Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-26 - Managed Care Plan › Section 5160-26-02 - Managed: eligibility and 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) Eligibility for managed care organization
			 (MCO) enrollment.
(1) Except as specified in
			 paragraphs (B)(3) to (B)(5) 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 an MCO if he or she has been determined medicaid
			 eligible in accordance with division 5160:1 of the Administrative
			 Code.
(2) MCO enrollment is
			 mandatory for the following individuals:
(a)
			 Children receiving Title IV-E federal foster care maintenance;
(b) Children receiving Title IV-E adoption
			 assistance:
(c) Children in foster
			 care or other out-of-home placement; and
(d) Children receiving services through the
			 Ohio department of health's bureau for children with medical handicaps (BCMH)
			 or any other family-centered, community-based, coordinated care system that
			 receives grant funds under Section 501(a)(1)(D) of Title V of the Social
			 Security Act,
			 42 U.S.C.
			 701(a)(1)(D)
										(July 1, 2022) and is defined by the state in terms of
			 either program participation or special health care needs.
(e)
										 Individuals who
			 meet the criteria specified in rule 5160-59-04 of the Administrative Code and
			 receive services through the OhioRISE home and community based services (HCBS)
			 waiver administered by the Ohio department of medicaid
			 (ODM).
(3) Medicaid
			 eligible individuals may voluntarily choose to enroll in an MCO if they are:
(a) Indians who are members of federally
			 recognized tribes; or
(b) Individuals diagnosed with a
			 developmental disability 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
			 HCBS waiver administered by the
			 Ohio department of developmental disabilities (DODD).
(4) Except for individuals
			 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), and individuals who meet
			 the criteria in 
									paragraphs
			 (B)(2)(e) and (B)(3)(b) of this rule,
			 medicaid eligible individuals are excluded from MCO enrollment if they:
(a) Reside in a nursing facility;
			 or
(b) Receive medicaid services
			 through a medicaid waiver component, as defined in section
			 5166.02
			 of the Revised Code.
(5)
			 The following individuals are excluded from MCO enrollment.
(a) Inmates of public institutions as defined
			 in
			 42 C.F.R.
			 435.1010 (October 1,
			 2021)
			 unless otherwise specified by ODM;
(b) Dually eligible individuals enrolled in
			 both the medicaid and medicare programs;
(c) Individuals receiving services in an
			 intermediate care facility for individuals with intellectual disabilities
			 (ICF-IID) or a developmental center as defined in rule
			 5123-9-30
			 of the Administrative Code;
(d)
			 Individuals enrolled in the program of all-inclusive care for the elderly
			 (PACE);
(e) Individuals who are
			 determined to be presumptively eligible and receive temporary, time-limited
			 medical assistance as described in rule
			 5160:1-2-13
			 of the Administrative Code;
(f)
			 Individuals who receive alien emergency medical assistance in accordance with
			 rule
			 5160:1-5-06
			 of the Administrative Code;
(g)
			 Individuals who receive refugee medical assistance in accordance with rule
			 5160:1-5-05
			 of the Administrative Code; and
(h)
			 Non-citizen victims of trafficking as set forth in rule
			 5160:1-5-08
			 of the Administrative Code.
(6) Nothing in this rule shall be construed
			 to limit or in any way jeopardize an eligible individual's basic medicaid
			 eligibility or eligibility for other non-medicaid benefits to which he or she
			 may be entitled.