5160-26-08.4 Managed health care programs: MCP grievance system.

 

 

 

 

PUBLIC HEARING NOTICE OHIO DEPARTMENT OF MEDICAID

 

DATE:                       December 1, 2014

 

TIME:                        10:30 A.M.

 

LOCATION:               Room A401, Lazarus Building

50 W. Town Street, Columbus, Ohio 43215

 

 

 

Pursuant to Section 5167.02 and Chapter 119. of the Ohio Revised Code (ORC), the director of the Ohio Department of Medicaid gives notice of the office's intent to consider the amendment or rescission of the rules identified below and of a public hearing thereon.

 

Rule 5160-26-01, entitled Managed health care programs: definitions, is being proposed for amendment due to five year rule review. The rule sets forth definitions related to the administration of the Medicaid managed care program and managed care plans (MCPs). Changes to the rule add definitions for subcontractor and authorized representative, and update the definitions of Medicaid consumer hotline, intermediate care facility, nursing facility, Ohio Department of Medicaid, oral interpretation services, oral translation services, program of all-inclusive care, primary care provider and subcontract. Other amendments to the rule delete references to automatic termination, corrective action plan, case, external quality review organization, quality assessment and performance improvement program, and termination. Additional amendments to the rule update legal citations and cross-references.

Rule 5160-26-02, entitled Managed health care programs: eligibility, membership, and automatic renewal of membership is being proposed for amendment due to five year rule review. The rule describes the managed care enrollment process and the categories of individuals who are eligible for enrollment in MCPs. Changes to the rule add modified adjusted gross income (MAGI)-based Medicaid eligibles to the list of groups eligible for Medicaid managed care. (MAGI)-based eligibility applies to the Covered Families and Children eligibility category. Other amendments to the rule clarify that this rule does not apply to MyCare Ohio plans, clarify the managed care mandatory and voluntary enrollment criteria, and update language regarding the coverage of newborns. Additional amendments to the rule update legal citations and cross-references.

 

Rule 5160-26-04, entitled Managed health care programs: procurement and plan selection, is being proposed for rescission due to five year rule review. The rule sets forth the process for procurement and for selection of MCPs.

 

Rule 5160-26-06, entitled Managed health care programs: program integrity - fraud and abuse, audits, reporting and record retention, is being proposed for amendment due to

 

 

 

 

 

five year rule review. The rule sets forth provisions for Medicaid MCP program integrity, including specific requirements on MCPs to guard against fraud and abuse, audits, the submission of reports, and record retention. Changes to the rule clarify language for the annual fraud and abuse report and record retention requirements. Additional amendments to the rule update legal citations and cross-references.

Rule 5160-26-07, entitled Managed health care programs: annual external quality review, is being proposed for rescission to update policy relating to administration of the Medicaid program. The rule describes the federal requirement requiring states to complete external quality reviews for MCPs.

Rule 5160-26-07.1, entitled Managed health care programs: Quality assessment and performance improvement program (QAPI), is being proposed for rescission due to five year rule review. The rule sets forth the federal quality assessment and performance improvement program (QAPI) requirements for MCPs.

Rule 5160-26-08, entitled Managed health care programs: marketing, is being proposed for amendment due to five year rule review. The rule sets forth marketing requirements for MCPs. Changes to the rule clarify language regarding marketing activities and materials. Additional amendments to the rule update legal citations and cross-references.

Rule 5160-26-08.1, entitled Managed health care programs: information and enrollment services, is being proposed for rescission due to five year rule review. The rule describes contracts with enrollment services entities for Medicaid managed care.

Rule 5160-26-08.2, entitled Managed health care programs: member services, is being proposed for amendment due to five year rule review. The rule sets forth requirements for MCPs regarding services and materials. Changes to the rule clarify language regarding member services and member materials that MCPs must provide to its members.

Additional amendments to the rule update legal citations and cross-references.

Rule 5160-26-08.3, entitled Managed health care programs: member rights, is being proposed for amendment to update policy relating to the administration of the Medicaid program. The rule sets forth requirements regarding the rights of members in MCPs.

Changes to this rule modify language regarding the MCP members' ability to participate in their health care decisions. Additional amendments to the rule update legal citations and cross-references.

Rule 5160-26-08.4, entitled Managed health care programs: MCP grievance system is being proposed for amendment due to five year rule review. The rule sets forth requirements for the MCP grievances and appeals and describes three avenues allowing a member to challenge certain actions taken by the MCP: (1) a grievance process, (2) an appeal to the MCP, and (3) a process allowing members to access the State's hearing system through the Ohio Department of Job and Family Services (ODJFS). Changes to the rule update and reorganize language regarding the obligations of the MCPs with respect to the grievance and appeals process and the processes for members to access the three avenues available to them. Additional amendments to the rule clarify that this rule does not apply to MyCare Ohio plans, and update legal citations and cross-references.

Rule 5160-26-08.5, entitled Managed health care programs: responsibilities for state hearings is being proposed for rescission due to five year rule review. The rule sets forth the obligations of the MCPs regarding compliance with state hearing decisions. The contents of the rescinded rule have been moved to OAC rule 5160-26-08.4.

Rule 5160-26-09, entitled Managed health care programs: reimbursement and financial responsibility is being proposed for amendment due to five year rule review. The rule describes ODM's payments to MCPs and the obligations of the MCPs with respect to financial reporting and reinsurance. Changes to the rule update language regarding the frequency of actuarial review and MCPs' responsibilities for cost reports and reinsurance requirements. Additional amendments to the rule update legal citations and cross- references.

Rule 5160-26-11, entitled Managed health care programs: managed care plan non- contracting providers, is being proposed for amendment to update policy relating to the administration of the Medicaid program. The rule sets forth requirements for providers that do not contract with Medicaid MCPs. Changes to the rule add clarifying language from state law which specifies that the compensation for inpatient hospital capital costs for emergency services provided by non-contracting hospitals shall not exceed the maximum amount established by the department. Other amendments clarify the activities related to external quality reviews and update the timeframe for record retention by non- contracting providers, consistent with the provisions of OAC rule 5160-26-06. Additional amendments to the rule update legal citations and cross-references.

Rule 5160-26-12, entitled Managed health care programs: member co-payments, is being proposed for amendment to update policy relating to the administration of the Medicaid program. The rule sets forth requirements for MCPs when they elect to implement a co- payment program. Changes to the rule simplify and clarify language regarding co- payments and update legal citations and cross-references.

A copy of the proposed rules is available, without charge, to any person affected by the rules, at the address listed below. The rules are also available on the internet at  http://www.registerofohio.state.oh.us/. A public hearing on the proposed rules will be held at the date, time, and location listed at the top of this notice. Both written and oral testimony will be taken at the public hearing. Written testimony submitted or postmarked no later than the date of the public hearing will be treated as testimony.

Requests for a copy of the proposed rules or comments on the rules should be submitted by mail to the Ohio Department of Medicaid Rule Administrator, Office of Legal Counsel, 50 W. Town Street, Fourth Floor, Columbus, Ohio 43215-3414, by fax at [phone], or by e-mail at [e-mail]. Testimony received may be reviewed at this address.