This letter transmits amended rules 5101:6-2-35 and 5101:6-4-01, effective July 1, 2009, five revised forms, and one new form, concerning hearing rights for members of Medicaid managed care plans (MCPs) and individuals enrolled by an MCP in the controlled substances and member management (CSMM) program defined in rule 5101:3-26-01 of the Administrative Code.

The rules and forms are associated with rule 5101:6-2-37 "Notices of enrollment, continued enrollment, or provider change denial for the managed care plan controlled substances and member management program," effective May 1, 2009 and transmitted via SHMTL No. 16.

Rule 5101:6-2-35, "Notice of a managed care plan's denial, reduction, or termination of a medicaid-covered service," sets forth the hearing rights and requirements for prior notification regarding an MCP's denial, reduction, or termination of a medicaid-covered service. The change to the rule is updating the numbers and titles of forms referenced in the rule to match the form changes described in this SHMTL.

Rule 5101:6-4-01, "Continuation of benefits when a state hearing is requested," sets forth the conditions where benefits will continue until a state hearing decision is rendered for a proposed adverse action. Changes to the rule include adding certain adverse actions for members of an MCP and individuals enrolled in a CSMM to the list of conditions where benefits will continue pending a hearing decision.

The JFS 01704 (rev. 7/2009), "Notice of Proposed Enrollment in the Controlled Substances and Member Management Program by Your Managed Care Plan," is used when an MCP intends to enroll an individual in the CSMM program, as described in rule 5101:6-2-37.

The JFS 01705 (rev. 7/2009), "Notice of Continued Enrollment in the Controlled Substances and Member Management Program by Your Managed Care Plan," is used when an MCP determines that enrollment should continue after the end of the enrollment period, as described in rule 5101:6-2-37.

The JFS 01706 (rev. 7/2009), "Notice of Denial of Designated Provider Change in the Controlled Substances and Member Management Program by Your Managed Care Plan," is used when the managed care plan (MCP) denies a members request for change of a designated provider, as described in rule 5101:6-2-37.

The previously existing JFS 04043 (rev. 7/2008), "Notice of Denial, Reduction, Suspension, or Termination of Medical Services by Your Managed Care Plan," was split into two different forms because continuation of MCP is not available for service denials. Therefore, there is now the JFS 04043 (rev. 7/2009), "Notice of Denial of Medical Services by Your Managed Care Plan" and the JFS 04066 (7/2009), "Notice of Reduction, Suspension, or Termination of Medical Services by Your Managed Care Plan." The JFS 04043 (rev. 7/2009) and JFS 04066 (7/2009) also include the additional methods by which a consumer can request a state hearing.

The JFS 04046 (rev. 7/2009), "Notice of Denial of Payment for Medical Services by Your Managed Care Plan," has also been revised to include the additional methods by which a consumer can request a state hearing.

Instructions: