Ohio Admin. Code 5160-26-10 - Managed care: sanctions and provider agreement actions

(A) This rule does not apply to the single pharmacy benefit manager as defined in rule 5160-26-01 of the Administrative Code.

(A)(B) If the MCP the MCO fails to fulfill its duties and obligations under 42 C.F.R. Part 438 (October 1, 2013 2021), 42 U.S.C. 1396b(m) (as in effect January 1, 2015 July 1, 2022), 42 U.S.C. 1396u-2 (as in effect January 1, 2015 July 1, 2022), Chapter 5160-26 or 5160-58 agency 5160 of the Administrative Code, or the MCP MCO provider agreement, ODM will provide timely written notification to the MCP MCO identifying the violations or deficiencies, and may impose corrective actions or any of the following sanctions in addition to or instead of any actions or sanctions specified in the provider agreement:

(1) ODM may require corrective action plans (CAPs) in accordance with the following:

(a) If requested by ODM, the MCP MCO must submit, within the specified time frame, a proposed CAP for each cited violation or deficiency.

(b) The CAP must contain the proposed correction date, describe the manner in which each violation or deficiency will be resolved, and address all items specified in the ODM notification.

(c) The CAP must be reviewed and approved by ODM.

(d) Following the approval of the CAP, ODM will monitor the correction process until all violations or deficiencies are corrected to the satisfaction of ODM.

(e) If the MCP MCO fails to submit an approvable CAP within the ODM-specified time frames, ODM may impose an ODM-developed CAP, sanctions, or both.

(f) If ODM has already determined the specific action that must be implemented by the MCP MCO, ODM may require the MCP MCO to comply with an ODM-developed or directed CAP.

(g) Failure by the MCP MCO to successfully complete the correction process and correct the violations or deficiencies to the satisfaction of ODM may lead to the imposition of any or all of the sanctions listed in paragraph ( B)(2) of this rule.

(2) Sanctions that may be imposed on MCPs the MCO by ODM include but are not limited to the following:

(a) Suspension of the enrollment of MCP the MCO's members.

(b) Disenrollment of the MCP's the MCO's members.

(c) Prohibition or reduction of the MCP's the MCO's voluntary assignments.

(d) Prohibition or reduction of the MCP's the MCO's involuntary assignments.

(e) Granting MCP the MCO's members the right to terminate without cause and notifying the affected members of their right to disenroll.

(f) Retention by ODM of the MCP's the MCO's premium payments or a portion thereof until the violations or deficiencies are corrected.

(g) Imposition of financial sanctions.

(B)(C) ODM will select sanction(s) specified in paragraph (A) (B)(2) of this rule based on a pattern of repeated violations or deficiencies, the severity of the cited violations or deficiencies, the failure of the MCP the MCO to meet the requirements of an approved CAP, or all these factors.

(C)(D) The sanctions in paragraph (A) (B)(2) of this rule are subject to reconsideration by ODM as specified in Chapter 5160-70 of the Administrative Code, with the exception that the involuntary assignments referenced in paragraph (A) (B)(2)(d) of this rule are not subject to reconsideration.

(D)(E) Regardless of any other sanction that may be imposed, ODM may impose temporary management on any MCP MCO that has repeatedly failed to meet substantive requirements in 42 U.S.C. 1396b(m) (as in effect January 1, 2015 July 1, 2022), 42 U.S.C. 1396 u-2 (as in effect January 1, 2015 July 1, 2022) or 42 C.F.R. Part 438 subpart I (October 1, 2013 2021). Such temporary management shall be imposed in accordance with the following:

(1) the MCP the MCO must pay the costs of a temporary manager for performing the duties of a temporary manager as determined by ODM.

(2) the MCP the MCO is solely responsible for any costs or liabilities incurred on behalf of the MCP MCO when temporary management is imposed by ODM.

(3) The imposition of temporary management is not subject to the appeals process provided under Chapter 119. of the Revised Code; however, the MCP the MCO may request that the director for the medicaid program reconsider this action. ODM will not delay imposition of temporary management to provide reconsideration prior to imposing this sanction.

(4) Unless the director for the medicaid program determines through the reconsideration process that temporary management should not have been imposed, the temporary management will remain in place until such time as ODM determines that the MCP the MCO can ensure that the sanctioned behavior will not recur.

(5) Regardless of the imposition of temporary management, the MCP the MCO retains the right to appeal any proposed termination or nonrenewal of its provider agreement under Chapter 119. of the Revised Code. The MCP The MCO also retains the right to initiate the sale of the MCP MCO or its assets.

(6) If temporary management is imposed, ODM will notify the MCP's MCO's members that such action has occurred and inform them that they therefore have the right to terminate their membership in the MCP MCO without cause. Termination of the MCP's MCO's membership without cause is not subject to the appeals process provided under Chapter 119. of the Revised Code; however, the MCP MCO may request that the director for the medicaid program reconsider this action. ODM will not delay the notification to the MCP's MCO's membership to provide reconsideration prior to imposing this sanction.

(E)(F) ODM will provide an MCP the MCO with written notice before imposing any sanction. The notice will describe any reconsideration or appeal rights that are available to the MCP MCO.

(F)(G) Regardless of whether ODM imposes a sanction, MCPs the MCO shall initiate corrective action for any MCP MCO program violations or deficiencies as soon as they are identified by either the MCP MCO or ODM.

(G)(H) The following provisions apply in the event ODM decides to terminate, nonrenew, deny, or amend the MCP's MCO provider agreement.

(1) ODM may terminate, nonrenew, deny, or amend the MCP's MCO provider agreement if at any time ODM determines that continuation or assumption of a provider agreement is not in the best interest of recipients or the state of Ohio. For the purposes of this rule, an amendment to an MCP's the MCO provider agreement is defined as, and limited to, the elimination of one or more service areas included in that MCP's the MCO's current provider agreement. The phrase "not in the best interest" includes, but is not limited to, the following:

(a) The MCP's MCO's delivery system does not assure adequate access to services for its members.

(b) The MCP's MCO's delivery system does not assure the availability of all services covered under the provider agreement.

(c) The MCP MCO fails to provide all medically-necessary covered services.

(d) The MCP MCO fails to provide proper assurances of financial solvency.

(e) The number of members enrolled by in the MCP MCO's in a service area is not sufficient to ensure the effective or efficient delivery of services to members.

(f) The MCP MCO fails to comply with any of the following:

(i) Chapter 5160-26, or 5160-58, or 5160-59 of the Administrative Code or both;

(ii) The MCO provider agreement;

(iii) The applicable requirements in 42 U.S.C. 1396b(m) (as in effect January 1, 2015 July 1, 2022) or 42 U.S.C. 1396u-2 (as in effect January 1, 2015 July 1, 2022);

(iv)42 C.F.R. Part 438 (October 1, 2021 2013).

(2) If ODM has proposed termination, nonrenewal, denial, or amendment of a the MCO's provider agreement, ODM may notify the MCP's MCO's members of this proposed action and inform the members of their right to immediately disenroll from the MCP MCO without cause.

(3) If ODM determines that the termination, nonrenewal, or denial of a provider agreement is warranted:

(a) ODM will provide notice, at a minimum, forty-five days prior to the effective date of the proposed action;

(b) The action will be in accordance with and subject to Chapter 5160-70 of the Administrative Code; and

(c) The action will be effective at the end of the last day of a calendar month.

(4) If ODM determines that the amendment of a provider agreement is warranted, the proposed action is subject to reconsideration pursuant to Chapter 5160-70 of the Administrative Code.

(5) Notwithstanding the preceding paragraphs of this rule, ODM may terminate an MCP's the MCO's provider agreement effective on the last day of the calendar month in which any of the following occur:

(a) The determination by ODM that the loss or reduction of federal or state funding has reduced funding to a level which is insufficient to maintain the activities or services agreed to in the provider agreement;

(b) The exclusion from participation of the MCP MCO in a program administered under Title XVIII, XIX, or XX of the Social Security Act due to criminal conviction or the imposition of civil monetary penalties in accordance with 42 C.F.R. Part 455 subpart B (October 1, 2013 2021), 42 C.F.R. Part 1002 subpart A (October 1, 2013 2021), and rule 5160-1-17.3 of the Administrative Code;

(c) The suspension, revocation, or nonrenewal of ODM's authority to operate the program under the state plan or waivers of certain federal regulations granted by CMS or congress;

(d) The suspension, revocation, or nonrenewal of the MCP's MCO's certificate of authority or license.

(e) The exclusion of the MCP MCO from participation in accordance with 42 C.F.R. 438.808 (October 1, 2013 2021).

(6) MCPs If the MCO's whose provider agreements are agreement is amended, terminated, denied, or nonrenewed for any reason including procurement, the MCO are is required to fulfill all duties and obligations under Chapter 5160-26 or 5160-58 or both agency 5160 of the Administrative Code, as applicable, and the MCO provider agreement.

Notes

Ohio Admin. Code 5160-26-10

Effective: 7/18/2022
Five Year Review (FYR) Dates: 7/19/2025
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5164.02, 5167.03, 5167.10
Prior Effective Dates: 05/02/1985, 10/01/1987, 02/15/1989 (Emer.), 05/08/1989, 05/01/1992, 05/01/1993, 11/01/1994, 07/01/1997 (Emer.), 09/27/1997, 12/10/1999, 07/01/2001, 07/01/2003, 07/01/2004, 10/31/2005, 01/01/2008, 08/26/2008 (Emer.), 10/09/2008, 07/02/2015, 07/19/2020