Ohio Administrative Code, Chapter 5160-59, Section 5160-59-02 - OhioRISE: eligibility and enrollment | Ohio Administrative Code

(A) To be eligible for enrollment in the Ohio resilience through integrated systems and excellence (OhioRISE) program, an individual has to meet either the criteria for first day eligibility and enrollment in rule 5160-59-02.1 of the Administrative Code or the criteria in paragraphs (A)(1) to (A)(3) along with either paragraph (A)(4), (A)(5), (A)(6) or (B) of this rule.

(1) Be twenty years of age or younger at the time of enrollment;

(2) Be determined eligible for Ohio medicaid in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code;

(3) Not be enrolled in a MyCare Ohio plan as described in Chapter 5160-58 of the Administrative Code;

(4) For youth age six through twenty years of age, have an Ohio children's initiative brief or comprehensive "child and adolescent needs and strengths" (CANS) assessment, using the tool available on https://www.managedcare.medicaid.ohio.gov, and completed by a certified Ohio CANS assessor within ninety days prior to eligibility determination that indicates paragraph (A)(4)(a) and either paragraph (A)(4)(b) or (A)(4)(c) of this rule have been met:

(a) For behavioral/emotional needs domain items, at least one of the following items is dangerous or disabling and needs immediate action or at least one of the following items is interfering with functioning and needs action to ensure that the identified need is addressed:

(i) Psychosis;

(ii) Impulsivity/hyperactivity;

(iii) Depression;

(iv) Anxiety;

(v) Oppositional behavior;

(vi) Conduct;

(vii) Adjustment to trauma;

(viii) Anger control;

(ix) Substance use;

(x) Eating disturbance;

(xi) Attachment difficulties;

(xii) For youth age fourteen or older, interpersonal problems.

(b) For risk behavior domain items, at least one of the following items is dangerous or disabling and needs immediate action or at least one of the following items is interfering with functioning and needs action to ensure that the identified need is addressed:

(i) Suicide risk;

(ii) Non-suicidal self-injury behavior;

(iii) Other self-harm;

(iv) Danger to others;

(v) Delinquent behavior;

(vi) Runaway;

(vii) Intentional misbehavior;

(viii) Fire setting;

(ix) Victimization/exploitation;

(x) Sexually problematic behavior.

(c) For life functioning domain items, at least one of the following items is dangerous or disabling and needs immediate action or at least one of the following items is interfering with functioning and needs action to ensure that the identified need is addressed:

(i) Family functioning;

(ii) Living situation;

(iii) Social functioning;

(iv) Sleep;

(v) For Ohio children's initiative brief CANS school or for Ohio children's initiative comprehensive CANS school attendance or school behavior.

(5) For youth age birth through five years of age, have an Ohio children's initiative brief or comprehensive CANS assessment, using the tool available on https://www.managedcare.medicaid.ohio.gov, and completed by a certified Ohio children's initiative CANS assessor within ninety days prior to eligibility determination that indicates paragraph (A)(5)(a) and either paragraph (A)(5)(b), (A)(5)(c), or (A)(5)(d) of this rule have been met:

(a) For early childhood challenge domain items, at least one of the following items is dangerous or disabling and needs immediate action or at least one of the following items is interfering with functioning and needs action to ensure that the identified need is addressed:

(i) Impulsivity/hyperactivity;

(ii) Depression;

(iii) Anxiety;

(iv) Oppositional behavior;

(v) Attachment difficulties;

(vi) Adjustment to trauma;

(vii) Regulatory.

(b) Meeting at least one of the following:

(i) For caregiver resources and needs domain items, at least one of the following items prevents the provision of care and needs immediate action or at least one of the following items is at least interfering with the provision of care and needs action to ensure that the identified need is addressed:

(a) Supervision;

(b) Residential stability;

(c) Medical/physical;

(d) Mental health;

(e) Substance use;

(f) Developmental;

(g) Family stress;

(h) Caregiver post-traumatic stress reaction;

(i) Marital/partner violence;

(j) Family relationship with the system;

(k) Legal involvement.

(ii) For early childhood domain item developmental or intellectual, the need is dangerous or disabling and needs immediate action or is interfering with functioning and needs action to ensure that the need is addressed.

(c) The caregiver resources and needs domain item "safety" is identified as a need that at least needs monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.

(d) For early childhood domain items, at least one of the following items is dangerous or disabling and needs immediate action or at least one of the following items is interfering with functioning and needs action to ensure that the identified need is addressed:

(i) Sleep;

(ii) Family functioning;

(iii) Early education;

(iv) Social and emotional functioning;

(v) Medical/physical;

(vi) Failure to thrive.

(6) For youth who meet one of the following but do not meet the criteria in paragraph (A)(4) or (A)(5) of this rule;

(a) Meets the criteria for moderate care coordination as described in paragraph (A)(1) or (A)(3) of rule 5160-59-03.2 of the Administrative Code; or

(b) Meets the criteria to receive intensive home-based treatment (IHBT) service as described in rule 5122-29-28 of the Administrative Code.

(B) Youth who meet the criteria in paragraphs (A)(1) to (A)(3) of this rule are eligible for OhioRISE enrollment when they are inpatient in a hospital, as defined in in Chapter 5160-2 of the Administrative Code, with a primary diagnosis of mental illness or substance use disorder, and will remain in OhioRISE until the youth meets the criteria for disenrollment in paragraph (D) of this rule.

(C) Enrollment in OhioRISE is mandatory for eligible youth who meet the criteria in paragraph (A) or (B) of this rule. Except for youth eligible for first day eligibility and enrollment in rule 5160-59-02.1 of the Administrative Code, enrollment begins the earlier of:

(1) The submission date of the CANS assessment that determines the youth meets the criteria in paragraph (A)(4), (A)(5), or (A)(6)(a) of this rule;

(2) The date of admission to an inpatient hospital with a primary diagnosis of mental illness or substance use disorder;

(3) The effective date of enrollment in the OhioRISE 1915(c) waiver as described in rule 5160-59-04 of the Administrative Code; or

(4) The date the youth met criteria for IHBT in paragraph (A)(6)(b) of this rule.

(D) Disenrollment from OhioRISE occurs upon the earliest of any of the following:

(1) The last day of the following month when:

(a) The youth turns twenty-one years of age, except for as described in paragraph (D)(2) of this rule; or

(b) Two years have passed since the youth's enrollment in OhioRISE and the youth subsequently:

(i) Has not had a CANS assessment meeting the eligibility criteria in paragraph (A)(4), (A)(5), or (A)(6)(a) of this rule in the last two years;

(ii) Has not received IHBT services in the last three hundred sixty-five days; and

(iii) Has not experienced an inpatient hospital stay as described in paragraph (B) of this rule in the last three hundred sixty-five days.

(2) Youth who are receiving inpatient psychiatric services in a hospital or psychiatric residential treatment facility (PRTF), as described in rule 5160-59-03.6 of the Administrative Code, upon turning twenty-one years of age, will remain enrolled in OhioRISE until the last day of the following month of whichever occurs first:

(a) The youth is discharged; or

(b) The youth reaches twenty-two years of age.

(3) The date the youth begins enrollment in a MyCare Ohio plan, as described in Chapter 5160-58 of the Administrative Code.

(4) The date of the youth's death.

(5) The date the youth is no longer eligible for medicaid.

(E) Member initiated disenrollment.

(1) In accordance with 42 CFR 438.56(d)(2) (October 1, 2023), a termination of OhioRISE program enrollment may be permitted for any of the following just cause reasons:

(a) The OhioRISE plan does not, for moral or religious objections, cover the service the youth seeks;

(b) The youth needs related services to be performed at the same time, not all related services are available within the OhioRISE plan's network, and the youth's primary care provider or another provider determines that receiving services separately would subject the youth to unnecessary risk;

(c) The youth has experienced poor quality of care and the services are not available from another provider within the OhioRISE plan's network; or

(d) The youth cannot access medically necessary medicaid-covered services or cannot access the type of providers experienced in dealing with the youth's care needs.

(e) After three hundred sixty-five days of continuous enrollment in the OhioRISE plan, disenrollment may be requested if the youth:

(i) Has not had a CANS assessment meeting the eligibility criteria in paragraph (A)(4), (A)(5), or (A)(6)(a) of this rule: or

(ii) Has not utilized any of the covered services, excluding care coordination, as described in paragraph (B) of rule 5160-59-03 of the Administrative Code, provided through the OhioRISE plan.

(2) The following provisions apply when a youth seeks a termination in OhioRISE enrollment for just cause:

(a) The youth may make the request for just cause directly to ODM or an ODM-approved entity, either orally or in writing.

(b) ODM will review all requests for just cause within seven working days of receipt. ODM may request documentation as necessary from both the youth and the OhioRISE plan. ODM will make a decision within 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.

(c) ODM may establish retroactive termination dates and recover capitation payments as determined necessary and appropriate.

(d) The effective date of an approved just cause request will be no later than the first day of the second month following the month in which the member requests change or termination.

(e) Requests for just cause may be processed at the individual level or case level as ODM determines necessary and appropriate.

(F) If a youth is denied enrollment in the program pursuant to paragraph (A) or (B) of this rule, is disenrolled from the program pursuant to paragraph (D) of this rule, or if the youth-initiated disenrollment is denied pursuant to paragraph (E) of this rule, the youth will be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

Ohio Administrative CodeTitle 5160 - Ohio Department of MedicaidChapter 5160-59 - OhioRISESection 5160-59-02 - OhioRISE: eligibility and enrollment

Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-59 - OhioRISE
Section 5160-59-02 - OhioRISE: eligibility and enrollment