Ohio Administrative Code
Title 5160:1 - Eligibility
Chapter 5160:1-2 - Medicaid Application Procedures
Section 5160:1-2-15 - Medicaid: healthchek (early and periodic screening, diagnostic and treatment services)
Universal Citation: OH Admin Code 5160:1-2-15
Current through all regulations passed and filed through September 16, 2024
(A) The purpose of this rule is to explain the requirements of healthchek, Ohio's early and periodic screening, diagnostic and treatment (EPSDT) benefit that all medicaid eligible individuals under twenty-one years of age are entitled to receive. A separate healthchek application is not required. Each county department of job and family services (CDJFS) is required to have a healthchek coordinator.
(B) Definitions. For the purposes of this rule, the following terms have the following meanings:
(1)
"Healthchek" is
Ohio's early and periodic screening, diagnostic and treatment benefit for all
medicaid eligible individuals under twenty-one years of age.
(2)
"Healthchek
coordinator" is the CDJFS employee who is responsible for the implementation of
healthchek services.
(3)
"Healthchek services" are periodic screening services
(including a comprehensive medical exam, vision, dental, and hearing
screenings) and such other necessary health care, diagnostic services,
treatment, and other measures described in
42
U.S.C. section 1396d(a) (as
in effect 03-06-2016) to correct or ameliorate defects and physical and mental
illnesses and conditions discovered by the screening services, whether or not
such services are covered under the state plan. Healthchek services are
identical to "EPSDT services" as defined at
42
U.S.C. section 1396d(r) (as
in effect 03/06/2016).
(4)
"Healthchek Services Implementation Plan" (HSIP), ODM
03517, (rev.07/2016) means the document submitted
by a CDJFS describing how it delivers healthchek services to individuals in its
county and who in the agency is responsible for ensuring the delivery of
healthchek services.
(5)
"Individual" means, for purposes of this rule, a person
under age twenty-one eligible for medicaid.
(6)
"Medically
necessary," otherwise known as "medical necessity," as used in this chapter is
the same as defined in paragraph (A) of rule
5160-1-01
of the Administrative Code.
(7)
"Prior
authorization" for a member of a medicaid managed care plan (MCP) is the
process outlined in rule 5160-26-03.1 of the Administrative Code. For all other
individuals, prior authorization is the process outlined in rule
5160-1-31
of the Administrative Code.
(8)
"Support
services" are non-medical services offered or provided by the administrative
agency to assist the individual and may include arranging or providing
transportation, making medical appointments, accompanying the individual to
medical appointments, and making referrals to community and other social
services. Support services shall be coordinated with the individual's
medicaid-contracting MCP, where applicable.
(C) The individual (or the individual's parent, guardian or legal custodian, as applicable) may:
(1)
Complete and sign the ODM 03528, "Healthchek and Pregnancy
Related Services Information Sheet" (rev. 7/2016) to verify receipt and
understanding of information about healthchek;
(2)
Complete, sign,
and return the ODM 03528 to identify service needs;
(3)
Request and
attend scheduled appointments for healthchek services.
(D) CDJFS responsibilities. Each CDJFS shall:
(1)
Inform. Each CDJFS shall use a combination of written
and oral methods (including telephone calls, office visits, or home visits) to
inform individuals (or such individuals' parents, guardians or legal
custodians, as applicable) in its county about healthchek within sixty days of
the eligibility determination and at least once each year thereafter.
Appropriate oral and written informing methods are described in this
rule.
(a)
Written informing.
(i)
Each CDJFS shall
ensure that each individual (or such individual's parent, guardian or legal
custodian, as applicable) in its county receives the ODM 03528 within sixty
days after the individual is determined eligible for medicaid and at least once
each year thereafter.
(ii)
Each CDJFS shall document that each individual (or such
individual's parent, guardian or legal custodian, as applicable) in its county
has received the ODM 03528.
(iii)
If written
healthchek information is sent to an individual (or such individual's parent,
guardian or legal custodian, as applicable) and returned as undeliverable, the
CDJFS shall make a second attempt to contact the individual by alternate means.
All attempts to contact an individual (or such individual's parent, guardian,
or legal custodian, as applicable) shall be documented in the electronic
information system.
(iv)
Upon completion of the ODM 03528, the individual (or
such individual's parent, guardian or legal custodian, as applicable) will be
asked to sign the ODM 03528 to acknowledge receipt of healthchek information
and to verify understanding of the healthchek services available. If the
individual (or such individual's parent, guardian or legal custodian, as
applicable) needs additional information in order to understand healthchek
services, the CDJFS shall immediately provide the necessary
information.
(v)
Each CDJFS shall enter data regarding individuals into
the electronic information system, as directed by ODM. Such information shall
include information from the completed ODM 03528, record of contacts with
individuals and any requests and referrals made or services
provided.
(vi)
Each entity that distributes or accepts applications
for medicaid shall prominently display a notice that complies with the methods
of providing information about healthcheck as established by section
5164.26 of the Revised
Code.
(vii)
ODM may develop additional written materials containing
information about healthchek. Each CDJFS shall distribute such written
materials, as directed by ODM. Any written materials developed by a CDJFS to
inform individuals about healthchek shall be submitted to ODM for review and
approval.
(b)
Oral informing. Each CDJFS shall ensure that each
individual (or such individual's parents, guardians, or legal custodians, as
applicable), who has a face-to-face meeting or telephone call with CDJFS staff
to apply for medicaid, is orally informed about healthchek using clear and
non-technical language about the following:
(i)
The benefits of
preventive health care, including:
(a)
Increased well-being;
(b)
Reduced risk to
the individual's health;
(c)
Identification and treatment of health problems early
to reduce the possibility of increase in severity and cost of treatment;
and
(d)
Education of the family to allow for optimal
health.
(ii)
The services covered by healthchek.
(iii)
Where and how
to obtain healthchek services.
(iv)
That services
covered by healthchek are without cost to individuals.
(v)
The individual's
ability to request and schedule dental, vision, and hearing services separately
from the healthchek screening visit.
(vi)
The availability
of medically necessary diagnostic and follow-up treatment services, including
referrals, for problems discovered during the healthchek screening
service.
(vii)
The prior authorization process, including that:
(a)
The process,
whether fee-for-service or managed care, must be started by the individual's
medicaid provider;
(b)
The prior authorization requirement for some services,
products, or procedures applies even when the individual is under twenty-one
years of age;
(c)
The prior authorization process may enable individuals
under twenty-one years of age to receive services not available to adults,
including services that are limited in number for adults; and
(d)
Certain services
require prior authorization, which must be requested by a provider and approved
by the Ohio department of medicaid before the service is
provided.
(viii)
The CDJFS must explain necessary transportation and
scheduling assistance is available to individuals under twenty-one years of
age, upon request, in accordance with Chapter 5160-15 of the Administrative
Code, and the following:
(a)
Transportation will be provided to any medicaid
reimbursable service;
(b)
How to request transportation and the timeframes for
requesting transportation;
(c)
Verification
requirements, if any; and
(d)
For an individual who is a member of an
MCP, transportation is also available through the individual's
MCP.
(c)
Each CDJFS shall
use appropriate methods to inform individuals who are blind, deaf, or who
cannot read or understand the English language (or such individuals' parents,
guardians, or legal custodians, as applicable) about healthchek. Information
provided to individuals who are blind, deaf, or who cannot read or understand
the English language shall meet the requirements of paragraphs (C)(1) and
(C)(2) of this rule.
(d)
Informing pregnant women. An ODM 03528 shall be used to
document the informing of pregnant women about healthchek services as outlined
in rule 5160:1-02-16 of the Administrative Code. The ODM 03528 shall be used to
document informing again upon the birth of the infant.
(e)
The CDJFS shall
use electronic means to track pregnant women and the births of their infants to
accomplish the following:
(i)
Identify newborns and the infant's parent, guardian,
legal custodian, as applicable;
(ii)
Ensure that any
infant born to a medicaid eligible woman is added to the medicaid case, in
accordance with rule 5160:1-4-02.2 of the Administrative Code;
(iii)
Inform the
infant's parent, guardian, legal custodian, as applicable, of healthchek
services within sixty days of the infant's birth;
(iv)
Contact the
infant's parent, guardian, legal custodian, as applicable, to assist in
securing an ongoing primary care provider for the newborn;
(v)
Coordinate the
activity in paragraphs (C)(1) to (C)(3) of this rule with the individual's MCP,
other agencies, and programs where applicable.
(2)
Provide support services.
(a)
The CDJFS shall
refer the individual (or the individual's parent, guardian, or legal custodian,
as applicable) to entities listed on the ODM 03528 and/or other community
supportive services as requested. The CDJFS will ensure:
(i)
That referrals
are made, as needed, for both medical and other services such as help me grow
(HMG); women, infants and children (WIC); maternal and child health clinics;
local health departments; head start (HS); child care; clothing and/or other
community social services, where applicable.
(ii)
Coordination
between the individual and the entity where the referral is
made.
(iii)
Coordination between the individual and the
individual's MCP by forwarding a copy of the ODM 03528 to the individual's MCP,
if applicable.
(iv)
The individual enrolled in a MCP (or the individual's
parent, guardian or legal custodian, as applicable) is advised to contact the
individual's MCP for medical care options and/or referrals.
(v)
Assistance is
provided with scheduling medical appointments as requested by the individual or
the individual's parent, guardian or legal custodian, as
applicable.
(vi)
Requests for support services available in the
individual's county of residence received by the individual's MCP and forwarded
to the CDJFS are acted upon and the requested service(s)
provided.
(b)
The CDJFS shall provide individuals with necessary
assistance in obtaining transportation to medicaid reimbursable services as
requested by the individual or the individual's parent, guardian or legal
custodian, as applicable.
(c)
Each individual in a household who requests or is in
need of non-medicaid covered medical services as indicated on the ODM 03528 or
through other verbal or written communication shall be referred by the CDJFS to
community, medical or other social services, as needed, including providers who
have expressed a willingness to furnish non-medicaid covered services at little
or no expense to the family. Community and medical service requests will be
documented and forwarded to the appropriate community provider, medical
provider and/or MCP.
(d)
Elevated blood lead level services for assisting
families of individuals identified as having elevated blood lead levels when
notified by the family, provider or the county or city department of health
shall be provided by the CDJFS and include:
(i)
Referral of the
individual to the Ohio department of health (ODH) for an environmental
assessment.
(ii)
Verification of the individual's medicaid eligibility
at the time the environmental assessment is conducted and the ODH agent is
informed of such eligibility. Verification shall only be provided upon receipt
of proper verification of the identity of the ODH agent who is requesting the
information.
(iii)
Education of the family about the purpose of the
environmental assessment by:
(a)
Informing the family of the need to remove the source
of lead or removing the individual from the contaminated
environment;
(b)
Explaining the family's responsibility to inform the
health department staff who conduct the environmental assessment of places the
individual visits regularly;
(c)
Assisting the
family with securing lead-free housing by making any necessary referrals if the
source of lead cannot or will not be removed from the
environment.
(iv)
The CDJFS is responsible for maintaining records of
environmental assessment recommendations made by the ODH and any action taken
as a result of those recommendations. If, as a result of CDJFS efforts, the
family relocates, the CDJFS must inform the ODH of the family's new
address.
(v)
In geographic areas with Ohio childhood lead poisoning
prevention regional resource centers or local arrangements for environmental
assessments and follow-up, the requirements of those programs supersede this
rule.
(3)
CDJFS healthchek
services implementation plan (HSIP) ODM 03517 (rev. 07/2016). Each CDJFS is
required to have a healthchek services implementation plan on file with ODM.
The plan shall be signed by the agency director or his designee.
(a)
The CDJFS shall
provide a description in the HSIP of the electronic and/or hard-copy methods
for ensuring permanent records and documentation are maintained in a case file
for each individual. The case file shall contain the following information,
when appropriate:
(i)
Copy of the ODM 03528;
(ii)
Copies of all
correspondence received and sent;
(iii)
Documentation
of attempted and successful contacts with the individual (or such individual's
parent, guardian or legal custodian, as applicable);
(iv)
Documentation of
the MCP in which individuals are enrolled, if applicable;
(v)
Documentation of
contacts with or forms provided by the medical provider;
(vi)
Information
received from other counties when an individual's case is an inter-county
transfer;
(vii)
Documentation of support services requested and/or
provided and referrals made on an individual's behalf, and the CDJFS' efforts
to fulfill the referrals and/or requests. At a minimum the documentation shall
contain:
(a)
Steps taken by the CDJFS to assure the requested support
services are provided, and whether or not the individual received the requested
support services;
(b)
A copy of all documentation of services requested by an
individual (or such individual's parent, guardian or legal custodian, as
applicable) and provided or facilitated by the CDJFS;
(c)
Records of
transportation requested and provided; and
(d)
Any communication
from or forms provided by the medical provider.
(b)
The
CDJFS shall identify, if applicable, any services or functions required in this
rule which are contracted out to other entities. A copy of the contract shall
be provided to ODM. The CDJFS shall also describe accountability and monitoring
measures, along with timeframes when monitoring takes place to ensure the
contracted entities are achieving all required functions and that these
functions are in accordance with applicable state and federal
rules.
(c)
The CDJFS shall submit a new or amended HSIP to ODM,
including but not limited to, when there has been a change of agency address,
director, Healthchek coordinator or where the responsibility for healthchek is
organizationally located within the agency. The HSIP shall be submitted to ODM
within ten business days of the change.
(4)
Release of
information. The CDJFS shall, if necessary, obtain a HIPAA-compliant signed
authorization for release of information, form ODM 03397 "Authorization for the
Release or Use of Protected Health Information (PHI)" (rev. 02/2016), if and
when the CDJFS needs additional medical information from the individual or the
individual's provider.
(5)
Provider recruitment. The CDJFS is required to take
steps to recruit and maintain a network of fee-for-service providers of
medical, dental, vision, and hearing services that is adequate to meet the
screening and treatment needs of the healthchek individuals. The CDJFS may make
use of a variety of methods including personal visits, telephone calls, and
letters to recruit providers.
(6)
Training. Each
CDJFS' healthchek coordinator, or such coordinator's designee(s), shall attend
available healthchek training offered by ODM. For video conference or other
training delivered electronically, verification of attendance shall consist of
documenting the county's presence during roll call and submission of an
evaluation form to the appropriate state monitored e-mail box within three days
of the training. Verification of attendance at an on site training shall be
documented by the healthchek coordinator, or such coordinator's designee,
signing the attendance log.
Replaces: 5160:1-2-05
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