5160:1-2-15. Medicaid: healthchek (early and periodic screening, diagnostic and treatment services)

(A) The purpose of this rule is to explain the requirements of healthchek, Ohio's early and periodic screening, diagnostic and treatment (EPSDT) benefit that all medicaid eligible individuals under twenty-one years of age are entitled to receive. A separate healthchek application is not required. Each county department of job and family services (CDJFS) is required to have a healthchek coordinator.

(B) Definitions. For the purposes of this rule, the following terms have the following meanings:

(1) "Healthchek" is Ohio's early and periodic screening, diagnostic and treatment benefit for all medicaid eligible individuals under twenty-one years of age.

(2) "Healthchek coordinator" is the CDJFS employee who is responsible for the implementation of healthchek services.

(3) "Healthchek services" are periodic screening services (including a comprehensive medical exam, vision, dental, and hearing screenings) and such other necessary health care, diagnostic services, treatment, and other measures described in 42 U.S.C. section 1396d(a) (as in effect 03-06-2016) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the state plan. Healthchek services are identical to "EPSDT services" as defined at 42 U.S.C. section 1396d(r) (as in effect 03/06/2016).

(4) "Healthchek Services Implementation Plan" (HSIP), ODM 03517, (rev.07/2016) means the document submitted by a CDJFS describing how it delivers healthchek services to individuals in its county and who in the agency is responsible for ensuring the delivery of healthchek services.

(5) "Individual" means, for purposes of this rule, a person under age twenty-one eligible for medicaid.

(6) "Medically necessary," otherwise known as "medical necessity," as used in this chapter is the same as defined in paragraph (A) of rule 5160-1-01 of the Administrative Code.

(7) "Prior authorization" for a member of a medicaid managed care plan (MCP) is the process outlined in rule 5160-26-03.1 of the Administrative Code. For all other individuals, prior authorization is the process outlined in rule 5160-1-31 of the Administrative Code.

(8) "Support services" are non-medical services offered or provided by the administrative agency to assist the individual and may include arranging or providing transportation, making medical appointments, accompanying the individual to medical appointments, and making referrals to community and other social services. Support services shall be coordinated with the individual's medicaid-contracting MCP, where applicable.

(C) The individual (or the individual's parent, guardian or legal custodian, as applicable) may:

(1) Complete and sign the ODM 03528, "Healthchek and Pregnancy Related Services Information Sheet" (rev. 7/2016) to verify receipt and understanding of information about healthchek;

(2) Complete, sign, and return the ODM 03528 to identify service needs;

(3) Request and attend scheduled appointments for healthchek services.

(D) CDJFS responsibilities. Each CDJFS shall:

(1) Inform. Each CDJFS shall use a combination of written and oral methods (including telephone calls, office visits, or home visits) to inform individuals (or such individuals' parents, guardians or legal custodians, as applicable) in its county about healthchek within sixty days of the eligibility determination and at least once each year thereafter. Appropriate oral and written informing methods are described in this rule.

(a) Written informing.

(i) Each CDJFS shall ensure that each individual (or such individual's parent, guardian or legal custodian, as applicable) in its county receives the ODM 03528 within sixty days after the individual is determined eligible for medicaid and at least once each year thereafter.

(ii) Each CDJFS shall document that each individual (or such individual's parent, guardian or legal custodian, as applicable) in its county has received the ODM 03528.

(iii) If written healthchek information is sent to an individual (or such individual's parent, guardian or legal custodian, as applicable) and returned as undeliverable, the CDJFS shall make a second attempt to contact the individual by alternate means. All attempts to contact an individual (or such individual's parent, guardian, or legal custodian, as applicable) shall be documented in the electronic information system.

(iv) Upon completion of the ODM 03528, the individual (or such individual's parent, guardian or legal custodian, as applicable) will be asked to sign the ODM 03528 to acknowledge receipt of healthchek information and to verify understanding of the healthchek services available. If the individual (or such individual's parent, guardian or legal custodian, as applicable) needs additional information in order to understand healthchek services, the CDJFS shall immediately provide the necessary information.

(v) Each CDJFS shall enter data regarding individuals into the electronic information system, as directed by ODM. Such information shall include information from the completed ODM 03528, record of contacts with individuals and any requests and referrals made or services provided.

(vi) Each entity that distributes or accepts applications for medicaid shall prominently display a notice that complies with the methods of providing information about healthcheck as established by section 5164.26 of the Revised Code.

(vii) ODM may develop additional written materials containing information about healthchek. Each CDJFS shall distribute such written materials, as directed by ODM. Any written materials developed by a CDJFS to inform individuals about healthchek shall be submitted to ODM for review and approval.

(b) Oral informing. Each CDJFS shall ensure that each individual (or such individual's parents, guardians, or legal custodians, as applicable), who has a face-to-face meeting or telephone call with CDJFS staff to apply for medicaid, is orally informed about healthchek using clear and non-technical language about the following:

(i) The benefits of preventive health care, including:

(a) Increased well-being;

(b) Reduced risk to the individual's health;

(c) Identification and treatment of health problems early to reduce the possibility of increase in severity and cost of treatment; and

(d) Education of the family to allow for optimal health.

(ii) The services covered by healthchek.

(iii) Where and how to obtain healthchek services.

(iv) That services covered by healthchek are without cost to individuals.

(v) The individual's ability to request and schedule dental, vision, and hearing services separately from the healthchek screening visit.

(vi) The availability of medically necessary diagnostic and follow-up treatment services, including referrals, for problems discovered during the healthchek screening service.

(vii) The prior authorization process, including that:

(a) The process, whether fee-for-service or managed care, must be started by the individual's medicaid provider;

(b) The prior authorization requirement for some services, products, or procedures applies even when the individual is under twenty-one years of age;

(c) The prior authorization process may enable individuals under twenty-one years of age to receive services not available to adults, including services that are limited in number for adults; and

(d) Certain services require prior authorization, which must be requested by a provider and approved by the Ohio department of medicaid before the service is provided.

(viii) The CDJFS must explain necessary transportation and scheduling assistance is available to individuals under twenty-one years of age, upon request, in accordance with Chapter 5160-15 of the Administrative Code, and the following:

(a) Transportation will be provided to any medicaid reimbursable service;

(b) How to request transportation and the timeframes for requesting transportation;

(c) Verification requirements, if any; and

(d) For an individual who is a member of an MCP, transportation is also available through the individual's MCP.

(c) Each CDJFS shall use appropriate methods to inform individuals who are blind, deaf, or who cannot read or understand the English language (or such individuals' parents, guardians, or legal custodians, as applicable) about healthchek. Information provided to individuals who are blind, deaf, or who cannot read or understand the English language shall meet the requirements of paragraphs (C)(1) and (C)(2) of this rule.

(d) Informing pregnant women. An ODM 03528 shall be used to document the informing of pregnant women about healthchek services as outlined in rule 5160:1-02-16 of the Administrative Code. The ODM 03528 shall be used to document informing again upon the birth of the infant.

(e) The CDJFS shall use electronic means to track pregnant women and the births of their infants to accomplish the following:

(i) Identify newborns and the infant's parent, guardian, legal custodian, as applicable;

(ii) Ensure that any infant born to a medicaid eligible woman is added to the medicaid case, in accordance with rule 5160:1-4-02.2 of the Administrative Code;

(iii) Inform the infant's parent, guardian, legal custodian, as applicable, of healthchek services within sixty days of the infant's birth;

(iv) Contact the infant's parent, guardian, legal custodian, as applicable, to assist in securing an ongoing primary care provider for the newborn;

(v) Coordinate the activity in paragraphs (C)(1) to (C)(3) of this rule with the individual's MCP, other agencies, and programs where applicable.

(2) Provide support services.

(a) The CDJFS shall refer the individual (or the individual's parent, guardian, or legal custodian, as applicable) to entities listed on the ODM 03528 and/or other community supportive services as requested. The CDJFS will ensure:

(i) That referrals are made, as needed, for both medical and other services such as help me grow (HMG); women, infants and children (WIC); maternal and child health clinics; local health departments; head start (HS); child care; clothing and/or other community social services, where applicable.

(ii) Coordination between the individual and the entity where the referral is made.

(iii) Coordination between the individual and the individual's MCP by forwarding a copy of the ODM 03528 to the individual's MCP, if applicable.

(iv) The individual enrolled in a MCP (or the individual's parent, guardian or legal custodian, as applicable) is advised to contact the individual's MCP for medical care options and/or referrals.

(v) Assistance is provided with scheduling medical appointments as requested by the individual or the individual's parent, guardian or legal custodian, as applicable.

(vi) Requests for support services available in the individual's county of residence received by the individual's MCP and forwarded to the CDJFS are acted upon and the requested service(s) provided.

(b) The CDJFS shall provide individuals with necessary assistance in obtaining transportation to medicaid reimbursable services as requested by the individual or the individual's parent, guardian or legal custodian, as applicable.

(c) Each individual in a household who requests or is in need of non-medicaid covered medical services as indicated on the ODM 03528 or through other verbal or written communication shall be referred by the CDJFS to community, medical or other social services, as needed, including providers who have expressed a willingness to furnish non-medicaid covered services at little or no expense to the family. Community and medical service requests will be documented and forwarded to the appropriate community provider, medical provider and/or MCP.

(d) Elevated blood lead level services for assisting families of individuals identified as having elevated blood lead levels when notified by the family, provider or the county or city department of health shall be provided by the CDJFS and include:

(i) Referral of the individual to the Ohio department of health (ODH) for an environmental assessment.

(ii) Verification of the individual's medicaid eligibility at the time the environmental assessment is conducted and the ODH agent is informed of such eligibility. Verification shall only be provided upon receipt of proper verification of the identity of the ODH agent who is requesting the information.

(iii) Education of the family about the purpose of the environmental assessment by:

(a) Informing the family of the need to remove the source of lead or removing the individual from the contaminated environment;

(b) Explaining the family's responsibility to inform the health department staff who conduct the environmental assessment of places the individual visits regularly;

(c) Assisting the family with securing lead-free housing by making any necessary referrals if the source of lead cannot or will not be removed from the environment.

(iv) The CDJFS is responsible for maintaining records of environmental assessment recommendations made by the ODH and any action taken as a result of those recommendations. If, as a result of CDJFS efforts, the family relocates, the CDJFS must inform the ODH of the family's new address.

(v) In geographic areas with Ohio childhood lead poisoning prevention regional resource centers or local arrangements for environmental assessments and follow-up, the requirements of those programs supersede this rule.

(3) CDJFS healthchek services implementation plan (HSIP) ODM 03517 (rev. 07/2016). Each CDJFS is required to have a healthchek services implementation plan on file with ODM. The plan shall be signed by the agency director or his designee.

(a) The CDJFS shall provide a description in the HSIP of the electronic and/or hard-copy methods for ensuring permanent records and documentation are maintained in a case file for each individual. The case file shall contain the following information, when appropriate:

(i) Copy of the ODM 03528;

(ii) Copies of all correspondence received and sent;

(iii) Documentation of attempted and successful contacts with the individual (or such individual's parent, guardian or legal custodian, as applicable);

(iv) Documentation of the MCP in which individuals are enrolled, if applicable;

(v) Documentation of contacts with or forms provided by the medical provider;

(vi) Information received from other counties when an individual's case is an inter-county transfer;

(vii) Documentation of support services requested and/or provided and referrals made on an individual's behalf, and the CDJFS' efforts to fulfill the referrals and/or requests. At a minimum the documentation shall contain:

(a) Steps taken by the CDJFS to assure the requested support services are provided, and whether or not the individual received the requested support services;

(b) A copy of all documentation of services requested by an individual (or such individual's parent, guardian or legal custodian, as applicable) and provided or facilitated by the CDJFS;

(c) Records of transportation requested and provided; and

(d) Any communication from or forms provided by the medical provider.

(b) The CDJFS shall identify, if applicable, any services or functions required in this rule which are contracted out to other entities. A copy of the contract shall be provided to ODM. The CDJFS shall also describe accountability and monitoring measures, along with timeframes when monitoring takes place to ensure the contracted entities are achieving all required functions and that these functions are in accordance with applicable state and federal rules.

(c) The CDJFS shall submit a new or amended HSIP to ODM, including but not limited to, when there has been a change of agency address, director, Healthchek coordinator or where the responsibility for healthchek is organizationally located within the agency. The HSIP shall be submitted to ODM within ten business days of the change.

(4) Release of information. The CDJFS shall, if necessary, obtain a HIPAA-compliant signed authorization for release of information, form ODM 03397 "Authorization for the Release or Use of Protected Health Information (PHI)" (rev. 02/2016), if and when the CDJFS needs additional medical information from the individual or the individual's provider.

(5) Provider recruitment. The CDJFS is required to take steps to recruit and maintain a network of fee-for-service providers of medical, dental, vision, and hearing services that is adequate to meet the screening and treatment needs of the healthchek individuals. The CDJFS may make use of a variety of methods including personal visits, telephone calls, and letters to recruit providers.

(6) Training. Each CDJFS' healthchek coordinator, or such coordinator's designee(s), shall attend available healthchek training offered by ODM. For video conference or other training delivered electronically, verification of attendance shall consist of documenting the county's presence during roll call and submission of an evaluation form to the appropriate state monitored e-mail box within three days of the training. Verification of attendance at an on site training shall be documented by the healthchek coordinator, or such coordinator's designee, signing the attendance log.

Replaces: 5160:1-2-05

Effective: 9/12/2016
Five Year Review (FYR) Dates: 09/12/2021
Promulgated Under: 111.15
Statutory Authority: 5162.03
Rule Amplifies: 5162.03 , 5164.26
Prior Effective Dates: 1/14/83, 3/20/83, 3/21/83, 11/1/85 (Emer), 1/1/86, 1/29/86 (Emer), 1/31/86, 4/1/86 (Emer), 1/1/87, 3/20/87, 9/28/87 (Emer), 12/23/87 (Emer), 3/15/88, 7/1/88 (Emer), 9/1/88, 1/1/89, 10/1/90, 7/1/92, 9/1/93, 6/1/97, 3/18/99 (Emer), 6/17/99, 4/1/01, 12/1/01, 9/19/05, 3/1/06, 10/1/09, 12/31/10, 2/14/11