Chapter 5101:1-37 Medicaid General Principles

5101:1-37-01 Medicaid: definitions.

(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) "Allocation" and "deeming" mean the distribution of income or resources from a responsible individual not included in the covered group to members of a covered group for whom they have a legal and/or financial responsibility. Allocation or deeming occurs when the responsible individuals are:

(a) The biological or adoptive parent(s) of an individual; or

(b) The spouse of an individual.

(4) "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.

(5) "BCCP" means the Ohio breast and cervical cancer project.

(6) "Case record" means electronic or paper documents and information used to determine or redetermine an individual's eligibility for medical assistance.

(7) "CDJFS" means county department of job and family services.

(8) "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.

(9) "Covered group" means an individual or individuals who qualify for medical assistance under Title XIX or Title XXI of the Social Security Act (as in effect on March 1, 2011).

(10) "CPA" means combined programs application.

(11) "Creditable insurance" or "creditable coverage" means health insurance coverage as defined in 42 U.S.C. 300gg(a) to (c) (as in effect on February 1, 2010).

(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 42 U.S.C. 1395i-5. (as in effect on February 1, 2010) or part B, as set forth in 42 U.S.C. 1395j to 42 U.S.C. 1395w-4 (as in effect on February 1, 2010).

(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 February 1, 2010).

(v) Armed forces health insurance as set forth in 10 U.S.C. 1071 to 10 U.S.C. 1110a (as in effect on January 7, 2011).

(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. 8901 to 5 U.S.C. 8992 (as in effect on January 7, 2011).

(ix) A public health plan.

(x) A peace corps volunteer health benefit plan under section 22 U.S.C. 2504 (as in effect on January 7, 2011).

(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 February 1, 2010), coverage supplemental to the coverage provided to military or former military personnel under 10 U.S.C. Chapter 55 (as in effect on January 7, 2011), and similar supplemental coverage provided to coverage under a group health plan.

(12) "Electronic equivalent" means an electronic version of an ODJFS form or application which has not been modified in any way other than format prior to completion and submission of that form to the administrative agency. The administrative agency is not required to accept forms that are materially altered.

(13) "Electronic signature" has the same meaning as in section 1306.01 of the Revised Code.

(14) "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.

(15) "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, legal guardians, or legal custodians of the individual;

(B)(15)(b) of this rule; and

(d) Minor dependent children of persons listed in paragraph

(B)(15)(a), (B)(15)(b), or (B)(15)(c) of this rule.

(16) "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 February 1, 2010).

(17) "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.

(18) "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.

(19) "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 October 1, 2011), 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.

(20) "Income" is defined in rule 5101:1-38-01.9 of the Administrative Code.

(21) "Individual" means an applicant for or recipient of a medical assistance program.

(22) "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.

(23) "LIF" means low-income families medicaid under section 1931 of the Social Security Act.

(24) "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.

(25) "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

(26) "Medical assistance program" includes all programs administered by the state medicaid administrative agency.

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

(28) "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.

(29) "ODJFS" means the Ohio department of job and family services.

(30) "PCPA" means a private child placing agency.

(31) "PCSA" means a public children services agency.

(32) "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.

(33) "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.

(34) "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.

(35) "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.

(36) "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.

(37) "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;

(d) The individual's authorized representative.

(38) "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.

(39) "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.

(40) "Self-declaration" means a statement or statements made by an individual.

(41) "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;

(42) "SSA" means the social security administration.

(43) "SSN" means social security number.

(44) "Suspend" or "suspended" means the temporary closing or terminating of eligibility.

(45) "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, except for individuals described in paragraph (B)(6) of rule 5101:1-40-02.2 of the Administrative Code.

(d) Child(ren) removed by the PCSA are considered temporarily absent as long as they meet the reunification requirements specified in the reunification plan.

(46) "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 October 1, 2011).

(47) "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.

(48) "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 January 7, 2011); 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 January 7, 2011).

(49) "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.

Effective: 01/09/2012
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: 9/3/71, 9/3/77, 10/26/78, 5/1/79, 9/21/79, 2/21/80, 7/3/80, 7/1/82, 12/1/82, 10/14/83 (Temp.), 12/22/83, 2/15/85 (Emer.), 3/12/85, 6/10/85, 8/1/86 (Emer.), 10/3/86, 7/1/87 (Emer.), 8/3/87, 10/1/02, 10/1/09, 7/17/11

5101:1-37-01.1 Medicaid: safeguarding and releasing information.

(A) This rule describes the requirements of disclosing information, maintaining confidentiality and safeguarding information for an individual participating in a medical assistance program. No information shall be released to anyone except as provided in sections 5101.26 to 5101.271 of the Revised Code.

(B) Definition of safeguard. "Safeguard" means security measures that need to be taken to ensure that federal tax information (FTI) of medicaid individuals is protected against unauthorized inspection or disclosure and use. Safeguarding also refers to the restriction on the use of, or disclosure of, individual information.

(1) Follow the safeguarding guidelines for protecting federal tax returns and federal tax return information as described in the internal revenue service (IRS) publication 1075 (as in effect November 1, 2009).

(2) Safeguard information about individuals by restricting the use of, or disclosure of, information concerning individuals to purposes directly connected with the administration of the medicaid program in accordance with 42 C.F.R. 431.302 (as in effect November 1, 2009). Purposes directly related to the administration of the medicaid program include:

(a) Establishing eligibility;

(b) Determining the amount of medical assistance;

(d) Conducting or assisting an investigation, prosecution, or civil or criminal proceeding.

(3) Publicize provisions governing the confidential nature of information about individuals. The agency shall provide copies of these provisions to individuals and to other persons and agencies to whom information is disclosed in accordance with 42 C.F.R. 431.304 (as in effect November 1, 2009).

(4) Protect the types of information about individuals that are safeguarded in accordance with 42 C.F.R. 431.305 (as in effect November 1, 2009). The information shall include:

(a) Names and addresses;

(b) Medical services provided;

(d) Administrative agency evaluation of personal information;

(e) Medical data, including diagnosis and past history of disease or disability;

(f) Any information received for verifying income eligibility and amount of medical assistance payments. Income information received from the social security administration or the internal revenue service shall be safeguarded according to the requirements of the agency furnishing the data.

(g) Any information received in connection with the identification of legally liable third party resources, in accordance with 42 C.F.R. 433.138 (as in effect on November 1, 2009).

(5) Release information as permitted in accordance with sections 5101.27 and 5101.271 of the Revised Code. Information and records, but only the minimum necessary to fulfill the need for the sharing of information concerning an individual, shall be released.

(6) Obtain a Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant authorization form when requests for information are received or when information is provided about the health care of an individual, the health care provided to an individual, or the payment for the provision of health care for an individual, in accordance with 45 C.F.R. 164.508 (as in effect November 1, 2009).

(7) Not release medical, psychiatric or psychological information to an individual or authorized representative if the administrative agency has reason to believe that the release may have an adverse effect on the individual, as provided in section 5122.31 of the Revised Code.

(8) Establish criteria specifying the conditions for release and use of information about individuals. The information must be restricted to persons or agency representatives who are subject to standards of confidentiality that are comparable to those of the agency in accordance with 42 C.F.R. 431.306(a) and (b) (as in effect November 1, 2009).

(9) Not publish names of individuals in accordance with 42 C.F.R. 431.306(c) (as in effect November 1, 2009).

(10) Obtain permission from an individual or authorized representative whenever releasing information, unless that information is used to verify income or eligibility (IEVS) in accordance with 42 C.F.R. 431.306(d) (as in effect November 1, 2009).

(11) Apply policies to all requests for information from outside sources, including governmental bodies, courts of law, or law enforcement officials except as provided in sections 5101.26 to 5101.30 of the Revised Code (as in effect on November 1, 2009).

(12) Distribute materials to individuals in accordance with 42 C.F.R. 431.307 (as in effect November 1, 2009). The materials shall:

(a) Have no political implications except to the extent required to implement the National Voter Registration Act (NVRA) of 1993.

(b) Include voter information and registration materials as provided in section 3503.10 of the Revised Code (as in effect on November 1, 2009).

(c) Contain only the names of individuals directly connected with the administration of the medicaid program and shall identify those individuals only in their official capacity.

(d) Not be materials such as holiday greetings, general public announcements, partisan voting information and alien registration notices.

(13) Have the authority to distribute materials directly related to the health and welfare of individuals, such as announcements of free medical examinations, availability of surplus food, and consumer protection information.

Replaces: 5101:1-37- 01.1

Effective: 11/01/2009
R.C. 119.032 review dates: 11/01/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011
Rule Amplifies: 307.981, 329.01, 1347, 3503.10, 5101.30, 5111.01, 5111.011, 5122.31, 5703.211
Prior Effective Dates: 4/14/03 (Emer), 7/1/03

**5101:1-37-02 [Rescinded] .**

Effective: 02/01/2010
R.C. 119.032 review dates: 11/12/2009
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011
Rule Amplifies: 5111.01, 5111.011
Prior Effective Dates: 10/1/97, 10/1/02

5101:1-37-02.3 Medicaid and covered families and children (CFC) medicaid: intercounty transfers (ICT). [Rescinded].

Rescinded eff 10-1-09

5101:1-37-03 Medicaid and covered families and children (CFC) medicaid: citizenship: required written declaration of citizenship/alien status and the use of the systematic alien verification for entitlements (SAVE) program. [Rescinded].

Rescinded eff 10-8-09

5101:1-37-03.1 Medicaid: income and eligibility verification system (IEVS).

(A) This rule describes the requirements in section 1137 of the Social Security Act (as in effect on November 1, 2009) and in section 42 C.F.R. 435.940 (as in effect on November 1, 2009), requiring state agencies administering certain federally funded, state administered public assistance programs, to establish procedures for obtaining, using and verifying information relevant to determinations of eligibility. The Ohio department of job and family services shall obtain and share income and benefit information with the following sources:

(1) The social security administration (SSA).

(2) The internal revenue service (IRS).

(B) Definition of IEVS. "IEVS" means income and eligibility verification system that shares income and asset information among SSA, IRS and the administrative agency.

(1) Provide adequate safeguards in accordance with rule 5101:1-37-01.1 of the Administrative Code.

(2) Inform all individuals in writing at the time of application and reapplication that the agency will obtain and use information available from IEVS to assist in the determination of eligibility under section 1137 of the Social Security Act.

(3) Within forty-five days of receipt of the information, review and compare against the case file all information received to determine whether it affects the individual's eligibility. Obtain verification, if appropriate, to determine eligibility and initiate appropriate action in accordance with 42 C.F.R. 435.952(c) (as in effect on November 1, 2009). For applicants, if the information is received during the application period, it must be used to the extent possible to make eligibility determinations, in accordance with 42 C.F.R. 435.952(b) (as in effect on November 1, 2009).

(4) Verify the information, in accordance with 42 C.F.R. 435.955(b) (as in effect on November 1, 2009) by:

(a) Contacting the originating entity, from which the information came, to verify the fact and amount of the income, resources or both; or

(b) Sending the individual a letter which includes the information received and requesting a response within a specified period. The letter must clearly explain what information was received and the relevance to the individual's past, current or future eligibility. The individual shall be given an opportunity to contest such findings.

(c) The number of determinations delayed beyond forty-five days from receipt, must not exceed twenty per cent of the reviews provided the reason for the delay is due to nonreceipt of verifications. Otherwise, all determinations shall be made promptly.

(5) Not terminate, deny, suspend benefits until appropriate steps have been taken to verify the information in accordance with 42 C.F.R. 435.955(a) (as in effect on November 1, 2009). The administrative agency must verify information relating to:

(a) The amount of the income and resource that generated the item involved;

(b) Whether the individual actually has or had access and use of the resource, income, or both;

(6) Make the decision to exclude duplicate information or earnings information previously researched in accordance with 42 C.F.R. 435.953(c) (as in effect on November 1, 2009).

(7) Maintain the individual's data in a standardized format that allows the administrative agency to furnish and to obtain eligibility and income information from the agencies listed in paragraph (A) of this rule or programs referenced in 42 C.F.R. 435.948(a) in accordance with 42 C.F.R. 435.960(a) (as in effect on November 1, 2009).

Replaces: 5101:1-37- 03.1

Effective: 11/01/2009
R.C. 119.032 review dates: 11/01/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011
Rule Amplifies: 5111.01, 5111.011
Prior Effective Dates: 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

5101:1-37-04 Medicaid: replacement checks.

(A) The purpose of this rule is to describe how the administrative agency replaces a check that is reported missing or damaged.

(B) Definitions:

(1) "Check" or "checks," for the purposes of this rule, means a payment issued to a payee for the residential state supplement (RSS), for reimbursement for medicaid-covered expenses, or for other payments related to medical assistance programs administered by the Ohio department of job and family services (ODJFS).

(2) "Holder" means the person who acquired possession of the check from the payee and is entitled to receive payment for the check.

(3) "Payee" means the individual to whom the check is payable.

(1) Notify the administrative agency of the missing or damaged check. The payee should notify the administrative agency in the county in which the recipient resides.

(2) Return the damaged check to the administrative agency.

(3) Complete the necessary forms and paperwork.

(4) Provide identification.

(5) Provide a copy of a police report, if the payee is alleging the check was stolen.

(6) Have the right to request a fair hearing, as described in division 5101:6 of the Administrative Code.

(D) Administrative agency responsibilities. The administrative agency shall:

(1) Verify the payee has met the requirements of paragraph (C) of this rule.

(2) Check the electronic eligibility system issuance history to complete the following steps. For checks not generated by the electronic eligibility system, contact the ODJFS for assistance in completing the following steps.

(a) Verify that a check was issued to the payee.

(b) Determine if a missing check was mailed to the payee's current address. If it was not, correct the address in the electronic eligibility system. Redirect the check, if possible.

(i) Canceled, issue a replacement check through the electronic eligibility system benefit issuance subsystem.

(ii) Redirected, advise the payee to allow five working days from the redirect date for delivery.

(iii) Voided, issue a replacement check through the electronic eligibility system benefit issuance subsystem.

(iv) Redeemed,

(a) Instruct the payee to complete forms JFS 02132, "Affidavit in Support of Application for Replacement Warrant" (rev. 11/2000) and the state of Ohio office of budget and management "Handwriting Specimens Claim for Alleged Forgery of Payee(s) Warrant" (rev. 06/2007).

(b) Forward the originals and one copy of each completed form to the ODJFS bureau of accounting, accounts receivable section.

(c) Issue a replacement check through the electronic eligibility system benefit issuance subsystem. If the payee alleges the check was stolen, collect a copy of the police report from the payee prior to issuing the replacement check.

(v) Not canceled, redirected, voided, or redeemed, and it has been five or more working days since the check mailing or redirect date, the administrative agency shall:

(a) Immediately telephone the ODJFS bureau of accounting, accounting information section to request payment be stopped on the check, if the payee had endorsed the check prior to it being lost or stolen, or

(b) Enter a stop payment request in the electronic eligibility system, if the payee had not endorsed the check prior to being lost or stolen.

(c) Instruct the payee to complete forms JFS 02132 and the state of Ohio office of budget and management, "Handwriting Specimens Claim for Alleged Forgery of Payee(s) Warrant". Retain the completed forms in the case record. These forms shall be forwarded to the ODJFS bureau of accounting, accounts receivable section if the original check is cashed.

(d) Issue a replacement check through the electronic eligibility system benefit issuance subsystem. If the payee alleges the original check was stolen, collect a copy of the police report from the payee prior to issuing the replacement check.

(3) Issue a replacement check within fourteen days of when a payee reports a damaged check is unable to be cashed.

(a) Collect the damaged check from the payee. If the check has been torn or mutilated, the payee must be able to surrender the major part of the check.

(b) Instruct the payee to complete and sign the JFS 02132.

(c) Attach the damaged check to the JFS 02132, write the words "damaged check" across the top of the form, and forward them to the ODJFS bureau of accounting, accounts receivable section.

(d) Issue a replacement check through the electronic eligibility system benefits issuance subsystem.

(4) Obtain additional samples of the payee's handwriting when requested by ODJFS. This additional sample can be copies of the payee's existing signatures in the case record or an additional state of Ohio office of budget and management, "Handwriting Specimens Claim for Alleged Forgery of Payee(s) Warrant" completed by the payee. The handwriting sample shall be returned, along with a copy of the ODJFS notice requesting the additional sample, to the ODJFS bureau of accounting, accounts receivable section.

(5) Meet with the payee when notified by ODJFS that the handwriting analysis indicates the payee endorsed the original check. During the interview, if the payee:

(a) Acknowledges endorsing and cashing the original check, the administrative agency shall recover the overpayment in accordance with rule 5101:1-38-20 of the Administrative Code.

(b) Denies endorsing and cashing the original check, the administrative agency may file charges against the payee through the county prosecutor, in accordance with section 2913.02 or 2913.401 of the Revised Code. Prior to referring the case to the county prosecutor, the administrative agency shall submit a written request to ODJFS for a report of the handwriting analysis. The case may be referred to the county prosecutor once the report is received.

(6) Act on any overpayment notifications from ODJFS or the county prosecutor in accordance with rule 5101:1-38-20 of the Administrative Code.

(7) Act on checks reported by the holder as missing after being cashed by the payee. Check the electronic eligibility system issuance history and with the ODJFS to verify the check has not been redeemed by the treasurer of state.

(a) If the check has been redeemed, a replacement check cannot be issued. The administrative agency shall obtain a copy of the redeemed check and forward it to the holder in due course.

(b) If the check does not show in the electronic eligibility system as being redeemed, the administrative agency shall:

(i) Immediately telephone the ODJFS bureau of accounting, accounting information section and order payment on the check stopped.

(ii) Complete an AUD 8184, "Auditor of State Handwriting Specimens Claim for Alleged Forgery of Payee(s) Warrant" (rev. 06/2007), or its equivalent. This form shall be signed by the holder. The administrative agency shall assist the holder in completing the form.

(iii) Forward the original and one copy of the AUD 8184, or its equivalent, to the ODJFS bureau of accounting, accounting information section.

(iv) Issue a replacement check through the electronic eligibility system benefit issuance subsystem. If the holder alleges the original check was stolen, collect a copy of the police report from the holder prior to issuing the replacement check.

Replaces: 5101:1-37-04

Effective: 11/01/2009
R.C. 119.032 review dates: 11/01/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011
Rule Amplifies: 5111.01, 5111.011, 2913.02, 2913.401
Prior Effective Dates: 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

5101:1-37-20 Medicaid: restrictions on payment for services.

(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.

(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.

(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.)