5160-26-02. Managed health care program: eligibility and enrollment

(A) This rule does not apply to "MyCare Ohio" plans as defined in rule 5160-58-01 of the Administrative Code. The eligibility and enrollment provisions for "MyCare Ohio" plans are described in rule 5160-58-02 of the Administrative Code.

(B) Eligibility for managed care plan (MCP) 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, 2018), an individual must be enrolled in an MCP if he or she has been determined medicaid eligible in accordance with division 5160:1 of the Administrative Code.

(2) MCP enrollment is mandatory for the following individuals:

(a) Children receiving Title IV-E federal foster care maintenance;

(b) Children receiving Title IV-E adoption assistance:

(c) Children in foster care or other out-of-home placement ; and

(d) Children receiving services through the Ohio department of health's bureau for children with medical handicaps (BCMH) or any other family-centered, community-based, coordinated care system that receives grant funds under Section 501(a)(1)(D) of Title V of the Social Security Act, 42 U.S.C. 701(a)(1)(D) (as in effect January 1, 2019) and is defined by the state in terms of either program participation or special health care needs.

(3) Medicaid eligible individuals may voluntarily choose to enroll in an MCP 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 5123:2-8-01 of the Administrative Code and receive services through a 1915(c) home and community based services (HCBS) waiver administered by the Ohio department of developmental disabilities (DODD).

(4) Except for individuals receiving medicaid in the adult extension category under section 1902(a)(10)(A)(i)(VIII) of the Social Security Act 42 U.S.C. 1396a(a) (10)(A)(i) (VIII) (as in effect January 1, 2019) and individuals who meet criteria in paragraph (B)(3)(b) of this rule, medicaid eligible individuals described in paragraph (B)(1) of this rule are excluded from MCP enrollment if they meet any of the following criteria:

(a) Residing in a nursing facility; or

(b) Receiving medicaid services through a medicaid waiver component, as defined in section 5166.02 of the Revised Code.

(5) The following individuals are excluded from MCP enrollment.

(a) Inmates of public institutions as defined in 42 C.F.R. 435.1010 (October 1, 2018) unless otherwise specified by the Ohio department of medicaid (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); and

(d) Individuals enrolled in the program of all-inclusive care for the elderly (PACE).

(6) Nothing in this rule shall be construed to limit or in any way jeopardize an eligible individual's basic medicaid eligibility or eligibility for other non-medicaid benefits to which he or she may be entitled.

(C) Enrollment in an MCP.

(1) The following applies to enrollment in an MCP:

(a) The MCP 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 MCP will not use any discriminatory policy or practice in accordance with 42 C.F.R. 438.3(d) (October 1, 2018).

(b) The MCP must accept eligible individuals who request MCP enrollment without restriction.

(c) If an MCP member loses managed care eligibility and is disenrolled from the MCP, and subsequently regains eligibility, his or her enrollment in the same MCP may be reinstated back to the date eligibility was regained in accordance with procedures established by ODM.

(d) ODM shall confirm the eligible individual's MCP 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.

(e) The MCP shall not be required to provide coverage until MCP enrollment is confirmed via the ODM-produced HIPAA compliant 834 daily or monthly enrollment files except as provided in paragraph (C)(2) of this rule or upon mutual agreement between ODM and the MCP.

(2) Newborn notification and enrollment.

(a) The MCP must notify ODM's designee, as directed by ODM, of the birth of any newborn whose mother is enrolled in an MCP.

(b) Infants born to mothers enrolled in an MCP are enrolled in an MCP 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 MCP is notified of the child's disenrollment via the ODM-produced HIPAA compliant 834 daily or monthly enrollment files.

(D) Commencement of coverage.

(1) Coverage of MCP 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 MCP, except as specified in paragraph (C)(2) of this rule.

(2) When an eligible individual is admitted to an inpatient facility prior to the effective date of MCP enrollment and remains in an inpatient facility on the enrollment effective date, the following responsibilities apply:

(a) The admitting medicaid payer, either fee-for-service or the admitting MCP, is responsible for all inpatient facility charges, pursuant to rule 5160-2-07.11 of the Administrative Code, through the date of discharge.

(b) The enrolling MCP is responsible for all other medically necessary medicaid covered services including professional services related to the inpatient stay, beginning on the enrollment effective date.

Effective: 2/14/2019
Five Year Review (FYR) Dates: 8/1/2021
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5164.02, 5167.03, 5167.10
Prior Effective Dates: 04/01/1985, 02/15/1989 (Emer.), 05/18/1989, 05/01/1992, 05/01/1993, 11/01/1994, 07/01/1996, 07/01/1997 (Emer.), 09/27/1997, 12/10/1999, 07/01/2000, 07/01/2001, 07/01/2002, 07/01/2003, 07/01/2004, 10/31/2005, 06/01/2006, 01/01/2007, 07/01/2007, 01/01/2008, 08/26/2008 (Emer.), 10/09/2008, 07/01/2009, 08/01/2011, 07/01/2013, 04/01/2015, 08/01/2016, 07/01/2017, 01/01/2018, 07/01/2018