Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-26 - Managed Care Plan › Section 5160-26-02.1 - Managed care: termination of enrollment

Current through all regulations passed and filed through July 1, 2024
(A) This rule does not apply to MyCare Ohio
			 plans as defined in rule
			 5160-58-01 of the Administrative
			 Code or the Ohio resilience through integrated systems and excellence
			 (OhioRISE) plan as defined in rule
			 5160-59-01 of the Administrative
			 Code.
(B) The Ohio department of
			 medicaid (ODM) will terminate a member from enrollment in a managed care
			 organization (MCO) for any of the following reasons:
(1) The member's permanent place of residence
			 is moved outside the MCO service area. When this occurs, termination of MCO
			 enrollment takes effect on the last day of the month in which the member moved
			 from the service area.
(2) The
			 member becomes ineligible for medicaid. When this occurs, termination of MCO
			 enrollment takes effect on the last day of the month in which the member became
			 ineligible.
(3) The member dies, in
			 which case MCO enrollment ends on the date of death.
(4) The member is not receiving medicaid in
			 the adult extension category under section 1902(a)(10)(A)(i)(VIII) of the
			 Social Security Act, 42
			 U.S.C. 1396a(a)(10)(A)(i)
			 (VIII) (July 1, 2022), is authorized for nursing facility services, and the
			 following criteria are met:
(a) The MCO has
			 authorized nursing facility services for no less than the month of nursing
			 facility admission and for two complete consecutive calendar months
			 thereafter;
(b) For the entire
			 period in paragraph (B)(4)(a) of this rule, the member has remained in the
			 nursing facility without any admission to an inpatient hospital or long-term
			 acute care facility;
(c) The
			 member's discharge plan documents that nursing facility discharge is not
			 expected in the foreseeable future and the member has a need for long-term
			 nursing facility care;
(d) For the
			 entire period in paragraph (B)(4)(a) of this rule, the member is not using
			 hospice services; and
(e) The MCO
			 has requested disenrollment, and ODM has approved the request.
(f) The member is found by ODM to meet the
			 criteria for the developmental disabilities level of care as specified in rule
			 5123-8-01 of the Administrative
			 Code and resides in an intermediate care facility for individuals with
			 intellectual disabilities (ICF-IID). Following MCO notification to ODM and
			 written approval by ODM, termination of MCO membership takes effect on the last
			 day of the month preceding the individual's stay in the ICF-IID.
(5) The member has third party
			 coverage, and ODM determines that continuing MCO enrollment may not be in the
			 best interest of the member. This determination may be based on the type of
			 coverage the member has, the existence of conflicts between provider networks,
			 or access requirements. When this occurs, the effective date of termination of
			 MCO enrollment shall be determined by ODM but in no event shall the termination
			 date be later than the last day of the month in which ODM approves the
			 termination.
(6) The member is not
			 eligible for MCO enrollment for one of the reasons set forth in rule
			 5160-26-02 of the Administrative
			 Code.
(7) The provider agreement
			 between ODM and the MCO is terminated.