Chapter 5101:1-37 Medicaid General Principles

(A) This rule contains the definitions of terms used in Chapters 5101:1-37, 5101:1-38, 5101:1-39, 5101:1-40, 5101:1-41, and 5101:1-42 of the Administrative Code. These definitions apply unless a term is otherwise defined in a specific rule.

(B) Definitions.

(1) “Administrative agency” means the CDJFS, ODJFS, or other entity that determines eligibility for a medical assistance program.

(2) “AEMA” means alien emergency medical assistance as established in rule 5101:1-41-20 of the Administrative Code.

(3) “Authorized representative” means an individual, eighteen years or older, who stands in place of the individual. The authorized representative may include a legal entity assisting in the application process. The administrative agency may request proper identification from the authorized representative.

(4) “BCCP” means the Ohio breast and cervical cancer project.

(5) “Case record” means electronic or paper documents and information used to determine or redetermine an individual’s eligibility for medical assistance.

(6) “CDJFS” means county department of job and family services.

(7) “Child” or “minor child” means a person who has not attained eighteen years of age or has not attained nineteen years of age and is a full-time student in a secondary school or in an equivalent level of vocational or technical training.

(8) “CPA” means combined programs application.

(9) “Creditable insurance” or “creditable coverage” means health insurance coverage as defined in 42 U.S.C. 300gg (a) to (c) (as in effect on September 1, 2009).

(a) This includes:

(i) A group health plan.

(ii) Health insurance coverage.

(iii) Medicare part A, as set forth in 42 U.S.C. 1395c to 1395i-5. (as in effect on September 1, 2009) or part B, as set forth in 42 U.S.C. 1395j to 1395w-4 (as in effect on September 1, 2009).

(iv) Coverage under medicaid, as set forth in Title XIX of the Social Security Act, other than coverage consisting solely of benefits under the pediatric vaccine program set forth in 42 U.S.C. 1396s (as in effect on September 1, 2009).

(v) Armed forces health insurance as set forth in 10 U.S.C. Chapter 55 (as in effect on September 1, 2009).

(vi) A medical care program of the Indian health service or of a tribal organization.

(vii) A state health benefits risk pool.

(viii) A federal employee health plan offered under 5 U.S.C. Chapter 89 (as in effect on September 1, 2009).

(ix) A public health plan.

(x) A peace corps volunteer health benefit plan under section 22 U.S.C. 2504 (as in effect on September 1, 2009).

(b) Creditable insurance does not include:

(i) Coverage only for accident, or disability income insurance.

(ii) Liability insurance, including general liability insurance and automobile liability insurance, or coverage issued as a supplement to liability insurance.

(iii) Workers’ compensation or similar insurance.

(iv) Automobile medical payment insurance.

(v) Credit-only insurance.

(vi) Coverage for on-site medical clinics.

(vii) Other similar insurance coverage under which benefits for medical care are secondary or incidental to other insurance benefits.

(viii) Limited-scope dental or vision benefits.

(ix) Benefits for long-term care, nursing home care, home health care, or community-based care.

(x) Coverage only for a specified disease or illness.

(xi) Hospital indemnity or other fixed indemnity insurance, if purchased separately.

(xii) Medicare supplemental health insurance as defined under 42 U.S.C. 1395ss (as in effect on September 1, 2009), coverage supplemental to the coverage provided to military or former military personnel under 10 U.S.C. Chapter 55 (as in effect on September 1, 2009), and similar supplemental coverage provided to coverage under a group health plan.

(10) “Electronic signature” has the same meaning as in section 1306.01 of the Revised Code.

(11) “EPSDT” means early and periodic screening, diagnosis and treatment as described in rule 5101:1-38-05 of the Administrative Code, also referred to as healthchek.

(12) “Family” means the following persons living in the same household as the individual for whom medical assistance is sought or received:

(a) The individual;

(b) If the individual is a minor, the biological, adoptive, step parents, or legal guardians of the individual;

(c) The spouse of any person listed in paragraph (B)(12)(a) or (B)(12)(b) of this rule; and

(d) Minor dependent children of persons listed in paragraph (B)(12)(a), (B)(12)(b), or (B)(12)(c) of this rule.

(13) “FPL” means the federal poverty level determined annually by the office of management and budget as required by 42 U.S.C. 9902(2) (as in effect on September 1, 2009).

(14) “Good cause” means circumstances that reasonably prevent an individual from cooperating with the administrative agency in the eligibility determination process. Factors relevant to good cause include, but are not limited to: natural disasters; riots or civil unrest; death or serious illness of the individual or a member of his/her immediate family; or the physical, mental, educational, or linguistic limitations of the individual.

(15) “Home and community-based (HCB) services waiver operational agency” means ODJFS or its designee that performs administrative functions related to an HCB services waiver program in accordance with division 5101:3 of the Administrative Code.

(16) “HCB services” or “HCBS” means specific home and community-based services furnished under the provision of 42 C.F.R. 441, subpart G (as in effect on September 1, 2009), that provide specific individuals an alternative to placement in a hospital, a nursing facility (NF), or an intermediate care facility for persons with mental retardation (ICF/MR) as set forth in rule 5101:3-1-06 of the Administrative Code.

(a) HCB services are approved by the federal centers for medicare and medicaid services (CMS) for certain individuals and are not otherwise covered by medicaid. These services may be provided:

(i) Only in certain areas of the state, and

(ii) Only to certain individuals.

(b) To receive HCB services, an individual must:

(i) Be eligible for medicaid; and

(ii) Apply separately for HCB services; and

(iii) Be found eligible to receive HCB services.

(17) “Income” means any benefit in cash received by the individual during a calendar month as a result of current or past labor or services, business activities, interests in real or personal property, or as a contribution from persons, organizations, or assistance agencies.

(a) “Countable income” means the amount of income compared to the appropriate payment or need standard to determine if an individual is eligible for medicaid. Countable income is determined by adding all of a family’s nonexempt unearned income to nonexempt earned income after subtracting all appropriate disregards.

(b) “Earned income” means payment received by an individual for services performed as an employee or as a result of the individual being engaged in self-employment or as a result of providing room and board or board, including salary, wages, royalties, honoraria, or “net earnings from self-employment” as defined in rule 5101:1-39-15 of the Administrative Code.

(c) “Gross income” means all nonexempt earned or unearned income.

(d) “Net income” means gross income minus any appropriate exclusions or disregards.

(e) “Unearned income” means all income that is not earned income.

(18) “Individual” means an applicant for or recipient of a medical assistance program.

(19) “Institution for mental diseases” (IMD) means a hospital, nursing facility, or other institution of more than sixteen beds primarily providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services.

(a) A facility established and maintained primarily for the care and treatment of individuals with mental diseases is an IMD, whether or not it is licensed as such.

(b) An institution for persons with mental retardation is not an institution for mental diseases.

(20) “LIF” means low-income families medicaid under section 1931 of the Social Security Act.

(21) “Limited English proficiency” (LEP) means any person or group of persons who cannot speak, read, write or understand the English language at a level that allows them to meaningfully communicate with county agencies or county agency contractors.

(22) “Medicaid eligibility fraud” means a violation of section 2913.401 of the Revised Code, which states that no person, in an application for medicaid benefits or in a document that requires a disclosure of assets for the purpose of determining eligibility to receive medicaid benefits, shall knowingly:

(a) Make or cause to be made a false or misleading statement; or

(b) Conceal an interest in property; or

(c) Fail to disclose a certain transfers of property.

(23) “Medical assistance program” includes all programs administered by the state medicaid administrative agency.

(24) “MBIWD” means the medicaid buy-in for workers with disabilities category set forth in rule 5101:1-41-30 of the Administrative Code.

(25) “Non-cooperation” or “failure to cooperate” means failure by an individual to present required verifications, or to explain why it is not possible to present the verifications, after being notified the verification was required for eligibility determination.

(26) “ODJFS” means the Ohio department of job and family services.

(27) “PCPA” means a private child placing agency.

(28) “PCSA” means a public children services agency.

(29) “Pend” or “pending” means the administrative agency has begun to process an individual’s application for medical assistance but has not yet determined whether an individual is eligible for a category of medical assistance.

(30) “Personal knowledge” means first-hand knowledge of circumstances of an event. A person verifying an event, based on personal knowledge, should be able to share such details as when and where the event occurred, who was involved and whether there were any special circumstances surrounding the event.

(31) “Postpartum coverage” means a span of medicaid eligibility beginning on the last day of a pregnancy (if the woman was eligible for and receiving medicaid on that date) and ends on the last day of the month in which the sixtieth day (after the last day of the woman’s pregnancy) falls.

(32) “PTR” means pre-termination review as set forth in rule 5101:1-38-01.2 of the Administrative Code. This is done prior to any termination of assistance to determine whether a consumer is eligible for any other category of assistance.

(33) “Redetermination” means a review to determine whether the individual continues to meet all of the eligibility requirements of the medical assistance category. A redetermination is performed periodically or when information about possible changes to an individual’s eligibility is received by the administrative agency.

(34) “Reporting” means notifying the administrative agency of any changes that may affect an individual’s eligibility for medical assistance. Reporting changes and providing verifications is the responsibility of any individual, person, or entity who has a legal or financial responsibility for or who stands in the place of an individual, including:

(a) The individual;

(b) The individual’s spouse, including a community spouse;

(c) The individual’s parent, guardian, or specified relative; and

(d) The individual’s authorized representative.

(35) “Residence” means the place the individual considers his or her established or principal home and to which, if absent, he or she intends to return.

(36) “Residential care facility” (RCF) means a home that provides either of the following:

(a) Accommodations for seventeen or more unrelated individuals and supervision and personal care services for three or more of those individuals who are dependent on the services of others by reason of age or physical or mental impairment; or

(b) Accommodations for three or more unrelated individuals, supervision and personal care services for at least three of those individuals who are dependent on the services of others by reason of age or physical or mental impairment, and, to at least one of those individuals, any of the skilled nursing care authorized by section 3721.011 of the Revised Code.

(37) “Self-declaration” means a statement or statements made by an individual.

(38) “Specified relative” means the following individuals who are age eighteen or older:

(a) The following individuals related by blood or adoption:

(i) Grandparents, including grandparents with the prefix great, great-great, or great-great-great;

(ii) Siblings;

(iii) Aunts, uncles, nephews, and nieces, including such relatives with the prefix great, great-great, grand, or great-grand; and

(iv) First cousins and first cousins once removed.

(b) Stepparents and stepsiblings;

(c) Spouses and former spouses of individuals named in (a) or (b) of this paragraph.

(39) “SSA” means the social security administration.

(40) “SSN” means social security number.

(41) “Suspend” or “suspended” means the temporary closing or terminating of eligibility.

(42) “Temporary absence” means that an individual (parent or child) who is otherwise considered part of the family is considered to be temporarily absent (and not to have changed residence) when all of the following conditions are met:

(a) The location of the absent individual is known;

(b) There is a definite plan for the return of the absent individual to the family’s place of residence; and

(c) The absent individual shared the place of residence with the family immediately prior to the absence.

(43) “Terminate” or “terminated” means a determination by the administrative agency that an individual is no longer eligible, or has failed to cooperate with verification of eligibility, for one or more categories of assistance currently being received by that individual, resulting in a written notice of the administrative agency’s intention to cease coverage under that category and providing notice of hearing rights as required by 42 C.F.R. 435.919 (as in effect on September 1, 2009).

(44) “United States (U.S.)” and “state(s)” means all fifty U.S. states, the District of Columbia, and the U.S. territories of American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, Swain’s Island and the U.S. Virgin Islands.

(45) “United States citizen or national” means any individual who is:

(a) A citizen or national through birth or collective naturalization as set forth in 8 U.S.C. Chapter 12, Subchapter III, Part I (as in effect on September 1, 2009); or

(b) A naturalized citizen or national as set forth in 8 U.S.C. Chapter 12, Subchapter III, Part II (as in effect on September 1, 2009).

(46) “Verification” means a document or statement from a third party or collateral contact confirming statements made by the individual about a specific eligibility criterion. A verification document or written statement may be an original, photocopy, facsimile (fax), or electronic version of the original, unless otherwise stated.

Replaces: 5101:1-37-01

Effective: 10/01/2009

R.C. 119.032 review dates: 10/01/2014

Promulgated Under: 111.15

Statutory Authority: 5111.01, 5111.011

Rule Amplifies: 5111.01, 5111.011, 5101.58

Prior Effective Dates: 9/3/1971, 9/3/1977, 10/26/1978, 5/1/1979, 9/21/1979, 2/21/1980, 7/3/1980, 7/1/1982, 12/1/1982, 10/14/1983 (Temp.), 12/22/1983, 2/15/1985 (Emer.), 3/12/1985, 6/10/1985, 8/1/1986 (Emer.), 10/3/1986, 7/1/1987 (Emer.), 8/3/1987, 10/1/2002

(A) All information and records concerning a recipient of medicaid or other medical assistance programs are confidential. No information shall be released to anyone except as provided in sections 5101.26 to 5101.28 of the Revised Code or as otherwise outlined in this rule pursuant to section 5101.30 of the Revised Code.

(B) Definitions:

(1) “Medical assistance program” includes medicaid, children’s health insurance program (CHIP), disability medical assistance (DMA) and refugee medical assistance (RMA).

(2) “Medical assistance program recipient” means an applicant, recipient or former recipient of a medical assistance program.

(3) “Administrative agency” means the county department of job and family services (CDJFS), Ohio department of job and family services (ODJFS) or other entity administering the medicaid program.

(C) Sharing of information.

In accordance with section 5101.30 of the Revised Code, information and records, but only the minimum necessary to fulfill the need for the sharing of information as allowed by this rule, concerning a recipient of medicaid may be released to the following:

(1) A provider of medical services or assistance connected with medicaid and other medical assistance programs. Access to information under this paragraph is limited to information that is essential for the medical provider to render services or assistance or to bill for services or assistance rendered. Providers receiving this information may use this information only for the purpose set out in this paragraph and are subject to penalties set out in section 5101.99 of the Revised Code for unauthorized use of the information.

(2) The department of aging, when investigating a complaint under section 173.20 of the Revised Code. Access to information under this paragraph is limited to essential information needed to complete the investigations.

(3) Any private contractor, grantee, or other state or county entity, performing administrative or other duties on behalf of ODJFS or the administrative agency when in compliance with paragraphs (C)(3)(a) to (C)(3)(d) of this rule. Access under this paragraph includes but is not limited to exchange of information pursuant to section 307.986 of the Revised Code. Information that can be accessed under this paragraph is limited only to information needed for completion of the administrative or other duties on behalf of ODJFS/administrative agency (contractee):

(a) There must be a signed, written agreement with the contractor, grantee, or entity, that establishes the purpose and scope of duties to be performed for the contractee.

(b) The agreement shall contain language that the contractor, grantee, or entity may not use the information received pursuant to the agreement for purposes other than those set out in the written agreement.

(c) The agreement shall include language which establishes that the contractor, grantee, or entity is bound by ODJFS rules and that disclosure of the information by the contractor, grantee, or entity in a manner not authorized by the rules is a breach of the contract and a violation of sections 5101.27 and 5101.99 of the Revised Code.

(d) If sharing of information (including eligibility information) pursuant to the contract involves any program listed in paragraph (B)(1) of this rule, the following additional language in the contract is required:

(i) The contractor will use safeguards to prevent unauthorized uses/disclosures of the information;

(ii) The contractor will report any authorized uses/disclosures of the information to the contractee;

(iii) The contractor will provide the same obligations outlined in the contract to all subcontractors/agents;

(iv) The contractor will share all information received pursuant to the contract with the contractee;

(v) Should an individual seek information to which they are the subject, seek amendment of that information or an accounting of disclosures of the information which the contractor is holding as a result of this contract, the contractor shall immediately refer the individual to the contractee and notify the contractee of the request;

(vi) The contractor shall make available its internal practices, books and records relating to use and disclosure of information about individuals which were received pursuant to this contract to the contractee upon request and to the United States department of health and human services (HHS) for the purpose of determining the states compliance with the Health Information Portability and Accountability Act (HIPAA) and regulations and amendments promulgated by HHS for the purpose of implementing HIPAA;

(vii) Upon termination of the agreement required by the provisions outlined in this rule, the contractee shall require that the contractor do one of the following:

(a) Return all information received about individuals pursuant to the agreement and retain no copies of the information, except as directed by the contractee or required by law. Any information that the contractor retains must be extended the same protections outlined in the written agreement for as long as the information is maintained by the contractor; or

(b) Destroy all information received about individuals pursuant to the agreement and keep no copies of the information except as directed by the contractee or required by law. If the contractor or its agent destroys the information, the contractor shall provide documentation evidencing such destruction to the administrative agency.

(4) The HHS, when exercising its role in overseeing implementation of the Health Insurance Portability and Accountability Act (HIPAA) or if authorized by other federal law.

(5) Third parties, such as health insurers, requesting social security numbers for the purpose of determining the existence of health care coverage that may be liable to pay all or part of medical bills. Third parties receiving information may not use the information except for the purposes set out in this paragraph and unauthorized use of the information shall be subject to penalties set out in section 5101.99 of the Revised Code.

(6) Any state licensing or certification authority while performing their statutory duties of conducting or assisting with investigations, prosecution or civil or criminal proceedings against medicaid providers, provided that any such licensing or certification authority agrees to be bound by the same rules and regulations regarding recipient confidentiality that binds ODJFS. To ensure agreement of confidentiality, these information requests and responses will be conducted solely between the requesting authority and the appropriate office within ODJFS.

(7) A county child support enforcement agency (CSEA) when requesting relevant information needed to secure child support as outlined in rule 5101:1-3-10 of the Administrative Code.

(8) State and local offices of women, infants and children program (WIC), child and family health services (CFHS), and the children with medical handicaps program (CMH). The information shared is limited to eligibility information for specific individuals or assistance groups receiving services from WIC, CFHS and/or CMH.

(9) Public children services agencies (PCSA) when the administrative agency is to report known or suspected instances of child abuse and neglect of a child receiving medicaid or other medical assistance programs or when the PCSA needs information in order to conduct an assessment/investigation of a report of alleged child abuse or neglect, as outlined in rule 5101:2-39-51 of the Administrative Code. Instances of abuse and neglect situations exist when a child experiences physical or mental injury, sexual abuse, or exploitation, or negligent treatment or maltreatment under circumstances which indicate that the child’s health or welfare is threatened.

(D) Recipient’s rights regarding personal data.

The following requirements must be explained at the time of application for assistance or services and are included to protect the medical assistance program recipient’s right to control personal data:

(1) Upon the request of any medical assistance program recipient, the administrative agency must make all data collected about that individual available to the individual unless precluded by law.

(a) The agency must supply an interpretation of the data if it is not readily understandable. If the individual feels that any data is incomplete or inaccurate, the individual has the right to include additional information in the their files.

(b) Medical, psychiatric or psychological information may not be released to the individual or his legal guardian if the administrative agency has reason to believe that its release may have an adverse effect on the individual.

(i) If the administrative agency has reason to believe that the release of medical, psychiatric or psychological information may have an adverse effect, the administrative agency shall release this information to a physician, psychiatrist or psychologist designated by the individual.

(ii) Once the individual provides expressed and informed consent, the administrative agency will send this information to the designated medical provider.

(iii) The medical provider will then determine whether the information should be disclosed to the recipient.

(2) Upon a medical assistance program recipient’s request, the administrative agency must inform the individual about the types of uses of the personal information, including the identity of any users usually granted access to the system.

(3) Upon any request for individual data through compulsory legal process, the medical assistance program recipient must be immediately informed of such request. In addition, the administrative agency must inform the court of the statutory and regulatory provisions against disclosure of information, if state or federal law precludes the release of the information. If the court still seeks the information, and if the information is not protected by any other privilege recognized by law, the administrative agency will furnish the specified information to the court itself along with the ODJFS policies for safeguarding that information. At the same time, the administrative agency must notify the individual that the information has been furnished to the court and must supply the individual duplicate copies of the information.

(4) Pursuant to division (D) of section 5101.27 of the Revised Code, the administrative agency may release information about a medical assistance program recipient if the recipient gives voluntary, written consent that specifically identifies the persons or government entities to which the information may be released.

(a) The consent must be directly for the purpose of the administration of medicaid or other medical assistance programs and whoever receives the information must be subject to the same or similar confidentiality standards as the administrative agency.

(E) Nondiscrimination.

(1) The administrative agency is responsible for rendering assistance without discrimination on account of race, religion, national origin, political beliefs, age, or sex in a manner consistent with the United States constitution, Social Security Act, Civil Rights Act, and the Constitution of the state of Ohio.

(F) Release of information.

(1) When the administrative agency requests information from a third party, a signed authorization which is HIPAA compliant shall be obtained.

(2) When a third party requests information from the administrative agency, a signed authorization which is HIPAA compliant shall be obtained.

(3) A copy of the signed authorization must be included in the individual’s file. In order for the authorization to be HIPAA compliant, it must contain all of the following:

(a) A description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion;

(b) The name or other specific identification of the person(s) or class of persons authorized to make the requested use or disclosure of the information;

(c) A description of each purpose of the requested use or disclosure of the information. The statement “at request of the individual” is a sufficient description of the purpose when an individual initiates the authorization and does not wish to provide a statement of purpose;

(d) Expiration date or an expiration event that relates to the individual or the purposes of the use or disclosure of the information;

(e) Statement that information used or disclosed under this authorization may be subject to re-disclosure by the recipient of the information and may no longer be protected from re-disclosure by this section;

(f) Must be signed by individual or authorized representative, dated and a copy provided to signatory;

(g) If signed by an authorized representative, a description of the representative’s authority to act for the individual;

(h) A statement of the individual’s right to prospectively revoke the authorization in writing, and either a description of how the individual or authorized representative may revoke the authorization, or a reference to the department’s privacy notice if it contains a description of how the individual or authorized representative may revoke the authorization;

(i) A statement that treatment, payment, enrollment or eligibility for medicaid or other medical assistance programs cannot be conditioned on signature of the authorization unless the authorization is necessary for the determination of eligibility for medicaid.

(G) Confidentiality requirements for information from the social security administration (SSA).

(1) The SSA sends information to ODJFS about retirement survivors disability insurance (RSDI) and supplemental security income (SSI) beneficiaries who are medical assistance program recipients. ODJFS displays this information to the administrative agency using the CRIS-E data exchange screens. The ODJFS state verification and exchange system (SVES) provides electronic interface with the SSA. The interface allows the transfer of Title II (SSA RSDI benefits), Title XVI (SSI), and benefit earnings exchange record (BEER) information about employment (whether or not the individual is a participant of RSDI and/or SSI). SVES replaces the paper transaction request, third party query (TPQY) between the state of Ohio and the SSA. The SSA limits use and disclosure of this SSA information.

(2) The Privacy Act of 1974 allows the SSA to release information to the administrative agency without a release of information from the beneficiary only as long as the information is for a “routine use” and for specified programs. Every use or disclosure of SSA information which is not routine or is not for an approved, specified program requires the prior written permission of the beneficiary or the SSA, respectively.

(a) The routine uses and approved programs for RSDI obtained from the beneficiary and earnings data exchange (bendex system) are: to determine eligibility for and administer medicaid, Ohio works first (OWF), disability assistance (DA), food stamps, Title XX social services, Title IV-E, child support and energy assistance.

(b) The routine uses and approved programs for SSI benefits obtained from the state data exchange (SDX) and SVES are: to determine eligibility for and administer medicaid, OWF, food stamps, DA, energy assistance, Title XX social services, Title IV-E, child support and interim assistance. SDX data may also be used to calculate the amount of a residential state supplement (RSS) payment and to monitor changes of circumstances of mandatory state supplement recipients.

(H) Disclosure, confidentiality, and physical safeguarding of SSA and IRS information.

(1) Whenever the administrative agency discloses SSA information received from the SSA to someone who is not an employee of the administrative agency, it must do so only for a routine use of an approved program. Additionally, it must disclose only the information needed to accomplish the purpose of the routine use.

(2) ODJFS may disclose SSA information to another state agency, provided it is for routine use for an approved program and only the needed information is disclosed.

(3) Although the administrative agency may obtain SSA information without a release of information from the beneficiary, they must keep a record any time they disclose this information to anyone who is not an employee of the administrative agency. This is true even though the disclosure is for a routine use.

(a) The required record of disclosure of SSA information must be kept in the individual case record and also in a centralized record-keeping system.

(i) The administrative agency must enter a notation about the disclosure in the case record. The notation must contain the date of disclosure, the information disclosed, the purpose of the disclosure, and the person to whom the information was disclosed.

(ii) The administrative agency must maintain a centralized record keeping system, containing separate records for each source of data disclosed. The centralized record must contain the date of disclosure, the information disclosed, the purpose of the disclosure, and the person to whom the information was disclosed.

(b) The case record notation and the centralized record-keeping system must contain the date of disclosure, the information disclosed, the purpose of the disclosure, and the person to whom the information was disclosed. For the case record, the administrative agency must enter the notation about the disclosure. For the centralized record keeping system, the administrative agency must maintain separate records for each source of data disclosed.

(c) The record of disclosure must be retained for five years or the life of the application, whichever is longer. The disclosure records are subject to inspection by the SSA.

(4) The internal revenue service (IRS) sends unearned income information received from 1099 forms filed with that agency to ODJFS regarding public assistance applicants and recipients. This federal tax information is displayed on the CRIS-E screen data exchange inquiry resource/unearned income (DERS).

(5) Internal revenue code (IRC) section 6103 allows the disclosure of tax return information to federal, state, and local agencies by the IRS for use in their medicaid, OWF and food stamp programs. The return information is disclosed solely for the purpose of, and to the extent necessary in, determining eligibility for, or the correct amount of, benefits under the specified programs.

(6) IRS return information may not be disclosed to, exchanged with, or utilized by any other state agency. The administrative agency employees who are entitled to access tax return information generally must not disclose this information to any party outside the agency other than the taxpayer to whom the information relates or the taxpayer’s duly appointed representative who has the explicit authority to obtain the tax return information.

(7) To the extent that disclosure of IRS information is necessary to verify eligibility for and the correct amount of benefits, including past benefits, such disclosure may be made only when there is no other means of verifying the unearned income information, and only to the extent necessary to verify the unearned income information.

(a) All administrative agency employees with access to IRS return information must have disclosure awareness training for safeguarding requirements and must be advised on an annual basis of IRS penalty provisions.

(b) The administrative agency must maintain a permanent system of standardized record keeping which documents requests for, and disclosure of return information. If redisclosure is authorized, the information disclosed outside the agency must be recorded on a separate list which reflects to whom the disclosure was made, what was disclosed, why and when it was disclosed.

(8) The administrative agency must physically protect SSA and IRS information from unauthorized access. The physical record number of SSA and IRS information required to be safeguarded include, but are not limited to, the following:

(a) Benefit earnings exchange record (BEER) information which contains federal wage information obtained from the SSA master earnings file;

(b) IRS information return master file which contains returns filed by payers of income such as dividends, interest and retirement income.

(9) The administrative agency must:

(a) Limit access to the data to only those employees and officials who need it to perform their official duties in connection with the approved programs.

(b) Store data in an area that is physically safe from access by unauthorized persons.

(c) Store and process magnetic tapes, screen prints and any electronic data in CRIS-E or any other computer system used in such a way that information cannot be retrieved by unauthorized persons.

(d) Advise all personnel who will have access to the data of the confidential nature of the information, the safeguards required, and the criminal and civil sanctions for noncompliance contained in federal and state statutes.

(e) Permit the SSA and internal revenue service to make onsite inspections to ensure that adequate safeguards are being maintained.

(f) Ensure that when interactive interviews using the CRIS-E system occur in the presence of an assistance group member who is not the subject of the confidential information, the computer screen is adjusted in such a manner that the visual screen is not exposed to that individual.

HISTORY: Eff 7-1-03

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.01

Rule amplifies: RC 5111.01, 5111.011

R.C. 119.032 review dates: 07/01/2008

(A) An individual convicted in federal or state court of having made a fraudulent statement or misrepresentation with respect to the place of residence in order to receive assistance simultaneously from two or more states shall be ineligible for medicaid and covered families and children medicaid for a ten year period.

(B) The ten year period of ineligibility begins on the date the individual is convicted in federal or state court.

(C) This provision shall not apply with respect to a conviction of an individual for any month beginning after the president of the United States grants a pardon with respect to the conduct that was the subject of the conviction.

HISTORY: Eff 10-1-97; 10-1-02

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.01, 5111.011

Rule amplifies: RC 5111.01, 5111.011

Replaces: 5101:1-39-29

R.C. 119.032 review dates: 10/01/2007

Rescinded eff 10-1-09

(A) The Immigration Reform and Control Act (IRCA) of 1986 requires the verification of immigration status of aliens applying for federally funded entitlements. Medicaid programs, including CFC medicaid, participate in a systematic verification of alien documentation. The immigration and naturalization service (INS) has developed the SAVE program to ensure that only lawfully admitted aliens receive federally subsidized benefits.

(1) Each applicant for medicaid, including CFC medicaid, must provide, under penalty of perjury, a written declaration of citizenship/alien status. This declaration must be provided whether or not the applicant is a citizen or national of the United States, or alien in satisfactory immigration status.

(2) The requirement of written declaration of citizenship/alien status shall be considered met for all members of the assistance group, including all dependent children, when a required adult assistance group member or authorized representative has signed and dated the JFS 07100 “Application for Income, Medical, and Food Assistance” (CAF), the JFS 07200 “Request for Cash, Medical, and Food Stamp Assistance” (APPL), the JFS 07216 “Combined Programs Application” (CPA), or the JFS 07103 “Application for Help With Medicare Expenses”.

(B) An assistance group member who is not a U.S. citizen or national and who claims to be of an eligible alien status must provide documentation from INS of his current alien status. Required documentation must be provided at initial application, when alien status changes, or when the original documentation becomes questionable. An individual who is otherwise a required assistance group member who claims to be of an ineligible alien status does not have to verify his status with the INS.

(1) Only original documentation of alien registration status shall be considered acceptable verification of alien status. If an applicant or recipient claims to have lost the original documents, the CDJFS shall refer the individual to the local ins office to request new documentation. The CDJFS will use only original documents to verify alien status through the SAVE system.

(2) Alien registration cards normally have an alien registration number. This number, often called the A-number, references the individual’s alien file at INS. The A-number contains seven or eight numerical digits preceded by the letter “A”. The A-number is unique to the individual. Even minors and infants who are aliens will have individual A-numbers assigned.

(3) Aliens may present other documents, such as marriage records or court orders, that indicate identity, immigration status, or U.S. residence of the holder. These documents are not considered adequate proof of current immigration status, but may be used to verify alien status through the secondary verification process.

(4) When the applicant provides the CDJFS with alien documentation which does not contain a photograph, the CDJFS should request valid identification which includes a photograph. While a photo identification is not required, the CDJFS should be satisfied that the applicant is properly identified.

(C) There are two methods of verifying alien registration status. Regardless of the method of verification used, no eligibility determination will be delayed solely because of the alien status verification index (ASVI) database or the INS office has failed to verify alien registration status. Primary verification is an automated process used to quickly provide alien verification. Secondary verification is a more extensive validation procedure and is used when the automated process is unable to provide information and under other specified circumstances. For most applicants, the CDJFS shall use primary verification.

(1) Primary verification is an automated process used to quickly provide alien verification. The SAVE program makes use of the ASVI database. For most alien applicants, the CDJFS shall use primary verification using ASVI. This database contains records on aliens within the United States. The CDJFS may access ASVI by telephone. This data base may be accessed by the CDJFS with the A-number from the individual’s original alien registration document.

(a) The CDJFS shall compare the information provided through ASVI with the data provided on the alien’s documentation. The CDJFS shall record the ASVI verification number and date of the ASVI transaction on the copy of the alien documentation. If there are no discrepancies between the document and the information provided through ASVI the copy shall be filed in the assistance group record.

(b) If instructed during primary verification, institute secondary verification or if there are material discrepancies, secondary verification methods must be pursued. Material discrepancies are defined as obvious irregularities in name, date of birth or county of birth. A slight difference in the spelling of a name would not normally be a material difference.

(2) Secondary verification provides a more extensive validation procedure through automated and paper INS files when problems appear in the verification of alien registration status. Secondary verification will be necessary in the following situations:

(a) When any of the items presented as documentation appear to be counterfeit or altered.

(b) When an alien presents unfamiliar INS documentation, or a document that indicates immigration status, but does not contain an A-number.

(c) When a document contains an A-number in the “A60 000 000” series.

(d) When the document contains an A-number in the “A80 000 000” series.

(e) When the document presented is any other form of an INS fee receipt, other than an I-689.

(f) When the document presented is a memorandum of creation of record of lawful permanent residence (form I-181a).

(g) When the document presented is a foreign passport and/or an arrival-departure record (form I-94) that bears the endorsement “processed for I-551, temporary evidence of lawful permanent residence” and the document is over one year old.

(h) Whenever an automated check through ASVI returns with a response “institute secondary verification” or when there is material discrepancy between an alien’s documentation and the record contained in ASVI.

(D) Procedures for obtaining secondary requests.

(1) The CDJFS shall complete a document verification request (form G-845), attach readable photocopies of original immigration documents, and forward this to the appropriate INS. A separate G-845 will be completed for each assistance group member.

(2) Secondary verification is a process used to verify alien status. This information may be shared routinely between the INS and the CDJFS.

HISTORY: Eff 6-1-93; 10-1-95; 7-1-98; 10-1-02

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.01, 5111.011

Rule amplifies: RC 5111.01, 5111.011

Replaces: 5101:1-1-50

R.C. 119.032 review dates: 10/01/2007

(A) Section 1137 of the Social Security Act mandates that state agencies administering federally funded public assistance programs develop and implement an income and eligibility verification system (IEVS). Under IEVS, the Ohio department of job and family services (ODJFS) will obtain income and benefit information from the following sources:

(1) The ODJFS, program liaison bureau.

(2) The social security administration (SSA).

(3) The internal revenue service (IRS).

(B) Under IEVS, the match data will be furnished to the county department of job and family services (CDJFS). The CDJFS shall take action to review and process the information immediately upon receipt. The CDJFS will have a forty-five-day to one hundred twenty-day processing time frame to receive the matched data, compare the matched information to the information in the assistance group record, obtain verification when applicable, determine eligibility, and initiate appropriate corrective action.

(C) Integration of IEVS into the client registry information system-enhanced (CRIS-E)

(1) All IEVS functions of ODJFS are provided through CRIS-E. The CDJFS shall follow the procedures as outlined in CRIS-E flash sixty-one for the processing of matched data reviews.

(2) The regular matching of social security numbers of assistance group members are reflected through IEVS consisting of the following three CRIS-E components:

(a) Data exchange

(b) Compliance tracking

(c) Reporting

(D) Specific sources of IEVS matches

(1) Under IEVS, ODJFS will regularly match social security numbers of applicants and assistance group members with the following source agencies:

(2) The ODJFS, program liaison bureau – wage records.

(a) The ODJFS, program liaison bureau acts as the state’s wage information collection agency (SWICA). Section 4141.20 of the Revised Code requires employers to report quarterly earnings of all employees by the last day of the month following the end of each calendar quarter. ODJFS will match all medicaid and CFC medicaid applicants and assistance group members against the SWICA files on a quarterly basis. Matches shall be displayed to the CDJFS as soon as they are received.

(b) The CDJFS shall treat information received from this source as a lead to possible employment. Verification of earnings must be obtained from the employer or assistance group member before benefits may be affected.

(3) The ODJFS, program liaison bureau – unemployment compensation records.

(a) ODJFS will match all medicaid applicants and assistance group members against the ODJFS, program liaison bureau files on a twice-per-month basis. Matches will be displayed to the CDJFS as soon as they are received.

(b) Information received from this source should be considered verified unless the client’s statement and/or case record fails to support the accuracy of the information.

(4) The social security administration (SSA) benefit earnings exchange record (BEER)

(a) SSA obtains wage records from employers on an annual basis. Twice a month ODJFS transmits a request through the SSA’s BEER for all new medicaid applicants and assistance group members. The SSA processes the BEER request twice a month and returns the matched file information to ODJFS for review.

(b) The BEER match includes out of state and federal employers and is expected to duplicate most of the information provided by SWICA received from ODJFS, program liaison bureau. However, the federal wage records match will include employers who do not report to SWICA. Matches from this source will be displayed to the CDJFS as soon as they are received and are to be considered as a lead that must be verified before benefits may be affected.

(c) Earnings information received from this source is considered as a lead toward possible current employment. The CDJFS must obtain verification of this data before initiating any adjustment to the assistance group case.

(5) Retirement survivors disability insurance (RSDI) and supplemental security income (SSI) benefits

(a) SSA provides information on RSDI and SSI benefits of individual participants. The ODJFS state verification and exchange system (SVES) provides electronic interface with the SSA. The interface allows the transfer of RSDI and SSI benefit information from the SSA.

(b) Beneficiary and SSI entitlement information is considered verified. Dual entitlement information should be verified, when or if, the assistance group record does not support the accuracy of the information.

(6) The internal revenue service (IRS)-unearned income records

(a) IRS compiles information concerning unearned income records on an annual tax year basis from IRS-1099 forms filed with that agency from vendors, businesses, banks, brokers, and other payers. All medicaid applicants and assistance group members will be matched with these files on an annual basis, usually in July. Newly approved applicants and assistance group members are matched monthly. The data received should be between eight months and twenty months old at the time of display to the CDJFS. Matches will be displayed as soon as they are received.

(b) There are many types of unearned income. The primary types are interest from bank accounts and certificates of deposit, dividends from stocks, winnings from gambling activities and prizes.

(c) The information received from this source is considered as a lead and must be verified by the CDJFS before it can be utilized in the determination of eligibility.

(E) Processing time frames

(1) Federal regulations allow the CDJFS a forty-five day processing time for IEVS matches. A one hundred-twenty day processing time frame as assigned by the ODJFS is dependent upon a priority level for the received match information.

(2) A CDJFS may only exceed this time period on up to twenty percent of their reviews, provided that the reason for the delay is due to nonreceipt of verifications, and provided that the review is completed by the next case action. During these forty-five and one hundred-twenty day periods, the CDJFS must review the assistance group record, contact the assistance group, obtain verification when necessary, determine eligibility and make appropriate adjustments.

(3) Once the CDJFS completes the IEVS match process, the results will be recorded in CRIS-E history.

(4) When the CDJFS determines that an IEVS match displayed is for an assistance group whose case record is now active in another county and/or is delinquent, the CDJFS shall refer to the CRIS-E transfer procedure.

(F) IEVS priority levels

(1) CDJFSs are assigned IEVS match information in the CRIS-E system with one of three priority levels: high, medium or low (information only). These priority levels are based upon ODJFS’ determined error prone factors.

(a) High priority matches shall be reviewed and completed by CDJFS within a forty-five day time frame.

(b) Medium priority matches shall be reviewed and completed within one hundred-twenty days.

(2) Low priority matches are issued to CDJFS for informational purposes only. These matches are available for a minimum of one hundred-eighty days. The CDJFS will not be required to follow-up or report the results of these reviews, however, other matches may be appended to them and change the low priority level to medium or high. In those instances, the CDJFS worker will be required to review and complete the matches.

(G) Reference rule 5101:1-37-01.1 of the Administrative Code for issues related to disclosure, confidentiality and physical safeguarding of SSA and IRS information.

(1) Refer to Chapter 5101:9-21 of the Administrative Code for closed IEVS documentation procedure.

(H) Required CDJFS action

(1) Upon receipt of an IEVS match, the CDJFS shall:

(a) Refer to CRIS-E flash sixty-one for procedural requirements.

(b) Regard the matched information (unless social security administration beneficiary and supplemental security income entitlement or unemployment compensation) as a lead indicating the possible receipt of income or resources (for medicaid and CFC medicaid) to an assistance group member, not as verification.

(c) Determine if the IEVS information is consistent with the information already provided by the assistance group. When the assistance group case record does not have information which resolves the IEVS match, the CDJFS shall contact the assistance group.

(2) When an assistance group is contacted for verification of income or resources, the CDJFS shall provide a deadline of ten calendar days for submission of the verification. The request for verification shall also state that if the assistance group fails to provide the information and/or contact the CDJFS, assistance may be terminated. At the end of the time period, if there has been no contact with the assistance group or if there has been a refusal to provide verification, prior notice shall be sent proposing termination as the CDJFS is unable to determine continued eligibility. Since the information from the IEVS match does not coincide with the information from the assistance group case record, the CDJFS must verify the match information. It is the responsibility of the assistance group to provide the information necessary to determine eligibility and to clarify any incomplete, inconsistent, or contradictory information received.

(3) If the assistance group agrees to cooperate in providing the requested information but is unable to provide the information, the CDJFS shall obtain a HIPAA compliant authorization or JFS 07341. “Applicant/Recipient Authorization for Release of Information”.

(4) Any adverse action resulting from information produced by a matching program must be processed in accordance with rule 5101:6-1-01 of the Administrative Code.

(5) When the review of the IEVS match results in a determination that the benefits were issued incorrectly, the CDJFS shall proceed in accordance with rule 5101:1-38-20 of the Administrative Code.

(6) When the review of the IEVS match results in a determination that the assistance group is not eligible for medicaid, the administrative agency shall not terminate medicaid for a member(s) of an assistance group until a pre-termination review (PTR) of continuing medicaid eligibility has been completed in accordance with rule 5101:1-38-01.1 of the Administrative Code.

(7) When the review of the IEVS match results in the discovery of previously unknown employment, the CDJFS shall secure appropriate third-party resource and medical support forms.

(I) The IEVS match investigation

The CDJFS shall investigate the IEVS match using the following guidelines:

(1) The CDJFS shall not deny, delay, or discontinue benefits while waiting for information when other evidence establishes the assistance group’s eligibility.

(2) The primary task of the IEVS match review is to check previous and current eligibility.

(3) The eligibility determiner’s purpose in the IEVS match is to discover the facts of the assistance group’s situation during the match period and to decide whether the assistance group received the correct benefits.

(4) Fraud investigation is an activity for the CDJFS overpayment recovery unit and the county prosecuting attorney.

HISTORY: Eff 1-1-83; 12-1-86; 3-13-87 (Emer.); 5-4-87; 9-1-89 (Emer.); 11-30-89; 1-1-90 (Emer.); 4-1-90; 1-1-93; 9-1-94; 11-1-96; 7-1-98; 7-1-99; 10-1-02; 10-6-03

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.01

Rule amplifies: RC 5111.01, 5111.012

R.C. 119.032 review dates: 06-13-2003 and 10-01-2008

(A) General principles

(1) Cash assistance payments related to medicaid include residential state supplement (RSS) program payments, qualified individuals-2 (QI-2) payments, and direct reimbursement payments (DRP) as defined in rules 5101:1-39-53.5 and 5101:3-1-60.2 of the Administrative Code. The client registry information system enhanced (CRIS-E) generates requests for certain categories of payments, including RSS and QI-2.

(2) The county department of job and family services (CDJFS) shall inform the assistance group of a waiting period of five working days that is required following the mailing date or redirect date prior to initiating replacement of warrants. The five working day waiting period may be waived if the warrant was received damaged or mutilated or not received due to a mail robbery. A “mail robbery” is defined as the robbery of a U.S. postal service building, vehicle, container, or employee. Verification of the mail robbery must be retained in the case and assistance group records. Acceptable verification of a mail robbery is a statement from the post office stating that a robbery of a specific U.S. postal service building, vehicle, container or employee, containing mail destined for a specific area has occurred.

(3) The CDJFS in the county in which the recipient is currently residing is responsible for providing the recipient(s) with forms requiring completion by the recipient(s) and authorizing the replacement of CRIS-E generated warrants, as set forth in paragraphs (B) to (L) of this rule.

(4) The CDJFS in the county in which the recipient is currently residing is responsible for providing the recipient(s) with forms requiring completion by the recipient(s) and for forwarding the forms to the Ohio department of job and family services (ODJFS), bureau of consumer and program support in situations where the replacement warrants are not CRIS-E generated. All of the procedures outlined in this rule are to be followed by the CDJFS, other than authorizing a replacement warrant, for warrants not issued by CRIS-E. These warrants will be authorized through the bureau of consumer and program support.

(5) If the recipient relocates to another county within Ohio, the CDJFS in the original county of residence shall provide any assistance needed to the CDJFS in the county of relocation.

(6) If the payee for the warrant is someone other than the medicaid recipient, the payee is the person responsible for cooperating with the agency and completing the necessary forms.

(7) CDJFS adherence to the provisions set forth in this rule is mandatory and is monitored by ODJFS regional office staff, and the ODJFS office of fiscal services. When necessary, ODJFS will notify the auditor of state or treasurer of state of any actions taken.

(8) All forms and any necessary correspondence should be addressed to the ODJFS, bureau of accounts receivable.

(B) Warrants reported as not received

When the payee reports that he or she did not receive a regularly scheduled warrant in the mail and it is past the time that the warrant should have been received (i.e., within five working days of the mailing date), the CDJFS shall determine whether the warrant was mailed correctly by taking the following actions:

(1) Check the CRIS-E issuance history to assure that a warrant was issued for that assistance group, that the person reporting nonreceipt is designated as the payee, and that the reported correct mailing address coincides with the CRIS-E mailing address or alternate address on AEFAM in CRIS-E. If the assistance group has moved from the address of record, the CDJFS shall take the necessary and appropriate actions to effect the address, assistance group, and case changes, and, if possible, redirect the warrant. The CDJFS should also check the CRIS-E authorized representative screens (AEFAR) to ensure that they do not contain incorrect information.

(2) Check CRIS-E issuance history to determine if the warrant was returned and canceled (or returned and redirected) as set forth in paragraph (C)(1) of this rule, or void (over ninety days old), as set forth in paragraph (C)(3) of this rule.

(3) For non-CRIS-E generated warrants, the CDJFS is required to contact the ODJFS to assure that a warrant was issued for that assistance group, that the person reporting nonreceipt is designated as the payee, and that the reported correct mailing address coincides with the mailing address or alternate address. If the assistance group has moved from the address of record, the CDJFS shall take the necessary and appropriate actions to effect the address, assistance group, and case changes, and, if possible, redirect the warrant. The CDJFS should also check the CRIS-E authorized representative screens (AEFAR) to ensure that they do not contain incorrect information

(C) Warrants shown on CRIS-E issuance history

(1) If CRIS-E issuance history shows that the warrant was returned and canceled (RC), the CDJFS shall issue a replacement warrant through the CRIS-E benefit issuance subsystem. Completion of forms JFS 02132, “Affidavit in Support of Application for Replacement Warrant”, and AUD 7202, “Auditor of State Welfare Audits and Investigation” is not required in this type of replacement warrant situation.

(2) In situations where warrants are shown as returned and redirected on CRIS-E issuance history, the CDJFS shall advise the payee to allow five working days from the redirect date for delivery.

(3) Warrants shown as void (VO) on CRIS-E issuance history

(a) Because the warrant is over ninety days old, the CDJFS shall issue a replacement warrant through the CRIS-E benefit issuance subsystem.

(b) Completion of forms JFS 02132, “Affidavit in Support of Application for Replacement Warrant”, and AUD 7202, “Auditor of State Welfare Audits and Investigation” are not required in this type of replacement warrant situation.

(4) Warrants reported as not received (or located) by the fifth working day from the mailing date and that show on CRIS-E issuance history as redeemed

(a) Since the warrant has already been redeemed, as confirmed by CRIS-E issuance history, attempting to effect a stop payment prior to replacing a warrant that has been redeemed cannot be done and is not required.

(b) In situations when the payee reports nonreceipt, loss, or theft of a warrant and that warrant is redeemed by the state treasurer, an analysis of the signature, as set forth in paragraph (H) of this rule, shall be made to determine whether the payee endorsed the warrant. Prior to replacing the warrant through the CRIS-E benefit issuance subsystem, the CDJFS shall require the completion of forms JFS 02132 and AUD 7202 by the payee. Both originals and one copy of each of the completed forms must immediately be forwarded to the ODJFS bureau of accounts receivable stop payment unit.

(c) If the warrant is reported as not received by the payee or located within five working days from the mailing date (or redirect date), and the warrant shows on CRIS-E issuance history as redeemed, the CDJFS shall issue a replacement warrant through the CRIS-E benefit issuance subsystem. A warrant shows as redeemed when the treasurer of state has negotiated the warrant.

(5) Warrants reported as not received by the fifth working day from mailing and that are not identified as redeemed, returned and canceled (or returned and redirected), or void on CRIS-E issuance history.

(a) If the warrant is reported as not received by the payee or located within five working days from the mailing date, and the CRIS-E issuance history does not show a disposition of returned and canceled (or returned and redirected), void, or redeemed, the warrant is “missing.” The CDJFS shall effect a stop payment in accordance with the provisions set forth in paragraph (B)(5)(b) of this rule and issue a replacement warrant through the CRIS-E benefit issuance subsystem.

(b) The CDJFS shall take action necessary to effect a stop payment on the missing warrant.

(i) The CDJFS action necessary to effect a stop payment is accomplished in CRIS-E by requesting payment stopped on the outstanding warrant via SFSP (support functions stop payment request screen). Once the CDJFS enters the information in SFSP, the stop payment information will be transmitted nightly to the treasurer’s office.

(ii) Following the CDJFS entering the stop payment request in CRIS-E via SFSP, the CDJFS shall require completion of forms JFS 02132 and AUD 7202 by the payee. However, these completed documents should not be forwarded to the ODJFS bureau of accounts receivable at this point, but should be retained in the assistance group record.

(iii) In the event that (following the CDJFS request for a stop payment via SFSP) the warrant is redeemed prior to the treasurer’s office effecting the stop payment, the CDJFS must immediately forward both the originals and one copy of each of the completed forms JFS 02132 and AUD 7202 to the ODJFS bureau of accounts receivable stop payment unit.

(iv) Situations of loss, theft, or damage after endorsement are the only situations in which the CDJFS is permitted to telephone a stop payment and then follow up with the required paperwork.

(D) Warrants reported as received but subsequently lost, stolen, or accidentally destroyed before endorsement

(1) When a payee reports that the warrant was received, but was subsequently lost, stolen, or accidentally destroyed before endorsement, (i.e., the payee no longer has the warrant in his possession) the CDJFS shall apply the procedures set forth in paragraph (B)(4) of this rule if the warrant has been redeemed as identified on issuance history or paragraph (B)(5) of this rule if the warrant is missing. The CDJFS shall issue a replacement warrant through the CRIS-E benefit issuance subsystem.

(2) If the payee alleges that the warrant was stolen, the CDJFS shall require the payee to file a police report, prior to replacing the warrant.

(E) Warrants reported as received but subsequently lost, stolen, or accidentally destroyed after endorsement

(1) When a payee reports that the warrant was received, but was subsequently lost, stolen, or accidentally destroyed after it was endorsed by the payee (i.e., the payee no longer has the endorsed warrant in his possession), a replacement warrant can be issued only after the CDJFS takes action to effect a stop payment on the original warrant and prevent the original warrant from being redeemed by the treasurer of state.

(2) Once the CDJFS has determined that the warrant has not been redeemed by the treasurer of state (as identified in CRIS-E issuance history), the CDJFS shall immediately telephone the ODJFS bureau of accounts receivable to order payment stopped on the original warrant. Situations of loss, theft, or damage after endorsement are the only situations in which the CDJFS is permitted to telephone a stop payment. The CDJFS must immediately follow up the telephone authorization by completion of the procedures set forth in paragraph (C) of this rule.

(3) If the payee alleges that the warrant was stolen, the CDJFS shall require the payee to file a police report prior to replacing the warrant.

(F) Warrants reported as received but damaged or mutilated

(1) When a payee reports that the warrant was received but is damaged or mutilated, (i.e., the payee still has the damaged/mutilated warrant in his possession) the action taken by the CDJFS is dependent upon the extent of the damage to the warrant and whether the payee endorsed the warrant before it was damaged.

(2) If a warrant is mutilated or damaged beyond recognition, the CDJFS shall follow the provisions set forth in paragraph (D) of this rule, if the warrant was damaged prior to endorsement. Conversely, the CDJFS shall follow the provisions set forth in paragraph (E) of this rule if the warrant was damaged beyond recognition after it was endorsed.

(3) If a payee reports that the warrant is not damaged beyond recognition but damaged enough that it cannot be cashed, as determined by a financial institution, the CDJFS shall proceed to replace the warrant as set forth in the steps below. The payee must have in his possession the damaged warrant, or the major part of the warrant. An example of a warrant damaged enough that the payee cannot cash it, but not damaged beyond recognition is the warrant being ripped into two pieces.

(a) The CDJFS shall obtain the damaged warrant from the payee.

(b) The CDJFS shall have the JFS 02132 completed by the payee. The words “damaged warrant” must be typed across the top of the form. The payee’s signature is required on this form.

(c) The CDJFS shall attach the damaged warrant to the JFS 02132 and forward them to the ODJFS payment distribution section.

(d) The CDJFS shall proceed to replace the warrant via the CRIS-E benefits issuance subsystem.

(4) All necessary activities as described in this rule must be completed within fourteen days of the date that the payee initially notified the CDJFS that the warrant was damaged or mutilated. The replacement warrant must be authorized within fourteen days of the date that the payee reported the warrant was damaged or mutilated.

(G) Warrants reported as lost, stolen, or destroyed by holder in due course.

(1) The payee may receive, endorse, and cash the warrant, after which the holder in due course, or second payee has the warrant and it is then lost, stolen or destroyed. The holder in due course is the vendor or the individual who cashed the warrant for the payee.

(2) The CDJFS must explain the following replacement procedure to both the payee and the holder in due course. The following actions shall be taken when a warrant is received, endorsed, and cashed by the payee and is subsequently lost, stolen, or destroyed:

(a) Check CRIS-E issuance history and with the ODJFS to verify that the warrant has not been redeemed by the treasurer of state.

(b) If the original warrant has been redeemed, as identified on issuance history, the warrant cannot be replaced. The CDJFS shall obtain a copy of the redeemed warrant and forward it to the holder in due course for possible legal action.

(c) If the warrant is not identified as redeemed in issuance history, the CDJFS shall immediately telephone the ODJFS bureau of accounts receivable and order payment on the warrant stopped. Situations of loss, theft, or damage after endorsement are the only situations in which the CDJFS is permitted to telephone a stop payment. The CDJFS must immediately follow up the telephone authorization by completion of the procedures set forth in paragraph (B) of this rule.

(d) Complete an AUD-8184, “Auditor of State Application for Replacement Warrant (Holder in Due Course)”, front side only. (This form is available from the ODJFS bureau of accounts receivable, as well as the auditor’s office.) This form must be signed by the holder in due course, or second payee. The back side of the form will be completed by ODJFS. The CDJFS is responsible for assisting the holder in due course in the completion and filing of this form with ODJFS.

(e) Forward the original and one copy of the AUD 8184 to the ODJFS bureau of accounts receivable.

(3) A replacement warrant can be issued to a holder in due course only if the original warrant has not been redeemed, and after all of the above activities are completed. When issuance of a replacement warrant to a holder in due course is necessary, the CDJFS shall issue the replacement warrant to the holder in due course by changing the payee for the assistance group to the holder in due course (person/organization) on the authorized representative (AEFAR) screen. Following the issuance of the replacement warrant to the holder in due course, the CDJFS must assure that the holder in due course information (listing the holder in due course as the authorized representative for the assistance group) is immediately deleted, so that any subsequent month’s warrants (or correspondence) are not incorrectly delivered to the holder in due course.

(H) Referral of warrants received by the treasurer of state for handwriting analysis

(1) Following completion of the warrant replacement procedures set forth in paragraph (B) of this rule, in situations when the payee reports nonreceipt, loss, or theft of a warrant and that warrant is redeemed by the state treasurer, an analysis of the signature shall be made to determine whether the payee endorsed the warrant.

(2) When ODJFS finds that the original warrant has been redeemed by the treasurer of state, ODJFS will obtain copies of the redeemed warrant and will forward copies of the redeemed warrants to the CDJFS. ODJFS shall send a copy of the redeemed warrant and the AUD 7202 to the document division, bureau of criminal investigation (BCI). BCI will conduct an examination to determine the degree of similarity between the payee’s handwriting on the AUD 7202 and the endorsement of the warrant.

(3) Following this examination, the document division, BCI, will return a notice to ODJFS indicating one of the following findings (the actions required after the handwriting analysis is completed are dependent upon the conclusions of the BCI determination.):

(a) The handwriting sample and the endorsement do not contain sufficient points of similarity. When the BCI’s examination reveals that there are not sufficient points of similarity, forgery is indicated. ODJFS will not notify the CDJFS as set forth in paragraph (I) of this rule.

(b) It cannot be determined whether there is a similarity between the handwriting sample and the endorsement. In this case, additional handwriting specimens are needed. When the examination reveals that a determination cannot be made and additional handwriting samples are required, ODJFS will notify the CDJFS. The CDJFS shall proceed to take the actions set forth in paragraph (J) of this rule.

(c) The handwriting sample and the endorsement contain sufficient points of similarity. Similarities indicate endorsement was written by the payee. When BCI’s determination reveals that there are sufficient points of similarity, an overpayment and possible fraud are indicated. ODJFS will notify the CDJFS of BCI’s determination. The CDJFS shall proceed to take the actions set forth in paragraph (K) of this rule.

(I) Actions taken after handwriting analysis is completed by BCI – cases in which forgery is indicated

(1) When the investigation by BCI indicates that the handwriting specimen and the endorsed warrant do not contain sufficient points of similarity, ODJFS shall send the original warrant and the original JFS 02132 to the treasurer of state. The treasurer will make a collection from the bank or merchant who cashed the warrant. The treasurer of state will then issue a depository trust fund (DTF) check to ODJFS as reimbursement (for the duplicate check issued to the payee).

(2) If the treasurer of state is unable to collect from the bank (or merchant) who cashed the check because the bank (or merchant) refuses to pay, the treasurer of state will refer the collection to the attorney general for further investigation and possible collection. If the attorney general determines that the payee endorsed the original warrant, the CDJFS shall follow the procedures set forth in paragraph (K) of this rule.

(J) Cases in which additional handwriting samples are required

(1) When BCI is not able to make a determination regarding the similarity between the handwriting specimen and the endorsement, ODJFS shall notify the CDJFS. The CDJFS must provide additional specimens of the payee’s handwriting. This can be accomplished by forwarding handwriting samples of the payee’s signature that are contained in the assistance group record or by having the payee complete an additional AUD 7202. The CDJFS must follow any additional instructions from ODJFS regarding this request.

(2) Within ninety days, the CDJFS must return the new handwriting specimen, along with a copy of the notice from ODJFS identifying the need for the additional handwriting specimen, to the ODJFS bureau of accounts receivable. The ODJFS bureau of accounts receivable will forward the handwriting specimen and the copy of the notice from ODJFS to BCI. BCI shall then continue the investigation of the case.

(3) If the CDJFS does not return the additional handwriting specimen to the ODJFS bureau of accounts receivable within ninety days, the ODJFS bureau of accounts receivable will notify the ODJFS bureau of county finance. The bureau of county finance will take a finding against the CDJFS administration line via the reconciliation/advance process.

(K) Cases in which it is determined by BCI that the payee endorsed the original warrant

(1) When BCI determines that there are sufficient points of similarity to indicate that the payee endorsed the original warrant, and notifies ODJFS of this determination as set forth in paragraph (H) of this rule, an overpayment has occurred because the payee endorsed and cashed the original warrant, as well as the replacement warrant. Recovery of the overpayment must be pursued by the CDJFS.

(2) When the notice that ODJFS sends to the CDJFS indicates that the payee’s known handwriting and the endorsed warrant contain sufficient points of similarity, the CDJFS shall call the payee in to the CDJFS for an interview. If the payee admits to having endorsed the original warrant, the CDJFS shall take action to recover the overpayment, in accordance with rule 5101:1-39-20 of the Administrative Code.

(3) If, during the interview, the payee denies endorsing the original warrant, (and a replacement warrant was also issued), the CDJFS may file charges against the payee, through the county prosecutor, in accordance with section 2913.02 or 2921.13 of the Revised Code. Prior to referring the case to the county prosecutor, the CDJFS must submit a written request to ODJFS that requests a written report about the handwriting analysis from BCI. ODJFS must forward the original warrant and the AUD 7202 to BCI requesting a written analysis. After the CDJFS receives BCI’s written report, the case can be referred to the county prosecutor and paragraphs (K)(4) to (K)(6) of this rule may be applied.

(4) The CDJFS is obligated to make a good faith effort to recover the overpayment. If the CDJFS does not make a good faith effort to recover the overpayment an audit exception may be taken by ODJFS against the CDJFS. The office of fiscal services tracks all cases in which both the original warrant and the replacement warrant were cashed by the payee and will monitor the CDJFS’s efforts to collect the overpayment. As long as a good faith effort to collect the overpayment is made by the CDJFS, no audit exception will be taken against the CDJFS by ODJFS.

(5) A good faith effort to recover is made when the CDJFS uses all methods available to recover the overpayment. Those methods include, but are not limited to, the following steps:

(a) Referral of the overpayment to the overpayment recovery unit.

(b) Following overpayment recovery procedures set forth in rule 5101:1-38-20 of the Administrative Code.

(c) Referring all cases in which there is probable cause to believe that the crime of fraud has been committed to the county prosecutor.

(d) Collecting from former recipients.

(e) Attempting to locate former recipients.

(f) Documenting all recovery efforts in CRIS-E running record comments (CLRC), or in running record comments in the BV subsystem.

(g) Justifying and documenting causes of failure to collect all or part of the overpayment.

(h) Reporting all recovery action, or lack of action, to ODJFS office of fiscal services.

(i) Proving that the case involved forgery instead of fraud and resubmitting the case (with the proof of forgery) to ODJFS for possible forgery collection.

(6) The good faith effort requirement is not met by simply referring the case to the county prosecutor, by the prosecutor’s rejection of a referral due to a minimum threshold, or by the prosecutor’s unwillingness to pursue collection. The CDJFS must take all feasible actions to recover the overpayment.

(L) Hearing rights in delayed payment situations

(1) All appeal rights available to assistance groups in all other situations are applicable to the provisions set forth in this rule.

(2) A state hearing decision in favor of the payee will instruct the CDJFS to follow the appropriate procedures in this rule, including completion of all required forms and issuance of a replacement warrant.

HISTORY: Eff 5-1-71; 5-1-75; 2-1-84 (Temp); 5-1-84; 6-1-84; 4-19-85; 1-1-86 (Emer.); 2-3-86 (Emer.); 4-1-86; 10-1-88 (Emer.); 12-20-88; 10-1-91 (Emer.); 12-20-91; 1-1-94 (Emer.); 3-18-94; 1-1-95; 1-1-96; 7-1-98; 10-1-98; 10-1-02

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.01, 5111.011

Rule amplifies: RC 5111.01, 5111.011

Replaces: 5101:1-2-55

R.C. 119.032 review dates: 10/01/2007

(A) This rule outlines when payment for medicaid services or refugee medical assistance services is not available to an otherwise eligible individual.

(B) Definitions:

(1) “Administrative agency” means the county department of job and family services (CDJFS), Ohio department of job and family services (ODJFS), or other entity that determines eligibility for a medical assistance program.

(2) “Confined” means serving time for a criminal offense or placed involuntarily in a prison, jail, detention facility, or other penal facility. This includes an individual awaiting criminal proceedings, penal disposition or other involuntary detainment determination.

(3) “Individual” means adult or child recipient of medicaid.

(4) “Institution” means a place where an individual has been admitted to live and receive treatment or services that are appropriate to the individual.

(5) “Institution for mental diseases” (IMD) means a hospital, nursing facility, or other institution of more than sixteen beds which primarily provides diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services.

(a) A facility established and maintained primarily for the care and treatment of individuals with mental diseases is an IMD, whether or not it is licensed as such.

(b) An institution for persons with mental retardation is not an institution for mental diseases.

(6) “Public institution” means an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control.

(C) Payment of services is not available during the time an individual:

(1) In accordance with 42 C.F.R. 435.1010 (as in effect on March 1, 2009);

(a) Is confined.

(b) Lives in a public institution.

(c) Is at least twenty-two years of age but not yet sixty-five who is a patient in an IMD.

(2) Has not provided satisfactory documentary evidence of citizenship or national status in accordance with 42 C.F.R. 435.1008 (as in effect on March 1, 2009).

(D) Upon notification, the administrative agency shall suspend medicaid payment for an individual during the time the individual meets any one of the criteria in paragraph (C) of this rule.

Replaces: 5101:1-37-20

Effective: 05/29/2009

R.C. 119.032 review dates: 05/01/2014

Promulgated Under: 111.15

Statutory Authority: 5111.01, 5111.011

Rule Amplifies: 5111.01, 5111.011, 5111.0119

Prior Effective Dates: 3/1/2009 (Emer.)