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

 

 

 

 

 

PUBLIC HEARING NOTICE OHIO DEPARTMENT OF MEDICAID

 

DATE:                         Monday, May 16, 2016

TIME:                        11:00am

LOCATION:             Room A501, Lazarus Building

50 W Town St., Columbus, Ohio 43215

 

Pursuant to section 5162.03, 5162.02, 5164.02, 5166.02, 5167.03, 5167.20, 5167.10,

         , 5167.12, 5167.201, and Chapter 119 of the Ohio Revised Code, the director of the Ohio Department of Medicaid gives notice of the department's intent to consider the adoption, amendment, or rescission of the rule or rules as identified below and of a public hearing thereon.

 

OAC Rule 5160-26-02, entitled Managed health care programs: eligibility, membership, and automatic renewal of membership is being proposed for rescission and will be replaced by a new rule of the same number to update policy relating to the administration of the Medicaid program. The rule describes the managed care enrollment process, enrollment exclusions, and the categories of individuals who are eligible for mandatory and voluntary enrollment in Medicaid managed care plans (MCPs). New rule 5160-26-02 has the simplified title, Managed health care programs: eligibility and enrollment.  In the new rule, the text of the rescinded rule is reorganized to achieve greater clarity and legal citations and cross-references are updated.  The new rule also updates managed care mandatory and voluntary enrollment criteria and adds the following groups to Medicaid recipients who must receive services through managed care:

·         Children receiving services from the Ohio Department of Health Bureau of Children with Medical handicaps, or any other family-centered, community- based, coordinated care system that receives grant funds under Section 501(a)(1)(D) of Title V of the Social Security Act,

·         Children receiving Title IV-E federal foster care maintenance or Title IV-E federal adoption assistance, and

·         Children in foster care or other out of home placement.

 

 

OAC Rule 5160-26-02.1, entitled Managed health care programs: termination of membership is being proposed for amendment to update policy relating to the administration of the Medicaid program. The rule sets forth reasons for membership termination from a MCP and the processes to be used when a member is terminated from a plan.  Changes to the rule reduce circumstances in which a MCP member can be terminated. The rule also clarifies when member placement in a nursing facility authorizes disenrollment.  Another amendment updates the requirements for any disenrollment requests from nursing facility admissions beyond a stay of two consecutive months. Changes to the rule also update cross-references.

 

 

 

 

 

 

 

OAC Rule 5160-26-03, entitled Managed health care programs: covered services, is being proposed for amendment to update policy relating to the administration of the Medicaid program. The rule sets forth the covered services that Medicaid MCPs are required to provide to their members.  MCP obligations around home and community based waiver services (HCBS) are clarified.  Language authorizing termination of membership for members placed in nursing facilities has been moved to 5160-26-02.1 in order to consolidate termination requirements. Changes to the rule also update cross- references.

OAC Rule 5160-26-05, entitled Managed health care programs: provider panel and subcontracting requirements is being proposed for amendment to update policy relating to the administration of the Medicaid program.  The rule sets forth Medicaid MCP provider panel and subcontracting requirements. Changes to the rule clarify and update subcontracting requirements for MCP subcontractors. Other amendments update the obligations of MCPs regarding member materials and quarterly reports, allowing the MCPs more administrative flexibility.

OAC Rule 5160-26-08.4, entitled Managed health care programs: MCP grievance system is being proposed for amendment to update policy relating to the administration of the Medicaid program. The rule sets forth Medicaid MCP member appeal and grievance rights.  One minor change to the rule clarifies and updates a requirement allowing the MCPs more administrative flexibility.

OAC Rule 5160-26-09.1, entitled Managed health care programs: third party liability and recovery is being proposed for amendment due to five year rule review. The rule sets forth Medicaid MCP third party recovery requirements.  Minor changes to the rule clarify and update requirements. Additional amendments to the rule update legal citations and cross-references.

OAC Rule 5160-26-12, entitled Managed health care programs: member co-payments, is being proposed for amendment due to five year rule review. The rule sets forth requirements for MCPs when they elect to implement a co-payment program. Changes to the rule update legal citations and cross-references.

OAC Rule 5160-58-02, entitled MyCare Ohio plans: eligibility, membership and automatic renewal of membership, is being proposed for amendment to update policy relating to the administration of the Medicaid program. This rule sets forth the MyCare Ohio enrollment process and the categories of individuals who are eligible for enrollment in MyCare Ohio plans (MCOPs). The title of the rule is simplified to MyCare Ohio plans: eligibility and enrollment. Other amendments to this rule clarify the new managed care mandatory and voluntary enrollment criteria, reorganize the text to achieve greater clarity, and update legal citations and cross-references.

OAC Rule 5160-58-02.1, entitled MyCare Ohio plans: termination of membership, is being proposed for amendment to update policy relating to the administration of the Medicaid program. This rule sets forth reasons for enrollment termination from a MCOP

and the processes to be used when a member is terminated from a plan. Changes to the rule update rule references and reduce circumstances in which a MCOP member can be terminated.

OAC Rule 5160-58-02.2, entitled MyCare Ohio plans: eligibility and enrollments, is being proposed for amendment to update policy relating to the administration of the Medicaid program. This rule sets forth the MyCare Ohio enrollment  process.  The changes to the rule comply with federal requirements relating to settings and person centered care in 42 CFR 441.301.

OAC Rule 5160-58-05.3, entitled MyCare Ohio plans: incident management system, is being proposed for amendment to update policy relating to the administration of the Medicaid program. This rule sets forth the MyCare Ohio incident requirements. The changes to the rule accommodate the inclusion of requirements specific to Specialized Recovery Service Program (SRSP) enacted pursuant to 1915(i) of the Social Security Act, including the population enrolled in SRSP and specific types of incidents.

OAC Rule 5160-58-08.4, entitled Appeals and Grievances for MyCare Ohio is being proposed for amendment to update policy relating to the administration of the Medicaid program. The rule sets forth Medicaid MCOP member appeal and grievance rights. One minor change to the rule clarifies and updates a requirement allowing the MCOPs more administrative flexibility

A copy of the proposed rules are available, without charge, to any person affected by the rule(s) 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 rule(s) 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 and testimony on the rules should be submitted by mail to the Ohio Department of Medicaid Rule Administrator, Office of Chief Legal Counsel, 50 W. Town St., Suite 400, Columbus, Ohio 43215-3414, by fax at (614) 995- 1301, or by e-mail at [e-mail]. Testimony received may be reviewed at this address.