(A) Definitions.
(1) "Abuse potential drug" as used in the
appendix to this rule, means any drug that contains substances which have a
potential for abuse because of depressant or stimulant effects on the central
nervous system or hallucinogenic effects. Abuse potential drugs include any
drug that is reportable to Ohio automated RX reporting system (OARRS) as
described in rules
4729:8-2-01
and
4729:8-2-02
of the Administrative Code, in addition to non-controlled drugs including
muscle relaxants.
(2) "Assigned
provider" means a hospital, health care facility, physician, dentist, pharmacy,
or otherwise licensed or certified single provider or provider entity that is
authorized to and is not excluded from receiving reimbursement for health care
services rendered to an individual. The assigned provider is selected in
accordance with paragraph (F) of this rule to serve as the primary provider of
non-emergency services for an individual enrolled in the coordinated services
program (CSP).
() "Coordinated services program"
(CSP) means a program that requires an individual to obtain services related to
the reason for enrollment from an assigned provider. An individual enrolled in
CSP is eligible for all medically necessary services covered by
medicaid.
(4)(3) "Fraud" for the
purpose of this rule, includes but is not limited to, forged prescriptions,
possession and use of multiple medicaid cards, card loaning, and sharing of
drugs or other supplies obtained through medicaid.
(5)(4) "Individual" is
defined in rule
5160:1-1-01
of the Administrative Code.
(6)(5) "Managed care
organization" (MCO) is defined in rule
5160-26-01
of the Administrative Code.
(7)(6) "Medication
Assisted Treatment" (MAT) is defined in rule
5160-1-73
of the Administrative Code.
(7)
"Ohio resilience through integrated systems and
excellence (OhioRISE)" is defined in rule 5160-59-01 of the Administrative
Code.
(B) CSP
provides continuity of medical care and helps to ensure the health and safety
of individuals by avoiding duplication of services, inappropriate or
unnecessary utilization of medical services, fraud and excessive use of
prescribed drugs.
(C) An individual
enrolled in CSP
must obtain
obtains medically necessary medicaid covered
services
only of the type related to the reason
for enrollment from an assigned provider.
(D) CSP enrollment criteria.
(1) The enrollment criteria found in the
appendix to this rule are based upon ninety days of utilization data within the
past twelve months. An individual who meets three or more of the criteria in
the appendix to this rule
shall
will be enrolled in CSP; or
(2) An individual
shall
will be
enrolled in CSP when a review of his or her utilization demonstrates a pattern
of receiving services at a high frequency as determined by the Ohio department
of medicaid or its designee (hereafter referred to as ODM).
(3) ODM may, at its discretion, choose to
apply additional criteria to identify individuals for CSP enrollment when
utilization of services appears to exceed, or appears not to follow, nationally
recognized treatment standards.
(4)
An individual may be enrolled in CSP upon external
referral from the individual's prescriber that will be reviwed by ODM on a case
by case basis.
(5)
An individual may be enrolled in CSP upon external
referral from ODM's program integrity unit/bureau that will be reviewed by ODM
or its designee on a case by case basis
(6)
An individual
will be enrolled in CSP upon self-referral.
(4)(7) An individual may
be excluded from CSP enrollment when he or she:
(a) Has a current diagnosis of cancer and is
actively receiving chemotherapy or radiation treatment;
(b) Resides in a
long-
term care
facility;
nursing facility (NF) as described
in section
5165.01 of the
Revised Code, or an intermediate care facility for individuals with
intellectual disabilities (ICF-IID) as described in section
5124.01 of the
Revised Code;
(c)
Is enrolled in the assisted living home and community
based services (HCBS) waiver program as described in Chapter 5160-33 of the
Administrative Code;
(c)(d) Receives hospice
services; or
(d)(e) Is enrolled in both
the medicaid and medicare programs
;.
or
(f)
Is enrolled in
the fee-for-service program and, at the sole discretion of ODM's clinical
staff, it is determined that it would not be appropriate to enroll the
individual in CSP.
(E) Initial enrollment, continued enrollment
and disenrollment procedures.
(1) Initial
enrollment.
(a) An individual proposed for
enrollment in CSP will receive the "Notice of Proposed Enrollment in the
Coordinated Services Program (CSP)" (ODM 01717,
1/2019
10/2022),
including the effective date of enrollment, from ODM in accordance with
division 5101:6 of the Administrative Code.
(b) Initial CSP enrollment will be for
twenty-four months from the effective date of enrollment.
(c) If an individual enrolled in CSP becomes
ineligible for medicaid, then resumes eligibility for medicaid within the
initial enrollment period, the individual will be reinstated into CSP until the
initial enrollment period is exhausted.
(2) Continued enrollment.
(a) If after the initial enrollment period,
ODM determines an individual's service utilization continues to support the
reasons for enrollment described in paragraph (D) of this rule, the individual
will continue to be enrolled in CSP for up
to an additional twenty-four months.
(b) ODM will notify the individual of the
continued enrollment by issuing the "Notice of Continued Enrollment in the
Coordinated Services Program (CSP)" (ODM 01705,
1/2019)
10/2022) in
accordance with division 5101:6 of the Administrative Code.
(c) If an individual enrolled in CSP becomes
ineligible for medicaid, then resumes eligibility for medicaid within a
continued enrollment period, the individual will be reinstated into CSP until
the continued enrollment period is exhausted.
(3) Disenrollment.
If
an individual enrolled in CSP meets any of the criteria described in paragraph
(D)(7) of this rule, the individual will be disenrolled from CSP. If the
individual no longer meets any of the criteria in paragraph (D) (7) of this
rule, ODM will reinstate the individual into CSP.
(a) If ODM determines an
individual's service utilization no longer supports the reasons for enrollment
described in paragraph (D) of this rule, the individual may be
disenrolled.
(b) If an individual enrolled in CSP
meets any of the criteria described in paragraph (D)(4) of this rule, the
individual will be disenrolled from CSP. If the individual is subsequently
discharged from the long-term care facility, hospice program or no longer
receives treatment for a cancer diagnosis during the CSP enrollment period, ODM
may reinstate the individual into CSP.
(F) Initial assignment or changing an
assigned provider.
(1) Initial provider
assignment.
(a) An individual enrolled in CSP
may request an assigned provider within thirty days of the mailing date on the
initial enrollment notification. If approved by ODM, this provider will serve
as the individual's assigned provider. The assigned provider
must
is to be
contracted with ODM, unless otherwise permitted by ODM.
(b) ODM will select an assigned provider for
the individual for any of the following reasons:
(i) The individual does not select an
assigned provider within thirty days of the mailing date on the initial
enrollment notification;
(ii) The
individual's selected assigned provider is denied by ODM; or
(iii) The selected assigned provider is
unwilling or unable to accept the individual.
(c)
Changes in
pharmacy will be made immediately following a request for individuals who are
receiving medication assisted treatment for addiction.
(2) Changing an assigned provider.
(a) An individual may request to change
an assigned provider, or ODM may
require
direct an
individual to make an alternative selection of an assigned provider
, under the following circumstances:
(i) The assigned provider's office is no
longer accessible to the individual for any of the following reasons:
(a) The assigned provider's office has
relocated or closed;
(b) The
individual has moved or is unable to travel to the provider;
(c) The assigned provider is no longer an
eligible provider;
(d) The assigned
provider chooses not to provide services to the individual; or
(e) The individual transfers from the
fee-for-service program to an
MCP
MCO, from an
MCP
MCO to the
fee-for-service program or from one
MCP
MCO to another.
(ii) The medical needs of the individual
require
call
for assignment of a provider with a different specialty.
(b) If the department denies the
individual's request to change the assigned provider, the department
shall
will
notify the individual by issuing the "Notice of Denial of Assigned Provider or
Pharmacy in the Coordinated Services Program (CSP)" (ODM 01718,
1/2019
10/2022) in accordance with division 5101:6 of the
Administrative Code.
(c)
ODM or its designee will immediately change an
individual's assigned pharmacy following a request from an individual or a
representative from the treatment facility who has permission from the
individual who is receiving inpatient treatment for addiction.
(d)
ODM or its
designee will immediately change an individual's assigned pharmacy following
discharge from an inpatient treatment program for addiction, upon
request.
Click to
view Appendix
Notes
Ohio Admin. Code
5160-20-01
Effective:
10/1/2022
Five Year Review (FYR) Dates:
1/1/2024
Promulgated Under:
119.03
Statutory Authority:
5164.02,
5164.758
Rule Amplifies:
5164.02,
5164.758
Prior Effective Dates: 12/01/1983, 04/01/1986, 07/01/1987,
02/01/1990, 04/01/1992, 11/01/1997, 01/01/2008, 01/01/2012, 01/01/2017,
01/01/2018, 01/01/2019, 01/01/2021