Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-26 - Managed Care Plan
Section 5160-26-10 - Managed care: sanctions and provider agreement actions
Universal Citation: OH Admin Code 5160-26-10
Current through all regulations passed and filed through September 16, 2024
(A) This rule does not apply to the single pharmacy benefit manager as defined in rule 5160-26-01 of the Administrative Code.
(B) If the MCO fails to fulfill its duties and obligations under 42 C.F.R. Part 438 (October 1, 2021), 42 U.S.C. 1396b(m) (as in effect July 1, 2022), 42 U.S.C. 1396u-2 (as in effect July 1, 2022), agency 5160 of the Administrative Code, or the MCO provider agreement, ODM will provide timely written notification to the MCO identifying the violations or deficiencies, and may impose corrective actions or any of the following sanctions in addition to or instead of any actions or sanctions specified in the provider agreement:
(1) ODM may require corrective action plans
(CAPs) in accordance with the following:
(a)
If requested by ODM, the MCO must submit, within the specified time frame, a
proposed CAP for each cited violation or deficiency.
(b) The CAP must contain the proposed
correction date, describe the manner in which each violation or deficiency will
be resolved, and address all items specified in the ODM notification.
(c) The CAP must be reviewed and approved by
ODM.
(d) Following the approval of
the CAP, ODM will monitor the correction process until all violations or
deficiencies are corrected to the satisfaction of ODM.
(e) If the MCO fails to
submit an approvable CAP within the ODM-specified time frames, ODM may impose
an ODM-developed CAP, sanctions, or both.
(f) If ODM has already determined the
specific action that must be implemented by the MCO, ODM may
require the MCO to comply with an ODM-developed or directed
CAP.
(g) Failure by the
MCO to
successfully complete the correction process and correct the violations or
deficiencies to the satisfaction of ODM may lead to the imposition of any or
all of the sanctions listed in paragraph (
the MCO by ODM include but are not limited to the
following:
(a) Suspension of the enrollment of
the MCO's
members.
(b) Disenrollment of
the
MCO's members.
(c)
Prohibition or reduction of
the MCO's voluntary assignments.
(d) Prohibition or reduction of
the
MCO's involuntary assignments.
(e) Granting the MCO's members
the right to terminate without cause and notifying the affected members of
their right to disenroll.
(f)
Retention by ODM of
the MCO's premium payments or a portion thereof
until the violations or deficiencies are corrected.
(g) Imposition of financial
sanctions.
(C) ODM will select
sanction(s) specified in paragraph (B)(2) of this rule based on a pattern of repeated
violations or deficiencies, the severity of the cited violations or
deficiencies, the failure of the MCO to meet the requirements of an approved CAP,
or all these factors.
(D) The sanctions in
paragraph (B)(2) of this rule are subject to reconsideration by
ODM as specified in Chapter 5160-70 of the Administrative Code, with the
exception that the involuntary assignments referenced in paragraph
(B)(2)(d)
of this rule are not subject to reconsideration.
(E) Regardless of any
other sanction that may be imposed, ODM may impose temporary management on any
MCO that
has repeatedly failed to meet substantive requirements in
42 U.S.C.
1396b(m) (as in effect
July
1, 2022),
42 U.S.C.
1396 u-2 (as in effect
July
1, 2022) or 42 C.F.R. Part 438 subpart I (October 1,
2021).
Such temporary management shall be imposed in accordance with the following:
(1)
the MCO must pay the costs of a
temporary manager for performing the duties of a temporary manager as
determined by ODM.
(2)
the
MCO is solely responsible for any costs or liabilities incurred on behalf
of the MCO
when temporary management is imposed by ODM.
(3) The imposition of temporary management is
not subject to the appeals process provided under Chapter 119. of the Revised
Code; however, the MCO may request that the director for the medicaid
program reconsider this action. ODM will not delay imposition of temporary
management to provide reconsideration prior to imposing this sanction.
(4) Unless the director for the
medicaid program determines through the reconsideration process that temporary
management should not have been imposed, the temporary management will remain
in place until such time as ODM determines that the MCO can ensure that the
sanctioned behavior will not recur.
(5) Regardless of the imposition of temporary
management, the MCO retains the right to appeal any proposed
termination or nonrenewal of its provider agreement under Chapter 119. of the
Revised Code. The MCO also retains the right to initiate the sale of
the MCO or
its assets.
(6) If temporary
management is imposed, ODM will notify the
MCO's members
that such action has occurred and inform them that they therefore have the
right to terminate their membership in the MCO without cause.
Termination of the
MCO's membership without cause is not subject to
the appeals process provided under Chapter 119. of the Revised Code; however,
the MCO
may request that the director for the medicaid program reconsider this action.
ODM will not delay the notification to the
MCO's
membership to provide reconsideration prior to imposing this sanction.
(F) ODM will provide
the
MCO with written notice before imposing any sanction. The notice will
describe any reconsideration or appeal rights that are available to the
MCO.
(G) Regardless of
whether ODM imposes a sanction,
the MCO shall initiate corrective action for any
MCO
program violations or deficiencies as soon as they are identified by either the
MCO or
ODM.
(H) The following
provisions apply in the event ODM decides to terminate, nonrenew, deny, or amend the
MCO provider
agreement.
(1) ODM may terminate, nonrenew,
deny, or amend the
MCO provider
agreement if at any time ODM determines that continuation or assumption of a
provider agreement is not in the best interest of recipients or the state of
Ohio. For the purposes of this rule, an amendment to
the MCO
provider agreement is defined as, and limited
to, the elimination of one or more service areas
included in
the MCO's current provider agreement. The phrase "not in the best
interest" includes, but is not limited to, the following:
(a) The
MCO's delivery
system does not assure adequate access to services for its members.
(b) The
MCO's delivery
system does not assure the availability of all services covered under the
provider agreement.
(c) The
MCO fails
to provide all medically-necessary covered services.
(d) The MCO fails to
provide proper assurances of financial solvency.
(e) The number of members enrolled
in the
MCO's
service area is not sufficient to
ensure the effective or efficient delivery of services to members.
(f) The MCO fails to
comply with any of the following:
(i) Chapter
5160-26,
5160-58, or 5160-59 of the Administrative Code
;
(ii) The MCO
provider agreement;
(iii) The
applicable requirements in
42 U.S.C.
1396b(m) (as in effect
July
1, 2022) or
42 U.S.C.
1396u-2 (as in effect
July
1, 2022);
(iv)42 C.F.R. Part
438 (October 1, 2021
).
(2) If ODM has proposed termination,
nonrenewal, denial, or amendment of
the MCO's provider agreement, ODM may notify the
MCO's
members of this proposed action and inform the members of their right to
immediately disenroll from the MCO without cause.
(3) If ODM determines that the termination,
nonrenewal, or denial of a provider agreement is warranted:
(a) ODM will provide notice, at a minimum,
forty-five days prior to the effective date of the proposed action;
(b) The action will be in accordance with and
subject to Chapter 5160-70 of the Administrative Code; and
(c) The action will be effective at the end
of the last day of a calendar month.
(4) If ODM determines that the amendment of a
provider agreement is warranted, the proposed action is subject to
reconsideration pursuant to Chapter 5160-70 of the Administrative
Code.
(5) Notwithstanding the
preceding paragraphs of this rule, ODM may terminate
the MCO's
provider agreement effective on the last day of the calendar month in which any
of the following occur:
(a) The determination
by ODM that the loss or reduction of federal or state funding has reduced
funding to a level which is insufficient to maintain the activities or services
agreed to in the provider agreement;
(b) The exclusion from participation of the
MCO in a
program administered under Title XVIII, XIX, or XX of the Social Security Act
due to criminal conviction or the imposition of civil monetary penalties in
accordance with 42 C.F.R. Part 455 subpart B (October 1,
2021), 42
C.F.R. Part 1002 subpart A (October 1, 2021), and rule
5160-1-17.3 of the
Administrative Code;
(c) The
suspension, revocation, or nonrenewal of ODM's
authority to operate the program under the state plan or waivers of certain
federal regulations granted by CMS or congress;
(d) The suspension, revocation, or nonrenewal of the
MCO's
certificate of authority or license.
(e) The exclusion of the
MCO from
participation in accordance with
42 C.F.R.
438.808 (October 1,
2021).
(6)
If the MCO's
provider
agreement
is amended, terminated, denied, or
nonrenewed for any reason including procurement, the
MCO
is required to fulfill all duties and obligations
under
agency 5160 of the Administrative Code, as applicable, and the MCO provider agreement.
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