Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-58 - MyCare Ohio
Section 5160-58-02.1 - MyCare Ohio plans: termination of enrollment
Universal Citation: OH Admin Code 5160-58-02.1
Current through all regulations passed and filed through December 16, 2024
(A) A member will be terminated from enrollment in a MyCare Ohio plan (MCOP) for any of the following reasons:
(1) The member becomes ineligible for full
medicaid or medicare parts A or B or D. Termination of MCOP enrollment is
effective the end of the last day of the month in which the member became
ineligible.
(2) The member's
permanent place of residence is moved outside the plan's service area.
Termination of MCOP enrollment is effective the end of the last day of the
month in which the member moved from the service area.
(3) The member dies, in which case plan
enrollment ends on the date of death.
(4) The member is found by the Ohio
department of medicaid (ODM), or their designee, to meet the criteria for the
developmental disabilities (DD) level of care and has a stay in an intermediate
care facility for individuals with intellectual disabilities (ICF-IID) or is
enrolled in a DD waiver. After the MCOP notifies ODM this has occurred,
termination of MCOP enrollment takes effect on the last day of the month
preceding the ICF-IID facility stay or enrollment on the DD waiver.
(5) The member has third party coverage,
excepting medicare coverage.. Termination of MCOP enrollment is effective the
end of the last day of the month in which ODM identified the third party
coverage.
(6) The provider
agreement between ODM and the MCOP is terminated or not renewed. The effective
date of termination shall be the date of provider agreement termination or
nonrenewal.
(7) The member is not
eligible for enrollment in an MCOP for one of the reasons set forth in rule
5160-58-02 of the Administrative
Code.
(B) All of the following apply when enrollment in a MyCare Ohio plan is terminated for any of the reasons set forth in paragraph (A) of this rule:
(1) All terminations
occur at the individual level;
(2) Terminations do not
require completion of a consumer contact record (CCR);
(3) If
ODM fails to notify the MCOP of a member's termination from the plan, ODM shall
continue to pay the MCOP the applicable monthly premium rate for the member.
The MCOP shall remain liable for the provision of covered services as set forth
in rule 5160-58-03 of the Administrative
Code, until ODM provides the MCOP with documentation of the member's
termination.; and
(4) ODM shall recover
from the MCOP any premium paid for retroactive enrollment termination occurring
as a result of paragraph (A) of this rule.
(C) Member-initiated terminations.
(1) A dual-benefits member may request
disenrollment from the MCOP and transfer between plans on a month-to-month
basis any time during the year. MCOP coverage continues until the end of the
month of disenrollment.
(2) A
medicaid-only member may request a different MCOP in a mandatory service area
as follows:
(a) From the date of initial
enrollment through the first three months of plan enrollment, whether the first
three months of enrollment are dual-benefits or medicaid-only enrollment
periods;
(b) During an open
enrollment month for the member's service area as described in paragraph (E) of
this rule; or
(c) At any time, if
the just cause request meets one of the reasons for just cause as specified in
paragraph (C)(4)(e) of this rule.
(3) A medicaid-only member may request a
different MCOP if available as follows:
(a) From the date of enrollment through the
initial three months of plan enrollment;
(b) During an open enrollment month for the
member's service area as described in paragraph (E) of this rule; or
(c) At any time, if the just cause request
meets one of the reasons for just cause as specified in paragraph (C)(4)(e) of
this rule.
(4) The
following provisions apply when a member requests a different MCOP in a
mandatory service area:
(a) The request may be
made by the member, or by the member's authorized representative.
(b) All member-initiated changes
must be voluntary. MCOPs
are not permitted to encourage members to change enrollment due to a member's 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. MCOPs may not use a policy or practice that has the effect of
discrimination on the basis of the listed criteria.
(c) If a member requests disenrollment
because he or she meets any of the requirements in rule
5160-58-02 of the Administrative
Code, the member will be disenrolled after the member notifies the consumer
hotline.
(d) Disenrollment will
take effect on the last day of the calendar month as specified by an
ODM-produced HIPAA compliant 834 daily or monthly file sent to the
plan.
(e) In accordance with
42 C.F.R.
438.56 (October 1, 2021), a change
of MCOP enrollment may be
permitted for any of the following just cause reasons:
(i) The member moves out of the MCOP's
service area and a nonemergency service must be provided out of the service
area before the effective date of a termination that occurs for one of the
reasons set forth in paragraph (A) of this rule;
(ii) The MCOP does not, for moral or
religious objections, cover the service the member seeks;
(iii) The member needs related services to be
performed at the same time in a coordinated manner; however, not all related
services are available within the MCOP network, and the member's primary care
provider (PCP) or another provider determines that receiving services
separately would subject the member to unnecessary risk;
(iv) The member has experienced poor quality
of care and the services are not available from another provider within the
MCOP's network;
(v) The member
receiving long-term services and supports would have to change their
residential, institutional, or employment supports provider based on that
provider's change in status from an in network to and out-of-network provider
with the MCOP and, as a result, would experience a disruption in their
residence or employment;
(vi) The
member cannot access medically necessary medicaid-covered services or cannot
access the type of providers experienced in dealing with the member's health
care needs;
(vii) ODM determines
that continued enrollment in the MCOP would be harmful to the interests of the
member.
(f) The
following provisions apply when a member seeks a change
in MCOP enrollment for just
cause:
(i) The member or an authorized
representative must contact the MCOP to identify providers of services before
seeking a determination of just cause from ODM.
(ii) The member may make the request for just
cause directly to ODM or an ODM-approved entity, either orally or in
writing.
(iii) ODM shall review all
requests for just cause within seven working days of receipt. ODM may request
documentation as necessary from both the member and the MCOP. ODM shall make a
decision within ten working days of receipt of all necessary documentation, or
forty-five days from the date ODM receives the just cause request. If ODM fails
to make the determination within this timeframe, the just cause request is
considered approved.
(iv) ODM may
establish retroactive termination dates and/or recover premium payments as
determined necessary and appropriate.
(v) Regardless of the procedures followed,
the effective date of an approved just cause request must be no later than the
first day of the second month following the month in which the member requests
change .
(vi) If the just cause request is not
approved, ODM shall notify the member or the authorized representative of the
member's right to a state hearing.
(vii) Requests for just cause may be
processed at the individual level or case level as ODM determines necessary and
appropriate.
(viii) If a member
submits a request to change
enrollment for just cause, and the member loses medicaid eligibility prior to
action by ODM on the request, ODM shall assure that the member's MCOP
enrollment is not automatically renewed if eligibility for medicaid is
reauthorized.
(g) A
member who is in a medicare Part D drug management program and is in a
potentially at-risk or at-risk status as defined in
42 C.F.R.
423.100 (October 1, 2021) is precluded from
changing MCOPs.
(D) The following provisions apply when a termination in MCOP enrollment is initiated by a MCOP for a medicaid-only member:
(1) An MCOP may submit a request to
ODM for the termination of a member for the following reasons:
(a) Fraudulent behavior by the member;
or
(b) Uncooperative or disruptive
behavior by the member or someone acting on the member's behalf to the extent
that such behavior seriously impairs the MCOP's ability to provide services to
either the member or other MCOP members.
(2) The MCOP may not request termination due
to a member's 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.
(3) The MCOP must provide covered services to
a terminated member through the last day of the month in which the MCOP
enrollment is terminated.
(4) If
ODM approves the MCOP's request for termination, ODM shall notify in writing
the member, the authorized representative, the medicaid consumer hotline and
the MCOP.
(E) Open enrollment
Open enrollment months will occur at least annually. At least sixty days prior to the designated open enrollment month, ODM will notify eligible individuals by mail of the opportunity to change enrollment in an MCOP and will explain how the individual can obtain further information.
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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