173-71-03 Enrollment.

(A) In accordance with section 173.722 of the Revised Code, ODA shall undertake outreach efforts to publicize the best Rx program and maximize participation in the program, which, at a minimum, shall include making applications, instructions for completing applications, and instructions for submitting applications available to anyone who requests such information (whether by telephone, in writing, electronically, or otherwise) or to the general public by displaying such information in community locations and on the internet.

(B) In accordance with section 173.724 of the Revised Code, ODA may coordinate the best Rx program with either of the following:

(1) The golden buckeye card program established under section 173.06 of the Revised Code. In coordinating the programs, ODA may establish a card that serves as both a golden buckeye card provided under section 173.06 of the Revised Code and a best Rx program enrollment card issued under section 173.773 of the Revised Code. ODA may identify the card by including the names of both programs on the card or by selecting a combined name for inclusion on the card; or,

(2) Any health benefit plan offered to the employees of state agencies and the eligible dependents of those employees, for purposes of enhancing efficiency, reducing the cost of drugs, and maximizing the benefits of the best Rx program and the health benefit plan.

(C) An individual may submit an application for the best Rx program on behalf of himself/herself or his/her family (which is defined by paragraph (B)(11) of rule 173-71-01 of the Administrative Code), so long as each individual family member on the application meets the eligibility criteria in section 173.76 of the Revised Code and rule 173-71-02 of the Administrative Code.

(D) An individual may submit a written application to ODA by returning a paper form prescribed and supplied by ODA; or, the applicant may apply by telephone or through the internet, in accordance with section 173.77 of the Revised Code.

(E) When submitting an application for enrollment into the best Rx program, the applicant shall include the following information on the application:

(1) For an application for an individual, the name and date of birth of the applicant; or, for an application for a family, the name, date of birth, and relationship to the primary applicant specified in accordance with paragraph (C) of this rule of each family member applying for the program;

(2) For an application for an individual, the address and telephone number; or, for an application for a family, the address and telephone number of the primary applicant specified in accordance with paragraph (C) of this rule;

(3) For an application for an individual, the total annual income of the applicant for the immediately preceding calendar year or the income for the three months preceding the month of application; or, for an application for a family, the total annual income of the family for the immediately preceding calendar year or the income for the three months preceding the month of application;

(4) Attestation that the applicant or primary applicant meets the eligibility requirements outlined in section 173.76 of the Revised Code and rule 173-71-02 of the Administrative Code; and,

(5) For an application for an individual submitted by the individual, the signature of the applicant; for an application for an individual submitted on behalf of the individual by a guardian or custodian, a statement attesting to the authority of the guardian or custodian to act on the behalf of the applicant; or, for an application for a family, the signature of the primary applicant specified in accordance with paragraph (C) of this rule.

(F) On each application, ODA shall inform each applicant that knowingly making a false statement in an application is falsification under section 2921.13 of the Revised Code, a misdemeanor of the first degree. In the case of a paper application form, ODA shall provide the information by including on the form a statement printed in bold letters.

(G) ODA shall return each application that is incomplete. With the returned application, ODA shall notify the applicant in writing that the applicant or family applying for the best Rx program is currently determined ineligible for the best Rx program due to an incomplete application and that the applicant is welcome to begin the enrollment process once again by submitting a complete application to ODA.

(H) Upon receipt of the application, ODA shall determine whether or not the applicant meets the eligibility requirements established by section 173.76 of the Revised Code and send a written notification of the determination to the applicant (or, in the case of a family, to the primary applicant) within four working days after ODA received the application. For an applicant who is not sixty years of age or older and who does not have a permanent total disability, ODA shall determine whether or not the income of the individual (or of the family) qualifies for enrollment into the best Rx program by comparing the annual income or the average monthly income during the preceding three months to three hundred per cent of the federal poverty guidelines for a family with the same number of members as that of the individual applying for the program. For the purposes of this paragraph, the determination of family size is based upon the total number of members of a family, as defined in paragraph (B)(12) of rule 173-71-01 of the Administrative Code, regardless of whether or not each individual member is party to the application for the best Rx program. In the event that the federal poverty guidelines change, ODA shall make adjustments to the eligibility requirements for the best Rx program that take effect within sixty days after the revised federal poverty guidelines are published in the Federal Register.

(I) An applicant, or anyone acting on behalf of an applicant, may not appeal the determination made under section 173.772 of the Revised Code and paragraph (H) of this rule by the appeal provisions of Chapter 119., section 5101.35, or any other provision of the Revised Code.

(J) If ODA determines that an applicant is ineligible, the applicant may reapply for the best Rx program at any time.

(K) At the same time that ODA issues a best Rx program enrollment cards to a new participant or notifies an applicant of its determination or ineligibility, ODA shall provide the participant or applicant with written information about the medicaid program. The information shall include general eligibility requirements, application procedures, and benefits. The information shall also explain the ways in which the medicaid program’s drug benefits are better than the best Rx program.

(L) If ODA determines that an applicant is eligible, ODA shall issue a best Rx program enrollment card to or on behalf of the participant. One enrollment card may cover each member of a family determined eligible to participate; however, ODA may issue up to two duplicate cards to such a family.

(M) At the same time that ODA issues a best Rx program enrollment cards to a new participant, ODA shall provide the participant with the following written information:

(1) General information about the best Rx program, such as the benefits of the program, how to use the card, and how to submit notification changes in address or family composition;

(2) Information on participating pharmacies; and,

(3) Information about how to contact ODA for assistance.

(N) A participant may use a best Rx card at any participating pharmacy or through the drug mail-order system.

(O) In accordance with division (B) of section 173.773 of the Revised Code, each time a drug is purchased under the program, the entity dispensing the drug shall confirm whether the individual for whom the drug is dispensed is enrolled in the program. If the drug is being purchased from a participating pharmacy, and the individual’s enrollment card is available for presentation at the time of the purchase, the purchaser shall present the card to the participating pharmacy as confirmation of the individual’s enrollment in the program. If the drug is being purchased through the drug mail-order system and the individual’s program identification number is available, the purchaser shall present the identification number as confirmation of enrollment. Otherwise, the participating pharmacy or the drug mail-order system shall confirm the individual’s enrollment through ODA.

(P) Purchasing a drug under the program by using an enrollment card or any other method shall serve as an attestation by the participant for whom the drug is dispensed that the participant meets the eligibility requirements specified in division (A)(3) of section 173.76 of the Revised Code regarding not having coverage for outpatient drugs.

(Q) A participant shall notify ODA of a change in address. Upon such a notification, ODA shall confirm whether or not the new address is in Ohio and meets the eligibility criteria for the best Rx program. ODA shall also update its records and send a response in writing to the participant acknowledging the change of address and its effect upon the participant’s continued eligibility.

(R) A participant shall notify ODA of a change in family composition. Upon such a notification, ODA shall update its records and send a response in writing to the participant with a replacement card(s) with the updated list of names on the card(s).

(S) A participant shall notify ODA of a loss of a best Rx card(s). Upon such a notification, ODA shall issue a replacement card(s) within one working day of notification.

Replaces: pt 5101:13-1-02

Effective: 10/04/2007

R.C. 119.032 review dates: 08/31/2011

Promulgated Under: 119.03

Statutory Authority: 173.02, 173.83

Rule Amplifies: 173.722, 173.724, 173.77, 173.771, 173.772, 173.773

Prior Effective Dates: 11/1/2004, 4/4/07 (Emer.), 7/5/07 (Emer.)