5160-58-05.3 MyCare Ohio waiver: incident management system.

 

 

 

 

PUBLIC HEARING NOTICE OHIO DEPARTMENT OF MEDICAID

 

DATE:           December 30, 2013

 

TIME:            1:00 p.m.

 

LOCATION: Room 621 A & B, Lazarus Building

50 W. Town Street, Columbus, Ohio 43215

 

 

Pursuant to Sections 5164.02, 5164.91, 5166.16, 5166.02, 5167.02, 5167.03 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 new rules identified below and of a public hearing thereon.

 

Rule 5160-58-01, entitled MyCare Ohio plans: definitions, is a proposed new rule that sets forth operational definitions for MyCare Ohio plans. With some exceptions, the definitions set forth in rule 5160-26-01 of the Administrative Code also apply to the MyCare Ohio rules set forth in Chapter 5160-58 of the Administrative Code. The proposed rule explains the definitions that will be different for MyCare Ohio, and sets forth additional definitions that will only apply to MyCare Ohio.

 

Rule 5160-58-01.1, entitled MyCare Ohio plans: application of general managed care rules, describes the manner in which the general Medicaid managed care rules in Chapter 5160-26 of the Administrative Code will apply to MyCare Ohio. Since MyCare Ohio plans are also Medicaid managed care plans, most of the provisions in Chapter 5160-26 will apply to them. Some requirements will be different for MyCare Ohio plans, and the proposed rule explains those differences.

 

Rule 5160-58-02, entitled MyCare Ohio plans: eligibility, membership, and automatic renewal of membership describes the categories of individuals who are eligible for enrollment in MyCare Ohio plans.  The proposed new rule also describes the process by which eligible individuals will be enrolled in MyCare Ohio plans, including the assignment of individuals who do not choose a MyCare Ohio plan after a notice of mandatory selection is sent to them.

 

Rule 5160-58-02.1, entitled MyCare Ohio plans: termination of membership establishes reasons for membership termination from a MyCare Ohio plan and the processes to be used when a member is terminated from a plan. The proposed rule describes circumstances that will be considered just cause when a member either requests a different plan or, where enrollment is not mandatory, requests disenrollment from the MyCare Ohio program.  The proposed rule also includes grounds for termination when a plan seeks to terminate a member.

 

 

 

 

 

 

 

Rule 5160-58-02.2, entitled MyCare Ohio waiver: eligibility and enrollment, sets forth waiver eligibility requirements. The proposed new rule sets forth the eligibility and enrollment criteria for individuals participating in the MyCare Ohio Waiver.  The rule also sets forth the circumstances under which a MyCare Ohio Waiver applicant may be denied enrollment, and under which a member may be disenrolled from the waiver.

Rule 5160-58-03, entitled MyCare Ohio plans: covered services, sets forth the Medicaid benefit package for beneficiaries served by MyCare Ohio plans. The proposed new rule describes the obligations of MyCare Ohio plans for ensuring that their members have access to all medically-necessary services covered by Medicaid. When services are provided for an emergency medical condition, a MyCare Ohio plan may be obligated to pay service providers that do not contract with the plan. Such payment may be required for the emergency services themselves, and for subsequent services after an emergency medical condition has been stabilized.

Rule 5160-58-03.2, entitled MyCare Ohio HCBS Waiver Program: Member Choice, Control, Responsibilities and Participant Direction, sets forth the choices and accompanying responsibilities of members enrolled in the MyCare Ohio Waiver.  This rule also outlines the support that MyCare Ohio plans shall provide to members enrolled in the waiver including assistance with participant direction.

Rule 5160-58-04, entitled MyCare Ohio HCBS Waiver Program Covered Services and Providers, sets forth the services that are covered by the MyCare Ohio Waiver and the providers eligible to furnish those services. The waiver's covered services include adult day health, alternative meals, assisted living, Choices home care attendant, chore, community transition, emergency response, enhanced community living, homemaker, home care attendant, home delivered meals, home medical equipment and supplemental adaptive and assistive devices, home modification, maintenance and repair, independent living assistance, nutrition consultation, out-of-home respite, personal care, pest control, social work counseling, waiver nursing and waiver transportation services. Providers seeking to furnish services in the MyCare Ohio Waiver must meet the requirements of Chapters 173-39 or 5160-45 of the Administrative Code, as appropriate, prior to furnishing waiver services. They must also meet the provider requirements for the specific service they wish to provide. The rule also establishes that participant direction may be available to a member for Choices home care attendant, personal care, alternative meals, home modification, maintenance and repair, pest control and home medical equipment and supplemental adaptive and assistive devices.

Rule 5160-58-05.3, entitled MyCare Ohio waiver: Incident Management System, sets forth that ODM and its designees (including MyCare Ohio plans) must assure the health and welfare of MyCare Ohio waiver members by protecting them from abuse, neglect, and exploitation and other threats to their well-being. The rule establishes an "incident management system" that applies to Ohio Department of Medicaid (ODM), MyCare Ohio plans, their designees, service providers and MyCare Ohio Waiver members. The incident management system includes responsibilities for reporting, responding to, investigating and remediating incidents involving members. ODM has the authority to

designate other agencies or entities to perform one or more of the incident management functions set forth in the rule.

Rule 5160-58-08.4, entitled Appeals and grievances for MyCare Ohio, sets forth the appeals, grievances and state hearing provisions for MyCare Ohio plan members. The proposed new rule requires a MyCare Ohio plan to have three avenues allowing a member to challenge certain actions taken by the MyCare Ohio plan: (1) a grievance process, (2) an appeal to the MyCare Ohio plan, and (3) a process allowing members to access the State's hearing system through the Ohio Department of Job and Family Services (ODJFS). The proposed rule sets forth detailed requirements for each of these three avenues, and prescribes the manner in which members must be advised of actions by the MyCare Ohio plan, so that the members receive clear and timely notice of plan actions that will affect the services they receive. It also describes the circumstances under which benefits may be continued while an appeal is pending.

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.