(A) For the purposes of this rule,
the following terms are defined as follows:
(1) "Managed care plan (MCP)
non-contracting provider" means any provider with an Ohio department of
medicaid (ODM) provider agreement who does not contract with the MCP but
delivers health care services to that MCP's members, as described in paragraphs
(C) and (D) of this rule.
(2) "MCP non-contracting provider of
emergency services" means any person, institution, or entity that does not
contract with the MCP but provides emergency services to an MCP member,
regardless of whether that provider has an ODM provider
agreement.
(B)(A)
MCP non
Non-contracting providers of emergency services must
accept as payment in full from
the
a
MCP
managed care organization (MCO) the lesser of
billed charges or one hundred per cent of the Ohio medicaid program
reimbursement rate (less any payments for indirect costs of medical education
and direct costs of graduate medical education that is included in the Ohio
medicaid program reimbursement rate) in effect for the date of service.
Pursuant to section
5167.10
5167.101
of the Revised Code, the
MCP
MCO shall not compensate a hospital for inpatient
capital costs in an amount that exceeds the maximum rate established by
ODM.
(C)(B) When ODM has
approved
an MCP's
the MCO's members to be referred to
an MCP
a
non-contracting hospital pursuant to rule
5160-26-03
of the Administrative Code, the
MCP
non-contracting hospital must provide the service for which the referral was
authorized and must accept as payment in full from the
MCP
MCO one
hundred per cent of the current Ohio medicaid program reimbursement rate in
effect for the date of service. Pursuant to section
5167.10
5167.101
of the Revised Code, the
MCP
MCO shall not compensate a hospital for inpatient
capital costs in an amount that exceeds the maximum rate established by ODM.
MCP non
Non-contracting hospitals are exempted from this
provision when:
(1) The hospital is located in
a county in which eligible individuals were required to enroll in an
MCP
MCO prior
to January 1, 2006;
(2) The
hospital is contracted with at least one
MCP
MCO serving the
eligible individuals specified in paragraph
(C)
(B)(1) of this
rule prior to January 1, 2006; and
(3) The hospital remains contracted with at
least one
MCP
MCO serving eligible individuals who are required to
enroll in an
MCP
MCO in the service area where the hospital is
located.
(D)(C)
MCP non
Non-contracting qualified family planning providers
(QFPPs) must accept as payment in full from the
MCP
MCO the lesser of
one hundred per cent of the Ohio medicaid program reimbursement rate or billed
charges, in effect for the date of service.
(E)(D)
An MCP
A managed
care entity (MCE) non-contracting provider may not bill
An MCP
the MCE
member unless
:
all of
the following conditions are met:
(1)
The conditions described in rule 5160-1-13.1 of the
Administrative Code are met; and
(1) The member was notified by the
provider of the financial liability in advance of service
delivery.
(2) The notification by the provider
was in writing, specific to the service being rendered, and clearly states that
the recipient is financially responsible for the specific service. A general
patient liability statement signed by all patients is not sufficient for this
purpose.
(3) The notification is dated and
signed by the member.
(4)(2) The reason the
service is not covered by the
MCP
MCE is specified and is one of the following:
(a) The service is a benefit
exclusion;
(b) The provider is not
contracted with the
MCP
MCE and the
MCP
MCE has denied
approval for the provider to provide the service because the service is
available from a contracted provider, at no cost to the member; or
(c) The provider is not contracted with the
MCP
MCE and
has not requested approval to provide the service.
(F)(E)
An MCP
An MCE
non-contracting provider may not bill
an
MCP
a member for a missed
appointment.
(G)(F)
MCP non
Non-contracting providers, including
MCP non-contracting providers of emergency
services, must contact the twenty-four hour post-stabilization services phone
line designated by the
MCP
MCO to request authorization to provide
post-stabilization services in accordance with rule
5160-26-03
of the Administrative Code.
(H)(G)
MCP non
Non-contracting providers, including
MCP non-contracting providers of emergency
services, must allow the
MCP
MCE, ODM, and ODM's designee access to all member
medical records for a period not less than ten years from the date of service
or until any audit initiated within the ten year period is completed. Access
must include copies of the medical records at no cost for the purpose of
activities related to the annual external quality review specified by
42.C.F.R.
42
C.F.R.438.358 (October 1,
2017
2021).
(I)(H)
When an MCP
If the
MCE elects to impose member co-payments in accordance with rule
5160-26-12
of the Administrative Code, applicable co-payments shall also apply to services
rendered by
MCP non-contracting providers.
When an MCP
If the
MCE has not elected to impose co-payments
in
accordance with rule
5160-26-12
of the Administrative Code,
MCP
non-contracting providers are not permitted to impose co-payments on
MCP
MCE
members.
Notes
Ohio Admin. Code
5160-26-11
Effective:
7/18/2022
Five Year Review (FYR) Dates:
1/1/2023
Promulgated Under:
119.03
Statutory Authority:
5167.02
Rule
Amplifies:
5162.03,
5164.02,
5167.03,
5167.10,
5167.20,
5167.201
Prior Effective Dates: 07/20/2001, 07/01/2003, 01/01/2006,
06/01/2006, 01/01/2007, 01/01/2008, 07/01/2013, 02/01/2015,
01/01/2018
