Managed care programs: care coordination - Ohio Admin. Code 5101:3-26-03.1

Managed health care programs (MCP) must meet the following care coordination responsibilities:

• Ensure that each member has a primary care provider who will serve as an ongoing source of primary care and assist with care coordination appropriate to the member’s needs;
• Provide for a second opinion from a qualified health care professional within the MCP’s panel, upon request from the member;
• Share specific information with non-panel providers designated by the department of job and family services;
• Provide information to the department documenting the non-contracting providers identified by the MCP and the information the MCP provided to each provider;
• Provide a centralized toll-free call-in system to provide members with medical advice and direct members to the appropriate care setting;
• Maintain a log for the call-in system that includes the following information:
  • Identification of the member;
  • Date and time of call;
  • Member’s question, concern, or presenting problem;
  • Disposition of call; and
  • Primary care or other provider if contacted by the MCP.
• Have services available to assist hearing impaired members and LEP members to use the call-in system;
• Have a utilization management program with clearly defined structures and processes designed to maximize the effectiveness of the care provided to the member;
• Provide care management services to coordinate and monitor treatment rendered to members with specific diagnoses or who require high-cost or extensive services;
• Include and document the following related to the care management program:
  • Identification of members who potentially meet the criteria for care management;
  • Assessment of the member’s health conditions to determine the need for care management; and
  • Development, implementation, and ongoing monitoring of a care treatment plan for members in care management.
• Report care management program-related data to the department, as required.

Primary care provider care coordination responsibilities include the following:

• Assisting with coordination of the member’s overall care, as appropriate for the member;
• Serving as the ongoing source of primary and preventative care;
• Recommending referrals to specialists, as required;
• Participating in the development of care management care treatment plans; and
• Notifying the MCP of members who may benefit from care management.