5160:1-2-16. Medicaid: pregnancy related services (PRS)

(A) The purpose of this rule is to outline the responsibilities of the administrative agency to inform medicaid-eligible pregnant women about the benefits and importance of pregnancy related services (PRS), to make requested or needed referrals to support services, and to provide non-medical services promoting healthy birth outcomes in accordance with 42 C.F.R. 440.210 (as in effect January 1, 2014).

(B) Definitions.

(1) "Individual" for the purpose of this rule, means a medicaid-eligible individual who is pregnant, as verified by either self-declaration or medical verification, including the sixty days post-partum period.

(2) ODM 03515 "Pregnancy Related Services Implementation Plan" (PRSIP) (rev.1/2015) means the document submitted by an administrative agency describing how it delivers PRS to pregnant women in its county and which entity is responsible for ensuring the delivery of PRS.

(3) "PRS coordinator" means the administrative agency employee who is responsible for the implementation of PRS.

(4) "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 will be coordinated with the individual's medicaid-contracting managed care plan (MCP), where applicable.

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

(1) Complete and sign the ODM 03528, "Healthchek and Pregnancy Related Services Information Sheet" (rev. 7/2014) to verify understanding of PRS and Healthchek services;

(2) Complete, sign, and return the ODM 03528 to identify her own and her children's need for services.

(D) Administrative agency responsibilities. The administrative agency shall:

(1) Inform individuals in its county about PRS within sixty days of the eligibility determination. Informing methods shall be written, oral or a combination of written and oral methods, as described below:

(a) Provide the ODM 03528, "Healthchek and Pregnancy Related Services Information Sheet" (rev. 7/2014).

(b) Provide information about:

(i) The benefits and importance of early and continual prenatal and postpartum care.

(ii) The services covered by PRS as described in Chapter 5160-4 of the Administrative Code.

(iii) The benefits of healthchek services as described in 5160:1-2-05 of the Administrative Code.

(iv) Transportation services and scheduling assistance available to individuals, if needed and upon request, in accordance with Chapter 5160-15 of the Administrative Code.

(v) Availability of transportation services through the individual's MCP. The transportation services shall be provided by the administrative agency if not available from the MCP.

(vi) Transportation services and scheduling assistance available to infants during the first year of life.

(vii) Medical and non-medical support services to include but not limited to:

(a) "The Help Me Grow" (HMG) program;

(b) The special supplemental food program for women, infants and children (WIC);

(c) Maternal and child health clinics;

(d) Local health departments;

(e) Social services and other community services.

(viii) Availability of assistance for scheduling medical appointments, as requested by the individual.

(ix) A list of medicaid prenatal care providers, if requested, available to the community and/or information about medicaid-contracting MCPs.

(2) Inform individuals enrolled in a MCP that they should contact the MCP for medical care options and referrals.

(3) Re-inform the individual of the benefits of healthchek services as soon as possible after the infant's birth.

(4) Refer the individual to support services as requested verbally, in writing, or via the ODM 03528 and ensure:

(a) Referrals are made, as needed, for medical and non-medical support services.

(b) Coordination between the individual, medical provider, MCP or other entity where the referral is made.

(c) Transportation assistance is provided to individuals, as requested.

(d) Individuals in need of non-medicaid covered medical services are referred to community, medical or other social services. This includes providers who have expressed a willingness to furnish non-medicaid covered services at little or no expense to the individual.

(5) Establish contact with the individual upon notification from the medical provider or MCP that the individual has missed appointments or there are other problems in the delivery of care and inform the individual's medical provider or MCP about the outcome of the contact.

(6) Provide a copy of the ODM 03528 (if applicable) and the ODM 03535 "Prenatal Risk Assessment Form" (if applicable) (rev. 7/2014) to the individual's MCP.

(7) Make a second attempt to contact the individual by alternate means if written information about PRS sent to the individual is returned as undeliverable.

(8) Submit a new or amended ODM 03515 "Pregnancy Related Services Implementation Plan" (rev. 1/2015) to Ohio department of medicaid (ODM), including but not limited to, when there has been a change of agency address, director, PRS coordinator or where the responsibility for PRS is organizationally located within the agency. The ODM 03515 shall be submitted to ODM within ten business days of the change.

(9) Obtain a HIPAA compliant signed authorization for release of information, ODM 03397 "Authorization for the Release or Use of Protected Health Information (PHI) or Other Confidential Information" (rev. 8/2014), when additional medical information is needed from the individual.

(10) Maintain a listing of fee-for-service providers who have expressed a willingness to furnish non-medicaid covered services at little or no expense to the individual. It is recognized that the ability of the administrative agency to recruit and maintain an adequate provider network depends on the existence of appropriate providers within a reasonable geographic area.

(11) Maintain documentation in a case file for each eligible individual. The file shall consist of permanent records, either hard copy or electronically stored, containing the following information, when appropriate:

(a) Copy of the ODM 03528, ODM 03535, or other referral forms received by the county;

(b) Copy of correspondence received and sent;

(c) Documentation of agency contacts with the individual, both attempted and established;

(d) Documentation of the MCP in which the individual is enrolled;

(e) Information received from another county when the individual is an intercounty transfer;

(f) Documentation of all service requests, steps taken by the administrative agency, and whether the individual received services; and

(g) Records of transportation services provided.

(E) Each administrative agency PRS coordinator, or such coordinator's designee(s), shall attend annual and other pertinent trainings offered by ODM. Verification of attendance shall consist of documentation of roll call and sending an evaluation form to the state email box within three days of the video conference or training. Verification of attendance at onsite training shall be documented by the PRS coordinator or such coordinator's designee(s) by signing the attendance log.

Replaces: 5160:1-2-06

Effective: 1/15/2015
Five Year Review (FYR) Dates: 01/15/2020
Promulgated Under: 111.15
Statutory Authority: 5160.02
Rule Amplifies: 5160.02 , 5164.26
Prior Effective Dates: 4/1/88 (Emer.), 6/30/88, 10/1/88 (Emer.), 12/20/88, 4/1/91, 2/1/92, 5/1/93, 10/1/98, 5/1/02, 10/6/03, 10/15/05