Rule 3701-43-15 | Application and review procedures for eligibility for payment for treatment.
(A) This rule prescribes the procedures for applying for a determination by the director as to whether the applicant is eligible for payment for treatment services and goods by the program because the applicant:
(1) Meets the definition of medically handicapped child established by paragraph (K) of rule 3701-43-01 of the Administrative Code; or
(2) Meets the definition of adult with cystic fibrosis established by paragraph (A) of rule 3701-43-01 of the Administrative Code.
(B) The application shall consist of:
(1) A completed medical application as described in paragraph (C) of this rule, signed by the managing physician;
(2) A completed financial application as described in paragraph (D) of this rule, signed by the applicant or applicant's parent, guardian, or other legal representative, unless the applicant is a recipient of benefits from the Ohio medicaid program; and
(3) A completed release and consent on a form prescribed by the director, signed by the applicant or applicant's parent, guardian or other legal representative.
(C) A medical application shall be submitted to the director in the following manner:
(1) The medical application shall be submitted by the applicant's managing physician on a form prescribed by the director;
(2) The medical application form shall be completed in full, shall include an individualized plan of treatment describing the medical and nonmedical interventions needed for treatment of the applicant and shall be signed by the managing physician. The managing physician also shall submit any medical reports necessary to determine medical eligibility under rule 3701-43-17 of the Administrative Code;
(3) The managing physician shall submit the medical application form so that it is received by the director no later than sixty days after the requested effective date of program eligibility. The requested effective date of program eligibility shall not be earlier than the date of the initial examination of the applicant by the managing physician; and
(4) The managing physician shall submit medical reports or additional information requested by the director for the purposes of determining medical eligibility so that it is received by the director no later than thirty days after the date appearing on the letter requesting the information.
(D) A financial application shall be submitted to the director in the following manner:
(1) The financial application shall be on a form prescribed by the director;
(2) The financial application shall be completed in full and shall include:
(a) Verification of income and medical and other expenses;
(b) Information concerning eligibility for third-party benefits; and
(c) Other documentation as specified on the application form or as necessary to determine financial eligibility under rule 3701-43-16 of the Administrative Code.
(3) The financial application and the signed consent and release form shall be submitted so that it is received by the director no later than sixty days after the forms were mailed by the program to the applicant; and
(4) Upon request by the director, the applicant or his or her parent, guardian or other legal representative shall submit the following information so that it is received by the director no later than sixty days after the date appearing on the letter requesting the information:
(a) Income verification such as federal income tax forms and schedules, pay stubs, employer statements or benefit notices;
(b) Verification of paid, unreimbursed medical or dental expenses or other expenses, such as receipts, cancelled checks, physician statements; and
(c) Any other information necessary to determine financial eligibility under this rule.
(E) If the director, upon review of the medical and financial applications and any necessary additional information, determines that the applicant is eligible for payment for treatment by the program, the director shall establish an effective date of eligibility. Except as provided in paragraph (F) of this rule, the effective date of eligibility shall be the date requested by the managing physician.
(F) If the director, upon review of the medical or financial application or any other relevant information, determines that the applicant is not eligible for the program, the director shall deny the application. In the event an application or any requested additional information is not submitted in compliance with the deadlines specified in paragraph (C) or (D) of this rule, the director either shall deny the application or shall establish, as the effective date of eligibility, the date thirty days before the date on which the application or the last item of requested additional information was received by the director.
(G) The director shall notify the applicant or his or her parent, guardian or other legal representative, selected providers of major services, the local health department and the managing physician of the approval or proposed denial of eligibility and the effective date of eligibility determination. The director shall issue this notification within thirty days of the date of receipt of the last document necessary to make the eligibility determination or of the failure to submit timely an application or requested additional information. A notice of proposed denial of eligibility shall contain a statement of the reasons for denial and a description of the reconsideration procedure established by paragraph (B) of rule 3701-43-23 of the Administrative Code.
(H) The director shall establish a period of eligibility for payment for treatment for each recipient. A recipient, other than an adult with cystic fibrosis, who becomes twenty-one years of age during the period, shall be medically and financially eligible for a period of twelve months after the effective date of eligibility specified under paragraph (E) or (F) of this rule except that the director may establish:
(1) A shorter period, based upon a reasonable expectation that the recipient may become medically or financially ineligible during the period; or
(2) A longer period, not to exceed thirty-six months, based upon a reasonable expectation that the recipient will remain medically or financially eligible during the period.
(I) The applicant or his or her parent, guardian or other legal representative shall notify the director in writing of any changes in information including name, address, phone number, medical care provider, insurance coverage, medicaid status, or change in any other available third party coverage within thirty days of such change. Failure to notify the director of a change may result in denial of coverage.
(J) Applications for renewal of eligibility shall be submitted and reviewed in the same manner as initial applications for eligibility under this rule. In the event that different time periods have been established for a recipient's medical and financial eligibility under paragraph (H) of this rule, the director may waive submission, for renewal purposes, of either the financial or medical application, as applicable.
Supplemental Information