Ohio Administrative Code
Title 5160:1 - Eligibility
Chapter 5160:1-2 - Medicaid Application Procedures
Section 5160:1-2-16 - Medicaid: pregnancy related services (PRS)
Universal Citation: OH Admin Code 5160:1-2-16
Current through all regulations passed and filed through September 16, 2024
(A) The purpose of this rule is to outline the responsibilities of the administrative agency to inform medicaid-eligible pregnant women about the benefits and importance of pregnancy related services (PRS), to make requested or needed referrals to support services, and to provide non-medical services promoting healthy birth outcomes in accordance with 42 C.F.R. 440.210 (as in effect January 1, 2014).
(B) Definitions.
(1)
"Individual" for
the purpose of this rule, means a medicaid-eligible individual who is pregnant,
as verified by either self-declaration or medical verification, including the
sixty days post-partum period.
(2)
ODM 03515
"Pregnancy Related Services Implementation Plan" (PRSIP) (rev.
1/2015) means the document submitted by an
administrative agency describing how it delivers PRS to pregnant women in its
county and which entity is responsible for ensuring the delivery of
PRS.
(3)
"PRS coordinator" means the administrative agency
employee who is responsible for the implementation of PRS.
(4)
"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 will be coordinated with the individual's
medicaid-contracting managed care plan (MCP), where applicable.
(C) The individual (or the individual's parent(s), guardian or legal custodian, as applicable) may:
(1)
Complete and sign the ODM 03528, "Healthchek and
Pregnancy Related Services Information Sheet" (rev. 7/2014) to verify
understanding of PRS and Healthchek services;
(2)
Complete, sign,
and return the ODM 03528 to identify her own and her children's need for
services.
(D) Administrative agency responsibilities. The administrative agency shall:
(1)
Inform individuals in its county about PRS within
sixty days of the eligibility determination. Informing methods shall be
written, oral or a combination of written and oral methods, as described
below:
(a)
Provide the ODM 03528, "Healthchek and Pregnancy Related Services Information
Sheet" (rev. 7/2014).
(b)
Provide information about:
(i)
The benefits and
importance of early and continual prenatal and postpartum care.
(ii)
The services
covered by PRS as described in Chapter 5160-4 of the Administrative
Code.
(iii)
The benefits of healthchek services as described in
5160:1-2-05 of the Administrative Code.
(iv)
Transportation
services and scheduling assistance available to individuals, if needed and upon
request, in accordance with Chapter 5160-15 of the Administrative
Code.
(v)
Availability of transportation services through the
individual's MCP. The transportation services shall be provided by the
administrative agency if not available from the MCP.
(vi)
Transportation
services and scheduling assistance available to infants during the first year
of life.
(vii)
Medical and non-medical support services to include
but not limited to:
(a)
"The Help Me Grow" (HMG) program;
(b)
The special
supplemental food program for women, infants and children
(WIC);
(c)
Maternal and child health clinics;
(d)
Local health
departments;
(e)
Social services and other community
services.
(viii)
Availability of assistance for scheduling medical
appointments, as requested by the individual.
(ix)
A list of
medicaid prenatal care providers, if requested, available to the community
and/or information about medicaid-contracting MCPs.
(2)
Inform individuals enrolled in a MCP that they should contact the MCP for
medical care options and referrals.
(3)
Re-inform the
individual of the benefits of healthchek services as soon as possible after the
infant's birth.
(4)
Refer the individual to support services as requested
verbally, in writing, or via the ODM 03528 and ensure:
(a)
Referrals are
made, as needed, for medical and non-medical support services.
(b)
Coordination
between the individual, medical provider, MCP or other entity where the
referral is made.
(c)
Transportation assistance is provided to individuals,
as requested.
(d)
Individuals in need of non-medicaid covered medical
services are referred to community, medical or other social services. This
includes providers who have expressed a willingness to furnish non-medicaid
covered services at little or no expense to the individual.
(5)
Establish contact with the individual upon notification from the medical
provider or MCP that the individual has missed appointments or there are other
problems in the delivery of care and inform the individual's medical provider
or MCP about the outcome of the contact.
(6)
Provide a copy
of the ODM 03528 (if applicable) and the ODM 03535 "Prenatal Risk Assessment
Form" (if applicable) (rev. 7/2014) to the individual's MCP.
(7)
Make a second
attempt to contact the individual by alternate means if written information
about PRS sent to the individual is returned as undeliverable.
(8)
Submit a new or
amended ODM 03515 "Pregnancy Related Services Implementation Plan" (rev.
1/2015) to Ohio department of medicaid (ODM), including but not limited to,
when there has been a change of agency address, director, PRS coordinator or
where the responsibility for PRS is organizationally located within the agency.
The ODM 03515 shall be submitted to ODM within ten business days of the
change.
(9)
Obtain a HIPAA compliant signed authorization for
release of information, ODM 03397 "Authorization for the Release or Use of
Protected Health Information (PHI) or Other Confidential Information" (rev.
8/2014), when additional medical information is needed from the
individual.
(10)
Maintain a listing of fee-for-service providers who
have expressed a willingness to furnish non-medicaid covered services at little
or no expense to the individual. It is recognized that the ability of the
administrative agency to recruit and maintain an adequate provider network
depends on the existence of appropriate providers within a reasonable
geographic area.
(11)
Maintain documentation in a case file for each
eligible individual. The file shall consist of permanent records, either hard
copy or electronically stored, containing the following information, when
appropriate:
(a)
Copy of the ODM 03528, ODM 03535, or other referral
forms received by the county;
(b)
Copy of
correspondence received and sent;
(c)
Documentation of
agency contacts with the individual, both attempted and
established;
(d)
Documentation of the MCP in which the individual is
enrolled;
(e)
Information received from another county when the
individual is an intercounty transfer;
(f)
Documentation of
all service requests, steps taken by the administrative agency, and whether the
individual received services; and
(g)
Records of
transportation services provided.
(E) Each administrative agency PRS coordinator, or such coordinator's designee(s), shall attend annual and other pertinent trainings offered by ODM. Verification of attendance shall consist of documentation of roll call and sending an evaluation form to the state email box within three days of the video conference or training. Verification of attendance at onsite training shall be documented by the PRS coordinator or such coordinator's designee(s) by signing the attendance log.
Replaces: 5160:1-2-06
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