agreement or the SPBM's contract with ODM. (FFF) "Subcontractor" means an individual or entity
that has entered into a subcontract with an MCE to perform a specific part of
the obligations specified under the MCO's provider agreement or the
SPBM's contract with ODM. A provider or network provider is not a
subcontractor by virtue of the provider's contract with an
MCE. (GGG) "Third party" means the same as in section
5160.35 of the Revised Code. (HHH) "Third party administrator" means any entity
used in accordance with the provisions of this chapter to manage or administer
a portion of services in fulfillment of the provider agreement with
ODM. (III) "Third party benefit" means any health care
service(s) available to members through any medical insurance policy or through
some other resource that covers medical benefits and the payment for those
services is either completely the obligation of the third party payer (TPP) or
in part the obligation of the member, the TPP, and/or the MCE. (JJJ) "Third party claim" or "COB claim"
means any claim submitted to an MCE for reimbursement after all TPPs have met
their payment obligations. In addition, the following will be considered third
party claims by an MCE: (1) Any claim received by
the MCE that shows no prior payment by a TPP, but the MCE's records
indicate that the member has third party benefits. (2) Any claim received by
the MCE that shows no prior payment by a TPP, but the provider's records
indicate that the member has third party benefits. (KKK) "Third party liability (TPL)" means the
payment obligations of the TPP for health care services rendered to a member
when the member also has third party benefits as described in paragraph (EEE)
of this rule. (LLL) "Third party payer (TPP)" means an
individual, an entity, or a program responsible for adjudicating and paying
claims for third party benefits rendered to an eligible member. (MMM) "Title X services" means services and
supplies allowed under 42 U.S.C. 300 (as in effect July 1, 2022), and provided
by a qualified family planning provider. (NNN) "Tort action," or "subrogation,"
means the right of ODM to recover payment received from a third party payer who
may be liable for the cost of medical services and care arising out of an
injury, disease, or disability to the member. (OOO) "Waste" means payment for or the attempt to
obtain payment for items or services when there may be no intent to deceive or
misrepresent, but poor or inefficient billing or treatment methods result in
unnecessary costs.
Last updated July 18, 2022 at 8:17 AM
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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
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Rule 5160-26-02.1 | Managed care: termination of enrollment.
Effective:
January 1, 2023
(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) The Ohio department of medicaid (ODM) will terminate a member
from enrollment in a managed care organization (MCO) for any of the following
reasons: (1) The member's permanent place of
residence is moved outside the MCO service area. When this occurs, termination
of MCO enrollment takes effect on the last day of the month in which the member
moved from the service area. (2) The member becomes
ineligible for medicaid. When this occurs, termination of MCO enrollment takes
effect on the last day of the month in which the member became
ineligible. (3) The member dies, in
which case MCO enrollment ends on the date of death. (4) The member is not 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), is
authorized for nursing facility services, and the following criteria are
met: (a) The MCO has authorized nursing facility services for no less
than the month of nursing facility admission and for two complete consecutive
calendar months thereafter; (b) For the entire period in paragraph (B)(4)(a) of this rule,
the member has remained in the nursing facility without any admission to an
inpatient hospital or long-term acute care facility; (c) The member's discharge plan documents that nursing
facility discharge is not expected in the foreseeable future and the member has
a need for long-term nursing facility care; (d) For the entire period in paragraph (B)(4)(a) of this rule,
the member is not using hospice services; and (e) The MCO has requested disenrollment, and ODM has approved the
request. (f) The member is found by ODM to meet the criteria for the
developmental disabilities level of care as specified in rule 5123-8-01 of the
Administrative Code and resides in an intermediate care facility for
individuals with intellectual disabilities (ICF-IID). Following MCO
notification to ODM and written approval by ODM, termination of MCO membership
takes effect on the last day of the month preceding the individual's stay
in the ICF-IID. (5) The member has third party coverage,
and ODM determines that continuing MCO enrollment may not be in the best
interest of the member. This determination may be based on the type of coverage
the member has, the existence of conflicts between provider networks, or access
requirements. When this occurs, the effective date of termination of MCO
enrollment shall be determined by ODM but in no event shall the termination
date be later than the last day of the month in which ODM approves the
termination. (6) The member is not eligible for MCO
enrollment for one of the reasons set forth in rule 5160-26-02 of the
Administrative Code. (7) The provider agreement between ODM
and the MCO is terminated. (C) Upon implementation of the single
pharmacy benefit manager (SPBM), ODM will terminate a member from enrollment in
the SPBM when a member is terminated from enrollment in an MCO as specified in
paragraph (B) of this rule or if the contract between ODM and the SPBM is
terminated. (D) All of the following apply when enrollment in an MCO or the
SPBM is terminated for any of the reasons set forth in paragraph (B) or (C) of
this rule: (1) Such terminations may
occur either in a mandatory or voluntary service area. (2) All such terminations
occur at the individual level. (3) Such terminations do
not require completion of a consumer contact record (CCR). (4) If ODM fails to
notify the MCO or the SPBM of a member's termination from an MCO or the
SPBM, ODM shall continue to pay the MCO or the SPBM the applicable monthly
capitation rate for the member. The MCO or the SPBM shall remain liable for the
provision of covered services as set forth in rule 5160-26-03 of the
Administrative Code, until such time as ODM provides the MCO or the SPBM with
documentation of the member's termination. (5) ODM shall recover
from the MCO or the SPBM any capitation paid for retroactive enrollment
termination occurring as a result of paragraph (B) or (C) of this
rule. (6) A member may lose
medicaid eligibility during an annual open enrollment period, and thus become
unable to change to a different MCO. If the member then regains medicaid
eligibility, the member may request to change plans within thirty days
following reenrollment in the MCO. (E) Member-initiated MCO terminations. (1) An MCO member who
qualifies as a mandatory managed care enrollment population as specified in
rule 5160-26-02 of the Administrative Code may request a different MCO as
follows: (a) From the date of enrollment through the initial three months
of MCO enrollment; (b) During an open enrollment month for the member's service
area as described in paragraph (G) of this rule; (c) At any time, if the member is a child receiving Title IV-E
federal foster care maintenance or is in foster care or other out of home
placement. The change must be initiated by the local public children's
services agency (PCSA) or the local Title IV-E juvenile court; or (d) At any time, if the just cause request meets one of the
reasons for just cause as specified in paragraph (E)(3)(f) of this
rule; (2) An MCO member who
qualifies as a voluntary managed care enrollment population as specified in
rule 5160-26-02 of the Administrative Code may request a different MCO, if
available, or be returned to medicaid fee-for-service (FFS) as
follows: (a) From the date of enrollment through the initial three months
of MCO enrollment; (b) During an open enrollment month for the member's service
area as described in paragraph (G) of this rule; or (c) At any time, if the just cause request meets one of the
reasons for just cause as specified in paragraph (E)(3)(f) of this
rule; (3) The following
provisions apply when a member either requests a different MCO or, if
applicable, requests to be returned to medicaid FFS: (a) The request may be made by the member, or by the
member's authorized representative. (b) All member-initiated changes or terminations must be
voluntary. The MCO is not permitted to encourage members to change or terminate
enrollment due to a member's age, gender, gender identity, sexual
orientation, disability, national origin, race, color, religion, military
status, ancestry, genetic information, health status or need for health
services. The MCO may not use a policy or practice that has the effect of
discrimination on the basis of the criteria listed in this rule. (c) If a member requests disenrollment because he or she meets
the requirements of paragraph (B)(3) of rule 5160-26-02 of the Administrative
Code, the member will be disenrolled after the member notifies the Ohio
medicaid consumer hotline. (d) Disenrollment will take effect on the last day of the
calendar month in which the request for disenrollment was made. (e) In accordance with 42 C.F.R. 438.56(d)(2) (October 1, 2021),
a change or termination of MCO enrollment may be permitted for any of the
following just cause reasons: (i) The member moves out
of the MCO's service area and a non-emergency service must be provided out
of the service area before the effective date of the member's termination
as described in paragraph (B)(1) of this rule; (ii) The MCO does not,
for moral or religious objections, cover the service the member
seeks; (iii) The member needs
related services to be performed at the same time; not all related services are
available within the MCO's network, and the member's PCP or another
provider determines that receiving services separately would subject the member
to unnecessary risk; (iv) The member has
experienced poor quality of care and the services are not available from
another provider within the MCO's network; (v) The member cannot
access medically necessary medicaid-covered services or cannot access the type
of providers experienced in dealing with the member's health care
needs; (vi) The PCP selected by
a member leaves the MCO's network and was the only available and
accessible PCP speaking the primary language of the member, and another PCP
speaking the language is available and accessible in another MCO in the
member's service area; and (vii) ODM determines that
continued enrollment in the MCO would be harmful to the interests of the
member. (f) The following provisions apply when a member seeks a change
or termination in MCO enrollment for just cause: (i) The member may make the request for just cause directly
to ODM or an ODM-approved entity, either orally or in writing. (ii) ODM shall review all requests for just cause within
seven working days of receipt. ODM may request documentation as necessary from
both the member and the MCO. ODM shall make a decision within forty-five days
from the date ODM receives the just cause request. If ODM fails to make the
determination within this timeframe, the just cause request is considered
approved. (iii) ODM may establish retroactive termination dates and
recover capitation payments as determined necessary and
appropriate. (iv) Regardless of the procedures followed, the effective
date of an approved just cause request must be no later than the first day of
the second month following the month in which the member requests change or
termination. (v) If the just cause request is not approved, ODM shall
notify the member or the authorized representative of the member's right
to a state hearing. (vi) Requests for just cause may be processed at the
individual level or case level as ODM determines necessary and
appropriate. (vii) If a member submits a request to change or terminate
enrollment for just cause, and the member loses medicaid eligibility prior to
action by ODM on the request, ODM shall ensure that the member's MCO
enrollment is not automatically renewed if eligibility for medicaid is
reauthorized. (F) MCO initiated terminations. (1) The MCO may submit a
request to ODM for the termination of a member for the following
reasons: (a) Fraudulent behavior by the member; or (b) Uncooperative or disruptive behavior by the member or someone
acting on the member's behalf to the extent that such behavior seriously
impairs the MCO's ability to provide services to either the member or
other MCO members. (2) The MCO may not
request termination due to the member's age, gender, gender identity,
sexual orientation, disability, national origin, race, color, religion,
military status, genetic information, ancestry, health status or need for
health services. (3) The MCO must provide
medicaid-covered services to a terminated member through the last day of the
month in which the MCO enrollment is terminated, notwithstanding the date of
ODM written approval of the termination request. Inpatient facility services
must be provided in accordance with rule 5160-26-02 of the Administrative
Code. (4) If ODM approves the
MCO's request for termination, ODM shall notify in writing the member, the
authorized representative, the Ohio medicaid consumer hotline, and the
MCO. (G) MCO open enrollment. (1) Open enrollment
months will occur at least annually. (2) At least sixty days
prior to the designated open enrollment month, ODM will notify eligible
individuals by mail of the opportunity to change or terminate MCO enrollment
and will explain where to obtain further information.
Last updated January 3, 2023 at 9:23 AM
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Rule 5160-26-03 | Managed care: covered services.
(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) Except as otherwise provided in this rule, a managed
care organization (MCO) and the single pharmacy benefit manager (SPBM) must
ensure members have access to all medically necessary services, as applicable,
covered by Ohio medicaid under the state plan. The MCO and SPBM must
ensure: (1) Services are
sufficient in amount, duration, and scope to reasonably be expected to achieve
the purpose for which the services are provided; (2) The amount, duration,
and scope of a required service is not arbitrarily denied or reduced solely
because of the diagnosis, type of illness, or condition; (3) Prior authorization
is available for services on which the MCO or the SPBM has placed a
pre-identified limitation to ensure the limitation may be exceeded when
medically necessary, unless the MCO or SPBM's limitation is also a
limitation for fee-for-service medicaid coverage; (4) Coverage decisions are based on the
coverage and medical necessity criteria published in agency 5160 of the
Administrative Code and practice guidelines specified in rule 5160-26-05.1 of
the Administrative Code; and (5) If a member is unable to obtain
medically necessary services offered by medicaid from an MCO or SPBM network
provider, the MCO or SPBM must adequately and timely cover the services out of
network, until the MCO or SPBM is able to provide the services from a network
provider. (C) The MCO and SPBM may place appropriate limits on a
service: (1) On the basis of
medical necessity for the member's condition or diagnosis; or (2) For the purposes of
utilization control, provided the services can be reasonably expected to
achieve their purpose as specified in paragraph (B)(1) of this
rule. (D) Upon implementation of the SPBM will provide pharmacy
services in compliance with rule 5160-9-03 of the Administrative Code,
including all prescribing and prior authorization requirements, and any
grandfathered drug classes as established by the Ohio department of medicaid
(ODM) preferred drug list located at https://pharmacy.medicaid.ohio.gov/. The
SPBM will not charge co-pays unless directed by ODM. Until implementation of
the SPBM, the provisions outlined in this paragraph are applicable to the
MCO. (E) Services covered by an MCO. (1) The MCO must cover annual physical
examinations for adults. (2) At the request of the member, the MCO
must provide for a second opinion from a qualified health care professional
within the MCO's network. If such a qualified health care professional is
not available within the MCO's network, the MCO must arrange for the
member to obtain a second opinion outside the MCO's network, at no cost to
the member. (3) The MCO must ensure emergency
services as defined in rule 5160-26-01 of the Administrative Code are provided
and covered twenty-four hours a day, seven days a week. At a minimum, such
services must be provided and reimbursed in accordance with the
following: (a) The MCO cannot deny payment for treatment obtained when
a member had an emergency medical condition as defined in rule 5160-26-01 of
the Administrative Code. (b) The MCO cannot limit what constitutes an emergency
medical condition on the basis of lists of diagnoses or symptoms. (c) The MCO must cover all emergency services without
requiring prior authorization. (d) The MCO must cover medicaid-covered services related to
the member's emergency medical condition when the member is instructed to
go to an emergency facility by a representative of the MCO, including but not
limited to, the member's primary care provider (PCP) or the MCO's
twenty-four-hour toll-free phone number. (e) The MCO cannot deny payment of emergency services based
on the treating provider, hospital, or fiscal representative not notifying the
member's PCP of the visit. (f) The MCO must cover emergency services as defined in
rule 5160-26-01 of the Administrative Code when the services are delivered by a
non-contracting provider of emergency services and claims for these services
cannot be denied regardless of whether the services meet an emergency medical
condition as defined in rule 5160-26-01 of the Administrative Code. Such
services must be reimbursed by the MCO at the lesser of billed charges or one
hundred per cent of the Ohio medicaid program reimbursement rate (less any
payments for indirect costs of medical education and direct costs of graduate
medical education that is included in the Ohio medicaid program reimbursement
rate) in effect for the date of service. If an inpatient admission results, the
MCO is required to reimburse at this rate only until the member can be
transferred to a provider designated by the MCO. Pursuant to section 5167.10 of
the Revised Code, the MCO shall not compensate a hospital for inpatient capital
costs in an amount that exceeds the maximum rate established by
ODM. (g) The MCO must cover emergency services until the member
is stabilized and can be safely discharged or transferred. (h) The MCO must adhere to the judgment of the attending
provider when requesting a member's transfer to another facility or
discharge. The MCO may establish arrangements with hospitals whereby the MCO
may designate one of its contracting providers to assume the attending
provider's responsibilities to stabilize, treat, and transfer the
member. (i) A member who has had an emergency medical condition may
not be held liable for payment of any subsequent screening and treatment needed
to diagnose the specific condition or stabilize the member. (4) The MCO must establish, in writing,
the process and procedures for the submission of claims for services delivered
by non-contracting providers, including non-contracting providers of emergency
services. Such information must be made available upon request to
non-contracting providers, including non-contracting providers of emergency
services. The MCO shall not establish claims filing and processing procedures
for non-contracting providers, including non-contracting providers of emergency
services, that are more stringent than those established for their contracting
providers. (5) The MCO must ensure
post-stabilization care services as defined in rule 5160-26-01 of the
Administrative Code are provided and covered twenty-four hours a day, seven
days a week. (a) The MCO must designate a telephone line to receive
provider requests for coverage of post-stabilization care services. The line
must be available twenty-four hours a day. The MCO must document that the
telephone number and process for obtaining authorization has been provided to
each emergency facility in the service area. The MCO must maintain a record of
any request for coverage of post-stabilization care services that is denied
including, at a minimum, the time of the provider's request and the time
the MCO communicated the decision in writing to the provider. (b) At a minimum, post-stabilization care services must be
provided and reimbursed in accordance with the following: (i) The MCO must cover services obtained within or outside
the MCO's network that are pre-approved in writing to the requesting
provider by an MCO provider or other MCO representative. (ii) The MCO must cover services obtained within or outside
the MCO's network that are not pre-approved by an MCO provider or other
MCO representative but are administered to maintain the member's
stabilized condition within one hour of a request to the MCO for pre-approval
of further post-stabilization care services. (iii) The MCO must cover services obtained within or outside
the MCO's network that are not pre-approved by an MCO provider or other
MCO representative but are administered to maintain, improve, or resolve the
member's stabilized condition if: (a) The MCO fails to respond within one hour to a provider
request for authorization to provide such services. (b) The provider has documented an attempt to contact the
MCO to request authorization, but the MCO connot be contacted. (c) The MCO's representative and treating provider
cannot reach an agreement concerning the member's care and an MCO provider
is not available for consultation. In this situation, the MCO must give the
treating provider the opportunity to consult with an MCO provider and the
treating provider may continue with care until an MCO provider is reached or
one of the criteria specified in paragraph (E)(5)(c) of this rule is
met. (c) The MCO's financial responsibility for
post-stabilization care services not pre-approved ends when: (i) An MCO provider with privileges at the treating
hospital assumes responsibility for the member's care; (ii) An MCO provider assumes responsibility for the
member's care through transfer; (iii) An MCO representative and the treating provider reach
an agreement concerning the member's care; or (iv) The member is discharged. (6) When an MCO member has a nursing
facility (NF) stay, the MCO is responsible for payment of medically necessary
NF services until the member is discharged or until the member is disenrolled
in accordance with the processes set forth in rule 5160-26-02.1 of the
Administrative Code. (7) The MCO is not responsible for
payment of home and community-based services (HCBS) provided to a member who is
enrolled in an HCBS waiver program administered by ODM, the Ohio department of
aging (ODA), or the Ohio department of developmental disabilities
(DODD). (8) MCO members are permitted to
self-refer to Title X services provided by any qualified family planning
provider (QFPP). The MCO is responsible for payment of claims for Title X
services delivered by QFPPs not contracting with the MCO at the lesser of one
hundred per cent of the Ohio medicaid program fee-for-service reimbursement
rate or billed charges in effect for the date of service. (9) The MCO must permit members to
self-refer to any women's health specialist within the MCO's network
for covered care necessary to provide women's routine and preventive
health care services. This is in addition to the member's designated PCP
if that PCP is not a women's health specialist. (10) The MCO must ensure access to covered
services provided by all federally qualified health centers (FQHCs) and rural
health clinics (RHCs). (11) Where available, the MCO must ensure
access to covered services provided by a certified nurse
practitioner. (12) ODM may approve an MCO's members
to be referred to certain MCO non-contracting hospitals, as specified in rule
5160-26-11 of the Administrative Code, for medicaid-covered non-emergency
hospital services. When ODM permits such authorization, ODM will notify the MCO
and the MCO non-contracting hospital of the terms and conditions, including the
duration, of the approval and the MCO must reimburse the MCO non-contracting
hospital at one hundred per cent of the current Ohio medicaid program
fee-for-service reimbursement rate in effect for the date of service for all
medicaid-covered non-emergency hospital services delivered by the MCO
non-contracting hospital. ODM will base its determination of when an MCO's
members can be referred to MCO non-contracting hospitals pursuant to the
following: (a) The MCO's submission of a written request to ODM for the
approval to refer members to a hospital that has declined to contract with the
MCO. The request must document the MCO's contracting efforts and why the
MCO believes it will be necessary for members to be referred to this hospital;
and (b) ODM consultation with the MCO non-contracting hospital to
determine the basis for the hospital's decision to decline to contract
with the MCO, including but not limited to whether the MCO's contracting
efforts were unreasonable and/or that contracting with the MCO would have
adversely impacted the hospital's business. (13) Paragraph (E)(12) of this rule is not
applicable when the MCO and an MCO non-contracting hospital have mutually
agreed that the non-contracting hospital will provide non-emergency hospital
services to an MCO's members. The MCO must ensure that such arrangements
comply with rule 5160-26-05 of the Administrative Code. (14) The MCO is not responsible for
payment of services provided through medicaid school program (MSP) pursuant to
Chapter 5160-35 of the Administrative Code. The MCO must ensure access to
medicaid-covered services for members who are unable to timely access services
or unwilling to access services through MSP providers. (15) When a member is determined to be no
longer eligible for enrollment in an MCO during a stay in an institution for
mental disease (IMD), the MCO is not responsible for payment of that IMD stay
after the date of disenrollment from the MCO. (16) The MCO must provide
two dental cleanings per year to pregnant members of the eligibility group
described in section 5163.06 of the Revised Code. (17) The MCO must cover respite services
as described in rule 5160-26-03.2 of the Administrative Code. (18) The MCO is not
responsible for covering services described in rule 5160-59-03 of the
Administrative Code for a member enrolled in the OhioRISE plan. (F) The MCO and SPBM are not required to cover services
provided to members outside the United States. (G) The MCO and SPBM must ensure that eligible members
receive all early and periodic screening, diagnosis and treatment (EPSDT)
services, also known as healthchek services, in accordance with rule 5160-1-14
of the Administrative Code. The MCO will ensure healthchek exams: (1) Include the components specified in
rule 5160-1-14 of the Administrative Code. All components of exams must be
documented and included in the medical record of each healthchek eligible
member and made available for the ODM annual external quality
review. (2) Are completed within ninety days of
the initial effective date of enrollment for those children found to have a
possible ongoing condition likely to require care management
services.
Last updated July 18, 2022 at 8:18 AM
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Rule 5160-26-03.1 | Managed care: primary care and utilization management.
(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) A managed care organization (MCO) must 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 MCO must ensure
PCPs are in compliance with the following triage requirements: (a) Members with emergency care needs must be triaged and treated
immediately on presentation at the PCP site; (b) Members with persistent symptoms must be treated no later
than the end of the following working day after their initial contact with the
PCP site; and (c) Members with requests for routine care must be seen within
six weeks. (2) PCP care coordination
responsibilities include at a minimum the following: (a) Assisting with coordination of the member's overall
care, as appropriate for the member; (b) Providing services which are medically necessary as described
in rule 5160-1-01 of the Administrative Code; (c) Serving as the ongoing source of primary and preventative
care; (d) Recommending referrals to specialists, as required;
and (e) Triaging members as described in paragraph (B)(1) of this
rule. (C) The MCO and the single pharmacy benfit manager (SPBM)
must have a utilization management (UM) program with clearly defined structures
and processes designed to maximize the effectiveness of the care provided to
the member. The MCO and the SPBM must ensure decisions rendered through the UM
program are based on medical necessity. (1) The UM program must
be based on written policies and procedures that include, at a
minimum: (a) The information sources used to make determinations of
medical necessity; (b) The criteria, based on sound clinical evidence, to make UM
decisions and the specific procedures for appropriately applying the
criteria; (c) A specification that written UM criteria will be made
available to both contracting and non-contracting providers; and (d) A description of how the MCO or SPBM will monitor the impact
of the UM program to detect and correct potential under- and
over-utilization. (2) The MCO and
SPBM's UM programs must also ensure and document the
following: (a) An annual review and update of the UM program. (b) The involvement of a designated senior physician in the UM
program. (c) The use of appropriate qualified licensed health
professionals to assess the clinical information used to support UM
decisions. (d) The use of board-certified consultants to assist in making
medical necessity determinations, as necessary. (e) That UM decisions are consistent with clinical practice
guidelines as specified in rule 5160-26-05.1 of the Administrative Code. The
MCO may not impose conditions around the coverage of a medically necessary
medicaid-covered service unless they are supported by such clinical practice
guidelines. (f) The reason for each denial of a service, based on sound
clinical evidence. (g) That compensation by the MCO or SPBM to individuals or
entities that conduct UM activities does not offer incentives to deny, limit,
or discontinue medically necessary services to any member. (h) Compliance with the Mental Health Parity and Addiction
Equity Act (MHPAEA) requirements outlined in 42 CFR Part 438 Subpart K (October
1, 2021). (3) The MCO and the SPBM
must process requests for initial and continuing authorizations of services
from their providers and members. The MCO and the SPBM must have written
policies and procedures to process initial requests and continuing
authorizations. Upon request, the MCO and SPBM's policies and procedures
for initial and continuing authorizations must be made available for review by
the Ohio department of medicaid (ODM). The MCO and SPBM's written policies
and procedures for initial and continuing authorizations of services must also
be made available to contracting and non-contracting providers upon request.
The MCO and SPBM must ensure and document the following occurs when processing
requests for initial and continuing authorizations of services: (a) Consistent application of review criteria for authorization
decisions. (b) Consultation with the requesting provider, when
necessary. (c) Any decision to deny a service authorization request or to
authorize a service in an amount, duration, or scope that is less than
requested, must be made by a health care professional who has appropriate
clinical expertise in treating the member's condition or
disease. (d) That a written notice will be sent to the member and the
requesting provider of any decision to reduce, suspend, terminate, or deny a
service authorization request, or to authorize a service in an amount,
duration, or scope that is less than requested. The notice to the member must
meet the requirements of division 5101:6 and rule 5160-26-08.4 of the
Administrative Code. (e) For standard authorization decisions, the MCO must provide
notice to the provider and member as expeditiously as the member's health
condition requires but no later than ten calendar days following receipt of the
request for service. If requested by the member, provider, or MCO, standard
authorization decisions may be extended up to fourteen additional calendar
days. If requested by the MCO, the MCO must submit to ODM for prior-approval,
documentation as to how the extension is in the member's interest. If ODM
approves the MCO's extension request, the MCO must give the member written
notice of the reason for the decision to extend the time frame and inform the
member of the right to file a grievance if he or she disagrees with that
decision. The MCO must carry out its determination as expeditiously as the
member's health condition requires and no later than the date the
extension expires. (f) If a provider indicates or the MCO determines that following
the standard authorization timeframe could seriously jeopardize the
member's life or health or ability to attain, maintain, or regain maximum
function, the MCO must make an expedited authorization decision and provide
notice of the authorization decision as expeditiously as the member's
health condition requires but no later than forty-eight hours after receipt of
the request for service. If requested by the member or MCO, expedited
authorization decisions may be extended up to fourteen additional calendar
days. If requested by the MCO, the MCO must submit to ODM for prior-approval,
documentation as to how the extension is in the member's interest. If ODM
approves the MCO's extension request, the MCO must give the member written
notice of the reason for the decision to extend the timeframe and inform the
member of the right to file a grievance if he or she disagrees with that
decision. The MCO must carry out its determination as expeditiously as the
member's health condition requires and no later than the date the
extension expires. (g) Upon implementation of the SPBM, for prior
authorization of covered outpatient drugs as defined in 42 U.S.C. 1396r-8(k)(2)
(as in effect January 1, 2022), the SPBM will provide a response to the
provider by telephone or other telecommunication device within twenty-four
hours of the initial request. Until implementation of the SPBM, all provisions
outlined in this paragraph are applicable to the MCO. (i) If the prior
authorization request contains sufficient information to render a final
decision, the SPBM must provide notice to the provider of the decision within
twenty-four hours of receipt of the initial request. (ii) If the prior
authorization request contains insufficient information to render a final
decision, the SPBM must notify the provider of the need for additional
information within twenty-four hours of the initial request. (iii) If the prior
authorization request is for an emergency situation, a seventy-two hour supply
of the covered outpatient drug that was prescribed must be authorized while the
SPBM reviews the prior authorization request. (h) The MCO and the SPBM must maintain and submit as
directed by ODM, a record of all authorization requests, including standard and
expedited authorization requests and any extensions granted. MCO and SPBM
records must include member identifying information, service requested, date
initial request received, any extension requests, decision made, date of
decision, date of member notice, and basis for denial, if
applicable. (4) Upon implementation of the SPBM, the
SPBM may, subject to ODM prior approval, implement strategies for the
management of drug utilization, and the MCO may, subject to ODM approval,
develop other UM programs. (5) At a minimum, the MCO
has to implement a coordinated services program (CSP) as described in rule
5160-20-01 of the Administrative Code. The MCO has to offer care management
services to any member enrolled in CSP
Last updated July 18, 2022 at 8:18 AM
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Rule 5160-26-03.2 | Managed care: long-term services and supports respite services for children.
(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) The managed care organization (MCO) is responsible for
payment of long-term services and supports (LTSS) respite services as defined
in rule 5160-26-01 of the Administrative Code. (C) To be eligible for respite services, the member has
to: (1) Reside with his or her informal, unpaid primary
caregiver in a home that is not owned, leased, or controlled by a provider of
any health-related treatment or support services; (2) Not be a foster child, as defined in Chapter 5101:2-1
of the Administrative Code; (3) Be under twenty-one years of age; (4) Have long-term services and supports (LTSS) needs
resulting in the need for respite services as indicated by: (a) Skilled nursing or
skilled rehabilitation services at least once per week; or (b) Having a need for at
least fourteen hours per week of home health aide services for at least two
consecutive months immediately preceding the date respite services are
requested; or (c) Being determined
eligible for social security income for children with disabilities or
supplemental security income; or (d) Having an LTSS needs
as determined by the MCO through an institutional level of care determination
as set forth in rule 5123-8-01 or 5160-3-08, of the Administrative
Code. (5) Be participating in a care management or coordination
arrangement. (D) Authorization for LTSS respite. (1) Prior authorization of LTSS respite services will be in
accordance with rule 5160-26-03.1 of the Administrative Code. (2) Respite services can be provided on a planned or
unplanned basis. (3) The MCO has to determine that the member's primary
caregiver has a need for temporary relief from the care of the member as a
result of the member's LTSS needs, or in order to prevent an inpatient,
institutional, or out-of-home stay. (E) LTSS respite services have to be provided by
individuals employed by medicaid enrolled agency providers that are either
medicare-certified home health agencies pursuant to Chapter 3701-60 of the
Administrative Code, or accredited by the "Joint Commission," the
"Community Health Accreditation Program," or the "Accreditation
Commission for Health Care." (1) LTSS respite providers have to comply with the criminal
records check set forth in rules 5160-45-07 and 5160-45-11 of the
Administrative Code. (2) The provider has to be awake when the member is awake
during the provision of respite services. (3) Respite providers has to not be the member's
"legally responsible family member," as defined in rule 5160-45-01 of
the Administrative Code. (4) Before commencing service delivery, the LTSS provider
agency employee has to: (a) Obtain a certificate
of completion of either a competency evaluation program or a training and
competency evaluation program approved or conducted by the director of health
under section 3721.31 of the Revised Code, and be registered as active or in
good standing on the Ohio nurse aide registry maintained by the director of
health under section 3721.32 of the Revised Code. (b) Obtain and maintain
first aid certification from a class that is not solely internet-based and that
includes hands-on training by a certified first aid instructor and a successful
return demonstration of what was learned in the course. At its discretion, ODM
may accept training conducted by a solely internet-based class as sufficient
for the purposes of first aid certification. (c) After commencing
service delivery, the LTSS provider agency employee has to: (i) Maintain evidence of completion of twelve hours of
in-service continuing education within a twelve-month period, excluding agency
and program-specific orientation, and (ii) Receive supervision from an Ohio-licensed registered
nurse (RN) and meet any additional supervisory requirements pursuant to the
agency's certification or accreditation.
Last updated March 25, 2024 at 9:11 AM
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Rule 5160-26-05 | Managed care: provider network and contracting requirements.
(A) Provider contracts. (1) A managed care entity (MCE) must
provide or arrange for the delivery of covered health care services described
in rule 5160-26-03 of the Administrative Code either through the use of
employees or through contracts with network providers of health care services
("providers"). All provider contracts must be in writing and in
accordance with paragraph (D) of this rule and 42 C.F.R. 434.6 and 438.6
(October 1, 2021). The MCE's execution of a provider contract does not
terminate the MCE's legal responsibility to the Ohio department of
medicaid (ODM) to ensure all of the MCE's activities and obligations are
performed in accordance with agency 5160 of the Administrative Code, as
applicable, the MCE's provider agreement or contract with ODM, and all
applicable federal, state, and local regulations. (2) The MCE shall make
all provider contracts available to ODM upon request. (3) Provider contracts may not include
language that conflicts with the specifications identified in paragraphs (C)
and (D) of this rule. (4) MCE network providers
have to maintain an active, valid medicaid provider agreement as set forth in
rule 5160-1-17.2 of the Administrative Code. (5) When utilizing an out of network
provider, the MCE must establish a mutually agreed upon compensation amount for
the authorized service and notify the provider of the applicable provisions of
paragraph (D) of this rule. For medicaid-covered non-emergency hospital
services outlined in rule 5160-26-03 of the Administrative Code, the
compensation amount is identified in rule 5160-26-11 of the Administrative
Code. (B) Notification. (1) Notwithstanding
paragraph (D)(13) of this rule, the MCE must notify ODM of any addition to or
deletion from its provider network on an ongoing basis, and must follow the
time restrictions contained in this paragraph unless the explanation of
extenuating circumstances is accepted by ODM. (2) At the direction of
ODM, the MCE must submit evidence of the following: (a) A copy of the provider's current licensure; (b) Copies of written agreements with the provider, including but
not limited to provider contracts, amendments, and the medicaid addendum as
specified in paragraph (D) of this rule; (c) Notification to ODM of any hospital provider contract for
which a date of termination is specified; and (d) The provider's medicaid provider number and provider
reporting number, if applicable. (3) The MCE shall notify ODM in writing
of the expiration, nonrenewal, or termination of any provider contract at least
fifty-five calendar days prior to the expiration, nonrenewal, or termination of
the provider contract in a manner and format directed by ODM. If the MCE
receives less than fifty-five calendar days' notice from the provider, the
MCE must inform ODM in writing within one working day of becoming aware of this
information. (4) If the provider contract is for a
hospital: (a) Forty-five calendar days prior to the effective date of
the expiration, nonrenewal or termination of the hospital's provider
contract, the MCO shall notify in writing all providers who have admitting
privileges at the hospital of the impending expiration, nonrenewal, or
termination of the provider contract and the last date the hospital will
provide services to members under the MCO provider contract. If the MCO
receives less than forty-five calendar days' notice from the hospital, the
MCO shall send the notice within one working day of becoming aware of the
expiration, nonrenewal, or termination of the provider contract. (b) Forty-five calendar days prior to the effective date of
the expiration, nonrenewal, or termination of the hospital's provider
contract, the MCO shall notify in writing all members in the service area, or
in an area authorized by ODM, of the impending expiration, nonrenewal, or
termination of the hospital's provider contract. If the MCO receives less
than forty-five calendar days' notice from the hospital provider, the MCO
shall send the notice within one working day of becoming aware of the
expiration, nonrenewal, or termination of the provider contract. (c) The MCO shall submit a template for member and provider
notifications to ODM along with the MCO's notification to ODM of the
impending expiration, nonrenewal, or termination of the hospital's
provider contract. The notifications shall comply with the
following: (i) The form and content of the member notice must be
prior-approved by ODM and contain an ODM designated toll-free telephone number
members can call for information and assistance. (ii) The form and content of the provider notice must be
prior-approved by ODM. (d) ODM may require the MCO to notify additional members or
providers if the impending expiration, nonrenewal, or termination of the
hospital's provider contract adversely impacts additional members or
providers. (5) If the provider contract is for a
primary care provider (PCP): (a) The MCO shall include the number of members that will
be affected by the change in the notice to ODM; and (b) The MCO shall notify in writing all members who use or
are assigned to the provider as a PCP at least forty-five calendar days prior
to the effective date of the change. If the MCO receives less than forty-five
calendar days prior notice from the PCP, the MCO shall issue the notification
within one working day of the MCO becoming aware of the expiration, nonrenewal,
or termination of PCP's provider contract. The form of the notice and its
content must be prior-approved by ODM and must contain, at a minimum, all of
the following information: (i) The PCP's name and last date the PCP is available
to provide care to the MCO's members; (ii) Information regarding how members can select a
different PCP; and (iii) An MCO telephone number members can call for further
information or assistance. (6) ODM may require the MCE to notify
members or providers of the expiration, nonrenewal, or termination of other
provider contracts that may adversely impact the MCE's
members. (7) In order to ensure availability of
services and qualifications of providers, ODM may require submission of
documentation in accordance with paragraph (B) of this rule regardless of
whether the MCE contracts directly for services or does so through another
entity. (8) In the event that the MCE's
medicaid managed care program participation in a service area is terminated,
the MCE must provide written notification to its affected contracted providers
at least forty-five calendar days prior to the termination date, unless
otherwise specified by ODM. (C) Provider qualifications. (1) The MCE must ensure
that none of its employees or contracted providers are sanctioned or excluded
from providing medicaid or medicare services. The MCE shall use available
resources for identifying sanctioned providers, at least monthly, including,
but not limited to, the following: (a) The federal office of inspector general provider exclusion
list; (b) The ODM excluded provider web page; and (c) The discipline pages of the applicable state boards that
license providers or an alternative data resource, such as the national
practitioner databank, that is as complete and accurate as the discipline pages
of the applicable state boards. (2) The MCE may not
discriminate with regard to the participation, reimbursement, or
indemnification of any provider who is acting within the scope of his or her
license or certification under applicable state law, solely on the basis of
that license or certification. If the MCE declines to include individual or
groups of providers in its network, it must give the affected providers written
notice of the reasons for its decision. This paragraph may not be construed
to: (a) Require the MCE to contract with providers beyond the number
necessary to meet the needs of its members as described in the MCE's
provider agreement or contract with ODM; (b) Preclude the MCE from using different reimbursement amounts
for different specialties or for different practitioners in the same specialty;
or (c) Preclude the MCE from establishing measures that are designed
to maintain quality of services and control costs and are consistent with its
responsibilities to members. (3) The MCE must have
written policies and procedures for the selection and retention of providers
that prohibit discrimination against particular providers that serve high-risk
populations or specialize in conditions that require costly
treatment. (4) The MCE will accept
ODM credentialing of ODM-enrolled providers and will not conduct any further
credentialing activities for those providers. (D) Provider contract
specifications. All provider contracts, including single case
agreements, must include a medicaid addendum that has been approved by ODM. The
medicaid addendum must include the following elements, appropriate to the
service being rendered, as specified by ODM: (1) An agreement by the
provider to comply with the applicable provisions for record keeping and
auditing in accordance with Chapter 5160-26 of the Administrative
Code. (2) Specification of the
medicaid population and service areas, pursuant to the MCE's provider
agreement or contract with ODM. (3) Specification of the
health care services to be provided. (4) Specification that
the provider contract is governed by, and construed in accordance with all
applicable laws, regulations, and contractual obligations of the MCE
and: (a) ODM shall notify the MCE and the MCE shall notify the
provider of any changes in applicable state or federal law, regulations,
waiver, or contractual obligation of the MCE; (b) The provider contract shall be automatically amended to
conform to such changes without the necessity for written execution;
and (c) The MCE shall notify the provider of all applicable
contractual obligations. (5) Specification of the
beginning date and expiration date of the contract, or an automatic renewal
clause, as well as the applicable methods of extension, renegotiation, and
termination. (6) Specification of the
procedures to be employed upon the ending, nonrenewal, or termination of the
contract, including an agreement by the provider to promptly supply all records
necessary for the settlement of outstanding medical claims. (7) Full disclosure of
the method and amount of compensation or other consideration to be received by
the provider from the MCE. (8) An agreement not to
discriminate in the delivery of services based on the member's race,
color, religion, gender, gender identity, genetic information, sexual
orientation, age, disability, national origin, military status, ancestry,
health status, or need for health services. (9) An agreement by the
provider to not hold liable ODM or members in the event that the MCE cannot or
will not pay for services performed by the provider pursuant to the contract
with the exception that: (a) Federally qualified health centers (FQHCs) and rural health
clinics (RHCs) may be reimbursed by ODM in the event of MCE insolvency.
(b) The provider may bill the member when the MCE has denied
prior authorization or referral for services and the conditions described in
rule 5160-1-13.1 of the Administrative Code are met. (10) An agreement by the
provider that with the exception of any member co-payments the MCE has elected
to implement in accordance with rule 5160-26-12 of the Administrative Code, the
MCE's payment constitutes payment in full for any covered service and the
provider will not charge the member or ODM any co-payment, cost sharing,
down-payment, or similar charge, refundable or otherwise. This agreement does
not prohibit nursing facilities or home and community-based services waiver
providers from collecting patient liability payments from members as specified
in rules 5160:1-6-07 and 5160:1-6-07.1 of the Administrative Code or FQHCs and
RHCs from submitting claims for supplemental payments to ODM as specified in
Chapter 5160-28 of the Administrative Code. Additionally, the MCE and the
provider agree to the following: (a) The MCE shall notify the provider whether the MCE has elected
to implement any member co-payments and if, applicable, the circumstances in
which member co-payment amounts will be imposed in accordance with rule
5160-26-12 of the Administrative Code; and (b) The provider agrees that member notifications regarding any
applicable co-payment amounts must be carried out in accordance with rule
5160-26-12 of the Administrative Code. (11) A specification that
the provider and all employees of the provider are duly registered, licensed or
certified under applicable state and federal statutes and regulations to
provide the health care services that are the subject of the contract, and that
provider and all employees of the provider have not been excluded from
participating in federally funded health care programs. (12) An agreement that
ODM administered home and community based services (HCBS) waiver providers are
currently enrolled as ODM providers with an active status in accordance with
agency 5160 of the Administrative Code, and all other providers are either
currently enrolled as ODM providers and meet the qualifications specified in
paragraph (C) of this rule, or they are in the process of enrolling as ODM
providers; (13) A stipulation that
the MCE will give the provider at least sixty-days' prior notice in
writing for the nonrenewal or termination of the contract except in cases where
an adverse finding by a regulatory agency or health or safety risks dictate
that the contract be terminated sooner or when the contract is temporary in
accordance with 42 C.F.R. 438.602 (October 1, 2021) and the provider fails to
enroll as an ODM provider within one hundred twenty days. (14) A stipulation that
the provider may nonrenew or terminate the contract if one of the following
occurs: (a) The provider gives the MCE at least sixty days prior notice
in writing for the nonrenewal or termination of the contract, or the
termination of any services for which the provider is contracted. The effective
date for any nonrenewal or termination of the contract, or termination of any
contracted service must be the last day of the month. (b) ODM has proposed action to terminate, nonrenew, deny or amend
the MCO's provider agreement in accordance with rule 5160-26-10 of the
Administrative Code, regardless of whether this action is appealed. The
provider's termination or nonrenewal written notice must be received by
the MCE within fifteen working days prior to the end of the month in which the
provider is proposing termination or nonrenewal. If the notice is not received
by this date, the provider must agree to extend the termination or nonrenewal
date to the last day of the subsequent month. (15) The provider's
agreement to serve members through the last day the contract is in
effect. (16) The provider's
agreement to make the medical records for medicaid eligible individuals
available for transfer to new providers at no cost to the
individual. (17) A specification that
all laboratory testing sites providing services to members must have either a
current clinical laboratory improvement amendments (CLIA) certificate of
waiver, certificate of accreditation, certificate of compliance, or certificate
of registration along with a CLIA identification number. (18) A requirement
securing cooperation with the MCO's quality assessment and performance
improvement (QAPI) program in all its provider contracts and employment
agreements for physician and nonphysician providers. (19) An agreement by the
provider and MCE that: (a) The MCE shall disseminate written policies in accordance with
the requirements of 42 U.S.C. 1396a(a)(68) (as in effect July 1, 2022) and
section 5162.15 of the Revised Code, regarding the reporting of false claims
and whistleblower protections for employees who make such a report, and
including the MCE's policies and procedures for detecting and preventing
fraud, waste, and abuse; and (b) The provider agrees to abide by the MCE's written
policies related to the requirements of 42 U.S.C. 1396a(a)(68) (as in effect
July 1, 2022) and section 5162.15 of the Revised Code, including the MCE's
policies and procedures for detecting and preventing fraud, waste, and
abuse. (20) A specification that hospitals and
other providers must allow the MCE access to all member medical records for a
period of not less than ten years from the date of service or until any audit
initiated within the ten year period is completed and allow access to all
record-keeping, audits, financial records, and medical records to ODM or its
designee or other entities as specified in rule 5160-26-06 of the
Administrative Code. (21) A specification, appearing above the
signature(s) on the signature page in all PCP contracts, stating the maximum
number of MCO members that each PCP can serve at each practice site for that
MCO. (22) A specification that the provider
must cooperate with the ODM external quality reviews required by 42 C.F.R.
438.358 (October 1, 2021) and on-site audits as deemed necessary based on
ODM's periodic analysis of financial, utilization, provider network and
other information. (23) A specification that the provider
must be bound by the same standards of confidentiality that apply to ODM and
the state of Ohio as described in rule 5160-1-32 of the Administrative Code,
including standards for unauthorized uses of or disclosures of protected health
information (PHI). (24) A specification that any third party
administrator (TPA) must include the elements of paragraph (D) of this rule in
its contracts and ensure that its contracted providers will forward information
to ODM as requested. (25) A specification that home health
providers must meet the eligible provider requirements specified in Chapter
5160-12 of the Administrative Code and comply with the requirements for home
care dependent adults as specified in section 121.36 of the Revised
Code. (26) A specification that PCPs must
participate in the care coordination requirements outlined in rule 5160-26-03.1
of the Administrative Code. (27) A specification that the provider in
providing health care services to members must identify and where necessary
arrange, pursuant to the mutually agreed upon policies and procedures between
the MCE and provider, for the following at no cost to the member; (a) Sign language services; and (b) Oral interpretation and oral translation
services. (28) A specification that the MCE agrees
to fulfill the provider's responsibility to issue notice of the
member's right to request a state hearing whenever the provider bills a
member due to the MCE's denial of payment of a service, as specified in
rules 5160-26-08.4 and 5160-58-08.4 of the Administrative Code, utilizing the
procedures and forms as specified in Chapter 5101:6-2 of the Administrative
Code. (29) The provider's agreement to
contact the twenty-four-hour post-stabilization services phone line designated
by the MCE to request authorization to provide post-stabilization services in
accordance with rule 5160-26-03 of the Administrative Code. (30) A specification that the MCE may not
prohibit or otherwise restrict a provider, acting within the lawful scope of
practice, from advising or advocating on behalf of a member who is his or her
patient for the following: (a) The member's health status, medical care, or treatment
options, including any alternative treatment that may be
self-administered; (b) Any information the member needs in order to decide among all
relevant treatment options; (c) The risks, benefits, and consequences of treatment versus
non-treatment; and (d) The member's right to participate in decisions regarding
his or her health care, including the right to refuse treatment, and to express
preferences about future treatment decisions. (31) A stipulation that the provider must
not identify the addressee as a medicaid recipient on the outside of the
envelope when contacting members by mail. (32) An agreement by the provider that
members will not be billed for missed appointments. (33) An agreement that in the performance
of the contract or in the hiring of any employees for the performance of
services under the contract, the provider shall not by reason of race, color,
religion, gender, gender identity, genetic information, sexual orientation,
age, disability, national origin, military status, health status, or ancestry,
discriminate against any citizen of Ohio in the employment of a person
qualified and available to perform the services to which the contract
relates. (34) An agreement by the provider that it
shall not in any manner, discriminate against, intimidate, or retaliate against
any employee hired for the performance of services under the contract on
account of race, color, religion, gender, gender identity, genetic information,
sexual orientation, age, disability, national origin, military status, health
status, or ancestry. (35) Notwithstanding paragraphs (D)(13)
and (D)(14) of this rule, in the event of a hospital's proposed nonrenewal
or termination of a hospital contract, an agreement by the contracted hospital
to notify in writing all providers who have admitting privileges at the
hospital of the impending nonrenewal or termination of the contract and the
last date the hospital will provide services to members under the MCE contract.
The contracted hospital must send this notice to the providers with admitting
privileges at least forty-five calendar days prior to the effective date of the
nonrenewal or termination of the hospital contract. If the contracted hospital
issues less than forty-five days prior notice to the MCE, the notice to
providers with admitting privileges must be sent within one working day of the
contracted hospital issuing notice of nonrenewal or termination of the
contract. (36) An agreement by the
provider to supply, upon request, the business transaction information required
under 42 C.F.R. 455.105 (October 1, 2021). (37) An agreement by the provider to
release to the MCO, ODM or ODM designee any information necessary for the MCE
to perform any of its obligations under the ODM provider agreement, including
but not limited to compliance with reporting and quality assurance
requirements. (38) An agreement by the provider that its
applicable facilities and records will be open to inspection by the MCE, ODM,
or ODM's designee, or other entities as specified in rule 5160-26-06 of
the Administrative Code. (E) In lieu of including a medicaid
addendum as required by paragraph (D) of this rule, an MCE may permit a TPA
that assists in the administration of health care services including
pharmaceutical, dental, vision and behavioral health services on behalf of the
MCE's members, to include elements in paragraphs (D)(1) to (D)(38) of this
rule in contracts with entities that provide for the direct provision of health
care services to its members. The MCE must receive written evidence that the
TPA complied with this paragraph and has informed the entities of the
obligation to provide health care services to the MCE's
members.
Last updated July 18, 2022 at 8:18 AM
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Rule 5160-26-05.1 | Managed care: provider services.
(A) A managed care entity (MCE) must
provide the following written information to their contracting
providers: (1) The MCE's
grievance, appeal and state fair hearing procedures and time frames,
including: (a) The member's right to file grievances and appeals and
the requirements and time frames for filing; (b) The MCE's toll-free telephone number to file oral
grievances and appeals; (c) The member's right to a state fair hearing, the
requirements and time frames for requesting a hearing, and representation rules
at a hearing; (d) The availability of assistance from the MCE in filing any of
these actions; (e) The member's right to request continuation of benefits
during an appeal or a state hearing and specification that at the discretion of
ODM the member may be liable for the cost of any such continued benefits;
and (f) The provider's rights to participate in these processes
on behalf of the provider's patients and to challenge the failure of the
MCE to cover a specific service. (2) The MCE's
requirements regarding the submission and processing of prior authorization
requests including: (a) A list of the benefits, if any, that require prior
authorization approval from the MCE; (b) The process and format to be used in submitting such
requests; (c) The time frames in which the MCE must respond to such
requests; (d) Pursuant to the provisions of paragraph (A)(1) of this rule,
how the provider will be notified of the MCE's decision regarding such
requests; and (e) Pursuant to the provisions of paragraph (A)(1) of this rule,
the procedures to be followed in appealing the MCE's denial of a prior
authorization request. (3) The MCE's documentation,
legibility, confidentiality, maintenance, and access standards for member
medical records; including a member's right to amend or correct his or her
medical record as specified in 45 C.F.R. 164.526 (October 1,
2021). (4) The MCE's process and
requirements for the submission of claims and the appeal of denied
claims. (5) The MCE's policies and
procedures regarding what action the MCE may take in response to occurrences of
undelivered, inappropriate, or substandard health care services, including the
reporting of serious deficiencies to the appropriate authorities. (6) The mutually agreed upon policies
and procedures between the MCE and the provider that explains the
provider's obligation to provide oral translation, oral interpretation,
and sign language services to the MCE's members including: (a) The provider's responsibility to identify those members
who may require such assistance; (b) The process the provider is to follow in arranging for such
services to be provided; (c) Information that members will not be liable for the costs of
such services; and (d) Specification of whether the MCE or the provider will be
financially responsible for the costs of providing these services. (7) The procedures that providers are to
follow in notifying the MCE of changes in their practice, including at a
minimum: (a) Address and phone numbers; (b) Providers included in the practice; (c) Acceptance of new patients; and (d) Standard office hours. (8) Specification of what service
utilization and provider performance data the MCE will make available to
providers. (9) Specification of the healthchek
components to be provided to eligible members as specified in Chapter 5160-14
of the Administrative Code. (B) In addition to the information in
paragraph (A) of this rule, a managed care organization (MCO) has to provide
the following written information to providers: (1) The MCO's
expectations for primary care providers (PCPs), including triage
obligations. (2) A description of the
MCO's care coordination and care management programs, and the role of the
provider in those programs, including: (a) The MCO's criteria for determining which members
might benefit from care management; (b) The provider's responsibility in identifying
members who may meet the MCO's care management criteria; and (c) The process for the provider to follow in notifying the
MCO when such members are identified. (3) The MCO's
expectations regarding the submission and processing of requests for specialist
referrals including: (a) A list of the provider types, if any, that need prior
authorization approval from the MCO; (b) The process and format to be used in submitting prior
authorization requests; (c) How the provider will be notified of the MCO's
decision regarding prior authorization requests; and (d) The procedures to be followed in appealing the
MCO's denial of prior authorization requests. (C) An MCO must adopt practice guidelines and disseminate
the guidelines to all affected providers, and upon request to members and
pending members. These guidelines must: (1) Be based on valid and
reliable clinical evidence or a consensus of health care professionals in the
particular field; (2) Consider the needs of
the MCO's members; (3) Be adopted in
consultation with contracting health care professionals; and (4) Be reviewed and
updated periodically, as appropriate. (D) The MCE must have staff specifically responsible for
resolving individual provider issues, including, but not limited to, problems
with claims payment, prior authorizations and referrals. The MCE must provide
written information to their contracting providers detailing how to contact
these designated staff.
Last updated July 18, 2022 at 8:18 AM
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Rule 5160-26-06 | Managed care: program integrity - fraud, waste and abuse, audits, reporting, and record retention.
(A) A managed care entity (MCE) must have
administrative and management arrangements or procedures, including a mandatory
compliance plan, to guard against fraud, waste and abuse as required in the MCE
provider agreement or contract with the Ohio department of medicaid (ODM)
located at http://medicaid.ohio.gov/. (1) These arrangements or procedures must
be made available to ODM upon request. (2) The MCE must annually submit to ODM a
report that summarizes the MCE's fraud, waste, and abuse activities for
the previous year and identifies any proposed changes to the MCE's fraud,
waste, and abuse program for the coming year. (B) ODM or its designee, the state
auditor's office, the state attorney general's office, and the U.S.
department of health and human services may evaluate or audit the MCE's
performance for the purpose of determining compliance with the requirements of
Chapter 5160-26 of the Administrative Code, fraud, waste, and abuse statutes,
applicable state and federal regulations, or requirements under federal waiver
authority. (C) ODM or its designee may conduct
on-site audits and reviews as deemed necessary based on periodic analysis of
financial, utilization, provider network, and other information. (D) The MCE must submit required reports
and additional information, as requested by ODM, as related to its duties and
obligations and where needed to ensure operation in accordance with all state
and federal regulations or requirements. (E) If the MCE fails to submit any
ODM-requested materials, as specified in paragraph (D) of this rule, without
cause as determined by ODM, on or before the due date, ODM may impose any or
all of the sanctions listed in rule 5160-26-10 of the Administrative Code or
the MCE's provider agreement or contract with ODM. (F) Record retention. The MCE and its contracted providers and
subcontractors shall retain and safeguard all hard copy or electronic records
originated or prepared in connection with the MCE's performance of its
obligations under the MCO provider agreement or the SPBM contract, including
but not limited to working papers or information related to the preparation of
reports, medical records, progress notes, charges, journals, ledgers, and
fiscal reports, in accordance with applicable sections of the federal
regulations, the Revised Code, and the Administrative Code. Records stored
electronically must be produced at the MCE's expense, upon request, in the
format specified by state or federal authorities. As specified in 42 C.F.R.
438.3 (October 1, 2021), such records must be maintained for a minimum of ten
years from the renewal, amendment or termination date of the provider
agreement. In the event the MCE has been notified that state or federal
authorities have commenced an audit or investigation of the MCO provider
agreement or the SPBM contract, records must be maintained until such time as
the matter under audit or investigation has been resolved. For the initial
three years of the retention period, the MCE and its contracted providers and
subcontractors must store the records in a manner and place that provides
readily available access.
Last updated July 18, 2022 at 8:19 AM
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Rule 5160-26-08.3 | Managed care: member rights.
(A) A managed care entity (MCE) must
develop and implement written policies in accordance with 42 C.F.R. 438.100
(October 1, 2021), as applicable, to ensure each member has and is informed of
his or her right to: (1) Receive all services
the MCE is required to provide pursuant to the terms of the MCE provider
agreement or contract, as applicable, with the Ohio department of medicaid
(ODM). (2) Be treated with
respect and with due consideration for their dignity and privacy. (3) Be ensured of
confidential handling of information concerning their diagnoses, treatments,
prognoses, and medical and social history. (4) Be provided
information about their health. Such information should also be made available
to the individual legally authorized by the member to have such information or
the person to be notified in the event of an emergency when concern for a
member's health makes it inadvisable to give him/her such
information. (5) Be given the
opportunity to participate in decisions involving their health
care. (6) Receive information
on available treatment options and alternatives, presented in a manner
appropriate to the member's condition and ability to
understand. (7) Maintain auditory and
visual privacy during all health care examinations or treatment
visits. (8) Be free from any form
of restraint or seclusion used as a means of coercion, discipline, convenience,
or retaliation. (9) Request and receive a
copy of their medical records, and to be able to request that their medical
records be amended or corrected. (10) Be afforded the
opportunity to approve or refuse the release of information except when release
is required by law. (11) Be afforded the
opportunity to refuse treatment or therapy. Members who refuse treatment or
therapy will be counseled relative to the consequences of their decision and
documentation will be entered into the medical record accordingly. (12) Be afforded the
opportunity to file grievances, appeals, or state hearings pursuant to the
provisions of rule 5160-26-08.4 of the Administrative Code. (13) Be provided written
member information from the MCE: (a) At no cost to the member, (b) In the prevalent non-English languages of members specified
by ODM, and (c) In alternative formats and in an appropriate manner that
takes into consideration the special needs of members. (14) Receive necessary
oral interpretation and oral translation services at no cost. (15) Receive necessary
services of sign language assistance at no cost. (16) Be informed of
specific student practitioner roles and the right to refuse student
care. (17) Refuse to
participate in experimental research. (18) Formulate advance
directives and to file any complaints concerning noncompliance with advance
directives with the Ohio department of health. (19) Change primary care
providers (PCPs) no less often than monthly. The MCO must mail written
confirmation to the member of his or her new PCP selection prior to or on the
effective date of the change. (20) Appeal to or file
directly with the United States department of health and human services office
of civil rights any complaints of discrimination on the basis of race, color,
national origin, age or disability in the receipt of health
services. (21) Appeal to or file
directly with the ODM office of civil rights any complaints of discrimination
on the basis of race, color, religion, gender, gender identity, sexual
orientation, age, disability, national origin, military status, genetic
information, ancestry, health status or need for health services in the receipt
of health services. (22) Be free to exercise
their rights and to be assured that exercising their rights does not adversely
affect the way the MCE, the MCE's providers, or ODM treats the
member. (23) Be assured the MCE
must comply with all applicable federal and state laws and other laws regarding
privacy and confidentiality. (24) Choose his or her
health professional to the extent possible and appropriate. (25) For female members,
to obtain direct access to a woman's health specialist within the network
for covered care necessary to provide women's routine and preventive
health care services. This is in addition to a member's designated PCP if
the PCP is not a woman's health specialist. (26) Be provided a second
opinion from a qualified health care professional within the MCO's
network. If such a qualified health care professional is not available within
the MCO's network, the MCO must arrange for a second opinion outside the
network, at no cost to the member. (27) Receive information
on their MCE. (B) The MCE must advise members via the
member handbook of the member rights specified in paragraph (A) of this
rule.
Last updated September 1, 2023 at 1:09 PM
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Rule 5160-26-08.4 | Managed care: appeal and grievance system.
Effective:
January 1, 2023
(A) This rule does not apply to MyCare
Ohio plans as defined in rule 5160-58-01 of the Administrative
Code. (B) Notice of action (NOA) by a managed care organization (MCO)
or the single pharmacy benefit manager (SPBM). (1) When an adverse
benefit determination has occurred or will occur, the MCO or SPBM shall provide
the affected member with a NOA. (2) The language and
format of the NOA shall comply with the requirements listed in 42 CFR 438.10
(October 1, 2021), and the NOA shall explain: (a) The adverse benefit determination the MCO or SPBM has taken
or intends to take; (b) The reasons for the adverse benefit determination, including
the right of the member to be provided, upon request and free of charge,
reasonable access to copies of all documents, records, and other relevant
determination information; (c) The member's right to file an appeal to the MCO or
SPBM; (d) Information related to exhausting the MCO or SPBM appeal
process; (e) The member's right to request a state hearing through
the state's hearing system upon exhausting the MCO or SPBM appeal
process; (f) Procedures for exercising the member's rights to appeal
the adverse benefit determination; (g) Circumstances under which expedited resolution is available
and how to request it; (h) If applicable, the member's right to have benefits
continue pending the resolution of the appeal, how to request that benefits be
continued, and the circumstances under which the member may be required to pay
for the cost of these services; and (i) The date the notice is issued. (3) NOAs shall be issued
within the following time frames: (a) For a decision to deny or limit authorization of a requested
service the MCO or SPBM shall issue a NOA simultaneously with the MCO or
SPBM's decision. (b) For reduction, suspension, or termination of services prior
to the member receiving the services previously authorized by the MCO or SPBM,
the MCO or SPBM shall give notice at least fifteen calendar days before the
effective date of the adverse benefit determination except: (i) If probable recipient
fraud has been verified, the MCO or SPBM shall give notice five calendar days
before the effective date of the adverse benefit determination. (ii) Under the
circumstances set forth in 42 CFR 431.213 (October 1, 2021), the MCO or SPBM
shall give notice on or before the effective date of the adverse benefit
determination. (c) For denial of payment for a non-covered service, the MCO or
SPBM shall give notice simultaneously with the MCO or SPBM's determination
to deny the claim, in whole or part, for a service not covered by medicaid,
including a service determined through the MCO or SPBM's prior
authorization process as not medically necessary. (d) For untimely prior authorization, appeal, or grievance
resolution, the MCO or SPBM shall give notice simultaneously with the MCO or
SPBM becoming aware of the untimely resolution. Service authorization decisions
not reached within the time frames specified in rule 5160-26-03.1 of the
Administrative Code constitutes a denial and is thus considered to be an
adverse benefit determination. Notice shall be given on the date the
authorization decision time frame expires. (C) Grievances. (1) A member may file a
grievance with the MCO or SPBM orally or in writing at any time. An authorized
representative must have the member's written consent to file a grievance
on the member's behalf. (2) The MCO or SPBM shall acknowledge the
receipt of each grievance to the member filing the grievance. Oral
acknowledgment by the MCO or SPBM is acceptable. If the grievance is filed in
writing, written acknowledgment shall be made within three business days of
receipt of the grievance. (3) The MCO or SPBM shall review and
resolve all grievances as expeditiously as the member's health condition
requires. Grievance resolutions, including member notification, shall meet the
following time frames: (a) Within two business days of receipt if the grievance is
regarding access to services. (b) Within thirty calendar days of receipt for non claims-related
grievances except as specified in paragraph (C)(3)(a) of this
rule. (c) Within sixty calendar days of receipt for claims-related
grievances. (4) At a minimum, the MCO or SPBM shall
provide oral notification to the member of a grievance resolution. If the MCO
or SPBM is unable to speak directly with the member, or the resolution includes
information that must be confirmed in writing, the resolution shall be provided
in writing simultaneously with the MCO or SPBM's resolution. (5) If the MCO or SPBM's resolution
to a grievance is to uphold the denial, reduction, suspension, or termination
of a service or billing of a member due to the MCO or SPBM's denial of
payment for that service, the MCO or SPBM shall notify the member of his or her
right to request a state hearing as specified in paragraph (G) of this rule, if
the member has not previously been notified. (D) Standard appeals. (1) A member, a
member's authorized representative, or a provider may file an appeal
orally or in writing within sixty calendar days from the date that the NOA was
issued. An oral appeal filing must be followed with a written appeal. The MCO
or SPBM shall: (a) Immediately convert an oral appeal filing to a written appeal
on behalf of the member; and (b) Consider the date of the oral appeal filing as the filing
date. (2) Any provider acting
on the member's behalf shall have the member's written consent to
file an appeal. The MCO or SPBM shall begin processing the appeal upon receipt
of the written consent. (3) The MCO or SPBM shall
acknowledge receipt of each appeal to the member filing the appeal. At a
minimum, acknowledgment shall be made in the same manner the appeal was filed.
If an appeal is filed in writing, written acknowledgment shall be made by the
MCO or SPBM within three business days of receipt of the appeal. (4) The MCO or SPBM shall
provide the member reasonable opportunity to present evidence and allegations
of fact or law, in person as well as in writing, and inform the member of this
opportunity sufficiently in advance of the resolution time frame. Upon request,
the member and/or member's authorized representative shall be provided,
free of charge and sufficiently in advance of the resolution time frame, the
case file, including medical records, other documents and records, and any new
or additional evidence considered, relied upon or generated by the MCO or SPBM,
or at the direction of the MCO or SPBM, in connection with the appeal of the
adverse benefit determination. (5) The MCO or SPBM shall
consider the member, the member's authorized representative, or an estate
representative of a deceased member as parties to the appeal. (6) The MCO or SPBM shall
review and resolve each appeal as expeditiously as the member's health
condition requires, but the resolution time frame shall not exceed fifteen
calendar days from the receipt of the appeal unless the resolution time frame
is extended as outlined in paragraph (F) of this rule. (7) The MCO or SPBM shall
provide written notice of the appeal's resolution to the member, and to
the member's authorized representative if applicable. At a minimum, the
written notice shall include the resolution decision and date of the
resolution. (8) For appeal
resolutions not resolved wholly in the member's favor, the written notice
to the member shall also include the following information: (a) The right to request a state hearing through the state's
hearing system; (b) How to request a state hearing; and if
applicable: (i) The right to continue
to receive benefits pending a state hearing; (ii) How to request the
continuation of benefits; and (iii) If the adverse
benefit determination is upheld at the state hearing, the member may be liable
for the cost of any continued benefit. (c) Oral interpretation is available for any
language; (d) Written translation is available in prevalent non-English
languages as applicable; (e) Written alternative formats may be available as needed;
and (f) How to access interpretation and translation services as well
as alternative formats that can be provided by the MCO or SPBM. (9) For appeal
resolutions decided in favor of the member, the MCO or SPBM shall: (a) Authorize or provide the disputed services promptly and as
expeditiously as the member's health condition requires, but no later than
seventy-two hours from the appeal resolution date, if the services were not
furnished while the appeal was pending. (b) Pay for the disputed services if the member received the
services while the appeal was pending. (E) Expedited appeals. (1) The MCO and SPBM
shall establish and maintain an expedited review process to resolve appeals
when the member requests and the MCO or SPBM determines, or the provider
indicates in making the request on the member's behalf or supporting the
member's request, that the standard resolution time frame could seriously
jeopardize the member's life, physical or mental health or ability to
attain, maintain, or regain maximum function. (2) In utilizing an
expedited appeal process, the MCO and SPBM shall comply with the standard
appeal process specified in paragraph (D) of this rule, except the MCO and SPBM
shall: (a) Determine within one business day of the appeal request
whether to expedite the appeal resolution; (b) Make reasonable efforts to provide prompt oral notification
to the member of the decision to expedite or not expedite the appeal
resolution; (c) Inform the member of the limited time available for the
member to present evidence and allegations of fact or law in person or in
writing; (d) Resolve the appeal as expeditiously as the member's
health condition requires, but the resolution time frame shall not exceed
seventy-two hours from the date the MCO or SPBM received the appeal unless the
resolution time frame is extended as outlined in paragraph (F) of this
rule; (e) Make reasonable efforts to provide oral notice of the appeal
resolution in addition to the required written notification; and (f) Ensure punitive action is not taken against a provider who
requests an expedited resolution or supports a member's
appeal. (3) If the MCO or SPBM
denies a member's request for expedited resolution of an appeal, the MCO
or SPBM shall: (a) Transfer the appeal to the standard resolution time frame of
fifteen calendar days from the date the appeal was received unless the
resolution time frame is extended as outlined in paragraph (F) of this
rule; (b) Make reasonable efforts to provide the member prompt oral
notification of the decision not to expedite, and within two calendar days of
the receipt of the appeal, provide the member written notice of the reason for
the denial, including information that the member can grieve the
decision. (F) Grievance and appeal resolution extensions. (1) A member may request
the time frame for the MCO or SPBM to resolve a grievance or a standard or
expedited appeal be extended up to fourteen calendar days. (2) The MCO or SPBM may
request the time frame to resolve a grievance or a standard or expedited appeal
be extended up to fourteen calendar days. The following requirements
apply: (a) The MCO or SPBM shall seek such an extension from ODM prior
to the expiration of the standard or expedited appeal or grievance resolution
time frame; (b) The MCO or SPBM request shall be supported by documentation
of the need for additional information and that the extension is in the
member's best interest; and (c) If ODM approves the extension, the MCO or SPBM shall make
reasonable efforts to provide the member prompt oral notification of the
extension and, within two calendar days, provide the member written notice of
the reason for the extension and the date by which a decision shall be
made. (3) The MCO and SPBM
shall maintain documentation of any extension request. (G) Access to state's hearing system. (1) Except as set forth in paragraph
(G)(2) of this rule, and in accordance with 42 CFR 438.402 (October 1, 2021),
members may request a state hearing only after exhausting the MCO or
SPBM's appeal process. If the MCO or SPBM fails to adhere to the notice
and timing requirements for appeals set forth in this rule, the member is
deemed to have exhausted the appeal process and may request a state
hearing. (2) In accordance with rule 5160-20-01 of
the Administrative Code, members proposed for enrollment or currently enrolled
in the coordinated services program (CSP) are afforded state hearing rights in
accordance with division 5101:6 of the Administrative Code and are not subject
to the requirement of first appealing to the MCO. (3) When required by
paragraph (D)(8) of this rule, and in accordance with division 5101:6 of the
Administrative Code, the MCO or SPBM shall notify members, and any authorized
representatives on file with the MCO or SPBM, of the right to a state hearing
subject to the following requirements: (a) If an appeal resolution upholds the denial of a request for
the authorization of a service, in whole or in part, the MCO or SPBM shall
simultaneously issue the "Notice of Denial of Medical Services By Your
Managed Care Entity" (ODM 04043). (b) If an appeal resolution upholds the decision to reduce,
suspend, or terminate services prior to the member receiving the services as
previously authorized by the MCO or SPBM, the MCO or SPBM shall issue the
"Notice of Reduction, Suspension or Termination of Medical Services By
Your Managed Care Entity" (ODM 04066). (c) If the MCO or SPBM learns a member has been billed for
services received by the member due to the MCO or SPBM's denial of
payment, and the MCO or SPBM upholds the denial of payment, the MCO or SPBM
shall immediately issue the "Notice of Denial of Payment for Medical
Services By Your Managed Care Entity" (ODM 04046). (4) The member or
member's authorized representative may request a state hearing within
ninety calendar days from the date of an adverse appeal resolution by
contacting the ODJFS bureau of state hearings or local county department of job
and family services (CDJFS). (5) There are no state
hearing rights for a member terminated from the MCO pursuant to an
MCO-initiated membership termination in accordance with rule 5160-26-02.1 of
the Administrative Code. (6) Following the bureau
of state hearing's notification to the MCO or SPBM that a member has
requested a state hearing, the MCO or SPBM shall: (a) Complete the "Appeal Summary for Managed Care
Entity" (ODM 01959) with appropriate supporting attachments, and file it
with the bureau of state hearings at least three business days prior to the
scheduled hearing date. The appeal summary shall include all facts and
documents relevant to the issue, in accordance with rule 5160-26-03.1 of the
Administrative Code, and be sufficient to demonstrate the basis for the MCO or
SPBM's adverse benefit determination; (b) Send a copy of the completed ODM 01959 to the member and the
member's authorized representative, if applicable, the CDJFS, and the
designated ODM contact; and (c) If benefits were continued through the appeal process in
accordance with paragraph (H)(1) of this rule, continue or reinstate the
benefit(s) if the MCO or SPBM is notified that the member's state hearing
request was received within fifteen days from the date of the appeal
resolution. (7) The MCO or SPBM shall
participate in the state hearing, in person or by telephone, on the date
indicated on the "Notice to Appear for a Scheduled Hearing" (JFS
04002) sent by the bureau of state hearings. (8) The MCO or SPBM shall
comply with the state hearing decision provided via the "State Hearing
Decision" (JFS 04005). If the state hearing decision sustains the
member's appeal, the MCO or SPBM shall submit the information required by
the "Order of Compliance" (JFS 04068) to the bureau of state
hearings. The information, including applicable supporting documentation, is
due to the bureau of state hearings and the designated ODM contact by no later
than the compliance date specified in the hearing decision. If applicable, the
MCO or SPBM shall: (a) Authorize or provide the disputed services promptly and as
expeditiously as the member's health condition requires, but no later than
seventy-two hours from the date it receives notice reversing the adverse
benefit determination if services were not furnished while the appeal was
pending. (b) Pay for the disputed services if the member received the
services while the appeal was pending. (H) Continuation of benefits while an appeal or state hearing are
pending. (1) Unless a member
requests that previously authorized benefits not be continued, the MCO or SPBM
shall continue a member's benefits when all the following conditions are
met: (a) The member requests an appeal within fifteen days of the MCO
or SPBM issuing the NOA; (b) The appeal involves the termination, suspension, or reduction
of services prior to the member receiving the previously authorized
services; (c) The services were ordered by an authorized provider;
and (d) The authorization period has not expired. (2) If the MCO or SPBM
continues or reinstates the member's benefits while the appeal or state
hearing are pending, the benefits shall be continued until one of the following
occurs: (a) The member withdraws the appeal or the state hearing
request; (b) The member fails to request a state hearing within fifteen
days after the MCO or SPBM issues an adverse appeal resolution; or (c) The bureau of state hearings issues a state hearing decision
upholding the reduction, suspension or termination of services. (3) If the final
resolution of the appeal or state hearing upholds the MCO or SPBM's
original adverse benefit determination, at the discretion of ODM, the MCO or
SPBM may recover the cost of the services furnished to the member while the
appeal and/or state hearing was pending. (I) Additional provisions regarding appeals and
grievances. (1) The MCO and SPBM
shall give members all reasonable assistance filing a grievance, an appeal, or
a state hearing request including but not limited to: (a) Explaining the MCO or SPBM's process to be followed in
resolving the member's appeal or grievance; (b) Completing forms and taking other procedural steps as
outlined in this rule; and (c) Providing oral interpretation and oral translation services,
sign language assistance, and access to the appeals and grievance system
through a toll-free number with text telephone yoke (TTY) and interpreter
capability. (2) The MCO and SPBM
shall ensure the individuals who make decisions on appeals and grievances are
individuals who: (a) Were neither involved in any previous level of review or
decision-making nor a subordinate of any such individual; and (b) Are health care professionals who have the appropriate
clinical expertise in treating the member's condition or disease if
deciding any of the following: (i) An appeal of a denial
based on lack of medical necessity; (ii) A grievance
regarding the denial of an expedited resolution of an appeal; or (iii) An appeal or
grievance involving clinical issues. (3) In reaching an appeal resolution, the
MCO and SPBM shall take into account all comments, documents, records, and
other information submitted by the member or their authorized representative
without regard to whether such information was submitted or considered in the
initial adverse benefit determination.
Last updated January 3, 2023 at 9:23 AM
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Rule 5160-26-09.1 | Managed care: third party liability and recovery.
(A) Tort. (1) Pursuant to sections 5160.37 and
5160.38 of the Revised Code, the Ohio department of medicaid (ODM) maintains
all rights of recovery (tort) against the liability of any third party payer
(TPP) for the cost of medical services. (2) A managed care entity
(MCE) is prohibited from accepting any settlement, compromise, judgment, award,
or recovery of any action or claim by a member. (3) The MCE must notify ODM and/or its
designated entity within fourteen calendar days of all requests for the release
of financial and medical records to a member or the member's
representative pursuant to the filing of a tort action. Notification must be
made via the "Notification of Third Party (tort) Request For Release"
form (ODM 03245, rev. 7/2014) or a method determined by the ODM designated
entity, provided ODM approved the designated entity's method and notified
the MCE. (4) The MCE must submit a summary of
financial information to ODM and/or its designated entity within thirty
calendar days of receiving an original authorization to release a financial
claim statement letter from ODM pursuant to a tort action. The MCE must use the
"Tort Summary Statement" form (ODM 03246, rev. 7/2014) or a method
determined by the ODM designated entity, provided ODM has approved the
designated entity's method and notified the MCE. Upon request, the MCE
must provide ODM and/or its designated entity with true copies of medical
claims. (B) Fraud, waste, and abuse recovery. ODM assigns to the managed
care organization (MCO) its rights of recovery against any TPP for costs due to
provider fraud, waste, or abuse as defined in rule 5160-26-01 of the
Administrative Code related to each member during periods of enrollment in the
MCO. In instances when the MCO fails to properly report suspected fraud, waste,
or abuse, before the suspected fraud, waste, or abuse is identified by the
state of Ohio, any portion of the fraud, waste, or abuse recovered by the state
shall be retained by the state. (C) Coordination of benefits. (1) ODM assigns its right to third party
resources (coordination of benefits) to the MCO for services rendered to each
member during periods of enrollment. ODM reserves the right to identify,
pursue, and retain any recovery of third party resources assigned to the MCO
but not collected by the MCO after one year from date of claim
payment. (2) Except as specified in paragraph
(C)(3) of this rule, the MCE must act to provide coordination of benefits if a
member has third party resources available for the payment of medical expenses
for medically necessary medicaid-covered services. Such expenses will be paid
in accordance with this rule and sections 5160.37 and 5160.38 of the Revised
Code. (3) Children that have
been legally placed in the custody of an Ohio county public children's
services agency (PCSA) or related entity are excluded from third party
liability cooperation and are exempt from post-payment recovery unless it is
confirmed that the child will not be put at risk for doing so (e.g. medical
support order). (4) The MCE is the payer of last resort
when a member has third party resources available for payment of medical
expenses for medicaid-covered services, except: (a) The MCE pays after any TPP including medicare but
before: (i) Resources provided through the children with medical
handicaps program under sections 3701.021 to 3701.0210 of the Revised
Code. (ii) Resources that are exempt from primary payer status under
federal medicaid law, 42 U.S.C. 1396 (as in effect July 1, 2022). (iii) Resources provided through the state sponsored program
awarding reparations to victims of crime, as set forth in sections 2743.51 to
2743.72 of the Revised Code. (b) The MCO pays first for preventive pediatric services before
seeking reimbursement from any liable third party. (5) The MCE will take reasonable measures
to ascertain and verify any third party resources available to a member. When
the MCE denies a claim due to third party liability (TPL), the MCE must timely
share, on the explanation of payment sent to providers, available information
regarding the third party resources for the purposes of coordination of
benefits, including: (a) Insurance company name; (b) Insurance company billing address for claims; (c) Member's group number; (d) Member's policy number; and (e) Policy holder name. (6) The MCE must require providers who
are submitting TPL claims to the MCE to request information regarding third
party benefits from the member or his/her authorized representative. If the
member or the member's authorized representative specifies that the member
has no third party benefits, or the provider is unable to determine that the
member has third party benefits, the MCE must permit the provider to submit a
claim to the MCE. If, as a result of requesting the information, the provider
determines that third party liability exists, the MCE must allow the provider
to submit a claim for reimbursement if he/she first takes reasonable measures
to obtain third party payment as set forth in paragraph (C)(7) of this
rule. (7) The MCE must require providers to
take reasonable measures to obtain all third party payments and file claims
with all TPPs prior to billing the MCE. The MCE must permit providers who have
taken reasonable measures to obtain all third party payments, but who have not
received payment from a TPP or received partial payment, to submit a claim to
the MCE requesting reimbursement for rendered services. (a) The MCE must process claims when the provider has complied
with one or more of the following reasonable measures: (i) The provider first submits a claim to the TPP for the
rendered services and does not receive a remittance advice or other
communication from the TPP within ninety days after the submission date. The
MCE may require providers to document the claim and date of the claim
submission to the TPP. (ii) The provider has retained and/or submitted one of the
following types of documentation indicating a valid reason for non-payment for
the services not related to provider error: (a) Documentation from the TPP; (b) Documentation from the TPP's automated eligibility and
claim verification system; (c) Documentation from the TPP's member benefits reference
guide/manual; or (d) Any other documentation from the TPP showing there is no
third party benefit coverage for the rendered services. (iii) The provider submitted a claim to the TPP and received a
partial payment along with a remittance advice documenting the allocation of
the charges. (b) Valid reasons for non-payment from a TPP to the provider for
a third party benefit claim include, but are not limited to: (i) The service is not covered under the member's third
party benefits. (ii) The member does not have third party benefits through the TPP
for the date of service. (iii) All of the provider's billed charges or the TPP's
approved rate was applied, in whole or in part, to the member's third
party benefit deductible amount, coinsurance and/or co-payment for the TPP. The
provider may then submit a secondary claim to the MCE showing the appropriate
amount received from the TPP. (iv) The member has not
met any required waiting periods, or residency requirements for his/her third
party benefits, or was non-compliant with the TPP's requirements in order
to maintain coverage. (v) The member is a dependent of the individual with third party
benefits, but the benefits do not cover the individual's
dependents. (vi) The member has reached the lifetime benefit maximum for the
medical service or third party benefits being billed to the TPP. (vii) The TPP is disputing or contesting its liability to pay the
claim or cover the service. (8) If the provider receives payment from
the TPP after the MCE has made payment, the MCE must require the provider to
repay the MCE any amount overpaid by the MCE. The MCE must not allow the
provider to reimburse any overpaid amounts to the member. (9) The MCE must make available to
providers information on how to submit a claim that will have a zero paid
amount in the third party field on the claim. (10) The MCE payment for third party
claims will not exceed the MCE allowed amount for the service, less all third
party payments for the service. (11) The MCE's timely filing limits
for provider claims shall be at least ninety days from the date of the
remittance advice that indicates adjudication or adjustment of the third party
claim by the TPP. (12) The MCE must ensure that providers do
not hold liable or bill members in the event that the MCE cannot or will not
pay for covered services unless all of the specifications set forth in rule
5160-26-05 and rule 5160-26-11 of the Administrative Code are met. The provider
may not collect and/or bill the member for any difference between the
MCE's payment and the provider's charge or request the member to
share in the cost through a deductible, coinsurance, co-payment, or other
similar charge, other than MCE co-payments. (D) The MCE is required to submit
information regarding members with third party coverage as directed by
ODM.
Last updated October 15, 2024 at 2:28 PM
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Rule 5160-26-10 | Managed care: sanctions and provider agreement actions.
(A) This rule does not apply to the
single pharmacy benefit manager as defined in rule 5160-26-01 of the
Administrative Code. (B) If the MCO fails to fulfill its duties and obligations
under 42 C.F.R. Part 438 (October 1, 2021), 42 U.S.C. 1396b(m) (as in effect
July 1, 2022), 42 U.S.C. 1396u-2 (as in effect July 1, 2022), agency 5160 of
the Administrative Code, or the MCO provider agreement, ODM will provide timely
written notification to the MCO identifying the violations or deficiencies, and
may impose corrective actions or any of the following sanctions in addition to
or instead of any actions or sanctions specified in the provider
agreement: (1) ODM may require
corrective action plans (CAPs) in accordance with the following: (a) If requested by ODM, the MCO must submit, within the
specified time frame, a proposed CAP for each cited violation or
deficiency. (b) The CAP must contain the proposed correction date, describe
the manner in which each violation or deficiency will be resolved, and address
all items specified in the ODM notification. (c) The CAP must be reviewed and approved by ODM. (d) Following the approval of the CAP, ODM will monitor the
correction process until all violations or deficiencies are corrected to the
satisfaction of ODM. (e) If the MCO fails to submit an approvable CAP within the
ODM-specified time frames, ODM may impose an ODM-developed CAP, sanctions, or
both. (f) If ODM has already determined the specific action that must
be implemented by the MCO, ODM may require the MCO to comply with an
ODM-developed or directed CAP. (g) Failure by the MCO to successfully complete the correction
process and correct the violations or deficiencies to the satisfaction of ODM
may lead to the imposition of any or all of the sanctions listed in paragraph
(B)(2) of this rule. (2) Sanctions that may be
imposed on the MCO by ODM include but are not limited to the
following: (a) Suspension of the enrollment of the MCO's
members. (b) Disenrollment of the MCO's members. (c) Prohibition or reduction of the MCO's voluntary
assignments. (d) Prohibition or reduction of the MCO's involuntary
assignments. (e) Granting the MCO's members the right to terminate
without cause and notifying the affected members of their right to
disenroll. (f) Retention by ODM of the MCO's premium payments or a
portion thereof until the violations or deficiencies are
corrected. (g) Imposition of financial sanctions. (C) ODM will select sanction(s) specified in paragraph
(B)(2) of this rule based on a pattern of repeated violations or deficiencies,
the severity of the cited violations or deficiencies, the failure of the MCO to
meet the requirements of an approved CAP, or all these factors. (D) The sanctions in paragraph (B)(2) of this rule are
subject to reconsideration by ODM as specified in Chapter 5160-70 of the
Administrative Code, with the exception that the involuntary assignments
referenced in paragraph (B)(2)(d) of this rule are not subject to
reconsideration. (E) Regardless of any other sanction that may be imposed,
ODM may impose temporary management on any MCO that has repeatedly failed to
meet substantive requirements in 42 U.S.C. 1396b(m) (as in effect July 1,
2022), 42 U.S.C. 1396 u-2 (as in effect July 1, 2022) or 42 C.F.R. Part 438
subpart I (October 1, 2021). Such temporary management shall be imposed in
accordance with the following: (1) The MCO must pay the
costs of a temporary manager for performing the duties of a temporary manager
as determined by ODM. (2) The MCO is solely
responsible for any costs or liabilities incurred on behalf of the MCO when
temporary management is imposed by ODM. (3) The imposition of
temporary management is not subject to the appeals process provided under
Chapter 119. of the Revised Code; however, the MCO may request that the
director for the medicaid program reconsider this action. ODM will not delay
imposition of temporary management to provide reconsideration prior to imposing
this sanction. (4) Unless the director
for the medicaid program determines through the reconsideration process that
temporary management should not have been imposed, the temporary management
will remain in place until such time as ODM determines that the MCO can ensure
that the sanctioned behavior will not recur. (5) Regardless of the
imposition of temporary management, the MCO retains the right to appeal any
proposed termination or nonrenewal of its provider agreement under Chapter 119.
of the Revised Code. The MCO also retains the right to initiate the sale of the
MCO or its assets. (6) If temporary
management is imposed, ODM will notify the MCO's members that such action
has occurred and inform them that they therefore have the right to terminate
their membership in the MCO without cause. Termination of the MCO's
membership without cause is not subject to the appeals process provided under
Chapter 119. of the Revised Code; however, the MCO may request that the
director for the medicaid program reconsider this action. ODM will not delay
the notification to the MCO's membership to provide reconsideration prior
to imposing this sanction. (F) ODM will provide the MCO with written notice before
imposing any sanction. The notice will describe any reconsideration or appeal
rights that are available to the MCO. (G) Regardless of whether ODM imposes a sanction, the MCO
shall initiate corrective action for any MCO program violations or deficiencies
as soon as they are identified by either the MCO or ODM. (H) The following provisions apply in the event ODM decides
to terminate, nonrenew, deny, or amend the MCO provider agreement. (1) ODM may terminate,
nonrenew, deny, or amend the MCO provider agreement if at any time ODM
determines that continuation or assumption of a provider agreement is not in
the best interest of recipients or the state of Ohio. For the purposes of this
rule, an amendment to the MCO provider agreement is defined as, and limited to,
the elimination of one or more service areas included in the MCO's current
provider agreement. The phrase "not in the best interest" includes,
but is not limited to, the following: (a) The MCO's delivery system does not assure adequate
access to services for its members. (b) The MCO's delivery system does not assure the
availability of all services covered under the provider agreement. (c) The MCO fails to provide all medically-necessary covered
services. (d) The MCO fails to provide proper assurances of financial
solvency. (e) The number of members enrolled in the MCO's service area
is not sufficient to ensure the effective or efficient delivery of services to
members. (f) The MCO fails to comply with any of the
following: (i) Chapter 5160-26,
5160-58, or 5160-59 of the Administrative Code; (ii) The MCO provider
agreement; (iii) The applicable
requirements in 42 U.S.C. 1396b(m) (as in effect July 1, 2022) or 42 U.S.C.
1396u-2 (as in effect July 1, 2022); (iv) 42 C.F.R. Part 438
(October 1, 2021). (2) If ODM has proposed
termination, nonrenewal, denial, or amendment of the MCO's provider
agreement, ODM may notify the MCO's members of this proposed action and
inform the members of their right to immediately disenroll from the MCO without
cause. (3) If ODM determines
that the termination, nonrenewal, or denial of a provider agreement is
warranted: (a) ODM will provide notice, at a minimum, forty-five days prior
to the effective date of the proposed action; (b) The action will be in accordance with and subject to Chapter
5160-70 of the Administrative Code; and (c) The action will be effective at the end of the last day of a
calendar month. (4) If ODM determines
that the amendment of a provider agreement is warranted, the proposed action is
subject to reconsideration pursuant to Chapter 5160-70 of the Administrative
Code. (5) Notwithstanding the preceding
paragraphs of this rule, ODM may terminate the MCO's provider agreement
effective on the last day of the calendar month in which any of the following
occur: (a) The determination by ODM that the loss or reduction of
federal or state funding has reduced funding to a level which is insufficient
to maintain the activities or services agreed to in the provider
agreement; (b) The exclusion from participation of the MCO in a program
administered under Title XVIII, XIX, or XX of the Social Security Act due to
criminal conviction or the imposition of civil monetary penalties in accordance
with 42 C.F.R. Part 455 subpart B (October 1, 2021), 42 C.F.R. Part 1002
subpart A (October 1, 2021), and rule 5160-1-17.3 of the Administrative
Code; (c) The suspension, revocation, or nonrenewal of ODM's
authority to operate the program under the state plan or waivers of certain
federal regulations granted by CMS or congress; (d) The suspension, revocation, or nonrenewal of the MCO's
certificate of authority or license. (e) The exclusion of the MCO from participation in accordance
with 42 C.F.R. 438.808 (October 1, 2021). (6) If the MCO's provider agreement
is amended, terminated, denied, or nonrenewed for any reason including
procurement, the MCO is required to fulfill all duties and obligations under
agency 5160 of the Administrative Code, as applicable, and the MCO provider
agreement.
Last updated July 18, 2022 at 8:19 AM
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Rule 5160-26-11 | Managed care: managed care plan non-contracting providers.
(A) Non-contracting providers of emergency services must accept as payment in full from a managed care organization (MCO) the lesser of billed charges or one hundred per cent of the Ohio medicaid program reimbursement rate (less any payments for indirect costs of medical education and direct costs of graduate medical education that is included in the Ohio medicaid program reimbursement rate) in effect for the date of service. Pursuant to section 5167.101 of the Revised Code, the MCO shall not compensate a hospital for inpatient capital costs in an amount that exceeds the maximum rate established by ODM. (B) When ODM has approved the MCO's members to be referred to a non-contracting hospital pursuant to rule 5160-26-03 of the Administrative Code, the non-contracting hospital must provide the service for which the referral was authorized and must accept as payment in full from the MCO one hundred per cent of the current Ohio medicaid program reimbursement rate in effect for the date of service. Pursuant to section 5167.101 of the Revised Code, the MCO shall not compensate a hospital for inpatient capital costs in an amount that exceeds the maximum rate established by ODM. Non-contracting hospitals are exempted from this provision when: (1) The hospital is located in a county in which eligible individuals were required to enroll in an MCO prior to January 1, 2006; (2) The hospital is contracted with at least one MCO serving the eligible individuals specified in paragraph (B)(1) of this rule prior to January 1, 2006; and (3) The hospital remains contracted with at least one MCO serving eligible individuals who are required to enroll in an MCO in the service area where the hospital is located. (C) Non-contracting qualified family planning providers (QFPPs) must accept as payment in full from the MCO the lesser of one hundred per cent of the Ohio medicaid program reimbursement rate or billed charges, in effect for the date of service. (D) A managed care entity (MCE) non-contracting provider may not bill the MCE member unless: (1) The conditions described in rule 5160-1-13.1 of the Administrative Code are met; and (2) The reason the service is not covered by the MCE is specified and is one of the following: (a) The service is a benefit exclusion; (b) The provider is not contracted with the MCE and the MCE has denied approval for the provider to provide the service because the service is available from a contracted provider, at no cost to the member; or (c) The provider is not contracted with the MCE and has not requested approval to provide the service. (E) An MCE non-contracting provider may not bill a member for a missed appointment. (F) Non-contracting providers, including non-contracting providers of emergency services, must contact the twenty-four hour post-stabilization services phone line designated by the MCO to request authorization to provide post-stabilization services in accordance with rule 5160-26-03 of the Administrative Code. (G) Non-contracting providers, including non-contracting providers of emergency services, must allow the MCE, ODM, and ODM's designee access to all member medical records for a period not less than ten years from the date of service or until any audit initiated within the ten year period is completed. Access must include copies of the medical records at no cost for the purpose of activities related to the annual external quality review specified by 42 C.F.R. 438.358 (October 1, 2021). (H) If the MCE elects to impose member co-payments in accordance with rule 5160-26-12 of the Administrative Code, applicable co-payments shall also apply to services rendered by non-contracting providers. If the MCE has not elected to impose co-payments, non-contracting providers are not permitted to impose co-payments on MCE members.
Last updated September 1, 2023 at 1:10 PM
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Rule 5160-26-12 | Managed care: member co-payments.
Effective:
January 1, 2023
(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) The managed care organization (MCO) may elect to implement a
member co-payment program pursuant to section 5162.20 of the Revised Code for
dental services, vision services, or non-emergency emergency department
services or until implementation of the single pharmacy benefit manager (SPBM),
prescription drugs as provided for in this rule. The MCO must receive prior
approval from the Ohio department of medicaid (ODM) before notifying members
that a co-payment program will be implemented. (C) Upon implementation of the SPBM, the
SPBM may only elect to implement a member co-payment program pursuant to
section 5162.20 of the Revised Code for prescription drugs as provided for in
this rule if directed to by ODM. (D) If the MCO or SPBM implements a member co-payment program,
the MCO and SPBM must: (1) Exclude the
populations and services set forth in paragraph (E) of this rule; (2) Not deny services to
members as specified in paragraph (F) of this rule; (3) Not impose co-payment
amounts in excess of the maximum amounts specified in 42 C.F.R. 447.54 (October
1, 2021); (4) Specify in provider
contracts governed by rule 5160-26-05 of the Administrative Code the
circumstances under which member co-payment amounts can be requested. If the
MCO or SPBM implements a co-payment program, no provider can waive a
member's obligation to pay the provider a co-payment except as described
in paragraph (I) of this rule; (5) Ensure that the
member is not billed for any difference between the MCO or SPBM's payment
and the provider's charge or request that the member share in the cost
through co-payment or other similar charge, other than medicaid co-payments as
defined in this rule; (6) Ensure that member
co-payment amounts are requested by providers in accordance with this rule;
and (7) Ensure that no
provider or drug manufacturer, including the manufacturer's
representative, employee, independent contractor, or agent shall pay any
co-payment on behalf of the member. (E) Exclusions to the member co-payment program for dental,
vision, non-emergency emergency department services, and prescription
medications include the following: (1) Children. Members who
are under the age of twenty-one are excluded from medicaid co-payment
obligations. (2) Pregnant women. With
the exception of routine eye examinations and the dispensation of eyeglasses
during a member's pregnancy or post-partum period, all services provided
to pregnant women during their pregnancy and the post-partum period are
excluded from a medicaid co-payment obligation. The post-partum period is the
period that begins on the last day of pregnancy and extends through the end of
the month in which the twelve month period following termination of pregnancy
ends. (3) Institutionalized
members. Services or medications provided to members who reside in a nursing
facility (NF) or intermediate care facility for individuals with intellectual
disabilities (ICF/IID) are excluded from medicaid co-payment
obligations. (4) Emergency. An MCO
shall not impose a co-payment obligation for emergency services provided in a
hospital, clinic, office, or other facility that is equipped to furnish the
required care, after the sudden onset of a medical condition manifesting itself
by acute symptoms of sufficient severity (including severe pain) that the
absence of immediate medical attention could reasonably be expected to result
in placing the patient's health in serious jeopardy; serious impairment to
bodily functions; or serious dysfunction of any bodily part or
organ. (5) Family planning
(pregnancy prevention or contraceptive management). The MCO or SPBM shall not
impose a medicaid co-payment obligation on any service identified by ODM as a
pregnancy prevention/contraceptive management service in accordance with rules
5160-21-02 and 5160-1-09 of the Administrative Code and provided to an
individual of child-bearing age. (6) Hospice. Members
receiving services for hospice care are excluded from medicaid co-payment
obligation. (7) Medicare cross-over
claims. Medicare cross-over claims defined in accordance with rule 5160-1-05 of
the Administrative Code will not be subject to medicaid co-payment
obligations. (8) Medications
administered to a member during a medical encounter provided in a hospital,
clinic, office or other facility, when the medication is part of the evaluation
and treatment of the condition, are not subject to a member
co-payment. (F) No provider may deny services to a member who is eligible for
services due to the member's inability to pay the member co-payment.
Members who are unable to pay their member co-payment may declare their
inability to pay for services or medication and receive their services or
medications without paying their member co-payment amount. This provision does
not relieve the member from the obligation to pay a member co-payment or
prohibit the provider from attempting to collect an unpaid member co-payment.
If it is the routine business practice of the provider to refuse service to any
individual who owes an outstanding debt to the provider, the provider may
consider an unpaid medicaid co-payment as an outstanding debt and may refuse
service to a member who owes the provider an outstanding debt. If the provider
intends to refuse service to a member who owes the provider an outstanding
debt, the provider shall notify the individual of the provider's intent to
refuse services. In such situations, the MCO or SPBM must still ensure that the
member has access to needed services. (G) The MCO or SPBM may impose member co-payments as
follows: (1) For dental services,
the member co-payment amount may not exceed the amount set forth in Chapter
5160-5 of the Administrative Code. Services provided to a member on the same
date of service by the same provider are subject to only one
co-payment. (2) For non-emergency
emergency department services, the member co-payment amount must not exceed the
amount set forth in Chapter 5160-2 of the Administrative Code. For purposes of
this rule, the hospital provider shall determine if services rendered are
non-emergency emergency department services and will report, through claim
submission, the applicable co-payment to the MCO in accordance with medicaid
hospital billing instructions. (3) For vision services,
the member co-payment amounts must not exceed the amounts set forth in Chapter
5160-6 of the Administrative Code. (4) For pharmacy
services, the member co-payment amounts must not exceed the amounts set forth
in Chapter 5160-9 of the Administrative Code. (H) Prescriptions for medications are subject to the applicable
member co-payment for medications if they are given to a member during a
medical encounter provided in the emergency department or other hospital
setting, clinic, office, or other facility as a result of the evaluation and
treatment of the condition, regardless of whether they are filled at a pharmacy
located at the facility or at an outside location. (I) If the MCO has implemented a member co-payment program for
non-emergency emergency department services, as described in paragraph (G)(2)
of this rule, a hospital may take action to collect a co-payment by providing,
at the time services are rendered to a managed care member, notice that a
co-payment may be owed. If the hospital provides the notice and chooses not to
take further action to pursue collection of the co-payment, the prohibition
against waiving co-payments, as described in paragraph (D)(4) of this rule,
does not apply. (J) If the MCO or SPBM does not to impose a co-payment amount for
dental services, vision services, non-emergency emergency department services
or prescription drugs, and the MCO or SPBM reimburses contracting or
non-contracting providers for these services using the medicaid provider
reimbursement rate, the MCO or SPBM must not reduce its provider payments by
the applicable co-payment amount set forth in this rule.
Last updated January 3, 2023 at 9:25 AM
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Rule 5160-26-13 | Managed health care programs: claim billing for pharmaceuticals.
Effective:
October 1, 2022
Upon implementation of the Ohio department of
medicaid's (ODM) single pharmacy benefit manager (SPBM), ODM or its
designees will accept provider claim submissions for pharmaceuticals through
ODM's managed care entities (MCEs) in the following manner: (A) Claims for pharmaceuticals that are
dispensed by pharmacy providers are billed through ODM's
SPBM. (B) For all other provider types, claims
for pharmaceuticals are billed through an MCO, or in accordance with rule
5160-59-03 of the Administrative Code for individuals enrolled in the OhioRISE
plan, as applicable. (C) This rule does not apply to "MyCare Ohio"
plans as defined in rule 5160-58-01 of the Administrative Code.
Last updated October 3, 2022 at 8:44 AM
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