5160-58-02 MyCare Ohio plans: eligibility and enrollment.  

  • Text Box: ACTION: Final Text Box: DATE: 02/04/2014 2:56 PM

     

     

     

    5160-58-02                  My Care Ohio plans: eligibility, membership, and automatic renewal of membership.

     

     

     

    (A)Eligibility.

     

    (1)In mandatory service areas as permitted by 42 CFR 438.52 (October 1, 2013), an individual must be enrolled in a MyCare Ohio plan (also known as "plan") if he or she meets all of the following criteria:

     

    (a) Age 18 or older at the time of enrollment in the plan;

     

    (b) Eligible for medicare Parts A and B and D, and full benefits under the medicaid program; and

     

    (c) Reside in a plan demonstration county in Ohio. A list of demonstration counties, and the plans available in those counties, is available at http://medicaid. ohio.gov.

     

    (2) The following individuals are not eligible for enrollment in a plan:

     

    (a) Individuals with intellectual disabilities who have a level of care that meets the criteria specified in rule 5160-3-07 of the Administrative Code and receive services through a 1915(c) home and community based services (HCBS) waiver or an intermediate care facility for individuals with intellectual disabilities (ICF-IID).

     

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

     

    (c) Individuals who have other third party creditable health care coverage, except Medicare coverage as authorized by 42 U.S.C. 1395 (October 1, 2013).

     

    (d)Individuals for whom a delayed medicaid spenddown is required.

     

    (3)Indians who are members of federally recognized tribes are not required to enroll in a plan, except as permitted under 42 C.F.R. 438.50(d)(2) (October 1, 2013).

     

    (4)Individuals are eligible for plan membership in the manner prescribed in this rule if ODM has a provider agreement with the plan applicable to the eligible individual's county of residence.

     

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

     

    (B)MyCare Ohio plan enrollment.

     

     

    (1) The following applies to plan enrollment:

    (a) The plan must accept eligible individuals without regard to race, color, religion, gender, sexual orientation, age, disability, national origin, veteran's status, military status, genetic information, ancestry, ethnicity, mental ability, behavior, mental or physical disability, use of services, claims experience, appeals, medical history, evidence of insurability, geographic location within the service area, health status or need for health services. The plan will not use any discriminatory policy or practice in accordance with 42 C.F.R. 438.6(d)(4) (September 27, 2013).

    (b) The plan must accept eligible individuals who request plan membership without restriction.

    (c) The plan must accept PCP(s) selected by the members when available, except as otherwise provided in this rule.

    (d)In the event that a plan member loses medicaid eligibility and is terminated from the plan, but regains medicaid eligibility within a period of sixty days or less, his or her membership in the same plan shall be re-instated.

    (e) The plan must cover all members that are designated by ODM in an ODM-produced roster of new members, continuing members, and terminating members.

    (f)The plan shall not be required to provide medicaid coverage to an individual until the individual's membership in the plan is confirmed via an ODM-produced roster or upon mutual agreement between ODM and the plan.

    (2) Should a service area change from voluntary to mandatory, the notice rights in this rule must be followed.

    (a) When a service area is initially designated by ODM as mandatory for eligible individuals specified in paragraph (A)(1) of this rule, ODM shall confirm the eligibility of each individual as prescribed in paragraph (A)(1) of this rule. Upon the confirmation of eligibility:

    (i) Eligible individuals residing in the service area who are currently plan members are deemed participants in the mandatory program; and

    (ii) All other eligible individuals residing in the mandatory service area may request plan membership at any time but must select a plan

    following receipt of a notification of mandatory selection (NMS) issued by ODM.

    (b) MyCare Ohio plan membership selection procedures for the mandatory program:

    (i) A newly eligible individual that does not make a choice following issuance of an NMS by ODM and one additional notice will be assigned to a plan by ODM, the medicaid consumer hotline, or other ODM-approved entity.

    (ii) ODM or the medicaid consumer hotline shall assign the individual to a plan based on prior medicaid fee-for-service or plan membership history.

    (C)Commencement of coverage.

    (1) Coverage of plan members will be effective on the first day of the calendar month specified on the ODM-produced 834 electronic data interchange (EDI) roster to the plan.

    Effective:

    03/01/2014

    R.C. 119.032 review dates:

    03/01/2019

     

    CERTIFIED ELECTRONICALLY

     

    Certification

     

     

    02/04/2014

     

    Date

     

     

    Promulgated Under:

     

    119.03

    Statutory Authority:

    5164.02, 5166.02, 5167.02

    Rule Amplifies:

    5164.02, 5166.02, 5167.02

Document Information

Effective Date:
3/1/2014
File Date:
2014-02-04
Last Day in Effect:
2014-03-01
Rule File:
5160-58-02_PH_FF_N_RU_20140204_1456.pdf
Related Chapter/Rule NO.: (1)
Ill. Adm. Code 5160-58-02. My Care Ohio plans: eligibility, membership, and automatic renewal of membership