Ohio Administrative Code|Rule 5160-58-03 | MyCare Ohio plans: covered services.

                                                
(A) A MyCare Ohio plan (MCOP) must ensure
		  members have access to all medically-necessary medical, drug, behavioral
		  health, nursing facility and home and community-based services (HCBS) covered
		  by Ohio medicaid. After consideration of verified third party liability
		  including medicare coverage pursuant to rule 5160-26-09.1 of the Administrative
		  Code, the MCOP must ensure:
(1) Services are
			 sufficient in amount, duration or scope to reasonably be expected to achieve
			 the purpose for which the services are furnished;
(2) The amount, duration,
			 or scope of a required service is not arbitrarily denied or reduced solely
			 because of the diagnosis, type of illness, or condition;
(3) Prior authorization
			 is available for services on which an MCOP has placed a pre-identified
			 limitation to ensure the limitation may be exceeded when medically necessary,
			 unless the MCOP's limitation is also a limitation for fee-for-service
			 medicaid coverage;
(4) Medicaid coverage decisions are based
			 on the coverage and medical necessity criteria published in agency 5160 of the
			 Administrative Code; and practice guidelines specified in rule 5160-26-05.1 of
			 the Administrative Code; and
(5) ) If a member is unable to obtain
			 medically-necessary medicaid services from an MCOP panel provider, the plan
			 must adequately and timely cover the services out of panel until the plan is
			 able to provide the services from a panel provider.
(B) The MCOP may place appropriate limits
		  on a service;
(1) On the basis of
			 medical necessity for the member's condition or diagnosis;
			 or;
(2) Except as otherwise
			 specified in this rule, to available panel providers; or
(3) For the purposes of utilization
			 control, provided the services furnished can be reasonably expected to achieve
			 their purpose as specified in paragraph (A)(1) of this rule.
(C) The MCOP must cover annual physical
		  examinations for adults.
(D) At the request of a member, an MCOP
		  must provide for a second opinion from a qualified health care professional
		  within the panel. If a qualified health care professional is not available
		  within the plan's panel, the plan must arrange for the member to obtain a
		  second opinion outside the panel, at no cost to the member.
(E) The MCOP must ensure emergency
		  services as defined in rule 5160-26-01 of the Administrative Code are provided
		  and covered twenty-four hours a day, seven days a week. At a minimum, such
		  services must be provided and reimbursed in accordance with the
		  following:
(1) The MCOP may not deny
			 payment for treatment obtained when a member had an emergency medical condition
			 as defined in rule 5160-26-01 of the Administrative Code.
(2) The MCOP cannot limit
			 what constitutes an emergency medical condition on the basis of diagnoses or
			 symptoms.
(3) The MCOP must cover
			 all emergency services without requiring prior authorization.
(4) The MCOP must cover
			 medicaid-covered services related to the member's emergency medical
			 condition when the member is instructed to go to an emergency facility by a
			 representative of the plan including but not limited to the member's
			 primary care provider (PCP) or the plan's twenty-four-hour toll-free
			 call-in-system.
(5) The MCOP cannot deny
			 payment of emergency services based on the treating provider, hospital, or
			 fiscal representative not notifying the member's PCP of the
			 visit.
(6) For the purposes of
			 this rule, "non-contracting provider of emergency services" means any
			 person, institution, or entity who does not contract with the MCOP but provides
			 emergency services to a plan member, regardless of whether that provider has a
			 medicaid provider agreement with ODM. The plan must cover emergency services as
			 defined in rule 5160-26-01 of the Administrative Code when the services are
			 delivered by a non-contracting provider of emergency services. Claims for these
			 services cannot be denied regardless of whether the services meet an emergency
			 medical condition as defined in rule 5160-26-01 of the Administrative Code.
			 Such services must be reimbursed by the plan at the lesser of billed charges or
			 one hundred per cent of the Ohio medicaid program fee-for-service reimbursement
			 rate (less any payments for indirect costs of medical education and direct
			 costs of graduate medical education that is included in the Ohio medicaid
			 program fee-for-service reimbursement rate) in effect for the date of service.
			 If an inpatient admission results, the plan is required to reimburse at this
			 rate only until the member can be transferred to a provider designated by the
			 plan.
(7) The MCOP must cover
			 emergency services until the member is stabilized and can be safely discharged
			 or transferred.
(8) The MCOP must adhere to the judgment
			 of the attending provider when the attending provider requests a member's
			 transfer to another facility or discharge. The plan may establish arrangements
			 with hospitals whereby the plan may designate one of its contracting providers
			 to assume the attending provider's responsibilities to stabilize, treat
			 and transfer the member.
(9) A member who has had an emergency
			 medical condition may not be held liable for payment of any subsequent
			 screening and treatment needed to diagnose the specific condition or stabilize
			 the member.
(F) The MCOP must establish, in writing,
		  the process and procedures for the submission of claims for services delivered
		  by non-contracting providers, including non-contracting providers of emergency
		  services as described in paragraph (E)(6) of this rule. These written policies
		  and procedures must be made available to non-contracting providers, including
		  non-contracting providers of emergency services, on request. The plan may not
		  establish claims filing and processing procedures for non-contracting
		  providers, including non-contracting providers of emergency services, that are
		  more stringent than those established for their contracting
		  providers.
(G) The MCOP must ensure
		  post-stabilization care services as defined in rule 5160-26-01 of the
		  Administrative Code are provided and covered twenty-four hours a day, seven
		  days a week.
(1) The MCOP must
			 designate a telephone line to receive provider requests for coverage of
			 post-stabilization care services. The line must be available twenty-four hours
			 a day, seven days a week. The plan must document the telephone number and
			 process for obtaining authorization has been provided to each emergency
			 facility in the service area. The plan must maintain a record of any request
			 for coverage of post-stabilization care services that is denied including, at a
			 minimum, the time of the provider's request and the time the plan
			 communicated the decision in writing to the provider.
(2) At a minimum,
			 post-stabilization care services must be provided and reimbursed in accordance
			 with the following:
(a) The MCOP must cover services obtained within or outside
				the plan's panel that have not been pre-approved in writing by a plan
				provider or other plan representative.
(b) If the MCOP does not respond within one hour of a
				provider's request for preapproval of further services administered to
				maintain the member's stabilized condition, the plan must cover the
				services, whether or not they were provided within the plan's
				panel.
(c) The MCOP must cover services obtained within or outside
				the plan's panel that are not pre-approved by a plan provider or other
				plan representative but are administered to maintain, improve or resolve the
				member's stabilized condition if:
(i) The MCOP fails to
				  respond within one hour to a provider request for authorization to provide such
				  services.
(ii) The MCOP cannot be
				  contacted.
(iii) The MCOP's
				  representative and treating provider cannot reach an agreement concerning the
				  member's care and a plan provider is not available for consultation. In
				  this situation, the plan must give the treating provider the opportunity to
				  consult with a plan provider and the treating provider may continue with care
				  until a plan provider is reached or one of the criteria specified in paragraph
				  (G)(3) of this rule is met.
(3) The MCOP's
			 financial responsibility for post stabilization care services not pre-approved
			 ends when:
(a) A plan provider with privileges at the treating
				hospital assumes responsibility for the member's care;
(b) A plan provider assumes responsibility for the
				member's care after the member is transferred to another
				facility;
(c) A plan representative and the treating provider reach
				an agreement concerning the member's care; or
(d) The member is discharged.
(H) MCOP responsibilities for payment of
		  other services.
(1) The MCOP must permit members to
			 self-refer to Title X services provided by any qualified family planning
			 provider (QFPP). The plan is responsible for payment of claims for Title X
			 services delivered by QFPPs not contracting with the plan at the lesser of one
			 hundred per cent of the Ohio medicaid program fee-for-service reimbursement
			 rate or billed charges, in effect for the date of service.
(2) The MCOP must permit members to
			 self-refer to any women's health specialist within the plan's panel
			 for covered care necessary to provide women's routine and preventative
			 health care services. This is in addition to the member's designated
			 primary care provider (PCP) if that PCP is not a women's health
			 specialist.
(3) The MCOP must ensure access to
			 covered services provided by all federally qualified health centers (FQHCs) and
			 rural health clinics (RHCs).
(4) Where available, the MCOP must ensure
			 access to covered services provided by a certified nurse
			 practitioner.
(5) The MCOP is not responsible for
			 payment of services provided through the medicaid schools program pursuant to
			 Chapter 5160-35 of the Administrative Code.
(6) The MCOP must provide all early and
			 periodic screening, diagnosis and treatment (EPSDT) services, also known as
			 healthchek services, in accordance with rule 5160-1-14 of the Administrative
			 Code, to healthchek eligible members and ensure healthchek exams:
(a) Include the components specified in rule 5160-1-14 of
				the Administrative Code. All components of exams must be documented and
				included in the medical record of each healthchek eligible member and made
				available for the ODM annual external quality review.
(b) Are completed within ninety days of the initial
				effective date of membership for those children found to have a possible
				ongoing condition likely to require care management services.
(7) An MCOP is not required to cover
			 services provided to members outside the United States.
(8) When a member is determined to be no longer eligible
			 for enrollment in an MCOP during a stay in an institution for mental disease
			 (IMD), the MCOP is not responsible for payment of that IMD stay after the date
			 of disenrollment from the plan.