Ohio Admin. Code 5160:1-2-16 - Medicaid: pregnancy related services (PRS)
(A) The purpose of this rule is to outline
the responsibilities of the administrative agency to inform
medicaid-eligible
a pregnant women
woman eligible for medical assistance about the
benefits and importance of pregnancy related services (PRS), to make requested
or needed referrals to support services, and to provide non-medical
support services that
promoting
promote healthy birth outcomes in accordance with
42 C.F.R.
440.210 (as in effect
January 1, 2014
October 1, 2023).
(B) Definitions.
(1)(2) "Individual" for
the purpose of this rule, means a medicaid-eligible
individual
pregnant woman eligible for medical
assistance
who is pregnant, as
verified by either self-declaration or medical verification, including
during
the sixty days
post-partum
the postpartum
period.
(2)(3) ODM 03515
"Pregnancy Related Services Implementation Plan" (PRSIP)
(rev. 1/2015) means the document submitted
by an
the
administrative agency describing how it delivers PRS to pregnant women in its
county and identifies which
entity is
entities
are responsible for ensuring the delivery of PRS.
(3)(7) "PRS coordinator"
means the administrative agency employee who is responsible for the
implementation
execution of PRS
the
PRSIP.
(4)(8) "Support services"
are non-medical services offered or provided by the administrative agency to
assist the individual and may include arranging or providing transportation,
making medical appointments, accompanying the individual to medical
appointments, and making referrals to community and other social services.
Support services will be coordinated with the individual's
medicaid-contracting
medicaid-contracted managed care
plan
organization
(MCP)
(MCO), where
applicable.
(1)
"Administrative
agency," for the purpose of this rule, means the county department of job and
family services (CDJFS).
(4)
ODM 03528
"Healthchek and Pregnancy Related Services Information Sheet" means the
document given to individuals by the administrative agency to meet the
informing requirement of this rule.
(5)
"Postpartum
period," for the purpose of this rule, is the same as defined in rule
5160:1-1-01 of the
Administrative Code.
(6)
"Pregnancy-related services" (PRS) are those services
that are necessary for the health of the pregnant woman and fetus, or that have
become necessary as a result of the individual having been pregnant. These
include, but are not limited to, prenatal care, delivery, postpartum care, and
family planning services.
(C) The
individual (or the individual's parent(s), guardian, or legal custodian, as applicable) may:
(1) Complete and sign the ODM 03528, "Healthchek and Pregnancy Related Services Information
Sheet" (rev. 7/2014) to verify understanding of PRS and Healthchek
services;
(2) Complete, sign, and
return the ODM 03528 to identify her own and
her
the need for services for the individual
and/or the individual's children's need for
services.
(D)
Administrative agency responsibilities. The administrative agency shall:
(6)(5) Provide a copy of
the ODM 03528 (if
when applicable) and the
ODM 03535 "Prenatal Risk Assessment Form" (if applicable) (rev. 7/2014) to the individual's
to the individual's
MCP
MCO.
(7)(6)
Make a second attempt to contact the individual by alternate means
if
when
written information about PRS sent to the individual is returned as
undeliverable.
(8)(7) Submit a new or
amended ODM 03515 "Pregnancy Related Services
Implementation Plan" (rev. 1/2015) to the Ohio department of medicaid (ODM),
including but not limited to, when there has been a
change of
when there has been a change,
including but not limited to, agency address, director, PRS
coordinator, or where the responsibility for PRS
is organizationally located within the
agency. The ODM 03515 shall be submitted to ODM within ten business days of
the
a
change.
(9)(8) Obtain a
Health Insurance Portability and Accountability Act of
1996
HIPAA
(HIPAA) compliant signed authorization for release of
information, ODM 03397 "Authorization for the Release or Use of Protected
Health Information (PHI) or Other Confidential
Information" (rev. 8/2014), when
additional medical information is needed from the individual.
(10)(9)
Maintain a listing of fee-for-service providers who have expressed a
willingness to furnish non-medicaid covered services at little or no expense to
the individual. It is recognized that the ability of the administrative agency
to recruit and maintain an adequate provider network depends on the existence
of appropriate providers within a reasonable geographic area.
(11)(10)
Maintain documentation in a case
secure file for each eligible individual. The file
shall consist of permanent records, either hard copy or electronically stored,
containing the following information, when appropriate:
(1) Inform individuals in its county about
PRS within sixty days of the eligibility determination. Contact shall be made
through either verbal or written forms of communication or a combination of the
two described as follows:(b)(c) Provide information
about:(ii)(iii) The services
covered by PRS as described in Chapter 5160-4 of the Administrative
Code.
(iii)(iv) The benefits of
healthchek services as described in 5160:1-2-05
rule
5160-1-14 of the
Administrative Code.
(iv)(v) Transportation
services and scheduling assistance available to individuals,
if
when needed
and upon request, in accordance with Chapter 5160-15 of the Administrative
Code.
(v)(vi) Availability of
transportation services through the individual's MCP
MCO. The
transportation services shall be provided by the administrative agency if not
available from the MCP
MCO.
(vi)(vii) Transportation
services and scheduling assistance available to infants during the first year
of life.
(vii)(viii) Medical and
non-medical support services to include but not limited to:
(c)(b)
Maternal and child health clinics;
Maternal, child and family health (MCFH)
clinics;
(d)(c) Local health
departments;
(e)(d) Social services and
other community services.
;
(viii)(ix) Availability of
assistance for scheduling medical appointments, as requested by the
individual.
(ix)(x) A list of medicaid
prenatal care providers, if
when requested,
available to the community and/or information about
medicaid-contracting MCPs.
(a) Provide the ODM
03528, "Healthchek and Pregnancy Related Services
Information Sheet" (rev. 7/2014).
(b)
Assist
individuals with care coordination and referrals as requested via the ODM 10257
"Report of Pregnancy (ROP)" and ODM 10207 "Pregnancy Risk Assessment
Communication (PRAF)."
(i) The benefits and importance of
early and continual prenatal and postpartum care.
(ii)
The special
supplemental food program for women, infants and children
(WIC).
(a)
" The
" Help Me Grow" (HMG) program;
(b)
The special supplemental food program for women,
infants and children (WIC);
(e)
Child care and head start; and
(f)
The program for
children and youth with special health care needs.
(2) Inform individuals enrolled in
a
an
MCP
MCO that
they should contact the MCP
MCO for medical
care options and referrals.
(3)
Re-inform the individual of the benefits of healthchek services as soon as
possible after the
an infant's birth.
(4) Refer the individual to support services
as requested verbally, in writing, or via the ODM 03528 and ensure:
(a) Referrals are made, as needed, for medical and non-medical support
services, as requested.
(b) Coordination between the individual,
medical provider, MCP
MCO, or other entity where the
a referral is
made.
(c) Transportation assistance
is provided to individuals, as requested.
(d) Individuals in need of
non-medicaid covered medical services are referred to
community, medical or other social services. This
includes providers who have expressed a willingness to furnish non-medicaid
covered services at little or no expense to the individual.
(5) Establish contact with the
individual upon notification from the medical provider or MCP that the
individual has missed appointments or there are other problems in the delivery
of care and inform the individual's medical provider or MCP about the outcome
of the contact.
(a) Copy of the ODM 03528,
ODM 03535
ODM
10207, ODM 10257, or other referral forms
received by the county
administrative agency;
(b) Copy of correspondence received and
sent;
(c) Documentation of agency
contacts
contact with the individual, both attempted and
established;
(d) Documentation of
the MCP
MCO in
which the individual is enrolled;
(e) Information received from another county
when the individual is an intercounty transfer;
(f) Documentation of all service
requests,
and
steps taken by the administrative agency to connect the
individual with the requested services, and
whether the individual received services; and
(g) Records of transportation services
provided.
(E)
Each administrative agency PRS coordinator, or such coordinator's designee(s),
shall attend annual and other pertinent trainings offered by ODM. Verification
of attendance shall consist of documentation of roll
call and sending
be provided for all trainings
and an evaluation form shall be sent to the
state email box within three days of completion
of the video conference or training.
Verification of attendance at onsite
in-person training shall be documented by the PRS
coordinator or such coordinator's designee(s) by signing the attendance
log.
Notes
Promulgated Under: 111.15
Statutory Authority: 5160.02
Rule Amplifies: 5160.02, 5164.26
Prior Effective Dates: 04/01/1988 (Emer.), 06/30/1988, 10/01/1988 (Emer.), 12/20/1988, 04/01/1991, 02/01/1992, 05/01/1993, 10/01/1998, 05/01/2002, 10/06/2003, 10/15/2005, 01/15/2015
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