Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-26 - Managed Care Plan
Section 5160-26-05 - Managed care: provider network and contracting requirements
Universal Citation: OH Admin Code 5160-26-05
Current through all regulations passed and filed through September 16, 2024
(A) Provider contracts.
(1) A managed care entity
(MCE) must provide or arrange for the delivery of covered health care
services described in rule
5160-26-03 of the Administrative
Code either through the use of employees or through
contracts with network providers of health care
services ("providers"). All Provider
contracts must be in writing and in accordance with paragraph (D) of this
rule and
42 C.F.R.
434.6 and
438.6
(October 1, 2021). The
MCE's execution of a provider
contract
does not
terminate the
MCE's legal responsibility to the Ohio department of
medicaid (ODM) to ensure all of the
MCE's activities and obligations are performed in
accordance with agency 5160 of the Administrative
Code, as applicable, the
MCE's provider agreement
or contract with
ODM, and all applicable federal, state, and local regulations.
(2)
The MCE shall make all
Provider contracts
available to ODM upon request.
(3)
Provider
contracts may not include language that conflicts with the specifications
identified in paragraphs (C) and (D) of this rule.
(4)
MCE network
providers have to maintain an active, valid medicaid provider agreement as set
forth in rule
5160-1-17.2 of the
Administrative Code.
(5) When utilizing an
out of
network provider, the
MCE must
establish a mutually agreed upon compensation amount for the authorized service
and notify the provider of the applicable provisions of paragraph (D) of this
rule. For medicaid-covered non-emergency hospital services outlined in rule
5160-26-03 of the Administrative
Code, the compensation amount is identified in rule
5160-26-11 of the Administrative
Code.
(B) Notification.
(1) Notwithstanding paragraph (D)(13) of this
rule,
the
MCE must notify ODM of any addition to or deletion from its provider
network
on an ongoing basis, and must follow the time restrictions contained in this
paragraph unless the explanation of extenuating circumstances is accepted by
ODM.
(2) At the direction of ODM,
the
MCE
must submit evidence of the following:
(a) A
copy of the provider's current licensure;
(b) Copies of written agreements with the
provider, including but not limited to Provider
contracts, amendments, and the medicaid
addendum as specified in paragraph (D) of this rule;
(c) Notification to ODM of any hospital
provider contract for which a date of termination is
specified; and
(d) The provider's
medicaid provider number and provider reporting number, if
applicable.
(3) The
MCE shall
notify ODM in writing of the expiration, nonrenewal, or termination of any
provider contract at least fifty-five calendar days prior to
the expiration, nonrenewal, or termination of the
provider
contract in a manner and format directed by ODM. If the
MCE
receives less than fifty-five calendar days' notice from the provider, the
MCE must
inform ODM in writing within one working day of becoming aware of this
information.
(4) If the
provider
contract is for a hospital:
(a) Forty-five calendar
days prior to the effective date of the expiration, nonrenewal or termination
of the hospital's provider contract, the MCO shall notify in writing all
providers who have admitting privileges at the hospital of the impending
expiration, nonrenewal, or termination of the provider
contract and the last date the hospital will provide services to members
under the MCO provider contract. If the MCO receives less than
forty-five calendar days' notice from the hospital, the MCO shall send the
notice within one working day of becoming aware of the expiration, nonrenewal,
or termination of the provider contract.
(b) Forty-five
calendar days prior to the effective date of the expiration, nonrenewal, or
termination of the hospital's provider
contract, the MCO shall notify in writing all members in the service
area, or in an area authorized by ODM, of the impending expiration, nonrenewal,
or termination of the hospital's provider
contract. If the MCO receives less than forty-five calendar days' notice
from the hospital provider, the MCO shall send the notice within one working
day of becoming aware of the expiration, nonrenewal, or termination of the
provider
contract.
(c) The MCO shall
submit a template for member and provider notifications to ODM along with the
MCO's notification to ODM of the impending expiration, nonrenewal, or
termination of the hospital's provider
contract. The notifications shall comply with the following:
(i) The form
and content of the member notice must be prior-approved by ODM and contain an
ODM designated toll-free telephone number members can call for information and
assistance.
(ii) The form
and content of the provider notice must be prior-approved by
ODM.
(d) ODM may require
the MCO to notify additional members or providers if the impending expiration,
nonrenewal, or termination of the hospital's provider
contract adversely impacts additional members or
providers.
(5) If the
provider
contract is for a primary care provider (PCP):
(a) The MCO shall
include the number of members that will be affected by the change in the notice
to ODM; and
(b) The MCO shall
notify in writing all members who use or are assigned to the provider as a PCP
at least forty-five calendar days prior to the effective date of the change. If
the MCO receives less than forty-five calendar days prior notice from the PCP,
the MCO shall issue the notification within one working day of the MCO becoming
aware of the expiration, nonrenewal, or termination of PCP's
provider contract. The form of the notice and its
content must be prior-approved by ODM and must contain, at a minimum, all of
the following information:
(i) The PCP's
name and last date the PCP is available to provide care to the MCO's
members;
(ii)
Information regarding how members can select a different PCP; and
(iii) An MCO
telephone number members can call for further information or
assistance.
(6) ODM may require the
MCE to
notify members or providers
of the expiration, nonrenewal, or termination of
other provider
contracts that may adversely impact the
MCE's
members.
(7) In order to ensure
availability of services and qualifications of providers, ODM may require
submission of documentation in accordance with paragraph (B) of this rule
regardless of whether the
MCE
contracts
directly for services or does so through another entity.
(8) In
the event that
the MCE's medicaid managed care program
participation in a service area is terminated, the
MCE must provide
written notification to its affected
contracted providers at least forty-five calendar days
prior to the termination date, unless otherwise specified by
ODM.
(C) Provider qualifications.
(1) The
MCE must
ensure that none of its employees or contracted providers are sanctioned or
excluded from providing medicaid or medicare services.
The MCE
shall use available resources for identifying sanctioned providers, at least monthly, including, but not limited to, the
following:
(a) The federal office of inspector
general provider exclusion list;
(b)
The ODM excluded provider web page; and
(c) The discipline pages of the applicable
state boards that license providers or an alternative data resource, such as
the national practitioner databank, that is as complete and accurate as the
discipline pages of the applicable state boards.
(2)
The MCE may not discriminate with
regard to the participation, reimbursement, or indemnification of any provider
who is acting within the scope of his or her license or certification under
applicable state law, solely on the basis of that license or certification. If
The
MCE declines to include individual or groups of providers in its network,
it must give the affected providers written notice of the reasons for its
decision. This paragraph may not be construed to:
(a) Require the
MCE to contract
with providers beyond the number necessary to meet the needs of its members
as described in the MCE's provider agreement or
contract with ODM;
(b)
Preclude the
MCE from using different reimbursement amounts for
different specialties or for different practitioners in the same specialty;
or
(c) Preclude the
MCE from
establishing measures that are designed to maintain quality of services and
control costs and are consistent with its responsibilities to
members.
(3) The
MCE must
have written policies and procedures for the selection and retention of
providers that prohibit discrimination against particular providers that serve
high-risk populations or specialize in conditions that require costly
treatment.
(4)
The MCE will accept ODM credentialing of ODM-enrolled
providers and will not conduct any further credentialing activities for those
providers.
(D) Provider contract specifications.
All Provider contracts, including single case agreements, must include a medicaid addendum that has been approved by ODM. The medicaid addendum must include the following elements, appropriate to the service being rendered, as specified by ODM:
(1) An
agreement by the provider to comply with the applicable provisions for record
keeping and auditing in accordance with Chapter 5160-26 of the Administrative
Code.
(2) Specification of the
medicaid population and service areas, pursuant to the
MCE's
provider agreement or contract with
ODM.
(3) Specification of the
health care services to be provided.
(4) Specification that the
provider
contract is governed by, and construed in accordance with all applicable
laws, regulations, and contractual obligations of the
MCE and:
(a) ODM shall notify the
MCE and
the
MCE
shall notify the provider of any changes in applicable state or federal law,
regulations, waiver, or contractual obligation of the
MCE;
(b)
The provider contract shall be automatically amended to
conform to such changes without the necessity for written execution;
and
(c) The
MCE shall
notify the provider of all applicable contractual
obligations.
(5)
Specification of the beginning date and expiration date of the
contract, or an automatic renewal clause, as well as
the applicable methods of extension, renegotiation, and termination.
(6) Specification of the procedures to be
employed upon the ending, nonrenewal, or termination of the
contract, including an agreement by the provider to
promptly supply all records necessary for the settlement of outstanding medical
claims.
(7) Full disclosure of the
method and amount of compensation or other consideration to be received by the
provider from the MCE.
(8) An
agreement not to discriminate in the delivery of services based on the member's
race, color, religion, gender, gender identity, genetic information, sexual
orientation, age, disability, national origin, military status, ancestry,
health status, or need for health services.
(9) An agreement by the provider to not hold
liable ODM or members in the event that the
MCE cannot or
will not pay for services performed by the provider pursuant to the
contract with the exception that:
(a) Federally qualified health centers
(FQHCs) and rural health clinics (RHCs) may be reimbursed by ODM in the event
of
MCE
insolvency.
(b) The provider may
bill the member when the
MCE has denied prior authorization or referral
for services and the conditions
described in rule
5160-1-13.1 of the
Administrative Code are met.
(10) An agreement by the provider that with
the exception of any member co-payments the
MCE has elected
to implement in accordance with rule
5160-26-12 of the Administrative
Code, the
MCE's payment constitutes payment in full for any
covered service and the provider will not charge the member or ODM any
co-payment, cost sharing, down-payment, or similar charge, refundable or
otherwise. This agreement does not prohibit nursing facilities or home and
community-based services waiver providers from collecting patient liability
payments from members as specified in rules
5160:1-6-07 and
5160:1-6-07.1 of the
Administrative Code or FQHCs and RHCs from submitting claims for supplemental
payments to ODM as specified in Chapter 5160-28 of the Administrative Code.
Additionally, the
MCE and the
provider agree to the following:
(a) The
MCE shall
notify the provider whether the
MCE has elected to implement any member
co-payments and if, applicable, the circumstances in which member co-payment
amounts will be imposed in accordance with rule
5160-26-12 of the Administrative
Code; and
(b) The provider agrees
that member notifications regarding any applicable co-payment amounts must be
carried out in accordance with rule
5160-26-12 of the Administrative
Code.
(11) A
specification that the provider and all employees of the provider are duly
registered, licensed or certified under applicable state and federal statutes
and regulations to provide the health care services that are the subject of the
contract, and that provider and all employees of the
provider have not been excluded from participating in federally funded health
care programs.
(12) An agreement
that ODM
administered home and community based services (HCBS) waiver providers
are currently enrolled as ODM providers with an active status in accordance
with agency 5160 of the Administrative Code, and all other
providers are either currently enrolled as ODM providers and meet the
qualifications specified in paragraph (C) of this rule, or they are in the
process of enrolling as ODM providers;
(13) A stipulation that the
MCE will
give the provider at least sixty-days' prior notice in writing for the
nonrenewal or termination of the contract
except in cases where an adverse finding by a regulatory agency or health or
safety risks dictate that the contract
be terminated sooner or when the contract is temporary in accordance with
42 C.F.R.
438.602 (October 1,
2021) and
the provider fails to enroll as an ODM provider within one hundred twenty
days.
(14) A stipulation that the
provider may nonrenew or terminate the contract
if one of the following occurs:
(a) The
provider gives the
MCE at least sixty days prior notice in writing
for the nonrenewal or termination of the contract,
or the termination of any services for which the provider is contracted. The
effective date for any nonrenewal or termination of the
contract, or termination of any contracted service
must be the last day of the month.
(b) ODM has proposed action to terminate,
nonrenew, deny or amend the MCO's provider agreement in accordance with rule
5160-26-10 of the Administrative
Code, regardless of whether this action is appealed. The provider's termination
or nonrenewal written notice must be received by the
MCE within
fifteen working days prior to the end of the month in which the provider is
proposing termination or nonrenewal. If the notice is not received by this
date, the provider must agree to extend the termination or nonrenewal date to
the last day of the subsequent month.
(15) The provider's agreement to serve
members through the last day the contract
is in effect.
(16) The provider's
agreement to make the medical records for medicaid eligible individuals
available for transfer to new providers at no cost to the individual.
(17) A specification that all laboratory
testing sites providing services to members must have either a current clinical
laboratory improvement amendments (CLIA) certificate of waiver, certificate of
accreditation, certificate of compliance, or certificate of registration along
with a CLIA identification number.
(18) A requirement securing cooperation with
the MCO's quality assessment and performance improvement (QAPI) program in all
its provider contracts and employment agreements for physician and
nonphysician providers.
(19) An
agreement by the provider and
MCE that:
(a)
The
MCE
shall disseminate written policies in accordance with the requirements of
42 U.S.C.
1396a(a)(68) (as in effect
July 1,
2022) and section
5162.15 of the Revised Code,
regarding the reporting of false claims and whistleblower protections for
employees who make such a report, and including the
MCE's policies
and procedures for detecting and preventing fraud, waste, and abuse;
and
(b) The provider agrees to abide
by the
MCE's written policies related to the requirements of
42 U.S.C.
1396a(a)(68) (as in effect
July 1,
2022) and section
5162.15 of the Revised Code,
including the MCE's policies and procedures for detecting and
preventing fraud, waste, and abuse.
(20) A specification that hospitals and other
providers must allow the
MCE access to all member medical records for a
period of not less than
ten years from the date of service or until any
audit initiated within the
ten year period is completed and allow access to
all record-keeping, audits, financial records, and medical records to ODM or
its designee or other entities as specified in rule
5160-26-06 of the Administrative
Code.
(21) A specification,
appearing above the signature(s) on the signature page in all PCP
contracts, stating the maximum number of MCO members
that each PCP can serve at each practice site for that MCO.
(22) A specification that the provider must
cooperate with the ODM external quality reviews required by
42 C.F.R.
438.358 (October 1,
2021) and
on-site audits as deemed necessary based on ODM's periodic analysis of
financial, utilization, provider
network and other information.
(23) A specification that the provider must
be bound by the same standards of confidentiality that apply to ODM and the
state of Ohio as described in rule
5160-1-32 of the Administrative
Code, including standards for unauthorized uses of or disclosures of protected
health information (PHI).
(24) A
specification that any third party administrator (TPA) must include the
elements of paragraph (D) of this rule in its contracts
and ensure that its
contracted providers will forward information to
ODM as requested.
(25) A
specification that home health providers must meet the eligible provider
requirements specified in Chapter 5160-12 of the Administrative Code and comply
with the requirements for home care dependent adults as specified in section
121.36 of the Revised
Code.
(26) A specification that PCPs
must participate in the care coordination requirements outlined in rule
5160-26-03.1 of the
Administrative Code.
(27) A
specification that the provider in providing health care services to members
must identify and where necessary arrange, pursuant to the mutually agreed upon
policies and procedures between the
MCE and provider, for the following at no cost to
the member;
(a) Sign language services;
and
(b) Oral interpretation and
oral translation services.
(28) A specification that the
MCE
agrees to fulfill the provider's responsibility to
issue notice of the member's right to request a state
hearing whenever the provider bills a member due to the
MCE's
denial of payment of a service, as specified in rules
5160-26-08.4 and 5160-58- 08.4
of the Administrative Code, utilizing the procedures and forms as specified in
Chapter 5101:6-2 of the Administrative Code.
(29) The provider's agreement to contact the
twenty-four-hour post-stabilization services phone line designated by the
MCE to
request authorization to provide post-stabilization services in accordance with
rule 5160-26-03 of the Administrative
Code.
(30) A specification that the
MCE may
not prohibit or otherwise restrict a provider, acting within the lawful scope
of practice, from advising or advocating on behalf of a member who is his or
her patient for the following:
(a) The
member's health status, medical care, or treatment options, including any
alternative treatment that may be self-administered;
(b) Any information the member needs in order
to decide among all relevant treatment options;
(c) The risks, benefits, and consequences of
treatment versus non-treatment; and
(d) The member's right to participate in
decisions regarding his or her health care, including the right to refuse
treatment, and to express preferences about future treatment
decisions.
(31) A
stipulation that the provider must not identify the addressee as a medicaid
recipient on the outside of the envelope when contacting members by
mail.
(32) An agreement by the
provider that members will not be billed for missed appointments.
(33) An agreement that in the performance of
the contract or in the hiring of any employees for the
performance of services under the contract,
the provider shall not by reason of race, color, religion, gender, gender
identity, genetic information, sexual orientation, age, disability, national
origin, military status, health status, or ancestry, discriminate against any
citizen of Ohio in the employment of a person qualified and available to
perform the services to which the contract
relates.
(34) An agreement by the
provider that it shall not in any manner, discriminate against, intimidate, or
retaliate against any employee hired for the performance of services under the
contract on account of race, color, religion, gender,
gender identity, genetic information, sexual orientation, age, disability,
national origin, military status, health status, or ancestry.
(35) Notwithstanding paragraphs (D)(13) and
(D)(14) of this rule, in the event of a hospital's proposed nonrenewal or
termination of a hospital contract, an agreement by the
contracted hospital to notify in writing all providers
who have admitting privileges at the hospital of the impending nonrenewal or
termination of the contract and the last date the hospital will provide
services to members under the MCE contract. The
contracted hospital must send this notice to the
providers with admitting privileges at least forty-five calendar days prior to
the effective date of the nonrenewal or termination of the hospital
contract. If the contracted hospital issues less than
forty-five days prior notice to the MCE, the notice to providers with admitting privileges
must be sent within one working day of the
contracted hospital issuing notice of nonrenewal or
termination of the contract.
(36) An agreement by the provider to supply,
upon request, the business transaction information required under
42
C.F.R. 455.105 (October 1,
2021).
(37)
An agreement by the provider to release to the MCO, ODM or ODM designee any
information necessary for the
MCE to perform any of its obligations under the
ODM provider agreement, including but not limited to compliance with reporting
and quality assurance requirements.
(38) An agreement by the provider that its
applicable facilities and records will be open to inspection by the
MCE,
ODM, or
ODM's designee, or other entities as specified in
rule 5160-26-06 of the Administrative
Code.
(E) In lieu of including a medicaid addendum as required by paragraph (D) of this rule, an MCE may permit a TPA that assists in the administration of health care services including pharmaceutical, dental, vision and behavioral health services on behalf of the MCE's members, to include elements in paragraphs (D)(1) to (D)(38) of this rule in contracts with entities that provide for the direct provision of health care services to its members. The MCE must receive written evidence that the TPA complied with this paragraph and has informed the entities of the obligation to provide health care services to the MCE's members.
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