Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-58 - MyCare Ohio
Section 5160-58-02 - MyCare Ohio plans: eligibility and enrollment
Universal Citation: OH Admin Code 5160-58-02
Current through all regulations passed and filed through December 16, 2024
(A) Eligibility.
(1) Except as specified in paragraph (A)(2)
of this rule, in mandatory service areas as permitted by
42 C.F.R.
438.52 (October 1, 2021), an
individual must be enrolled in a MyCare Ohio plan (MCOP) if he or she meets all of the following
criteria:
(a) Age eighteen or older at the
time of enrollment in the
MCOP;
(b) Eligible for medicare parts A, B and D,
and full benefits under the medicaid program; and
(c) Reside in a plan demonstration county in
Ohio. A list of demonstration counties, and the
MCOPs available
in those counties, is available at http://medicaid.ohio.gov.
(2) Indians who are members of
federally recognized tribes may voluntarily choose to enroll in
an
MCOP.
(3) The following
individuals are not eligible for enrollment in
an MCOP:
(a) Individuals enrolled in the program of
all-inclusive care for the elderly (PACE);
(b) Individuals who have other third party
creditable health care coverage, except medicare coverage as authorized by
42 U.S.C.
1395 (July 1, 2022);
(c) Individuals who are inmates of public
institutions as defined in
42 C.F.R.
435.1010 (October 1,
2021);
(d)
Individuals with intellectual disabilities who have a level of care that meets
the criteria specified in rule 5123-8-01
of the Administrative Code and receive services through a home and
community-based services (HCBS) waiver administered by the Ohio department of
developmental disabilities (DODD); and
(e) Individuals with intellectual
disabilities who receive services through an intermediate care facility for
individuals with intellectual disabilities (ICF-IID).
(4) Individuals are eligible for
MCOP
enrollment if the Ohio department of medicaid (ODM) has a provider agreement
with the
MCOP applicable to the eligible individual's county of
residence.
(5) Nothing in this rule
shall be construed to limit or in any way jeopardize an eligible individual's
basic medicaid eligibility or eligibility for medicare or other non-medicaid
benefits to which he or she may be entitled.
(B) MyCare Ohio plan enrollment.
(1) The following applies to
MCOP
enrollment:
(a) The
MCOP
must accept eligible individuals without regard to race, color, religion,
gender, gender identity, sexual orientation, age,
disability, national origin, veteran's status, military status, genetic
information, ancestry, ethnicity, mental ability, behavior, mental or physical
disability, use of services, claims experience, appeals, medical history,
evidence of insurability, geographic location within the service area, health
status or need for health services. The
MCOP will not
use any discriminatory policy or practice in accordance with
42 C.F.R.
438.3(d) (October 1,
2021).
(b)
The
MCOP
must accept eligible individuals who request
MCOP membership
without restriction.
(c) If
an
MCOP member loses managed care eligibility and is disenrolled from the
MCOP, and
subsequently regains eligibility, his or her membership in the same
MCOP
shall be re-instated back to the date eligibility was regained in accordance
with procedures established by ODM.
(d) The
MCOP must cover
all members designated by ODM in an ODM-produced Health Insurance Portability
and Accountability Act of 1996 (HIPAA) compliant 834 daily or monthly
enrollment file of new members, continuing members, and terminating
members.
(e) The
MCOP
shall not be required to provide medicaid coverage to an individual until the
individual's membership in the
MCOP is confirmed via an ODM-produced HIPAA
compliant 834 daily or monthly enrollment file or upon mutual agreement between
ODM and the MCOP.
(2) Should a service area change from
voluntary to mandatory, the notice rights in this rule must be followed.
(a) When a service area is initially
designated by ODM as mandatory for eligible individuals specified in paragraph
(A)(1) of this rule, ODM shall confirm the eligibility of each individual as
prescribed in paragraph (A)(1) of this rule. Upon the confirmation of
eligibility:
(i) Eligible individuals residing
in the service area who are currently
MCOP members are deemed participants in the
mandatory program; and
(ii) All
other eligible individuals residing in the mandatory service area may request
MCOP
membership at any time but must select a
MCOP following
receipt of a notification of mandatory enrollment (NME) issued by
ODM.
(b) MyCare Ohio
plan membership selection procedures for the mandatory program:
(i) A newly eligible individual who does not
make a choice following issuance of a NME by ODM and one additional notice,
will be assigned to a
MCOP by ODM, the medicaid consumer hotline, or
other ODM-approved entity.
(ii) ODM
or the medicaid consumer hotline shall assign the individual to a
MCOP
based on prior medicaid fee-for-service, managed care
organization, or
MCOP membership history, whenever available, or
at the discretion of ODM.
(C) Commencement of coverage.
Coverage of MCOP members will be effective on the first day of the calendar month specified on the ODM-produced HIPAA compliant 834 daily or monthly enrollment file to the MCOP.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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