Ohio Admin. Code 5160-26-02.1 - Managed care: termination of enrollment
(A) This rule does not apply to MyCare Ohio
plans as defined in rule
5160-58-01 of the Administrative
Code or the Ohio resilience through integrated systems and excellence
(OhioRISE) plan as defined in rule
5160-59-01 of the Administrative
Code.
(B) The Ohio department of
medicaid (ODM) will terminate a member from enrollment in a managed care
organization (MCO) for any of the following reasons:
(1) The member's permanent place of residence
is moved outside the MCO service area. When this occurs, termination of MCO
enrollment takes effect on the last day of the month in which the member moved
from the service area.
(2) The
member becomes ineligible for medicaid. When this occurs, termination of MCO
enrollment takes effect on the last day of the month in which the member became
ineligible.
(3) The member dies, in
which case MCO enrollment ends on the date of death.
(4) The member is not receiving medicaid in
the adult extension category under section 1902(a)(10)(A)(i)(VIII) of the
Social Security Act, 42
U.S.C. 1396a(a)(10)(A)(i)
(VIII) (July 1, 2022), is authorized for nursing facility services, and the
following criteria are met:
(a) The MCO has
authorized nursing facility services for no less than the month of nursing
facility admission and for two complete consecutive calendar months
thereafter;
(b) For the entire
period in paragraph (B)(4)(a) of this rule, the member has remained in the
nursing facility without any admission to an inpatient hospital or long-term
acute care facility;
(c) The
member's discharge plan documents that nursing facility discharge is not
expected in the foreseeable future and the member has a need for long-term
nursing facility care;
(d) For the
entire period in paragraph (B)(4)(a) of this rule, the member is not using
hospice services; and
(e) The MCO
has requested disenrollment, and ODM has approved the request.
(f) The member is found by ODM to meet the
criteria for the developmental disabilities level of care as specified in rule
5123-8-01 of the Administrative
Code and resides in an intermediate care facility for individuals with
intellectual disabilities (ICF-IID). Following MCO notification to ODM and
written approval by ODM, termination of MCO membership takes effect on the last
day of the month preceding the individual's stay in the ICF-IID.
(5) The member has third party
coverage, and ODM determines that continuing MCO enrollment may not be in the
best interest of the member. This determination may be based on the type of
coverage the member has, the existence of conflicts between provider networks,
or access requirements. When this occurs, the effective date of termination of
MCO enrollment shall be determined by ODM but in no event shall the termination
date be later than the last day of the month in which ODM approves the
termination.
(6) The member is not
eligible for MCO enrollment for one of the reasons set forth in rule
5160-26-02 of the Administrative
Code.
(7) The provider agreement
between ODM and the MCO is terminated.
(C) Upon implementation of the single
pharmacy benefit manager (SPBM), ODM will terminate a member from enrollment in
the SPBM when a member is terminated from enrollment in an MCO as specified in
paragraph (B) of this rule or if the contract between ODM and the SPBM is
terminated.
(D) All of the
following apply when enrollment in an MCO or the SPBM is terminated for any of
the reasons set forth in paragraph (B) or (C) of this rule:
(1) Such terminations may occur either in a
mandatory or voluntary service area.
(2) All such terminations occur at the
individual level.
(3) Such
terminations do not require completion of a consumer contact record
(CCR).
(4) If ODM fails to notify
the MCO or the SPBM of a member's termination from an MCO or the SPBM, ODM
shall continue to pay the MCO or the SPBM the applicable monthly capitation
rate for the member. The MCO or the SPBM shall remain liable for the provision
of covered services as set forth in rule
5160-26-03 of the Administrative
Code, until such time as ODM provides the MCO or the SPBM with documentation of
the member's termination.
(5) ODM
shall recover from the MCO or the SPBM any capitation paid for retroactive
enrollment termination occurring as a result of paragraph (B) or (C) of this
rule.
(6) A member may lose
medicaid eligibility during an annual open enrollment period, and thus become
unable to change to a different MCO. If the member then regains medicaid
eligibility, the member may request to change plans within thirty days
following reenrollment in the MCO.
(E) Member-initiated MCO terminations.
(1) An MCO member who qualifies as a
mandatory managed care enrollment population as specified in rule
5160-26-02 of the Administrative
Code may request a different MCO as follows:
(a) From the date of enrollment through the
initial three months of MCO enrollment;
(b) During an open enrollment month for the
member's service area as described in paragraph (G) of this rule;
(c) At any time, if the member is a child
receiving Title IV-E federal foster care maintenance or is in foster care or
other out of home placement. The change must be initiated by the local public
children's services agency (PCSA) or the local Title IV-E juvenile court;
or
(d) At any time, if the just
cause request meets one of the reasons for just cause as specified in paragraph
(E)(3)(f) of this rule;
(2) An MCO member who qualifies as a
voluntary managed care enrollment population as specified in rule
5160-26-02 of the Administrative
Code may request a different MCO, if available, or be returned to medicaid
fee-for-service (FFS) as follows:
(a) From the
date of enrollment through the initial three months of MCO
enrollment;
(b) During an open
enrollment month for the member's service area as described in paragraph (G) of
this rule; or
(c) At any time, if
the just cause request meets one of the reasons for just cause as specified in
paragraph (E)(3)(f) of this rule;
(3) The following provisions apply when a
member either requests a different MCO or, if applicable, requests to be
returned to medicaid FFS:
(a) The request may
be made by the member, or by the member's authorized representative.
(b) All member-initiated changes or
terminations must be voluntary. The MCO is not permitted to encourage members
to change or terminate enrollment due to a member's age, gender, gender
identity, sexual orientation, disability, national origin, race, color,
religion, military status, ancestry, genetic information, health status or need
for health services. The MCO may not use a policy or practice that has the
effect of discrimination on the basis of the criteria listed in this
rule.
(c) If a member requests
disenrollment because he or she meets the requirements of paragraph (B)(3) of
rule 5160-26-02 of the Administrative
Code, the member will be disenrolled after the member notifies the Ohio
medicaid consumer hotline.
(d)
Disenrollment will take effect on the last day of the calendar month in which
the request for disenrollment was made.
(e) In accordance with
42 C.F.R.
438.56(d)(2) (October 1,
2021), a change or termination of MCO enrollment may be permitted for any of
the following just cause reasons:
(i) The
member moves out of the MCO's service area and a nonemergency service must be
provided out of the service area before the effective date of the member's
termination as described in paragraph (B)(1) of this rule;
(ii) The MCO does not, for moral or religious
objections, cover the service the member seeks;
(iii) The member needs related services to be
performed at the same time; not all related services are available within the
MCO's network, and the member's PCP or another provider determines that
receiving services separately would subject the member to unnecessary
risk;
(iv) The member has
experienced poor quality of care and the services are not available from
another provider within the MCO's network;
(v) The member cannot access medically
necessary medicaid-covered services or cannot access the type of providers
experienced in dealing with the member's health care needs;
(vi) The PCP selected by a member leaves the
MCO's network and was the only available and accessible PCP speaking the
primary language of the member, and another PCP speaking the language is
available and accessible in another MCO in the member's service area;
and
(vii) ODM determines that
continued enrollment in the MCO would be harmful to the interests of the
member.
(f) The
following provisions apply when a member seeks a change or termination in MCO
enrollment for just cause:
(ii)(i)
The member may make the request for just cause directly to ODM or an
ODM-approved entity, either orally or in writing.
(iii)(ii) ODM shall review
all requests for just cause within seven working days of receipt. ODM may
request documentation as necessary from both the member and the MCO. ODM shall
make a decision within forty-five days from the date ODM receives the just
cause request. If ODM fails to make the determination within this timeframe,
the just cause request is considered approved.
(iv)(iii) ODM may
establish retroactive termination dates and recover capitation payments as
determined necessary and appropriate.
(v)(iv) Regardless of the
procedures followed, the effective date of an approved just cause request must
be no later than the first day of the second month following the month in which
the member requests change or termination.
(vi)(v) If the just cause
request is not approved, ODM shall notify the member or the authorized
representative of the member's right to a state hearing.
(vii)(vi)
Requests for just cause may be processed at the individual level or case level
as ODM determines necessary and appropriate.
(viii)(vii) If a member
submits a request to change or terminate enrollment for just cause, and the
member loses medicaid eligibility prior to action by ODM on the request, ODM
shall ensure that the member's MCO enrollment is not automatically renewed if
eligibility for medicaid is reauthorized.
(i) The member or an authorized
representative must contact the MCO to identify providers of services before
seeking a determination of just cause from ODM.
(F) MCO initiated terminations.
(1) The MCO may submit a request to ODM for
the termination of a member for the following reasons:
(a) Fraudulent behavior by the member;
or
(b) Uncooperative or disruptive
behavior by the member or someone acting on the member's behalf to the extent
that such behavior seriously impairs the MCO's ability to provide services to
either the member or other MCO members.
(2) The MCO may not request termination due
to the member's age, gender, gender identity, sexual orientation, disability,
national origin, race, color, religion, military status, genetic information,
ancestry, health status or need for health services.
(3) The MCO must provide medicaid-covered
services to a terminated member through the last day of the month in which the
MCO enrollment is terminated, notwithstanding the date of ODM written approval
of the termination request. Inpatient facility services must be provided in
accordance with rule
5160-26-02 of the Administrative
Code.
(4) If ODM approves the MCO's
request for termination, ODM shall notify in writing the member, the authorized
representative, the Ohio medicaid consumer hotline, and the MCO.
(G) MCO open enrollment.
(1) Open enrollment months will occur at
least annually.
(2) At least sixty
days prior to the designated open enrollment month, ODM will notify eligible
individuals by mail of the opportunity to change or terminate MCO enrollment
and will explain where to obtain further information.
Notes
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5164.02, 5167.03, 5167.10
Prior Effective Dates: 04/01/1985, 02/15/1989 (Emer.), 05/08/1989, 05/18/1989, 10/09/1989, 11/01/1989 (Emer.), 02/01/1990, 02/15/1990, 05/01/1992, 05/01/1993, 11/01/1994, 07/01/1996, 07/01/1997 (Emer.), 09/27/1997, 12/10/1999, 07/01/2000, 11/06/2000, 07/01/2001, 07/01/2002, 07/01/2003, 07/01/2004, 10/31/2005, 06/01/2006, 07/01/2007, 01/01/2008, 08/26/2008 (Emer.), 10/09/2008, 07/01/2009, 02/01/2010, 08/01/2010, 07/01/2013, 07/02/2015, 08/01/2016, 07/01/2017, 07/19/2020, 07/18/2022, 01/01/2023
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.