Chapter 5101:1-38 Medicaid Application Procedures

5101:1-38-01 Medicaid: individual and administrative agency responsibilities.

(A) This rule sets forth responsibilities of the individual and the administrative agency that apply at all times: at application; at the initial eligibility determination; at a scheduled or unscheduled redetermination; and between redeterminations.

(B) Individual responsibilities. The individual shall:

(1) Provide verification of all eligibility criteria as requested by the administrative agency.

(2) Report to the administrative agency, within ten days of the change, any change in the following:

(a) Household composition, living arrangements, or address.

(b) Earned or unearned income, including:

(i) The receipt of a non-recurring lump-sum payment; or

(ii) A change in employment status, including a change in hourly wage or salary, full- or part-time status, new employment, or loss of employment.

(i) New coverage under a health insurance policy, regardless of who is paying for the coverage; or

(ii) A change in health insurers; or

(iii) A court order requiring a person or entity pay some or all of an individual’s medical expenses; or

(iv) Any accident or injury for which another person or entity may be responsible, such as a work-related injury or an injury sustained in an automobile collision; or

(v) Termination of a health insurance policy.

(d) An individual’s pregnancy status, such as an individual becoming pregnant or a pregnancy ending.

(e) An improvement of the individual’s condition, if the individual is receiving medicaid for the blind or medicaid for the disabled.

(f) For any category of medical assistance with a resource limitation:

(i) A change in the ownership of a resource; or

(ii) A change in the amount or value of any available resource; or

(iii) Any change in ownership an individual or spouse has in an annuity, or any change to the remainder beneficiary designation.

(3) Cooperate with the application, determination, redetermination, auditing, and quality control processes, including:

(a) Completing, signing, and dating an initial application; and

(b) Answering all relevant questions and providing the necessary verifications to establish initial or continued eligibility; and

(d) Requesting assistance from the administrative agency if the individual is unable to obtain requested information, and providing the information necessary for the administrative agency to assist.

(4) Select a managed care plan (MCP) in accordance with rule 5101:3-26-02 of the Administrative Code, unless the individual falls within one of the exceptions listed in that rule.

(1) Render assistance and determine eligibility and benefits without discrimination on account of race, religion, disability, 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.

(2) Determine or redetermine an individual’s eligibility for medical assistance within the application processing time limits set forth in rule 5101:1-38-01.2 of the Administrative Code.

(3) Not approve medical assistance to an individual merely because of an agency error or delay in determining eligibility, unless all eligibility factors are met.

(4) Determine eligibility for medical assistance promptly upon receipt of required information and verifications. The administrative agency shall not delay the approval of medical assistance due to the lack of information or verifications necessary to determine eligibility for other public assistance programs.

(5) Upon request, provide assistance to individuals having difficulty completing an application or gathering verifications.

(6) Advise applicants, authorized representatives, and individuals of:

(a) The effect of any delay in completing an application upon the starting date of potential medical coverage; and

(b) Verification requirements and time lines; and

(c) The requirement that the individual or authorized representative cooperate with the eligibility determination and redetermination process; and

(d) The penalties for medicaid eligibility fraud set forth in section 2913.401 of the Revised Code.

(7) Provide an interpreter at no charge to an individual with limited English proficiency and, when available, provide vital applications, forms, or brochures in the individual’s language.

(8) Determine whether the individual’s eligibility for medical assistance is affected by a change. This determination shall be made within ten days of learning of the change through data systems, a report from an individual, or by other means.

(9) If an individual reports a new address in the state of Ohio, the administrative agency shall:

(a) Give or mail to the individual a notice meeting the requirements of section 3503.10 of the Revised Code; and

(b) Give or mail to the individual a voter registration form as required by section 329.051 of the Revised Code; and

(c) Advise the individual that, upon request, the administrative agency will help the individual register to vote or update voter registration as outlined in rule 5101:1-2-15 of the Administrative Code.

(10) Obtain verification of reported information that is new, has changed or is subject to change. Verification shall be obtained as set forth in Chapter 5101:1-38 of the Administrative Code.

(11) Issue an itemized, dated receipt when an application for medical assistance or a verification document related to eligibility for medical assistance is received.

(12) Document and record determinations of eligibility. The administrative agency shall:

(a) Record, in physical or electronic case records, any information, action, decision, or delay in the application, eligibility determination, or termination processes, as well as the reasons for any action, decision, or delay.

(b) Record receipt of all verification documents, photocopy or scan the documents, and retain copies or images of the documents in the case record.

(d) Not request that an individual provide duplicate copies of previously submitted verifications.

(e) Not require that an individual provide verification of unchanged information unless the information is incomplete, inaccurate, inconsistent, outdated, or missing from the case record due to record retention limitations.

(f) If information is verified through a telephone contact, record the following data:

(i) The name and telephone number of the person giving the information; and

(ii) The name of the agency or business contacted, if applicable; and

(iii) The date of the contact; and

(iv) An accurate summary of the information provided.

(13) Approve medical assistance for an individual who:

(a) Has signed an application under penalty of perjury; and

(b) Has provided all necessary verifications; and

(14) Deny an application for medical assistance for an individual who:

(a) Has not signed an application under penalty of perjury; or

(b) Withdraws the application; or

(c) Fails to cooperate in the application or determination process or fails to provide all necessary verifications, as set forth in paragraph (H)(4) of rule 5101:1-38-01.2 of the Administrative Code; or

(d) Does not meet all conditions of eligibility for any covered group.

(15) Suspend medical assistance upon notification that an individual meets any of the criteria for ineligibility for payment of services set forth in rule 5101:1-37-20 of the Administrative Code. Redetermine eligibility upon notification that an individual no longer meets the previously cited criteria.

(16) Terminate medical assistance for an individual who:

(a) Requests that assistance be terminated; or

(b) Is deceased; or

(c) Fails to cooperate in the redetermination or quality control processes, or fails to provide all necessary verifications; or

(d) No longer meets all conditions of eligibility for any covered group.

(17) Notify individuals of all determinations and proposed changes in coverage or benefits, including any applicable premium, patient liability, or spenddown.

(18) Follow the safeguarding guidelines set forth in rule 5101:1-37-01.1 of the Administrative Code when providing or gathering information by telephone, in person, or in electronic or written form.

(19) Process an intercounty transfer (ICT) upon receipt of a report (verbal or written) that an individual has changed residence from one county to another within the state of Ohio. Both the county of original residence and the county of new residence have responsibilities in the ICT process. The ICT process shall be followed whether the individual reporting a change of residence is an applicant or is currently in receipt of medical assistance benefits.

(a) The CDJFS receiving report of a move shall determine whether the move is a change of residence or a temporary absence from the home. If the move is a temporary absence from the home, the county in which the individual is physically located shall provide necessary medical and transportation services.

(b) The CDJFS receiving report of a change of residence shall:

(i) Update the address in the electronic eligibility system. If the individual does not have an address in the new county, use the address of the administrative agency in the new county.

(ii) If the report was made to the administrative agency in the county of new residence, inform the county of original residence.

(i) Transfer the case in its current status in the electronic eligibility system within five working days of the reported change.

(ii) Transfer the case records, or a physical or electronic copy of the records, to the county of new residence within fifteen days of the reported change. The case record to be transferred shall contain the original (or, if the administrative agency uses an imaging system, a scanned image) of the following documents:

(a) The most recently signed “Printed Copy of Information” (PCI) or application for medical assistance benefits; and

(b) Other pertinent documents, such as citizenship, income or resource verifications.

(iii) Complete a JFS 03900 “Notice of Intercounty Transfer” (rev. 9/2008), attach a copy of the JFS 03900 to the records being transferred to the county of new residence, and keep a copy of the JFS 03900 in the retained case record.

(iv) Maintain a copy of transferred documents for future reference, while making originals available, to the extent available, to the county of new residence.

(d) The CDJFS in the county of new residence shall:

(i) Not require the individual reapply or cooperate with a redetermination of eligibility for medical assistance merely due to the change in county of residence.

(ii) Provide the medical assistance benefits for which the individual is eligible.

(iii) Perform the periodic redetermination or redetermination upon a change in circumstances as outlined in rule 5101:1-38-01.2 of the Administrative Code.

(e) If the case being transferred is subject to a claim for overpayment as set out in rule 5101:1-38-20 of the Administrative Code:

(i) An existing claim shall not be transferred. The records transferred to the CDJFS in the county of new residence shall include copies of the documentation of the claim. The CDJFS establishing the claim remains responsible for any necessary action on the claim.

(ii) A potential claim, which has not yet been established, may be transferred to the CDJFS in the county of new residence, for that CDJFS to establish, only if the CDJFS of both counties agree that the county of new residence shall establish the claim.

(20) Advise potentially eligible individuals of the supplemental nutrition program for women, infants and children (WIC) and refer them to the WIC agency by forwarding a copy of the individual’s medicaid application and any supplemental application, unless the individual is already receiving WIC assistance.

(a) The following individuals are potential WIC recipients:

(i) A woman who is:

(a) Pregnant; or

(b) Within a six-month period after termination of pregnancy; or

(ii) A child younger than five years old.

(b) For any individual in receipt of medical assistance who is a potential WIC recipient, the administrative agency shall advise the individual of the WIC program at least annually.

(21) Report to the Ohio department of job and family services (ODJFS) any available information about a third party liable for an individual’s health care costs.

(a) When determining an individual’s eligibility for medical assistance coverage, the agency shall report any potential third-party liability (TPL) to the ODJFS using:

(i) The JFS 06612 “Health Insurance Information Sheet” (rev. 5/2001), or its electronic equivalent, to report possible health insurance coverage. A separate JFS 06612 shall be completed for each possible health insurance policy.

(ii) The JFS 06613 “Accident/Injury Insurance Information Form” (rev. 6/2009), or its electronic equivalent, to report potential TPL due to an injury, disability or court order.

(b) At a redetermination, or upon any reported change, the administrative agency shall compare the individual’s current information to the information on the most recent JFS 06612 or JFS 06613. If any information has changed, the administrative agency shall report the changes to ODJFS by submitting a new JFS 06612 or JFS 06613, or an electronic equivalent.

(c) Upon a request by ODJFS, the administrative agency shall contact the individual to obtain information about potential TPL. If the individual fails to cooperate, the agency shall propose to terminate or deny medical assistance for failure to cooperate, as set forth in rule 5101:1-38-01.2 of the Administrative Code.

(22) Issue proper notice and hearing rights as outlined in division 5101:6 of the Administrative Code.

Replaces: 5101:1-37-02.3, 5101:1-38-01, 5101:1-38-01.2, 5101:1-38-02

Effective: 10/01/2009

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

Promulgated Under: 111.15

Statutory Authority: 5111.01, 5111.011, 5111.012

Rule Amplifies: 5111.01, 5111.011, 5111.012, 329.051

Prior Effective Dates: 11/1/1974, 8/1/1975, 10/1/1975, 6/1/1976, 7/14/1977, 12/31/1977, 9/1/1982, 9/24/1983, 8/1/1984, 10/20/1984, 11/1/1984, 12/1/1984 (Emer.), 2/10/1985, 7/1/1985, 4/1/1986, 8/1/1986 (Emer.), 10/3/1986, 10/1/1987 (Emer.), 12/24/1987, 4/1/1988 (Emer.), 6/10/1988, 6/30/1988, 7/1/1988 (Emer.), 8/1/1988 (Emer.), 9/1/1988, 9/24/1988, 10/1/1988 (Emer.), 10/15/1988, 10/25/1988 (Emer.), 12/20/1988, 3/1/1989 (Emer.), 5/28/1989, 12/1/1989, 4/1/1990 (Emer.), 6/22/1990, 8/1/1990 (Emer.), 10/25/1990, 1/1/1991 (Emer.), 2/21/1991, 4/1/1991 (Emer.), 6/1/1991, 7/1/1991 (Emer.), 9/15/1991, 10/1/1991 (Emer.), 12/20/1991, 4/1/1992, 7/1/1992, 1/1/1993, 1/1/1993 (Emer.), 2/11/1993, 3/18/1993, 5/1/1993, 9/1/1993, 1/1/1994, 3/1/1994(Emer.), 4/18/1994, 1/1/1995 (Emer.), 1/1/1995, 4/1/1995, 7/1/1995, 10/1/1995, 6/1/1996, 10/1/1996 (Emer.), 10/1/1996, 12/15/1996, 5/1/1997, 10/1/1997 (Emer.), 10/30/1997, 12/30/1997, 7/1/1998, 7/1/1999, 10/1/1999, 5/4/2000, 7/1/2000, 6/1/2003, 6/1/2003 (Emer.), 9/20/2003, 10/6/2003, 9/25/2006, 10/1/2006, 6/1/2007, 8/1/2007

5101:1-38-01.1 Medicaid: pre-termination review (PTR) of continuing medicaid eligibility. [Rescinded]

Rescinded eff 10-1-09

5101:1-38-01.2 Medicaid: application, determination, and redetermination processes.

(A) This rule sets forth the processes for determining an individual’s eligibility for medical assistance at initial application or redetermination.

(B) Calculation of time periods. All calculations of time periods used in the determination and redetermination of eligibility shall be computed as follows:

(1) When counting the number of days in a specified time period, the initial day is excluded from the computation and the last day is included.

(2) When the last day of the time period falls on a Saturday, Sunday, or legal holiday, the time period shall end on the next working day.

(1) Inform the individual that the beginning date of benefits is dependent upon the date the signed and dated application is received by the administrative agency.

(2) Neither deny an individual’s right to apply nor discourage an individual from applying.

(3) Give or mail an application on the day the request is received. The proper application to provide to an individual depends upon the category of medical assistance for which the individual is applying.

(a) The JFS 07200 “Request for Cash, Food Stamp, and Medical Assistance” (rev. 10/2006) is an application for cash and food assistance and for all forms of medical assistance except for the Ohio breast and cervical cancer project (BCCP) outlined in rule 5101:1-41-05 of the Administrative Code.

(b) If the individual wishes to apply for medical assistance for a child or children, a low-income family, a pregnant woman, or an adult up to age twenty-one described in Chapter 5101:1-40 of the Administrative Code, the administrative agency shall provide the JFS 07216 “Combined Programs Application” (CPA) (rev. 3/2009).

(i) The JFS 07216 may also be used to apply for the following Ohio department of health programs:

(a) The special supplemental food program for women, infants, and children (WIC); and

(b) The child and family health services program (CFHS); and

(c) The bureau for children with medical handicaps program (BCMH).

(ii) If an individual requests WIC or CFHS assistance, the administrative agency shall forward copies of the CPA to the appropriate local health department office. If an individual requests BCMH assistance, a copy shall be sent to the bureau for children with medical handicaps.

(c) If the individual wishes to apply for assistance with medicare expenses, the administrative agency shall provide the JFS 07103 “Application for Help with Medicare Expenses” (rev. 5/2003), and inform the individual that additional information is needed to explore eligibility for other medical assistance programs.

(d) If the individual wishes to apply only for coverage under BCCP, the administrative agency shall provide the JFS 07161 “Ohio Breast and Cervical Cancer Project Medicaid Application” (rev. 6/2007), and inform the individual that this is not an application for other medical assistance programs.

(D) Documents. The administrative agency shall give or send the following documents to every applicant at initial application and at every redetermination of eligibility for medical assistance:

(1) Pamphlet describing the local service programs available; and

(2) Preaddressed, postage-paid envelope for return to the administrative agency; and

(3) JFS 04059 “Explanation of State Hearing Procedures” (rev. 10/2008); and

(4) JFS 07236 “Your Rights and Responsibilities as a Consumer of Medicaid Health Coverage” (rev. 10/2006); and

(5) JFS 07400 “Ohio Medicaid Estate Recovery” (rev. 9/2009); and

(6) JFS 08000 “Your Rights” (rev. 12/2008); and

(7) JFS 08033 “Program Guide” (rev. 4/2009); and

(8) JFS 08058 “Medicare Premium Assistance Program” (rev. 4/2008); and

(9) A notice meeting the requirements of section 3503.10 of the Revised Code, and a voter registration form as required by section 329.051 of the Revised Code.

(E) Assistance with application.

(1) The administrative agency shall allow a person or persons of the individual’s choice to accompany, assist, and represent the individual in the application or redetermination process.

(2) Authorized representative. Unless otherwise stated in the documents authorizing a representative, an authorized representative shares all responsibilities of an individual. The acts or omissions of an authorized representative shall be deemed to be the acts or omissions of the individual.

(a) An individual who wishes to designate an authorized representative shall, in writing, identify the authorized representative and the duties the authorized representative may perform on the individual’s behalf.

(i) The individual shall notify the administrative agency in writing of any change in the authorized representative or the duties the authorized representative may perform.

(ii) When written authorization cannot be obtained due to the individual’s incompetence, the administrative agency shall waive the written statement and assist in naming a responsible party to act as authorized representative for the individual.

(b) When the individual has an authorized representative, all notices and correspondence issued by the administrative agency for the individual shall be issued to both the authorized representative and the individual.

(c) The administrative agency may contact an individual to clarify or verify information provided by an authorized representative if the information provided on the application seems contradictory, unclear, or unrealistic.

(3) The administrative agency shall help complete the application if assistance is needed.

(a) An eligibility worker shall, at the individual’s request, assist in completing the application by asking the individual for answers needed to complete the application, then recording the individual’s answers on the application form or in the electronic eligibility system.

(i) The eligibility worker shall not alter any answers given by the individual.

(ii) If an eligibility worker assists or helps to complete an application, the worker shall sign the application form and include the worker’s title.

(b) The normal process of inputting data into the electronic eligibility system or determining an individual’s eligibility shall not be construed as providing assistance.

(F) Receipt of initial application.

(1) An application for medical assistance, or a printed copy of an electronic equivalent, must be signed under penalty of perjury by the applicant, an authorized representative, or, if the applicant is incompetent or incapacitated, someone acting responsibly for the applicant.

(2) Upon receipt of any signed application for medical assistance or for specific medicaid services or programs, the administrative agency shall issue a receipt to the individual showing the date of application.

(3) The administrative agency shall accept and register an application on the day a signed application is received, whether it is an original, a facsimile, or an electronic signature (“e-signature”) submitted after the approval of an e-signature policy by the Ohio office of information technology and ODJFS. An original signature is not required.

(a) If the application is received by the administrative agency on a day when the administrative agency is closed, the administrative agency must register the application on the next business day and back date the registration date to the date the application was actually received by the administrative agency.

(b) If an application is received from a local WIC clinic, CFHS clinic, or BCMH office within five days of the signature date, the application shall be registered using the signature date. If the application is not received within five days of the signature date, the application shall be registered using the date it was received by the administrative agency.

(c) An application taken by an outstationed worker assigned to a federally qualified health center (FQHC) or a disproportionate share hospital (DSH) must immediately be submitted to the appropriate administrative agency. The administrative agency must register the application using the signature date.

(d) The administrative agency shall not delay the registration or processing of an application due to the lack of a signed JFS 07236.

(G) Determination of eligibility. The CDJFS shall determine eligibility for all medical assistance programs except BCCP.

(1) Initial determination:

(a) No later than ten business days after the receipt of a signed application for medical assistance for the aged, blind, or disabled (ABD), the administrative agency shall conduct a face-to-face interview with the individual or authorized representative.

(i) Exceptions to the ABD face-to-face requirement are:

(a) When an individual is potentially eligible for ABD medicaid, but qualifies for medicaid under Chapter 5101:1-40 of the Administrative Code; or

(b) When the individual is applying for the medicaid buy-in for workers with disabilities (MBIWD) as set out in rule 5101:1-41-30 of the Administrative Code; or

(c) When the individual is in the custody of a public children services agency (PCSA); or

(d) When the individual is unable to participate because of a physical or mental condition and has no authorized representative.

(ii) An individual’s failure to appear for a required face-to-face interview constitutes failure to cooperate in the application process and, unless the individual has rescheduled the appointment or shows good cause for the failure, the administrative agency shall deny the application.

(b) Unless an interview is requested by the applicant, the agency shall not schedule a face-to-face interview if an application is for medical assistance on behalf of a person who has not applied for ABD medicaid under Chapter 5101:1-39 of the Administrative Code.

(c) The administrative agency shall advise the individual of or explain the following, either during an interview, by telephone, electronically or in writing:

(i) The eligibility requirements for relevant medical assistance programs; and

(ii) What information and verifications must be provided in order to determine the individual’s eligibility for medical assistance, and the consequences of failing to provide information or verifications in a timely fashion; and

(iii) How the administrative agency will assist in securing the required verifications and information if assistance is requested; and

(iv) The individual’s reporting responsibilities; and

(v) The confidential nature of:

(a) All information given to the administrative agency; and

(b) The income and eligibility verification system (IEVS) program described in rule 5101:1-37-03.1 of the Administrative Code; and

(c) The use of a social security number; and

(vi) The individual’s right to view the contents of the individual’s case record; and

(vii) A quality control review may be undertaken with or without the full knowledge of the individual, and the individual’s responsibility to cooperate with the review; and

(viii) The availability, purpose, and provision of relevant social service programs within and outside the agency including WIC, pregnancy-related services (PRS) described in rule 5101:1-38-06 of the Administrative Code, and early and periodic screening, diagnosis and treatment (EPSDT) described in rule 5101:1-38-05 of the Administrative Code; and

(ix) The right to request a state hearing, including a description of the state hearing process; and

(x) The responsibility under medical assistance programs of a parent for minor children and spouses for each other; and

(xi) The issuance and use of medical assistance cards, including the ability of providers to verify eligibility, and that the individual need not wait for receipt of a health care card to receive services if medical assistance is approved; and

(xii) The responsibility to select an MCP in accordance with rule 5101:3-26-02 of the Administrative Code, unless the individual falls within one of the exceptions listed in that rule; and

(xiii) The automatic assignment of third-party medical payments and medical support and the good cause exemption that may be claimed for medical support; and

(xiv) The availability of free legal services through legal aid; and

(xv) An explanation of transitional medicaid as outlined in rule 5101:1-40-05 of the Administrative Code; and

(xvi) An explanation of the medicaid estate recovery program as outlined in rule 5101:1-38-10 of the Administrative Code; and

(xvii) Upon request, the administrative agency will help the individual register to vote or update voter registration as outlined in rule 5101:1-2-15 of the Administrative Code; and

(xviii) For individuals who apply for or receive long-term care services, home and community-based (HCB) services, or services under the program of all inclusive care for the elderly (PACE), an explanation of the annuity disclosure requirements outlined in rule 5101:1-39-22.8 of the Administrative Code. For individuals disclosing such ownership interest in any annuity, the administrative agency shall explain the remainder beneficiary requirements outlined in rule 5101:1-39-22.8 of the Administrative Code.

(d) The administrative agency shall:

(i) Determine an individual’s eligibility for all categories of medical assistance for which the individual has applied, and issue notice of the determination.

(a) If an individual may be eligible for, or has applied for, a category of medical assistance for which the application completed by the individual does not gather sufficient information, the administrative agency shall request the information from the individual. The administrative agency shall not deny, or fail to explore, a category of medical assistance for failure to complete an application specific to that category. The following documents are applications for medical assistance:

(i) JFS 07200 “Request for Cash, Food Stamp, and Medical Assistance” (rev. 10/2006); or

(ii) JFS 07216 “Combined Programs Application” (CPA) (rev. 3/2009); or

(iii) JFS 07103 “Application for Help with Medicare Expenses” (rev. 5/2003); or

(iv) JFS 07161 “Ohio Breast and Cervical Cancer Project Medicaid Application” (rev. 6/2007); or

(v) JFS 01137 “Child Care/Healthy Start and Healthy Families Supplement” (rev. 10/2006), if accompanied by the JFS 01138 “Application for Child Care Benefits” (rev. 6/2009).

(b) If notice is not issued through the electronic eligibility system, use the following forms:

(i) To approve medical assistance, the JFS 04074 “Notice of Approval of Your Application for Assistance” (rev. 2/2009); or

(ii) To deny medical assistance, the JFS 07334 “Notice of Denial of Your Application for Assistance” (rev. 2/2009).

(ii) If an individual is eligible for more than one medical assistance covered group, inform the individual of the options and, unless the individual chooses otherwise, approve coverage that provides the most family members with assistance.

(iii) Approve medical assistance beginning on the first day of the month in which the administrative agency received the application if an individual is eligible for medical assistance as described in Chapters 5101:1-37 through 5101:1-40 or rule 5101:1-41-30 of the Administrative Code, except:

(a) Coverage for an individual born during a month cannot precede the individual’s date of birth.

(b) Coverage for an individual who became an Ohio resident during a month cannot precede the date the individual became an Ohio resident.

(c) Coverage for an individual eligible through the spenddown process is addressed in rule 5101:1-39-10 of the Administrative Code.

(e) Time limits. The administrative agency shall determine eligibility within thirty calendar days (ninety days if a disability determination is required) from the date of application.

(i) The application processing time limits may be exceeded if:

(a) The administrative agency cannot reach a decision because the applicant or an examining physician delays or fails to take a required action; or

(b) There is an administrative or other emergency beyond the administrative agency’s control.

(ii) The administrative agency shall not:

(a) Use application processing time limits as a waiting period before approving medical assistance benefits; or

(b) Approve or deny an application because the time limits have been reached before an individual’s eligibility has been determined.

(f) Retroactive coverage. The administrative agency shall approve eligibility for medical assistance (except for a recipient of transitional medicaid as described in rule 5101:1-40-05 of the Administrative Code or a qualified medicare beneficiary as described in rule 5101:1-38-03 of the Administrative Code) effective no later than the first day of the third month before the month of application if the individual:

(i) Received medical services of a type covered by medicaid at any time during that period; and

(ii) Would have been eligible for medicaid at the time the services were provided if an application had been made at that time, regardless of whether the individual was alive when the application actually was made.

(2) Redetermination upon change. The administrative agency shall promptly determine whether a reported or discovered change affects the individual’s eligibility for a medical assistance program, and shall issue written notice of any denial, termination or change in benefits.

(a) An administrative agency may redetermine eligibility at any time based upon a reasonable belief that circumstances that may affect eligibility have changed.

(b) The administrative agency shall document in the case record the reasons for requiring or performing a redetermination at a time other than the scheduled redetermination date.

(3) Annual redetermination. The administrative agency shall:

(a) Contact the individual by telephone, mail, or electronic means to determine whether there have been any changes that may affect the individual’s eligibility for medical assistance. At the individual’s request, a face-to-face interview may be scheduled.

(b) Determine whether any changes affect the individual’s eligibility for medical assistance no less often than:

(i) Every twelve months; or

(ii) The time frames specified in rule 5101:1-40-05 of the Administrative Code for recipients of transitional medical assistance.

(c) Not require an individual complete or sign an application unless all individuals who signed the initial application, or signed an application at a prior redetermination, no longer reside in the household. In this case, an application will need to be completed for the individuals currently residing in the household.

(d) Not require a face-to-face interview.

(e) Provide to the individual the documents set forth in paragraph (D) of this rule.

(f) Inform the individual of or explain the items set forth in paragraph (G)(1)(c) of this rule.

(g) Follow the process set forth in paragraph (H) of this rule for requesting verification documents as at an initial application.

(h) Not perform an annual redetermination of a pregnant woman’s eligibility during her pregnancy or postpartum period or of a deemed newborn during the year of deemed eligibility.

(i) Not terminate eligibility due to a delay in redetermination or an inability to complete the redetermination of eligibility on time unless the individual fails to cooperate with the redetermination.

(H) Request for information or verification. If information needed to determine an individual’s initial or continuing eligibility for a medical assistance program must be verified, but was not submitted with the application:

(1) The administrative agency shall provide the applicant with a JFS 07105 “Application/Reapplication Verification Request Checklist” (rev. 6/2009) or an equivalent written checklist including:

(a) A list of information that must be verified in order to determine eligibility; and

(b) The date by which the information must be provided to the administrative agency; and

(d) A clear statement that, upon request, the administrative agency will assist in obtaining the required information or verification.

(2) The administrative agency shall explain:

(a) Where and how to obtain the required verifications; and

(b) When and how the administrative agency will assist the individual in securing verifications.

(3) If the information or verification required to establish the individual’s eligibility for assistance is not received by the administrative agency by the stated date, the administrative agency shall contact the individual in writing, mailed or personally delivered no more than twenty days from the date of the application. The contact letter shall state that the required information or verification has not been received, and that if the information or verification is not received within ten days the administrative agency shall deny the application for medical assistance. This written follow-up letter:

(a) Shall include a clear statement that the administrative agency will assist in obtaining the required information or verification if the request for assistance is received on or prior to the given deadline.

(b) Does not serve as a notice of denial of application. If the requested information or verification is not received, the administrative agency shall propose a denial or termination of benefits.

(4) The administrative agency shall deny an application for medical assistance or terminate eligibility if an individual fails or refuses, without good cause, to cooperate by providing necessary verifications or by providing consent for the administrative agency to obtain the verifications. The administrative agency shall:

(a) Allow the individual a reasonable opportunity, not to exceed the time limits for timely determination of eligibility, to obtain verifications and resolve discrepancies prior to determining the individual’s eligibility.

(b) Deny or terminate medical assistance if:

(i) An individual provides incomplete or inconsistent information, is non-cooperative, or is unable to clarify information; and

(ii) The administrative agency is unable to verify a required eligibility factor.

(i) If the individual is otherwise eligible for medicaid but meets the requirements of rule 5101:1-38-01.7 of the Administrative Code; or

(ii) For a failure or refusal to cooperate in verifying past eligibility.

(5) Verification is not required if an individual’s own statement establishes an individual is ineligible for medical assistance. The administrative agency shall:

(a) Confirm the accuracy of the statement; and

(b) If it is correct, deny or terminate eligibility; and

(6) If an individual does not reside in a permanent dwelling or does not have a fixed home or mailing address, the administrative agency shall:

(a) Approve the individual’s application for medicaid if the individual is eligible for a category of medical assistance based upon the individual’s statements, an affidavit, or the best available evidence. If the individual is applying for medicaid for the blind, or disabled, the individual must be determined to be blind or disabled pursuant to rule 5101:1-39-03 of the Administrative Code.

(b) Attempt to obtain verification of all eligibility factors for the case record, and record all attempts to obtain verification.

(I) Pre-termination review (PTR). Pursuant to 42 C.F.R. 435.930 (as in effect on October 1, 2009) the administrative agency shall determine whether the individual is eligible for any other category of medical assistance before proposing to terminate an individual’s medical assistance for any reason.

(1) If there is sufficient information in the physical or electronic records available to the administrative agency to complete the PTR, the administrative agency shall determine the individual’s eligibility for medicaid based upon that information.

(2) If there is insufficient information in the physical or electronic records available to the administrative agency to complete the PTR, the administrative agency shall take reasonable steps to obtain the needed information before proposing termination.

(3) If the individual fails to cooperate by providing requested information, the administrative agency shall determine eligibility based on available information.

(4) If the individual is eligible for another category of medical assistance, the administrative agency shall approve assistance under that category for the individual; if the individual is not eligible for any category of assistance, the agency shall propose to terminate the individual’s medical assistance benefits.

(J) Effective date of termination of coverage.

(1) A change in circumstances (other than death) during the month cannot adversely affect eligibility for the month during which the change occurred.

(a) If an individual is no longer eligible for medical assistance, the administrative agency shall propose to terminate coverage on the last day of the month, if there are enough days remaining in the month for prior notice and an opportunity to request a hearing to be given to the consumer before the next month begins.

(b) A change occurring too late in a month for prior notice and an opportunity to request a hearing to be given to the consumer before the next month begins shall be effective the first of the second month following the month of change.

(2) If an individual was incorrectly determined to be eligible for medical assistance, the administrative agency shall propose to terminate coverage and explore the possibility of overpayment recovery as set forth in rule 5101:1-38-20 of the Administrative Code.

(3) An individual’s eligibility, once it has been approved and a notice has been generated, can not be retroactively deleted or rescinded.

(4) An established termination date for an individual can be changed to an earlier date only in the case of the individual’s death. Coverage for an individual shall terminate on the date of the individual’s death.

Replaces: 5101:1-38-01, 5101:1-38-01.1, 5101:1-38-01.2, 5101:1-38-01.3, 5101:1-38-01.4, 5101:1-38-02

Effective: 10/01/2009

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

Promulgated Under: 111.15

Statutory Authority: 5111.01, 5111.011, 5111.012

Rule Amplifies: 5111.01, 5111.011, 5111.012, 2913.401, 3501.01, 3503.10, 5101.58, 329.051

Prior Effective Dates: 8/1/1975, 10/1/1975, 6/1/1976, 7/14/1977, 9/3/1977, 12/31/1977, 9/1/1982, 08/01/2007, 9/24/1983, 8/1/1984, 10/20/1984, 11/1/1984, 12/1/1984 (Emer.), 2/10/1985, 4/1/1986, 8/1/1986 (Emer.), 10/3/1986, 7/1/1987 (Emer.), 8/3/1987, 10/1/1987 (Emer.), 12/24/1987, 3/24/1988 (Emer.), 4/1/1988 (Emer.), 6/10/1988, 6/30/1988, 7/1/1988 (Emer.), 9/1/1988, 9/24/1988, 10/1/1988 (Emer.), 10/25/1988 (Emer.), 12/20/1988, 3/1/1989 (Emer.), 5/28/1989, 12/1/1989, 1/1/1990 (Emer.), 4/1/1990, 6/22/1990, 8/1/1990 (Emer.), 10/25/1990, 1/1/1991 (Emer.), 2/21/1991, 4/1/1991 (Emer.), 6/1/1991, 7/1/1991 (Emer.), 9/15/1991, 10/1/1991 (Emer.), 12/20/1991, 4/1/1992, 7/1/1992, 1/1/1993, 1/1/1993 (Emer.), 2/11/1993, 3/18/1993, 5/1/1993, 9/1/1993, 1/1/1994, 3/1/1994 (Emer.), 4/18/1994, 1/1/1995, 1/1/1995 (Emer.), 4/1/1995, 7/1/1995, 10/1/1995, 6/1/1996, 10/1/1996 (Emer.), 10/1/1996, 12/15/1996, 5/1/1997, 10/1/1997 (Emer.), 10/30/1997, 12/30/1997, 7/1/1998, 10/1/1999, 11/1/1999 (Emer.), 2/1/2000, 5/4/2000, 7/1/2000, 10/1/2002, 6/1/2003, 6/1/2003 (Emer.), 9/20/2003, 10/6/2003, 9/25/2006, 10/1/2006, 6/1/2007

5101:1-38-01.3 Medicaid and covered families and children medicaid (CFC): retroactive coverage. [Rescinded]

Rescinded eff 10-1-09

5101:1-38-01.4 Data systems and medicaid health care coverage.

(A) The Ohio department of job and family services (ODJFS) has two data systems which interact regarding the health care date of medicaid recipients for health care coverage. The medicaid management information system (MMIS) contains information, including health care eligibility dates, which is used to pay the health care claims of medicaid recipients. The client registry information system-enhanced (CRIS-E) contains information regarding the eligibility of medicaid recipients. The initial health care dated entered by the CDJFS into CRIS-E becomes the current health care date for both systems. Any changes to the beginning health care date after the first submission cannot be done via CRIS-E. The change can only be made by sending a completed JFS 07102 “Change in Medicaid Health Care Coverage Dates/Buy-in Eligibility Form”, to ODJFS. ODJFS will then change the MMIS file.

(B) New recipients, new assistance groups and reopened assistance groups

(1) Eligibility begins the first of the month for individuals who are eligible for medicaid on a regular monthly basis.

(2) The beginning date of eligibility for individuals eligible for medicaid on a spenddown basis will vary from month to month and depends on the date the individual incurred sufficient medical expenses to meet the spenddown or paid-in the spenddown liability to the CDJFS.

(3) The beginning date of eligibility for individuals who move into Ohio during a month and meet Ohio’s eligibility requirements for medicaid cannot extend further back than the date the individual met Ohio’s residency requirements.

(4) At the time a new individual is added to an existing assistance group, a new assistance group is approved, or a reopened assistance group is approved, CRIS-E will accept the health care date, even though it may be considered a back date, for up to seven months.

(1) To correct health care dates after they are on CRIS-E, the CDJFS must send a completed JFS 07102 to ODJFS. ODJFS will then correct the MMIS file.

(2) ODJFS will not delete eligibility if there is coverage for medicaid/managed care, covered periods will not be taken away.

(3) The CDJFS can also submit a JFS 07102 to correct the health care dates for individuals eligible for medicaid on a spenddown basis.

(D) Correcting an effective date of termination

(1) To correct an effective date of termination in MMIS after it is on CRIS-E, the CDJFS must send a completed JFS 07102 to ODJFS. ODJFS will then correct the MMIS file to reflect the new termination date.

(2) Currently, the only valid reasons to change an effective date of termination to a date prior to the established termination date is due to the death or incarceration of the medicaid-eligible individual.

(E) New health care date appearing on MMIS as a result of other changes

(1) In the MMIS, the health care dates are linked to several transactions that affect the status of an active assistance group.

(2) MMIS automatically changes the health care date when there is an enrollment or disenrollment in a managed care plan change in living arrangement, a category change, or a county transfer.

(3) Changes to health care dates will be done automatically by the system when the CDJFS enters one of the transactions listed in paragraph (E)(1) of this rule.

(4) The old health care date will be retained on the MMIS file.

(5) MMIS will reflect the most current health care date.

(6) MMIS will track major action types for reporting purposes and to correctly identify health care coverage when the recipient is in a managed care plan.

(7) While a new health care date has been entered, the recipient’s health care eligibility remains in effect for the previous time period.

(F) The CDJFS must document on CRIS-E screen CLRC (running record comments) what action was taken and why.

HISTORY: Eff 10-1-02

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.01, 5111.011

Rule amplifies: RC 5111.01, 5111.011

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

5101:1-38-01.5 Medicaid: Health Insurance Portability and Accountability Act (HIPAA).

(A) In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), a certificate of creditable coverage must be issued automatically when an individual ceases coverage under a medical coverage plan or policy. The administrative agency must also issue a certificate of creditable coverage upon request.

(B) Definitions:

(1) “Certificate of creditable coverage” is a document that reflects certain details about an individual’s creditable health coverage.

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

(3) “Medical assistance program recipient” means a recipient or former recipient of a medical assistance program.

(4) The concept of “creditable coverage” is that individuals should be given credit for previous health coverage when moving from one group health plan to another, from an employer group health plan to an individual policy, or from certain kinds of individual coverage to an employer group health plan.

(a) “Creditable coverage” includes coverage of the individual under a group health plan, health insurance coverage, medicare, medicaid, medical care programs, COBRA, public health plans and other coverage.

(5) “Significant break in coverage” means sixty-three or more full days in a row during which an individual does not have creditable coverage.

(C) Upon request, the administrative agency must issue the CRIS-E “Certificate of Group Health Plan Coverage” or the JFS 03748 “Certificate of Group Health Plan Coverage”. The administrative agency has the option to create its own certificate provided it contains all of the following items, as cited in 45 CFR 146.115(a)(3)(ii):

(1) Date the certificate is issued;

(2) Name of the group health plan;

(3) Name(s) of the participant(s);

(4) Medicaid billing number;

(5) Name, address and telephone number of the administrative agency member who is responsible for issuing certificates and accepting telephone inquiries regarding the certificates;

(6) Statement that an individual has a minimum of eighteen months of creditable coverage before a significant break in coverage;

(7) Dates of creditable coverage; and

(8) Date the creditable coverage ended.

(D) Certificate of creditable coverage requirements:

(1) The medical assistance program recipient must sign the JFS 03749 “Authorization for Certificate of Group Health Plan Coverage” and the administrative agency must retain the signed form in the case record.

(2) To comply with HIPAA provisions, information may be exchanged with group health plans to provide information and assistance to the individual in securing health insurance.

(3) Upon termination from a medical assistance program, CRIS-E will automatically issue a “Certificate of Group Health Plan Coverage”.

(4) Certificates must reflect all periods of coverage during the twenty-four months that preceded the date of the request for a certificate.

(5) The administrative agency must issue certificates, including duplicate certificates within a reasonable time frame from the date of request.

(6) The administrative agency must issue certificates, including duplicate certificates, at no expense to the medical assistance program recipient.

(E) Administrative agency responsibilities:

(1) The administrative agency must protect a medical assistance program recipient’s rights to privacy and control of personal data, as outlined in rule 5101:1-37-01.1 of the Administrative Code.

(2) The administrative agency must 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.

(3) The administrative agency must issue proper notice and hearing rights as outlined in division level designation 5101:6 of the Administrative Code.

HISTORY: Eff 10-1-98; 10-6-03

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.01

Rule amplifies: RC 5111.01, 5111.012

Replaces: 5101:1-2-99

R.C. 119.032 review dates: 10/01/2008

5101:1-38-01.6 Medicaid: application for home and community-based (HCB) services.

(A) This rule sets forth the process for determining whether an individual is eligible for medicaid payments for services under the HCB services waivers set out in division 5101:3 of the Administrative Code.

(B) Eligibility for HCB services. To receive HCB services, the individual shall:

(1) Be in receipt of medicaid, as described in Chapters 5101:1-37 through 5101:1-40 or rule 5101:1-41-30 of the Administrative Code;

(2) Be in need of HCB services under a waiver described in division 5101:3 of the Administrative Code; and

(3) Be enrolled in an HCB services waiver described in rule 5101:3-1-06 of the Administrative Code.

(C) Determination of eligibility for HCB services. The county department of job and family services (CDJFS) shall approve HCB services for an individual in receipt of medicaid only upon:

(1) Approval by the HCB services waiver operational agency; and

(2) If services under the waiver are available only to a specific number of individuals, notification that the individual may be enrolled in the waiver from the Ohio department of job and family services (ODJFS), its designee, or a waiver operating agency.

(D) Coverage period. The HCB services coverage period can have a different beginning date or ending date from the medicaid eligibility period. However, HCB services cannot begin before an individual’s medicaid eligibility period or before an individual’s retroactive medicaid eligibility period as determined under rule 5101:1-38-01.2 of the Administrative Code; HCB services cannot extend beyond the termination date of an individual’s medicaid coverage; and HCB services cannot be provided during any period of medicaid ineligibility.

(1) Medicaid coverage of HCB services begins on the latest of the following dates:

(a) The process date for application for HCB services. The process date is:

(i) The date the CDJFS receives a signed application for HCB services from an individual; or

(ii) The signature date, if the CDJFS receives a signed and dated HCB services application from a waiver operational agency no more than five working days after the date of signature; or

(iii) The date the CDJFS receives the signed application for HCB services, if the application was received from a waiver operational agency more than five working days after the date of signature.

(b) The date the individual meets all criteria for coverage of an HCB services waiver described in rule 5101:3-1-06 of the Administrative Code.

(2) Medicaid coverage of HCB services terminates when either:

(a) The CDJFS determines the individual no longer meets medicaid conditions of eligibility as described in rule 5101:1-38-01.8 of the Administrative Code or the criteria for coverage of HCB services; or

(b) The waiver operational agency notifies the CDJFS that it no longer authorizes the individual to receive its HCB services.

(E) HCB services waiver operational agency responsibilities. HCB services waiver operational agencies shall:

(1) Submit a JFS 02399 “Request for Medicaid Home and Community-Based Services (HCBS)” (rev. 1/2006), signed by the individual, to the CDJFS within five days of the signature date, if assisting an individual with an application for HCB services.

(2) Determine, in accordance with this rule and division 5101:3 of the Administrative Code, whether the individual requesting medicaid coverage of HCB services meets the requirements of the applicable HCB services waiver program.

(3) Provide written notification of determinations to individuals, including to whom any patient liability must be paid, if applicable.

(4) Notify the CDJFS of determinations and subsequent changes regarding approval of HCB services.

(F) Administrative agency responsibilities. The CDJFS shall:

(1) Determine an individual’s eligibility for HCB services in accordance with this rule and Chapters 5101:1-37, 5101:1-38, 5101:1-39, 5101:1-40, 5101:1-41, and 5101:1-42 of the Administrative Code.

(a) If an individual who applies for HCB services is currently in receipt of medicaid, the CDJFS shall process the individual’s application for HCB services.

(b) If an individual who applies for HCB services is not currently in receipt of medicaid, the CDJFS shall begin the application process described in rule 5101:1-38-01.2 of the Administrative Code.

(c) If the CDJFS determines that an individual who applies for HCB services is not eligible for any category of medical assistance under Chapters 5101:1-37 through 5101:1-40 or rule 5101:1-41-30 of the Administrative Code, the agency shall deny both medical assistance and HCB services for that individual.

(2) Within five days of the receipt of a signed JFS 02399, notify the applicable waiver agency via the electronic eligibility system of the receipt of the application. If the waiver agency is not known or if multiple waiver agencies are indicated on the application, the CDJFS shall submit the JFS 02399 to the Ohio department of job and family services (ODJFS) bureau administering HCB waiver services.

(3) Notify the applicable HCB services waiver operational agency of changes in the individual’s eligibility for medicaid coverage of HCB services.

Replaces: 5101:1-38-01.6

Effective: 10/01/2009

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

Promulgated Under: 119.03

Statutory Authority: 5111.01, 5111.011, 5111.871

Rule Amplifies: 5111.01, 5111.011, 5111.012, 5111.87, 5111.871, 5111.91

Prior Effective Dates: 6/1/1988 (Emer.), 8/1/1988 (Emer.), 10/30/1988, 1/1/1990 (Emer.), 3/1/1990 (Emer.), 3/30/1990 (Emer.), 4/1/1990, 6/29/1990, 7/1/1990, 10/1/1990, 1/1/1991 (Emer.), 4/1/1991, 1/1/1992 (Emer.), 3/20/1992, 3/30/1992, 5/1/1992 (Emer.), 7/1/1992, 8/14/1992 (Emer.), 1/1/1992, 5/1/1993, 9/1/1993, 7/1/1994, 10/1/2002, 10/1/2004

5101:1-38-01.7 Medicaid: assisting individuals unable to access verifications due to a physical or mental impairment.

(A) The purpose of this rule is to establish the procedures the administrative agency must follow when processing an application for medical assistance for an individual unable to access verifications or means of self-support due to a physical or mental impairment, in order to prevent any physical or mental disability from negatively impacting the eligibility determination process. This rule applies to all medical assistance programs administered by the Ohio department of job and family services.

(B) Definitions.

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

(2) “Durable power of attorney” means power of attorney established in accordance with section 1337.09 of the Revised Code.

(3) “Guardian” means any person, association, or corporation appointed by the probate court to have responsibility for the care and management of an incompetent individual and/or their assets under Title XXI of the Revised Code.

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

(5) “Means of self-support” means all countable income, assets and resources attributable to the individual.

(1) For an individual having a physical or mental impairment substantially limiting the individual’s ability to access verifications or access a known means of self-support, and who has not granted any person with durable power of attorney, and who does not have a court-appointed guardian or a person with other legal authority and obligation to act on behalf of the individual, the administrative agency shall:

(a) Determine eligibility in accordance with Chapters 5101:1-37 to 5101:1-42 of the Administrative Code, but without considering eligibility factors for which verification cannot be obtained or means of self-support that cannot be accessed because of the physical or mental impairment.

(b) Determine if another person is available to assist in obtaining verifications or accessing the individual’s means of self-support, and, if such a person is available, request the person assist in obtaining the verifications or accessing the individual’s means of self-support. If verifications are provided, or if means of self-support are accessed by the individual or on the individual’s behalf by another person, the administrative agency shall consider those factors in the eligibility determination process.

(c) If no person is available to assist the individual, refer the individual’s case to the administrative agency’s legal counsel and request counsel evaluate whether the matter should be referred to the probate court, adult protective services, or another entity deemed by the administrative agency’s legal counsel to be appropriate. For cases referred to counsel for such evaluation, the administrative agency shall also:

(i) Note in the individual’s case record that verifications or means of self-support are not available and shall not be considered a disqualifying factor until a means of access to those items is obtained or established, and

(ii) Inform the administrative agency’s legal counsel of any eligibility approval or denial.

(d) Redetermine the individual’s eligibility:

(i) If a means of access to verifications or means of self-support is obtained or established, or

(ii) During the next regularly-scheduled redetermination using the best evidence available, whichever occurs sooner.

(2) The administrative agency shall not delay the eligibility determination if a case is referred to the administrative agency’s legal counsel, adult protective services, or another entity deemed by the administrative agency’s legal counsel to be appropriate. Instead, the administrative agency shall complete the eligibility determination using the best evidence available.

Effective: 08/01/2009

R.C. 119.032 review dates: 08/01/2014

Promulgated Under: 111.15

Statutory Authority: 5111.01, 5111.011

Rule Amplifies: 5111.01, 5111.011

5101:1-38-02 Medicaid: verification and reporting requirements.

(A) The purpose of this rule is to establish the basic requirements necessary for the determination of eligibility for all medical assistance programs. Verification is not an eligibility requirement in its own right, but a method for assuring that an eligibility requirement is met. Timely reporting of complete and accurate information is essential for the determination of eligibility for both initial and continuing medical assistance coverage.

(B) Definitions.

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

(2) “Available” means reasonably present or ready for immediate use.

(3) “Case record” means the electronic eligibility determination system.

(4) “Case record file” means the hard-copy case or scanned copy of the hard-copy case.

(5) “Good cause” means circumstances that reasonably prevented 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.

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

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

(8) “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.

(9) “Reporting” means notification to the administrative agency of any changes that may affect an individual’s eligibility for medical assistance.

(a) An individual, person or entity who has a financial responsibility for, or who stands in the place of an individual including spouses, parents, guardians, specified relatives and authorized representatives has the responsibility of reporting changes and providing verifications.

(b) The community spouse of an institutionalized individual also has the responsibility to report changes.

(10) “Residential care facility” has the same meaning as in section 3721.01 of the Revised Code.

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

(12) “United States (U.S.)” and “state(s)” include(s) 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.

(13) “United States citizen or national” means any individual born in the United States, or born abroad to parents who are U.S. citizens, qualifies for acquisition of citizenship, has become a U.S. citizen through naturalization, or otherwise qualifies for U.S. citizenship under section 301 of the Immigration and Nationality Act, 8 U.S.C. 1401 (4/21/2006).

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

(C) Verification of all eligibility factors, including changes, is required to establish initial and ongoing eligibility for a medical assistance program. These requirements include:

(1) Age- self-declaration of age is acceptable verification, unless the information is confusing or contradictory to other information available to the administrative agency.

(2) Citizenship- all individuals, who are applying for or receiving medical assistance and stating they are U.S. citizens or nationals, must provide one-time documentation of their citizenship in accordance with section 6036 of the Deficit Reduction Act of 2005 Pub. L. No. 109-171 (2/08/2006). Individuals not subject to documenting their U.S. citizenship are defined in paragraphs (C)(2)(d) to (C)(2)(i) of this rule. An individual who is already receiving medicaid will remain eligible if the individual continuously shows a good faith effort to present satisfactory evidence of citizenship or birth and identity. All documents must be originals or copies certified by the issuing agency.

(a) Citizenship shall be documented using this list:

(i) A United States passport, unless it was issued with a limitation; limited passports are issued through the department of homeland security (DHS) using form I-131. A passport does not have to be currently valid;

(ii) A certificate of naturalization (DHS form N-550 or N-570);

(iii) A certificate of United States citizenship (DHS form N-560 or N-561);

(iv) A valid state-issued driver’s license, if the state issuing the license requires proof of U.S. citizenship before issuance of such license or obtains a social security number from the applicant and verifies before certification that such number is valid and assigned to the individual, who is a citizen;

(v) A state match with the state data exchange (SDX) for supplemental security income (SSI) or social security disability insurance (SSDI) recipients, for states which do not provide medicaid to individuals by virtue of their the individual’s receipt of SSI or SSDI;

(vi) Such other documents as the secretary of the department of health and human services may specify, by regulation, provide proof of U.S. citizenship or nationality and that provide a reliable means of personal identity.

(b) If none of the documents from paragraph (C)(2)(a) of this rule is available, the administrative agency shall verify U.S. citizenship using a combination of one birth or nationality document from paragraph (C)(2)(b) of this rule and one identity document from paragraph (C)(2)(c) of this rule. Although some documents may be listed as both birth and nationality documents and identity documents, a document may only be used to satisfy either birth and nationality or identity, not both. A birth or nationality document or an identity document alone does not satisfy the citizenship documentation requirement. Birth or nationality shall be documented using an item from the following hierarchical list:

(i) A U.S. public birth record or birth document, showing birth in one of the fifty states, the District of Columbia, American Samoa, Guam (on or after April 10, 1899), the Northern Mariana Islands(NMI) (after November 4, 1986 NMI local time), Puerto Rico (on or after January 13, 1941), Swain’s Island, or the U.S. Virgin Islands (on or after January 17, 1917) and for individuals whose U.S. citizenship may be established for collectively naturalized individuals as designated, by regulation, from the secretary of the department of health and human services;

(ii) Birth information obtained through the administrative agency’s data exchanges, as authorized by federal regulation or guidance from the secretary of the department of health and human services;

(iii) A certification of birth abroad issued by the department of state (DS-1350);

(iv) A certification of birth abroad (FS-545);

(v) A United States citizen identification card (I-197 or I-179);

(vi) A report of birth abroad of a citizen of the United States (FS-240);

(vii) A Northern Mariana Islands identification card (I-873), issued by the United States immigration and naturalization services (INS), to a collectively naturalized citizen of the United States who was born in the Northern Mariana Islands before November 3, 1986;

(viii) An American Indian card (I-872) issued by the department of homeland security (DHS) with the classification code “KIC.” This card is issued by DHS to identify United States citizen members of the Texas band of Kickapoos living near the United States/Mexican border;

(ix) A final adoption decree or a statement from a state approved adoption agency showing the individual’s name and U.S. place of birth. In situations in which the adoption is not finalized and the state will not release a birth certificate prior to a final adoption decree, a statement showing the individual’s name and U.S. place of birth, and stating that the source of the place of birth information is an original birth certificate;

(x) Evidence of civil service employment by the U.S. government prior to June 1, 1976;

(xi) An official military record of service showing a U.S. place of birth;

(xii) A data verification with the systematic alien verification for entitlements (SAVE) program for naturalized citizens, including but not limited to the provision of the individual’s alien registration number;

(xiii) Evidence showing an individual meets the requirements of the Child Citizenship Act of 2000, Pub. L. No. 106-295 (October 30, 2000). The administrative agency must obtain documentary evidence verifying that at any time on or after February 27, 2001, the following conditions have been met:

(a) At least one parent of the child is a United States citizen by either birth or naturalization;

(b) The child is under the age of eighteen years;

(d) The child was admitted to the United States for lawful permanent residence, as verified under the requirements of 8 U.S.C. 1641 as in effect on July 13, 2007 pertaining to verification of qualified alien status; and

(e) If adopted, the child satisfies the requirements of section 101 (b)(1) of the Immigration and Nationality Act 8 U.S.C. section 1101 (b)(1) pertaining to international adoptions, as in effect on July 13, 2007 including:

(i) Admission for lawful permanent residence as a child adopted outside the United States (IR-3); or

(ii) Admission for lawful permanent residence as a child coming to the United States to be adopted, with final adoption having subsequently occurred (IR-4).

(xiv) An extract of a hospital record on hospital letterhead which was established at the time of the individual’s birth, was created at least five years before the initial medicaid application date, and indicates a U.S. place of birth. For a child under sixteen, the document must have been created near the time of birth or five years before the application;

(xv) A life insurance, health insurance, or other insurance record showing a U.S. place of birth and created at least five years before the initial medicaid application date. For a child under sixteen, the document must have been created near the time of birth or five years before the application;

(xvi) A religious record recorded in the U.S. within three months of birth, showing the birth occurred in the U.S. and showing either the date of the birth or the individual’s age at the time the record was made. The record must be an official record recorded with a religious organization;

(xvii) An early school record showing a U.S. place of birth. The record must show the name of the individual, the date of admission to the school, the date of birth, a U.S. place of birth and the names and places of birth for the individual’s parents;

(xviii) A federal or state census record showing U.S. citizenship or a U.S. place of birth, including the individual’s age;

(xix) An institutional admission paper from a nursing home, skilled nursing care facility or other institution which indicates a U.S. place of birth;

(xx) Native American tribal documents, including, but not limited to:

(a) A Seneca Indian tribal census record;

(b) The bureau of Indian affairs tribal census records of the Navajo Indians;

(d) U.S. American Indian or Alaska native tribal document; or

(e) Other native American tribal documents;

(xxi) A U.S. vital statistics official notification of birth registration;

(xxii) A delayed U.S. public birth record which was recorded more than five years after the individual’s birth. For the purpose of this rule, in the state of Ohio, a corrected birth record as defined in section 3705.15 of the Revised Code, is the equivalent of a delayed U.S. public birth record;

(xxiii) A statement signed by the physician or midwife who was in attendance at the time of birth;

(xxiv) The roll of Alaska natives maintained by the bureau of Indian affairs;

(xxv) A medical record from a clinic, doctor, or hospital which was created at least five years before the initial medicaid application date and indicates a U.S. place of birth. For children under sixteen the document must have been created near the time of birth or five years before the date of application;

(xxvi) Affidavits made under penalty of perjury. The affidavits do not need to be notarized. Affidavits may be used only in rare circumstances when the state is unable to secure evidence of citizenship from another listing. If the documentation requirement needs to be met through affidavits, the following rules apply:

(a) There must be at least two affidavits by people who have personal knowledge of the event(s) establishing the individual’s claim of citizenship. The two affidavits could be combined in a joint affidavit. At least one of the persons making the affidavit cannot be related to the individual and neither person can be the individual;

(b) Persons making the affidavit must be able to provide proof of their own citizenship and identity. If the persons making the affidavit have information which explains why documentary evidence establishing the individual’s claim of citizenship does not exist or cannot be readily obtained, the affidavit should contain this information as well;

(c) The administrative agency must obtain a separate affidavit, from the individual or other knowledgeable persons, explaining why the evidence does not exist or cannot be obtained;

(xxvii) Such other documents as the secretary of the department of health and human services may specify, by regulation, that provide proof of U.S. citizenship or nationality.

(c) The administrative agency must use one of the following identity documents in combination with a birth or nationality document listed in paragraph (C)(2)(b) of this rule.

(i) A driver’s license or similar document issued for the purpose of identification by a state, if it contains a photograph of the individual or such other personal identifying information relating to the individual, such as: name, date of birth, gender, height, eye color and address;

(ii) An identification card issued by federal, state, or local government agencies or entities, provided it contains a photograph or other information such as: name, date of birth, gender, height, eye color and address;

(iii) A United States military card or draft record;

(iv) A military dependent’s identification card;

(v) A United States coast guard merchant mariner card;

(vi) A school identification card with a photograph;

(vii) A cross match with a federal or state governmental office, public assistance agency, law enforcement agency, or corrections agency data system to establish identity, if the agency establishes and certifies true identity of individuals;

(viii) A Native American tribal document as defined in paragraphs (C)(2)(b)(xx)(a) to (C)(2)(b)(xx)(d)(e) of this rule; or

(ix) An affidavit of identity, signed under penalty of perjury, by a residential care facility director or administrator on behalf of an institutionalized individual in the facility. All other means of verifying identity should be pursued prior to accepting this type of affidavit. The affidavit does not need to be notarized;

(x) Three or more documents that together reasonably corroborate the identity of an individual, provided such documents have not been used to establish the individual’s birthplace or nationality. The administrative agency must first ensure no other evidence of identity is available to the individual prior to accepting such documents. Such documents must at a minimum contain the individual’s name, plus any additional information establishing the individual’s identity. All documents used must contain consistent identifying information. These documents include, but are not limited to: employer identification cards, high school diplomas, general education and high school equivalency diplomas, college diplomas from accredited institutions, marriage certificates, divorce decrees, and property deeds and titles;

(xi) An affidavit on behalf of an individual under the age of eighteen years, when school identification cards and drivers’ licenses are not available to the individual. The affidavit does not need to be notarized;

(xii) In the case of individuals under sixteen years of age, in a state which does not provide for the issuance of an identification document (other than a driver’s license) a parent, legal guardian, authorized representative, or representative of a nonprofit organization, association or program may provide documentation for the individual, including:

(a) A school record or report card;

(b) A childcare or nursery school record;

(d) An affidavit signed under penalty of perjury by a parent, caretaker relative or guardian, stating the date and place of birth of the child. An individual cannot use an affidavit for identity if he or she also submitted an affidavit for proof of birth or nationality. The affidavit does not need to be notarized; or

(xiii) Such other documents of personal identity as the secretary of the department of health and human services finds, by regulation, provide a reliable means of identification.

(d) Non-citizens, applying for or receiving medical assistance, who state they are not U.S. citizens or nationals, shall provide verification of their alien status in accordance with rules 5101:1-37-03, 5101:1-38-02.3, 5101:1-38-02.4, and 5101:1-38-02.5 of the Administrative Code.

(e) The citizenship requirement shall not apply to the following groups, because these individuals have already satisfied the citizenship requirement in order to receive the following assistance:

(i) Individuals enrolled in any part of medicare, as defined in Chapter 5101:1-39 of the Administrative Code;

(ii) Individuals who are receiving supplemental security income (SSI);

(iii) Individuals receiving social security disability insurance (SSDI);

(iv) Individuals to whom adoption or foster care assistance is made available under Title IV-E of the Social Security Act;

(v) Individuals in foster care to whom child welfare services are made available under Title IV-B of the Social Security Act; and

(vi) Other individuals on such other basis as the secretary of the department of health and human services may specify, by regulation, that satisfactory documentary evidence of citizenship or nationality was previously presented.

(f) Individuals who are not applying for medical assistance for themselves, but are applying for medical assistance for other individuals, are not required to verify their own U.S. citizenship or their alien status.

(g) A child who is deemed eligible under either of the following conditions is not required to verify citizenship until redetermination at twelve months of age:

(i) As established in rule 5101:1-40-02.2 of the Administrative Code; or

(ii) If the mother gave birth and was determined eligible for medicaid under the category of alien medical emergency assistance.

(h) Individuals applying for alien emergency medical assistance (AEMA) are not required to verify alien status in accordance with rule 5101:1-41-20 of the Administrative Code.

(i) Individuals applying for or receiving disability medical assistance (DMA) shall not be required to provide documentation of their U.S. citizenship.

(3) Identity- self-declaration of identity is acceptable verification for individuals who are not applying for or in receipt of medical assistance or for individuals who are otherwise excluded or exempted from the verification of U.S. citizenship requirement.

(4) Income- all income, earned and unearned, must be verified for all individuals whose income is used in the eligibility determination.

(a) Verification of earned income is not required when:

(i) An individual alleges that he or she is not working and there is no reason to question the statement; or

(ii) An individual reports earnings sufficiently high to make the individual, or the individuals for whom they are financially responsible, clearly ineligible for benefits.

(b) Verification of income is not required if some other eligibility factor is not met. Income must be verified, however, when such a factor is 5101:1-38-02 11 questionable and not yet resolved.

(5) Limiting physical factor- verification that the individual meets the limiting physical factor requirement for medical assistance for the aged, blind, or disabled is required. Limiting physical factor is defined in Chapter 5101:1-39 of the Administrative Code.

(6) Living arrangement- self-declaration of living arrangement is acceptable verification, unless the information is confusing or contradictory to other information available to the administrative agency. Living arrangement is defined in Chapters 5101:1-39 and 5101:1-40 of the Administrative Code, specifically for the different types of medical assistance.

(7) Pregnancy- the individual must provide written medical verification of pregnancy. The statement must be completed and signed by a doctor or nurse. If not included with the verification, the administrative agency may contact the woman’s doctor or nurse to obtain the number of fetuses and the expected due date.

(8) Residency- self-declaration of residency is acceptable verification, unless the information is confusing or contradictory to other information available to the administrative agency. Residency is further defined in Chapters 5101:1-38 to 5101:1-41 of the Administrative Code.

(9) Resources- for those categories of medical assistance that have a resource limit, all available resources, including the remainder beneficiary designation for annuities, must be verified. Resources are further defined in Chapters 5101:1-39 to 5101:1-41 of the Administrative Code.

(10) Social security number- self-declaration of the social security number is acceptable verification, unless the information is confusing or contradictory to other information available to the administrative agency. Reference rule 5101:1-38-02.1 of the Administrative Code for guidance regarding social security numbers. Non-citizens who are applying for or receiving AEMA are not required to provide a social security number, as defined in rule 5101:1-41-20 of the Administrative Code.

(11) Third-party medical support- the individual must cooperate in providing verification of any third-party liability or coverage of medical expenses as defined in Chapter 5101:1-38 of the Administrative Code.

(D) Administrative agency responsibilities.

(1) The administrative agency must deny an application for medical assistance if an individual fails or refuses, without good cause, to cooperate in establishing initial eligibility. When the individual or authorized representative is aware of the required verifications, but fails or refuses, without good cause, either to provide consent for the administrative agency to obtain the verifications or to provide the necessary verifications, the administrative agency must deny assistance.

(2) The administrative agency must terminate eligibility for medical assistance when an individual fails or refuses, without good cause, to cooperate in determining ongoing eligibility. The administrative agency shall not terminate medical assistance when the individual fails or refuses, without good cause, to cooperate in validating past eligibility because past eligibility has no bearing upon present need and eligibility.

(3) When an individual’s own statement on the application form establishes the individual is ineligible for medical assistance, verification is not required. The administrative agency shall confirm the statement on the application to assure it was an accurate statement and not a mistake in completing the form. The individual shall be advised of the right to reapply at any time.

(4) The administrative agency must:

(a) Provide a written explanation of the verifications, information, and any deadlines for providing the verifications necessary to establish eligibility for medical assistance;

(b) Explain where and how to obtain the required verifications;

(d) Assist the individual in securing the verifications necessary to establish eligibility;

(i) When the individual requests such assistance; or

(ii) When the individual is unable to provide the verifications without the help of the administrative agency.

(e) Obtain written consent to secure verifications or information from private sources; and

(f) Utilize a health insurance portability and accountability act (HIPAA) compliant form to obtain medical records in accordance with Chapter 5101:1-37 of the Administrative Code.

(5) The administrative agency must not:

(a) Interpret the inability or incompetency of an individual to provide verifications, or the unavailability of documents, as non-cooperation; or

(b) Terminate or deny medical assistance due to the inability or incompetency of an individual to provide the verifications, or the unavailability of documents, needed to determine eligibility for medical assistance.

(c) Require a person to present original documents for verification of U.S. citizenship. Original documents are acceptable in person or by mail.

(6) The administrative agency is not required to obtain written consent from the individual regarding information that is verifiable from public records.

(7) The administrative agency must conduct a match of the individual’s name against the corresponding social security number provided as part of the social security number verification requirements.

(8) The administrative agency must act on all changes, both reported and unreported, within a reasonable period of time.

(9) The administrative agency must allow the individual a reasonable opportunity to obtain verifications and resolve discrepancies prior to an eligibility determination. Reasonable opportunity must not exceed time limits established for timely determination of eligibility as defined in rule 5101:1-38-02.1 of the Administrative Code. When evidence conflicts, the decision must be based on the strongest evidence. When absolute proof is not available, the eligibility determination is based on the best possible evidence.

(a) The administrative agency must not deny or terminate medical assistance when verifications are not available and self-declaration is not acceptable; however, the administrative agency shall accept a signed affidavit from the individual, a third-party statement, a notarized statement, or the statement on the application form, if the information is consistent with other facts or statements. Refer to paragraph (C)(2)(b)(xxi) of this rule for documenting citizenship through an affidavit.

(b) The administrative agency must exhaust all reasonable possibilities for verification before accepting any of the statements mentioned in paragraph (D)(9)(a) of this rule. When the normal sources of verification have been exhausted and no documentation can be obtained, the administrative agency may accept the statement if such statements are complete and consistent with other facts and statements. The use of a statement should be on a case-by-case basis when no other approach is possible and shall be used only in rare circumstances.

(10) The administrative agency must deny or terminate medical assistance if eligibility cannot be established for an individual providing incomplete or inconsistent information, is non-cooperative, or if the individual is unable to clarify the information and the administrative agency is not able to establish an eligibility factor.

(11) The administrative agency must abide by the following procedures for homeless individuals and/or migrant individuals who are applying for or receiving medical assistance. Although verifications may exist, these individuals may not have easy access to them or may be unable to obtain them in a timely fashion or without assistance.

(a) The administrative agency must approve the application for medical assistance if the individual meets the eligibility criteria based on the individual’s statements on the application or signed affidavit, and the best evidence available. However, the administrative agency must verify the limiting physical factor is met for determination of eligibility for the aged, blind, or disabled medical assistance program.

(b) The administrative agency must attempt to obtain verification of all eligibility factors for the case record file. If the verification cannot be obtained by the next redetermination, the administrative agency must document each attempt in the case record until the information is obtained.

(12) The administrative agency must follow procedures regarding the retention and documentation of all documents submitted.

(a) The administrative agency must thoroughly document receipt of all verifications in the case record, photocopy the documents, and retain the copies in the case record file.

(b) The administrative agency must maintain copies in the case record file and/or database and make this information available for compliance audits.

(c) The administrative agency must not request the individual to provide duplicate copies of previously submitted verifications; unchanged information need not be verified unless the information is incomplete, inaccurate, inconsistent, outdated, or missing from the case record file due to record retention limitations as defined in rule 5101-9-21.1 of the Administrative Code.

(d) The administrative agency may use an attachment form or case recording method to record the verifications obtained in conjunction with the photocopies. Documentation must be in sufficient detail to permit a reviewer to determine the reasonableness and accuracy of the eligibility determination.

(e) The administrative agency may make a telephone contact to secure verifications. The source of the information and information obtained must be carefully recorded in the case record. The recording must include all of the following:

(i) The name and telephone number of the person who gave the information;

(ii) The name of the agency or business contacted, if applicable;

(iii) The date of the contact; and

(iv) An accurate summary of the information secured as a result of the telephone contact.

(E) Individual responsibilities.

(1) The individual must provide the information necessary to establish eligibility and to cooperate in the verification process as provided in this rule. The individual may request assistance in obtaining required verification from the administrative agency as defined in paragraph (D)(4) of this rule.

(2) The individual must report changes to the administrative agency in a timely manner when changes occur. These changes include, but are not limited to:

(a) A change in household composition.

(b) A change in an individual’s pregnancy, such as when:

(i) An individual becomes pregnant; or

(ii) An individual’s pregnancy ends.

(i) An individual becomes disabled; or

(ii) An individual is no longer disabled.

(d) A change in ownership of a resource, for any medical assistance program for which there is a resource limitation.

(e) A change in the amount of any available resource, or if the total of the individual’s resources equals or exceeds the applicable resource limits, for any medical assistance program for which there is a resource limitation.

(f) A change in residence.

(g) The receipt of a non-recurring lump-sum payment.

(h) A change in private medical insurance, such as:

(i) The acquisition of private medical insurance;

(ii) The acquisition of third-party medical coverage or medical support; and

(iii) The termination of private medical insurance.

(i) A change in living arrangement.

(j) Any violation of a condition of an individual’s probation or parole, if the individual is in receipt of DMA.

(k) If an individual in receipt of DMA becomes a fugitive felon.

(l) Any change in the source of earned or unearned income, including, but not limited to:

(i) New employment;

(ii) Receipt of unearned income;

(iii) Changes due to loss of earned or unearned income; and/or

(iv) Changes in employment status, such as part-time to full-time or full-time to part-time.

(m) Any change in ownership an individual or spouse has in an annuity or any change to the remainder beneficiary designation.

(F) The administrative agency shall issue proper notice and hearing rights as outlined in division 5101:6 of the Administrative Code.

Effective: 07/01/2008

R.C. 119.032 review dates: 09/01/2011

Promulgated Under: 111.15

Statutory Authority: 5111.01, 5111.011

Rule Amplifies: 5111.01, 5111.011, 5111.012

Prior Effective Dates: 10/1/75, 9/1/82, 8/1/86 (Emer.), 10/3/86, 10/1/87 (Emer.), 12/24/87, 4/1/88, (Emer.) 6/30/88, 10/1/88 (Emer.), 12/20/88, 3/1/89 (Emer.), 5/28/89, 10/1/91 (Emer.), 12/20/91, 5/1/97, 7/1/00, 10/6/03, 9/25/06, 08/01/07

5101:1-38-02.1 Medicaid: Social security number requirement.

(A) This rule addresses the social security number criterion for medical assistance programs. Individuals applying for medical assistance are required to provide a social security number.

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

(3) “Well established religious objections” means the applicant:

(a) Is a member of a recognized religious sect or division of the sect; and

(b) Adheres to the tenets or teachings of the sect or division of the sect and for that reason is conscientiously opposed to applying for or using a national identification number.

(1) The administrative agency shall determine eligibility for medical assistance in accordance with the eligibility rules contained in Chapters 5101:1-37 to 5101:1-41 of the Administrative Code.

(2) The administrative agency shall require, as a condition of eligibility for medical assistance, that each applicant provide a social security number.

(3) If the individual cannot recall or has not been issued a social security number, the administrative agency shall:

(a) Request for the social security administration (SSA) to provide the social security number if there is evidence of a previously issued social security number; or

(b) Assist the individual in completing an application for a social security number, and in obtaining the evidence required under SSA regulations to establish the age, citizenship or alien status, and the true identity of the individual; and

(4) If the information provided by the individual is contradictory or confusing, the administrative agency shall attempt to verify the social security number by submitting the social security number to the SSA via the state verification and exchange system.

(5) The administrative agency must advise the individual of:

(a) The federal requirement to request the individual’s social security number in accordance with 42 CFR 435.910 (1/11/2001); and

(b) The use of the social security number by the administrative agency.

(6) The administrative agency shall not deny or delay eligibility for medical assistance to the individual pending the issuance or verification of a social security number when all other medical assistance eligibility criteria have been met.

(D) The individual is required to provide a social security number as a condition of eligibility for medical assistance.

(E) Exceptions to the social security number requirement.

(1) Individuals applying for alien emergency medical assistance (AEMA), in accordance with rule 5101:1-41-20 of the Administrative Code, are not required to provide a social security number.

(2) In accordance with 42 CFR 435.910 (1/11/2001), individuals applying for medical assistance are not required to provide a social security number when the individual has “well established religious objections” and refuses to obtain a social security number.

Replaces: 5101:1-38-021

Effective: 07/01/2006

R.C. 119.032 review dates: 07/01/2011

Promulgated Under: 111.15

Statutory Authority: 5111.01

Rule Amplifies: 5111.01, 5111.012, 5101.181, 5101.182.

Prior Effective Dates: 9/3/1977, 7/18/1978, 2/1/1979, 4/19/1979, 9/1/1986 (Emer.), 11/16/1986, 4/9/1987, 7/1/2000

5101:1-38-02.2 Medicaid and covered families and children medicaid: automatic assignment of third party and medical support payments, right of recovery of third party resources, and role of ODJFS and the CDJFS regarding third party resources.

(A) Definitions

(1) “Assignment” means the assistance group has transferred the right to collect and retain third party and medical support payments only to the extent of medical services which are paid under the medicaid program.

(2) “Medical support” means a requirement by court order for an absent parent to make payment for medical care. If the absent parent must pay a dollar amount specified in the court order for medical care in addition to the court-ordered child support, the additional amount is medical support.

(3) “Cooperation in assignment of medical support” means applicants and recipients shall assist in securing medical support payments and third party payments. Cooperation also includes assisting in establishing paternity and establishing or modifying child support orders to the extent that it is necessary to secure medical support and third party payments.

Cooperation in assignment or enforcement of child support is not an eligibility requirement for any category of medicaid. Failure to cooperate in the assignment or enforcement of child support does not cause ineligibility for medicaid.

(4) “Right of recovery” means that any medical bill paid by or to be paid by ODJFS, for which insurance or any other available third party resource exists, becomes an obligation to ODJFS. This includes situations in which a recipient or participant files a suit against another individual, whereby an insurance company becomes the third party to a suit. The money received as a result of the tort action would also be subrogated to ODJFS. Recoupment from a third party resource will be equal to the actual medical payment made by ODJFS on behalf of the assistance group.

(5) “Third party” means any private medical insurer, individual, entity, or public or private medical program that is or may be liable to pay all or part of the cost of injury, disease, or disability on behalf of a medicaid assistance group. Private medical insurers include commercial insurance companies, prepaid medical plans, organizations administering medical insurance plans for professional associations, unions, fraternal groups, employer-employee benefit plans, and any similar organization offering payments for medical care or offering medical care, including self-insured and self-funded medical plans. Other third-party sources include homeowners, owners, tenants, landlords, and tortfeasors in product liability, malpractice, workers’ compensation, and civil assault actions.

(B) The acceptance of medicaid gives a right of recovery to ODJFS against the liability of a third party for the cost of medical services and care arising out of injury, disease, or disability of the recipient or participant.

(C) The application for or acceptance of medicaid constitutes an automatic assignment to ODJFS by the applicant and recipient, and also the rights of any other member of the assistance group for whom the applicant and/or recipient, can legally make an assignment. Medicare benefits are not subject to the automatic assignment provision.

(D) All third parties must make payment for medical care to the maximum extent of their liability before medicaid funds may be used to pay providers for covered services.

(1) For any medical support payments received directly by the assistance group, ODJFS will be reimbursed by the assistance group up to the extent such medical payments would be made by ODJFS.

(2) In the case of a recipient or participant who receives medical services or care through a managed health care organization, ODJFS shall claim the amount the managed health care organization pays for medical services or care rendered to the individual, even if the amount is more than the amount ODJFS pays to the managed health care organization for the individual’s medical services or care.

(3) Any settlement, compromise, judgment, or award that excludes the cost of medical services or care shall not preclude ODJFS from enforcing their rights.

(E) Exception to cooperation in assignment of medical support requirement

(1) A pregnant woman, including a woman who is in the sixty-day post partum period, who is eligible for any category of medicaid is not required to cooperate in establishing paternity and in obtaining medical support for herself, as well as for any other person for whom she can legally assign rights.

(2) Any individual receiving transitional medicaid benefits is not required to cooperate in establishing paternity and/or in obtaining or pursuing medical support.

(F) Cooperation and assignment requirements

(1) The assignment of third party and medical support payments and the requirement for cooperation applies to all members of an assistance group. The assignment is effective as of the assistance group’s health care effective date, or June 1, 1982, whichever is later.

(2) Medicare benefits are not subject to the automatic assignment provision.

(3) A caretaker relative who is a medicaid recipient and who fails to cooperate in the assignment of medical support for an individual who is a member of the caretaker relative’s medicaid assistance group, shall be ineligible for any category of medicaid, unless the caretaker relative had good cause as set forth in paragraph (D) of rule 5101:1-29-96.2 of the Administrative Code.

(a) The caretaker relative remains ineligible for medicaid until such time as he or she does cooperate in the assignment of medical support as determined by the CSEA.

(b) There is no minimum ineligibility period for the ineligible caretaker. The ineligible caretaker must be permitted to cooperate and regain eligibility immediately

(G) Good cause

(1) Prior to requiring cooperation, the CDJFS must notify the assistance group in writing of the right to claim good cause. This must be accomplished via the same procedure and form required for Title IV-D (IV-D) purposes.

(2) The CSEA shall determine whether good cause exists according to the same guidelines utilized for IV-D good cause determinations

(3) The assistance group must be notified of the CSEA determination on the good cause claim via the same procedure and form required for IV-D purposes.

(4) If the CSEA finds that good cause does exist, the good cause finding must be periodically reviewed for cases in which the finding was based on circumstances that are subject to change.

(5) Even though the CSEA determines the assistance group is not required to cooperate in securing medical support, the assistance group’s right to collect and retain medical support is still automatically assigned to ODJFS as outlined in paragraph (C) of this rule.

(6) When the CSEA determines that good cause for refusing to cooperate does not exist, or the assistance group requests that the good cause claim be denied or withdrawn, the assistance group is required to cooperate as a condition of eligibility for medicaid as outlined in this rule.

(H) Restoration of future third party and medical support rights

When an assistance group’s medicaid and/or covered families and children medicaid assistance is terminated, the automatic assignment provision ends. The assistance group’s rights to any further third party and medical support payments are automatically restored. However, the assignment remains in effect for the time period during which the assistance group was receiving medicaid.

(I) Role of ODJFS and the CDJFS regarding third party resources

(1) ODJFS collects information regarding third party resources and uses the data in the medicaid claims payment system to reduce medicaid expenditures as appropriate.

(a) ODJFS reviews invoices submitted by the appropriate providers for possible third party involvement by comparing them with data contained in the third party resources file. When an invoice is received and third party coverage appears to exist, ODJFS does one of the following:

(i) ODJFS denies payment of the invoice until the provider determines that the third party is not liable.

(ii) ODJFS pays the balance remaining on the invoice if appropriate, in accordance with the department’s fee schedule, after the amount of the third party liability has been deducted by the designated provider.

(iii) ODJFS pays the invoice in the full amount allowed according to the department’s fee schedule and then seeks reimbursement from the third party to the limit of its legal liability. This post-payment recovery procedure is also used if ODJFS learns of the existence of a liable third party after the claim has been paid.

(b) ODJFS screens invoices submitted by providers for diagnosis codes which indicate that an accident or injury has occurred.

(d) The ODJFS cost avoidance unit corresponds directly with appropriate individuals/agencies when it is necessary to obtain additional information. The assistance of the CDJFS is requested if the individual does not respond to ODJFS inquiries.

(2) The CDJFS provides ODJFS with third party information which is used to reduce medical expenditures.

(a) The CDJFS must complete the JFS 06612 “Health Insurance Information Form” and/or the JFS 06613 “Accident/injury Insurance Form” for each assistance group applying for or receiving medicaid at the time of application when any of the following circumstances exist:

(i) The assistance group indicates which member(s) of the assistance group has health, medical, or accident insurance or some other third party medical coverage (JFS 06612). A separate JFS 06612 must be completed for each insurance policy when multiple insurance is available.

(ii) A court has ordered a third party, including an absent parent, to pay medical expenses on behalf of an assistance group member (JFS 06613).

(iii) An assistance group member is injured in an automobile or other type of accident which may result in medicaid expenditures (JFS 06613). A separate JFS 06613 must be completed for each accident/injury situation.

(iv) An assistance group member has sustained an employment connected injury, illness, or disability (JFS 06613). a separate JFS 06613 must be completed for each accident/injury situation.

(v) There is any other condition or resource that indicates potential third party coverage (JFS 06612).

(b) During the reapplication process or at anytime a change in health insurance information is reported, the health insurance information shall be compared to information contained on the most recently completed JFS 06612 or JFS 06613 and CRIS-E screen AEFMC.

An JFS 06612 or JFS 06613 must be completed any time the information recorded on the latest JFS 06612 or JFS 06613 no longer reflects the current situation. Indicators of possible changes in third party coverage include, but are not limited to:

(i) An individual previously unemployed is now employed and may be covered by group health insurance.

(ii) A domestic relations action has occurred such as a legal separation, award of custody, or a divorce has been finalized and the court has ordered payment of medical expenses.

(iii) An accident or injury has occurred.

(iv) An assistance group has purchased health insurance or someone has purchased health insurance on the assistance group’s behalf.

(v) An assistance group’s health insurance coverage is terminated.

(c) CDJFS assistance will be requested when the assistance group fails to respond to inquiries initiated by ODJFS by the cost avoidance unit. The CDJFS will notify the cost avoidance unit when attempts to contact the assistance group or obtain the requested information are unsuccessful. If the assistance group refuses to cooperate, the appropriate CDJFS activity as delineated in this rule will be taken.

HISTORY: Eff 9-30-76; 9-1-82; 4-1-89 (Emer.); 5-28-89; 6-18-89; 7-1-92 (Emer.); 9-21-92; 1-1-93; 9-1-93; 3-1-95; 10-30-95; 7-1-98; 1-1-03

Rule promulgated under: RC 119.03

Rule authorized by: RC 5111.01, 5111.011, 5101.58

Rule amplifies: RC 5111.01, 5111.011, 5101.58

Replaces: 5101:1-1-20, 5101:1-39-56.1

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

5101:1-38-02.3 Medicaid: citizenship.

(A) An individual must be a citizen of the United States, a qualified alien, or meet requirements as set forth in paragraph (C) of this rule to be eligible for medicaid and covered families and children (CFC) medicaid.

(B) Definitions.

(1) “Active Duty.” In order for an individual with veteran status to meet the “active duty” requirements set forth in this rule, the minimum requirement is twenty-four months or the period for which the person was called to active duty.

(2) “Asylee” means a person who seeks asylum and is already present in the United States when he or she requests permission to stay.

(3) “Federal means-tested public benefit” is a benefit in which eligibility for the benefit or the amount of the benefit, or both, is determined on the basis of income or resources of the assistance group seeking the benefit. Federal means-tests public benefits include medicaid and CFC medicaid.

(4) “Illegal alien” (or “undocumented immigrant”) is defined as someone who enters or lives in the United States without official authorization, either by entering without inspection by the immigration and naturalization service (INS), overstaying his visa, or violating the terms of his visa.

(5) “Immigrant” is a general term for new arrivals. This term includes legal immigrants, refugees, asylees, parolees, and other legal immigrants.

(6) “Lawful permanent resident (LPR)” is an alien who lives in the United States permanently and qualifies as a refugee, asylee, or immigrant, or who has been granted amnesty.

(7) “Nonimmigrant” is an alien who is allowed to enter the United States for a specific purpose and for a limited period of time (e.g., tourist, student, business visitor).

(8) “Non-qualified alien” is an alien who is not a qualified alien as defined in this rule.

(9) “Parolee.” The justice department has discretionary authority to permit certain persons or groups to enter the United States in an emergency or because it serves an overriding public interest. These entrants are granted temporary residence, are ineligible for special federal benefits and are not on a predetermined path to permanent resident status.

(10) “Permanently residing under color of law (PRUCOL)” status means that an alien is considered to be legally residing in the United States for an indefinite period of time. PRUCOL is not a method for entering the country, but indicates that an individual is legally present under statutory authority and may remain under administrative discretion.

(11) “Qualified alien” is an alien who at the time he/she applies for, receives, or attempts to receive, medicaid and CFC medicaid:

(a) Lawfully admitted for permanent residence under the Immigration and Nationality Act (INA); or

(b) Granted asylum under section 208 of the INA; or

(d) Paroled into the United States under section 212(d)(5) of the INA for a period of at least one year; or

(e) An alien whose deportation is being withheld under section 243(h) or 241(b)(3) of the INA; or

(f) Granted conditional entry pursuant to section 203(a)(7) of the INA as in effect prior to April 1, 1980; or

(g) A Cuban or Haitian entrant as defined in section 501(e) of the Refugee Education Assistance Act of 1980; or

(h) An Amerasian immigrant; or

(i) An alien or alien’s child who has been battered or subjected to extreme cruelty, or an alien child of a battered parent. This shall not apply to an alien during any period in which the individual responsible for such battery or cruelty resides in the same household or assistance group as the individual subjected to such battery or cruelty. When the CDJFS evaluates whether an individual meets the definition of a “qualified alien” as the result of an assertion of battery or cruelty, the following criteria shall be used in that determination:

(i) An alien who has been battered or subjected to extreme cruelty in the United States by a spouse or a parent, or by a member of the spouse or parent’s family residing in the same household as the alien and the spouse or parent consented to, or acquiesced in, such battery or cruelty, but only if (in the opinion of the CDJFS) there is a substantial connection between such battery or cruelty and the need for the benefits to be provided and has been approved or has a petition pending which sets forth a prima facie case for one of the following:

(a) Status as a spouse or a child of a United States citizen pursuant to clause (ii), (iii), or (iv) of section 204(a)(1)(a) of the INA.

(b) Classification pursuant to clause (ii) or (iii) of section 204(a)(1)(b) of the INA.

(d) Status as a spouse or child of a United States citizen pursuant to clause (i) of section 204(a)(1)(a) of the INA, or classification pursuant to clause (i) of section 204(a)(1)(b) of the INA.

(ii) An alien whose child has been battered or subjected to extreme cruelty in the United States by a spouse or a parent of the alien (without the active participation of the alien in the battery or cruelty), or by a member of the spouse or parent’s family residing in the same household as the alien and the spouse or parent consented or acquiesced to such battery or cruelty, and the alien did not actively participate in such battery or cruelty, but only (in the opinion of the CDJFS) there is a substantial connection between such battery or cruelty and the need for the benefits to be provided and who meets the requirement of paragraph (B)(11)(i)(i)(b) of this rule.

(iii) An alien child who:

(a) Resides in the same household as a parent who has been battered or subjected to extreme cruelty in the United States by that parent’s spouse or by a member of the spouse’s family residing in the same household as the parent and the spouse consented or acquiesced to such battery or cruelty, but only if (in the opinion of the CDJFS) there is a substantial connection between such battery or cruelty and the need for the benefits to be provided; and

(b) Meets the requirements of paragraph (B)(11)(i)(i) of this rule.

(12) “Qualifying quarters.” In determining the number of qualifying quarters of coverage under Title II of the Social Security Act an alien shall be credited as follows:

(a) All of the qualifying quarters of coverage worked by a natural or adoptive parent can be credited if the quarters were worked before the date the alien attains age eighteen; and

(b) All of the qualifying quarters worked by a spouse of such alien during their marriage and the alien remains married to such spouse or such spouse is deceased.

(c) A qualifying quarter does not include any quarter, after December 31, 1996 in which the individual worked and also received a federal means-tested public benefit.

(13) “Refugee” is a person who flees his or her country due to persecution or a well-founded fear of persecution because of race, religion, nationality, political opinion, or membership in a social group.

(14) “United States citizen.” Individuals are United States citizens if they were born in the United States or were naturalized as a citizen. For purposes of qualifying as a United States citizen, the United States is defined as including the fifty states. District of Columbia, Puerto Rico, Guam, Virgin Islands, and nationals from American Samoa or Swain’s Island.

(15) “Victims of severe forms of trafficking.” Severe forms of trafficking in persons means:

(a) Sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained eighteen years of age; or,

(b) The recruitment, harboring, transportation, provision, or obtaining of a person for labor or service, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.

(16) “Indefinite detainee or lifer.” A non-citizen who has served time for a criminal conviction and has received a final order of removal by INS, but remains indefinitely in the United States because neither his/her home country nor any other country will accept him/her.

(C) An alien who is lawfully residing in the United States as of August 22, 1996, shall continue to meet the citizenship requirements for medicaid and CFC medicaid. The alien:

(1) Does not have to meet the definition of a qualified alien; or

(2) Did not have to be receiving assistance prior to August 22, 1996; or

(3) May have entered the United States more than five years ago.

(D) Five-year period of ineligibility for benefits for qualified aliens.

(1) An alien who is a qualified alien and enters the United States on or after August 22, 1996 does not meet the citizenship requirement for, medicaid and CFC medicaid for a period of five years beginning on the date of the alien’s entry into the United States with a status within the meaning of the term “qualified alien.”

(2) The following additional criteria apply in the determination of the beginning of the five-year period:

(a) For Cuban and Haitian entrants as defined in paragraph (B)(11)(g) of this rule, the five years is computed from the date status as a Cuban-Haitian entrant is granted;

(b) For Amerasians as defined in paragraph (B)(11)(h) of this rule, the five years is computed from the date admitted to the United States as an Amerasian immigrant.

(3) Exceptions to the period of ineligibility for benefits set forth in paragraph (D) of this rule are:

(a) Qualified aliens as defined in paragraphs (B)(11)(b), (B)(11)(c),(B)(11)(e), (B)(11)(g), and (B)(11)(h) of this rule have potential eligibility for medicaid and CFC medicaid for seven years from date of entry into the United States as defined in paragraph (D)(1) and (D)(2) of this rule.

(b) Victims of severe forms of trafficking are potentially eligible for benefits and services to the same extent as an alien admitted to the United States as a refugee under Section 207 of the INA in accordance with rule 5101:1-38-0.24 of the Administrative Code; or

(c) Indefinite detainees or lifers after being convicted of a crime that triggers a final order of removal, may have a status that makes them potentially eligible for medicaid.

(d) Aliens who are lawfully admitted to the United States for permanent residence under the INA and have worked forty qualifying quarters of coverage under Title II of the Social Security Act or can be credited with such qualifying quarters, and in the case of any such qualifying quarters creditable for any period beginning after December 31, 1996, did not receive any federal means-tested public benefit, during any such quarter; or

(e) Veterans and active duty service personnel who are lawfully residing in Ohio and are:

(i) A veteran with a discharge characterized as an honorable discharge and not on account of alienage; or

(ii) On active duty (other than active duty for training) in the armed forces of the United States; or

(f) A spouse or unmarried dependent child of an individual identified in paragraph (D)(3)(d)(i) or paragraph (D)(3)(d)(ii) of this rule; or

(g) The surviving spouse of a deceased veteran or individual on active duty, provided the spouse has not remarried and the marriage fulfills the requirements of section 1304 of Title 38, United States Code:

(i) Married for at least one year; or

(ii) Married before the end of a fifteen-year time span following the end of the period of military service in which the injury or disease was incurred or aggravated; or

(iii) Married for any period if a child was born of the marriage or was born before the marriage.

(h) Military personnel who die during active duty service, as defined in sections 1101 and 1301 of Title 38, United States Code; and Filipinos described in section 107 of Title 38, United States Code. These are individuals who served in the Philippine Commonwealth army during World War II or as Philippine scouts following the war.

(i) With respect to eligibility for medicaid, paragraph (D) of this rule shall not apply to any individual:

(i) Who is an American Indian born in Canada to whom the provisions of section 289 of the Immigration and Nationality Act (8 U.S.C. 1359) apply; or

(ii) Who is a member of an Indian tribe, as defined in section 4(E) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450B[E]).

(4) An individual who is subject to the five-year period of ineligibility delineated in paragraph (D)(1) of this rule and has now been in the United States longer than the period of ineligibility, must either have become a citizen or meet one or more of the criteria set forth in paragraph (D)(3)(c), (D)(3)(d), (D)(3)(e) or (D)(3)(f) of this rule in order to meet the citizenship requirements for the public assistance programs set forth in this rule.

(5) An individual who has potential eligibility for benefits in accordance with paragraph (D)(3)(a) of this rule and has now been in the United States longer than the designated period of potential eligibility as set forth in paragraph (D)(3)(a) of this rule, must either have become a citizen or meet one or more of the criteria set forth in paragraph (D)(3)(c), (D)(3)(d), (D)(3)(e) or (D)(3)(f) of this rule in order to meet the citizenship requirements for the public assistance programs set forth in this rule.

(E) Individuals who are not considered qualified aliens and individuals who are qualified aliens ineligible for benefits in accordance with paragraph (D) of this rule, have potential eligibility for alien emergency medical assistance (AEMA).

HISTORY: Eff 4-1-03 (Emer.); 9-20-03

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.01

Rule amplifies: RC 5111.01

R.C. 119.032 review dates: 09/01/2008

5101:1-38-02.4 Medicaid: benefit eligibility - victims of trafficking.

(A) The Trafficking Victims Protection Act of 2000, Pub.L. No. 106-386, Division A. 114 Stat. 1464 (2000) makes victims of severe forms of trafficking eligible for benefits and services to the same extent as an alien who is admitted to the United States as a refugee under Section 207 of the Immigration and Nationality Act (INA).

(1) Adult victims of severe forms of trafficking must be certified by the U.S. department of health and human services (HHS).

(2) Individuals under age eighteen who are victims of severe forms of trafficking do not need to be certified.

(B) Definition

Under Section 103(8) of the Trafficking Victims Protection Act of 2000, the term “severe forms of trafficking in persons” means:

(1) Sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained eighteen years of age; or.

(2) The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.

HHS’ office of refugee resettlement (ORR) will make certification determinations and issue letters of certification for adult victims of severe forms of trafficking. Children under eighteen years of age who are determined to have been subjected to a severe form of trafficking do not need to be certified in order to receive benefits. ORR will issue notarized letters, similar to adult certification letters, stating that a child is a victim of a severe form of trafficking. Only the ORR certification letter or letter for children may be accepted as proof of certification under this rule.

(1) Certification letters for adults and eligibility letters for children will not contain expiration dates.

(2) Expired letters are being reissued by the ORR with a lowercase “r” beside the HHS tracking number confirming that the individual continues to meet certification requirements.

(D) County agency procedure

The county agency shall:

(1) Accept the original certification letter or letter for children in place of the immigration and naturalization service (INS) documentation and retain a copy in the case file. Victims of severe forms of trafficking are not required to provide any other immigration documents to receive benefits.

(2) Call the trafficking verification telephone line to confirm the validity of the certification letter before providing benefits. During the verification telephone call, the agency must notify the ORR of the benefits for which the victim of trafficking has applied.

Note: The INS systematic alien verification for entitlements (SAVE) program does not contain information about victims of severe forms of trafficking. The county agency shall not contact the SAVE program to confirm eligibility for benefits.

(3) Confirm identity. Benefits shall not be automatically denied if the individual is unable to provide verification of identity. The county agency must call the trafficking verification telephone number for assistance.

(4) Assist in obtaining a social security number. The county agency shall not delay, deny, or discontinue assistance to any eligible applicant because he or she does not have a social security number. If an individual is required to provide or apply for a social security number for another benefit program; or the victim of severe forms of trafficking does not yet have or is unable to obtain a social security number for work purposes, assistance must be given to these individuals in obtaining non-work social security numbers as follows.

The individual must present a letter to the social security administration (SSA) from the county agency that:

(a) Is on county agency letterhead;

(b) Includes the applicant’s name:

(d) States that the applicant meets the requirements to receive the benefit except for the social security number.

The letter cannot be a generic application, form letter or photo copy.

(5) Note: the “entry date” for refugee benefits purposes. Once the certification letter or letter for children is received and the validity of the document is verified by calling the trafficking verification line, the county agency shall note the individual’s “entry date” for refugee benefit purposes. The entry date is the date of certification. The certification date appears in the body of the certification letter or letter for children.

(6) Determine eligibility or redetermine eligibility in accordance with the appropriate program rules. If an individual presents an expired certification letter when applying for benefits or when a redetermination is being completed and the county agency finds that a certification letter has expired, the agency shall call the ORR trafficking verification line at (202) 401-5510 for assistance.

(7) Issue benefits. If the applicant meets other program eligibility criteria (e.g., income levels), the individual shall receive benefits and services to the same extent as a refugee.

(E) Individuals without certification from ORR

If a county agency encounters an individual or a child that is believed to meet the definition a victim of a severe form of trafficking, but the individual has no certification the county agency shall contact the appropriate contact person at ORR.

If the county agency encounters a child believed to have been subjected to a severe form of trafficking and lacks a letter for children, the county agency shall contact the appropriate contact person at ORR.

HISTORY: Eff 4-1-03 (Emer.); 9-20-03

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.01

Rule amplifies: RC 5111.01

R.C. 119.032 review dates: 09/01/2008

5101:1-38-02.5 Medicaid: benefit eligibility-indefinite detainees/lifers.

Indefinite detainees or lifers are non-citizens who, after having served time for a criminal conviction and being given a final order of removal by the immigration and naturalization service (INS), remain indefinitely in the United States (U.S.) because their home country and no other country will accept them. The U.S. supreme court issued a decision on June 28, 2001, that the law limits an alien’s detention to a period reasonably necessary to bring about the alien’s removal from the U.S., and does not permit indefinite detention.

(A) Some aliens with final orders of removal may have come to the U.S. as refugees or may have a status that makes them eligible for refugee medical assistance (RMA) benefits. These individuals most likely will not have documentation of their original status.

(B) The INS systematic alien verification for entitlements (SAVE) program will not be able to provide the needed eligibility information through primary verifications. Secondary verification may provide some verification but may not have needed information and will not arrive in a timely manner.

(C) When determining status of an applicant who receives a final order of removal, but who has been released from detention because he/she cannot be removed to his/her home country or any other country, an applicant should present:

(1) An order of supervision (INS I-220 B). The order of supervision should include the individual’s alien registration number and notation concerning exclusion deportation or removal.

(2) The individual may also have an employment authorized document (INS form I-688B) showing � 274a. 12(c)(18) as the provision of law.

(D) The county department of job and family services (CDJFS) shall:

(1) Collect the following available information from the applicant:

(a) Name:

(b) Alien registration number (“A number”):

(d) Social security number:

(e) Home country:

(f) Number on the I-94:

(g) Parents’ name:

(h) Copies of any immigration documents.

(2) Call the office of refugee resettlement (ORR) contact person to inform him/her about the need for an eligibility determination for an indefinite detainee.

(3) Send a fax with the collected information from the applicant and contact information for the eligibility determiner handling the case at the CDJFS, to the ORR at (202) 401-0981 or (202) 401-5487. The ORR will work with the INS to determine applicant’s original status; entry date and eligibility.

(4) After information has been received by the CDJFS, the ORR contact person may contact the CDJFS for additional information. The ORR will notify the CDJFS of applicant’s status, entry date and eligibility by fax.

(5) Based upon the information received from ORR, the CDJFS shall determine eligibility of the indefinite detainee or lifer for RMA benefits in accordance with rule 5101:1-2-40.1 of the Administrative Code.

HISTORY: Eff 4-1-03 (Emer.); 9-20-03

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.01

Rule amplifies: RC 5111.01

R.C. 119.032 review dates: 09/01/2008

5101:1-38-02.6 Medicaid: medicaid extension for elderly or disabled refugees.

(A) The purpose of this rule is to temporarily extend medicaid beyond the seven-year limit, as described in rule 5101:1-38-02.3 of the Administrative Code, for certain aliens.

(B) Definitions.

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

(2) “Alien awaiting naturalization” means an alien who meets the criteria in paragraph (B)(3) of this rule, whose application for naturalization is pending or who has been approved for naturalization but not yet sworn in as a United States citizen.

(3) “Alien qualified for extension” means an alien who is:

(a) A refugee who is admitted to the United States under section 207 of the Immigration and Nationality Act (INA) (as of October 1, 2008); or

(b) Granted asylum under section 208 of the INA (as of October 1, 2008); or

(c) An alien whose deportation is being withheld under section 243(h) or 241(b)(3) of the INA (as of October 1, 2008); or

(d) A Cuban or Haitian entrant as defined in section 501(e) of the Refugee Education Assistance Act of 1980; or

(e) An Amerasian immigrant pursuant to section 584 of the Foreign Operations, Export Financing, and Related Programs Appropriations Act of 1988.

(f) A victim of trafficking.

(i) Victims of a severe form of trafficking as identified in 22 U.S.C. 7105(b)(1) (as of October 1, 2008) and certain family members, as identified in the Trafficking Victims Protection Reauthorization Act of 2003 (TVPRA) (Pub. L. No. 108-193), are eligible for federally funded or administered benefits to the same extent as refugees.

(ii) Victims of a severe form of trafficking are awarded a certification letter from the office of refugee resettlement (ORR) and are potentially eligible for medicaid. Certain family members are awarded “Derivative T” visas and are potentially eligible for medicaid.

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

(5) “Lawful permanent resident” (LPR) means any individual who has been lawfully residing permanently in the United States as an immigrant in accordance with the immigration laws, such status not having changed.

(C) Eligibility criteria. In order to be potentially eligible for the extension of medicaid benefits, an individual shall:

(1) Meet all other medicaid eligibility criteria, and

(2) Be either an alien qualified for extension or an alien awaiting naturalization, and

(3) Be either in receipt of SSI benefits, or formerly in receipt of SSI benefits which ended between August 22, 1996 and September 30, 2008 solely by reason of the termination of the seven-year period of eligibility for SSI and which have subsequently been restarted, and

(4) Apply during the eligibility period, as described in paragraph (D) of this rule, and

(5) Meet one of the following criteria:

(a) Be younger than eighteen years of age; or

(b) Be seventy years of age or older; or

(d) Have filed within four years from the SSI start date an application to become an LPR; or

(e) Have been granted status as a Cuban or Haitian entrant; or

(f) Have had deportation or removal withheld.

(D) Eligibility period. The eligibility period begins October 1, 2008 and ends September 30, 2011.

(1) During the eligibility period, an alien qualified for extension may have up to two years of potential medicaid eligibility.

(2) For the duration of the eligibility period, aliens awaiting naturalization are not subject to a time limitation on medicaid eligibility, potentially allowing a three-year period of medicaid eligibility.

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

(1) Determine eligibility in accordance with Chapters 5101:1-37 to 5101:1-42 of the Administrative Code.

(2) During the eligibility period described in paragraph (D) of this rule, determine the eligibility of the individual as if the individual were still within the seven-year period.

(3) Issue hearing rights and notices as described in division 5101:6 of the Administrative Code.

(F) Individual responsibilities. The individual:

(1) Shall cooperate in establishing eligibility and provide verification in accordance with Chapter 5101:1-38 of the Administrative Code.

(2) Whose medicaid was terminated due to the expiration of the seven-year limit, and whose SSI is reinstated, shall apply for medicaid.

Replaces: 5101:1-38-02.6 (Emer.)

Effective: 04/01/2009

R.C. 119.032 review dates: 04/01/2014

Promulgated Under: 111.15

Statutory Authority: 5111.01, 5111.011

Rule Amplifies: 5111.01, 5111.011

Prior Effective Dates: 01/05/09 (Emer.)

5101:1-38-03 Medicaid: buy-in.

(A) Buy-in is an agreement between the Ohio department of job and family services (ODJFS) and the social security administration which enables ODJFS to pay the part B (supplemental medical insurance) premium for certain medicaid eligible individuals. Payment of the part A premium (hospital insurance) is limited to individuals who are eligible for qualified medicare beneficiary medicaid (QMB) or as a qualified working disabled individual (QWDI).

(B) In order to be eligible for buy-in, an individual must first be eligible to enroll in medicare part B. The following people are eligible for part B:

(1) Individuals age sixty-five or over who have, or are entitled to, medicare part A (hospital insurance).

(2) Individuals under age sixty-five who are eligible for medicare part A because they have been entitled to monthly social security disability benefits under Title II or railroad disability benefits for more than twenty-four months.

(3) Individuals who are eligible for medicare part A because they have chronic renal disease.

(C) Individuals eligible for medicaid as ongoing or delayed spenddown recipients are not eligible for buy-in as a categorically needy individual. However, spenddown recipients who become regular medicaid recipients will be automatically added to the buy-in by ODJFS. Regular medicaid recipients who become spenddown recipients will be automatically deleted from buy-in coverage by ODJFS unless they remain eligible for buy-in as a QMB, SLMB, or QI-1.

(D) The following individuals are eligible for buy-in of the part B premium:

(1) Medicaid recipients who reside in a Title XIX certified nursing facility (NF) or intermediate care facility for the mentally retarded (ICF-MR).

(2) Medicaid recipients in receipt of a home and community-based services (HCBS) waiver.

(3) Medicaid recipients enrolled in PACE are eligible to have for the buy-in.

(4) Individuals who are eligible for assistance as a specified low-income medicare beneficiary (SLMB) as defined in rule 5101:1-39-01.1 of the Administrative Code

(5) Individuals who are eligible as a qualified individual-1 (QI-1) as defined in rule 5101:1-39-01.1 of the Administrative Code are entitled to have their medicare part B premium paid through the buy-in program.

(E) Individuals who are eligible for assistance as a qualified medicare beneficiary (QMB) as defined in rule 5101:1-39-01.1 of the Administrative Code are entitled to have their monthly premiums for medicare part A and part B paid through the buy-in program.

(F) Individuals who are eligible for assistance as a QWDI as defined in rule 5101:1-39-01.2 of the Administrative Code are entitled to have their monthly medicare part A premium paid through the buy-in program.

(G) Beginning date of buy-in coverage

(1) Medicaid eligible individuals in receipt of cash assistance through Ohio works first (OWF) or supplemental security income (SSI) are eligible for buy-in effective the month they are eligible for medicare and cash assistance.

(2) For individuals eligible through the QMB program, the beginning date of buy-in is the month following the month eligibility for QMB was authorized.

(3) For individuals eligible through the SLMB program, the beginning date of buy-in is the month of application and up to three months prior to the month of application, if eligibility exists in the retroactive period.

(4) For individuals eligible through the QI-1 program, the beginning date of eligibility is the month of application and up to three months prior to the month of application, if eligibility exists in the retroactive period.

(5) For medicaid eligible individuals who are not in receipt of OWF or SSI payments, the beginning date of buy-in is the first day of the second month after the month in which eligibility for medicaid was determined to exist.

(H) Buy-in coverage ends with the earliest of the events specified below:

(1) Death. Coverage ends on the last day of the month in which the individual dies.

(2) Loss of entitlement to part B benefits. If an individual is under age sixty-five and loses entitlement to part B, buy-in coverage ends on the last day of the last month for which the individual is entitled to part B benefits.

(3) Loss of eligibility in a covered group. If an individual loses eligibility for inclusion in the state’s covered group, buy-in coverage ends on either:

(a) The last day of the last month for which the individual is eligible for inclusion in the covered group, or,

(b) On the last day of the second month before the month in which the centers of medicare and medicaid (CMS) receives a deletion notice which was not submitted within a reasonable time. A reasonable time is no later then the twenty-fifth day of the second month after the month in which the individual is no longer eligible for buy-in under a covered group.

(I) An individual’s part B coverage under buy-in can be terminated retroactively for as many as two months before the state’s notice to CMS that the individual is no longer eligible.

(1) After receipt of the notice by CMS from the state, a notice is sent by CMS to the individual telling him that he is responsible for paying his own part B premiums beginning with the month following the last month of buy-in coverage. Because of administrative delays, an individual can already be in the third month after buy-in termination and owe three months of part B premiums before he is notified that his buy-in coverage has been terminated.

(2) Equitable relief can be granted by CMS to allow an individual’s part B coverage to end effective with the termination of buy-in coverage (thus allowing him to avoid entirely any premium liability) if all of the following conditions are met:

(a) The individual submits a written request to CMS to have his individual part B coverage end effective with the end of buy-in coverage.

(b) Such request is filed within thirty days of the date of the notice from CMS notifying the individual of his buy-in termination.

(c) The individual certifies that he has incurred no medical services covered under part B during the months after buy-in termination.

HISTORY: Eff 8-15-82; 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: 5101:1-39-63, 5101:1-39-64

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

5101:1-38-04 Medicaid: outstationing workers at disproportionate share hospitals and federally qualified health centers.

(A) This rule describes the administrative agency’s role in facilitating outreach services for low-income pregnant women and children through the process of outstationing at disproportionate share hospitals and federally qualified health centers.

(B) Definitions

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

(2) “Combined program application” (CPA) is a multiple program application that contains clearly identifiable medicaid-only sections or parts.

(3) An “individual” is:

(a) An applicant or recipient of a medical assistance program; and,

(b) For the purpose of this rule, a pregnant woman or child.

(4) “Initial processing” means taking applications, assisting applicants in completing the application, providing information and referrals, obtaining required documentation needed to complete processing of the application, assuring completeness of the information contained on the application and conducting any necessary interviews. Initial processing does not include evaluating the information on the application and supporting documentation, or making a determination of eligibility.

(5) “Outstationing” is the federal requirement that states provide low-income pregnant women and children opportunities to apply for medicaid, at locations other than the local county department of job and family services.

(1) The outstationed worker must complete the initial processing of the CPA as defined in paragraph (B) of this rule. When authorized by the administrative agency, the outstationed worker may also determine medicaid eligibility.

(2) If the outstationed worker is only performing initial processing duties, the outstationed worker must forward the CPA to the administrative agency in accordance with Chapter 5101:1-38 of the Administrative Code.

(3) The outstationed worker must accept and refer applications for other public assistance programs to the administrative agency for processing.

(4) If the administrative agency determines that an outstation site is infrequently used and does not require a full-time outstationed worker, a notice must be displayed advising the following:

(a) The hours when an outstationed worker will be available; and

(b) The telephone number of the administrative agency that individuals may call for assistance.

(D) Responsibilities of the individual: an individual is required to supply verification in accordance with Chapter 5101:1-38 of the Administrative Code.

Replaces: 5101:1-38-04

Effective: 01/01/2006

R.C. 119.032 review dates: 01/01/2011

Promulgated Under: 111.15

Statutory Authority: 5111.01, 5111.013

Rule Amplifies: 5111.01, 5111.013

Prior Effective Dates: 5/1/1995, 7/1/2000

5101:1-38-05 Medicaid: early and periodic screening, diagnosis and treatment (EPSDT) - "Healthchek".

(A) Healthchek is the Ohio medicaid early and periodic screening, diagnosis and treatment (EPSDT) program. Healthchek’s focus is on helping all children, including children with disabilities, get and stay healthy.

(B) Healthchek principles.

(1) All families and children need a medical home, receiving services whenever possible from a medical provider who has an ongoing relationship with the family and/or child;

(2) Medicaid coverage provides quality medically necessary treatment services in a cost effective way; and

(3) Medicaid covers medical screening services at least annually or more frequently for children under age two.

(1) Healthchek screening services;

(2) Vision services;

(3) Hearing services;

(4) Dental services;

(5) Behavioral health and other rehabilitative services; and

(6) Other services that are medically necessary, including further diagnosis and/or treatment.

(D) Definitions of terms.

(1) “Healthchek” is Ohio’s early and periodic, screening, diagnosis and treatment (EPSDT) program, which is a federally mandated program of comprehensive prevention and treatment services for children under age twenty-one.

(2) “Caretaker” is a person with whom the healthchek eligible individual resides, or the person responsible for the healthchek eligible individual’s daily care. This includes parent, guardian, custodian, or a children services agency holding legal custody of the healthchek eligible individual. The public children services agency (PCSA) or the private child placement agency (PCPA) shall designate the individual who will participate as the actual caretaker for the healthchek individual.

(3) “Diagnosis and treatment” is the use of medical care, procedures, or services to identify, prevent, correct, or ameliorate abnormalities or diseases detected by the screening services.

(4) “Healthchek eligible consumer” is a medicaid eligible individual from birth through the age of twenty years.

(5) The healthchek and pregnancy services assessment form (JFS 03528, effective 6/2003) is used by the county department of job and family services (CDJFS) during the process of informing parents or other caretakers about healthchek or informing pregnant women about pregnancy related services. The healthchek eligible consumer or caretaker signs the form to verify that informing was completed. Pregnant women who are informed about pregnancy related services also sign and indicate what services are requested.

(6) “Informing” is the process of presenting face-to-face or written information describing the healthchek program’s services and benefits to the healthchek eligible consumer or caretaker.

(7) “Medically necessary services” are services which are necessary for the diagnosis or treatment of disease, illness, or injury and without which the customer can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. A medically necessary service must meet acceptable standards of medical practice, be appropriate to the illness or injury for which it is performed as to type of service and expected outcome, be appropriate to the intensity of service and level of setting, and the medically necessary service provided must be the lowest cost alternative that effectively addresses and treats the medical problem.

(8) “Necessary assistance” is the need for support services such as transportation, scheduling appointments, and names of providers to enable a consumer to participate in the healthchek program.

(9) “Screening service” is a general health assessment comprised of individual screening components that evaluate a child’s health. Based on the findings of the screening service, the screening provider may render further diagnosis and/or treatment services or make referrals for further diagnosis and/or treatment.

(10) “Tracking” is a record keeping system which includes timely identification of healthchek eligible consumers based on healthchek services received and/or needed to enable participation in the program and documentation of all required follow-up contacts with healthchek eligible consumers.

(11) “Healthchek coordinator” is the staff person or primary liaison within a unit in the CDJFS who is responsible for the implementation of the EPSDT/healthchek program.

(12) “Consumer participation in the healthchek program” is when a consumer receives screening, diagnosis, and/or treatment services.

(13) “Managed care plan” or “MCP” is a health insuring corporation (formerly HMO) licensed in the state of Ohio as well as alternative licensing arrangements for managed care entities.

(E) Informing the consumer.

(1) The CDJFS shall inform all new and ongoing healthchek eligible consumers or their caretakers of the healthchek program services and benefits using a combination of oral and written methods as often as the CDJFS determines, but at a minimum of once a year. The JFS 03528 or a CDJFS version approved by the bureau of consumer and program support (BCPS) must be completed to document the informing activity.

(2) A copy of the healthchek brochure (JFS 08009), effective 9/2003, must be given to the new healthchek eligible consumer and/or caretaker. If the brochure is mailed to the consumer, a cover letter identifying the healthchek coordinator with his/her telephone number and the JFS 03528 must also be included.

(3) The following items must be explained using clear and nontechnical language during the face-to-face interview, telephone contacts, or in the written information provided:

(a) Benefits of preventive health care:

(i) Increases the consumer’s well-being;

(ii) Reduces the risk to the consumer’s health;

(iii) Identifies health problems early and treats them in order to prevent them from becoming more serious; and

(iv) Provides education to the family to allow optimal health.

(b) The components offered as part of the healthchek screening service are:

(i) Comprehensive physical exam;

(ii) Health and developmental histories;

(iii) Nutrition, vision, hearing, developmental, psychological, and dental assessments;

(iv) Lab tests;

(v) Appropriate immunizations; and

(vi) Health education.

(c) The healthchek eligible consumer may request and schedule dental, vision, and hearing services separately from the healthchek screening visit. Medicaid-contracting managed care plan (MCP) enrollees must be advised to work through their MCP to obtain these services.

(d) Diagnosis and medically necessary treatment services will be provided for problems discovered during the healthchek screening service, and assistance in referral will be given for needed medical services not covered by medicaid.

(e) The recommended number of healthchek screening services which a healthchek eligible consumer receiving services from medicaid fee-for-service providers or a medicaid-contracting MCP may receive are: The department will follow the recommendations for preventive pediatric health care developed by the committee on practice and ambulatory medicine of the American academy of pediatrics (AAP). For more information about healthchek screening frequencies and the reimbursement of screening services, refer to rule 5101:3-14-04 of the Administrative Code.

(f) The CDJFS or the medicaid-contracting MCP will provide necessary assistance in obtaining transportation, names of doctors or clinics, and with scheduling appointments for screening, vision, hearing, and dental services if the healthchek eligible consumer or caretaker requests it. MCPs may provide transportation, and enrollees and their caretakers may contact their MCP to verify if this service is available.

(g) The healthchek eligible consumer may receive healthchek services from any participating medicaid provider if the child is in the medicaid fee-for-service delivery system or through the medicaid-contracting MCP in which he/she is enrolled.

(h) If the eligible consumer does not wish to participate in the healthchek program immediately, he/she may request participation any time during his/her medicaid eligibility period.

(i) Healthchek screening, vision, hearing, and dental services are available at no cost to the healthchek eligible consumer or caretaker.

(4) Informing – special circumstances/groups.

(a) Healthchek eligible consumers in the custody of a PCSA or a PCPA and/or their foster parents, shall be informed about healthchek services by the PCSA or PCPA. The CDJFS is responsible for developing interagency procedures to inform PCSAs or PCPAs who have the authority to assume custody of children in the county.

(b) The CDJFS must have/use procedures suitable for informing healthchek eligible consumers or caretakers who are vision or hearing impaired, have difficulty reading, or do not understand the English language.

(c) The CDJFS shall inform at the next redetermination all families or consumers who transfer into the county about paragraphs (E)(1) to (E)(3) of this rule and offer assistance in obtaining healthchek services.

(5) Informing pregnant women.

(a) The CDJFS in coordination with the eligible consumer’s medicaid-contracting MCP, where applicable, shall inform medicaid eligible pregnant women about the availability of the healthchek program for their infants as soon as they are identified as pregnant, whether or not they have been informed previously for their older children.

(b) Healthchek eligible pregnant women who are in the custody of the PCSA or PCPA shall be informed by the PCSA or PCPA staff of the availability of healthchek services for the mother and the child and the availability of pregnancy related services in accordance with rule 5101:1-38-06 of the Administrative Code.

(c) The CDJFS in coordination with the eligible consumer’s MCP, where applicable, shall take steps after the birth to encourage the mother to take advantage of the healthchek program for her infant as soon as the CDJFS becomes aware of the infant’s birth.

(6) Re-informing of assistance groups.

The CDJFS must re-inform healthchek eligible consumers or caretakers about the healthchek program at least annually.

(F) Documentation requirements for the informing process.

Following completion of the informing activity, the CDJFS and the PCSA must obtain a response from the family/consumer as to the services being offered and document the information on the JFS 03528. The following information must be collected to document the response:

(1) Name, social security number (optional), case number, telephone number, if available;

(2) Signature of the eligible consumer or caretaker and date the face-to-face, telephone or written informing was completed;

(3) Most current medicaid eligibility date;

(4) Services requested by the consumer: screening services, vision services, hearing services, dental services, assistance in obtaining names of providers, transportation, or scheduling medical or dental appointments;

(5) Healthchek eligible consumer’s name, birth date, and medicaid billing number;

(6) Whether the children’s immunizations and well-child exams are up-to-date;

(7) The names of the children’s current physician and dentist;

(8) Names of pregnant women in the assistance group, due dates, whether they are currently receiving prenatal care, and the name of the prenatal care provider, if available;

(9) Name or initials of the staff person who did the informing;

(10) Whether the assistance group is in need of other social services;

(11) Whether the individual/family is enrolled in a medicaid-contracting MCP and has been advised to seek services through the MCP;

(12) The method of informing used: face-to-face, telephone, or in writing;

(13) If the CDJFS needs additional medical information from the assistance group, it may be necessary to obtain a signed authorization which is health insurance portability and accountability act of 1996 (HIPAA) compliant, as outlined in rule 5101:1-37-01.1 of the Administrative Code; and

(14) An indication that the assistance group did not request participation in the program.

(G) Record keeping.

(1) The CDJFS shall maintain copies of signed JFS 03528 and any other reports, correspondence, or written information pertinent to the consumer’s participation in the program.

(2) If the assistance group moves to a new county, the CDJFS shall transfer copies of all healthchek records to the new county of residence.

(H) Provision of support services for screening and treatment.

(1) The CDJFS and medicaid-contracting MCPs in cooperation must offer to the healthchek eligible consumer or caretaker the following support services when requested:

(a) Lists with names, addresses, and telephone numbers of providers of screening services, vision services, hearing services, and dental services;

(b) Necessary assistance with scheduling appointments for healthchek services; and

(c) Necessary assistance in obtaining transportation to healthchek services. Transportation services may include, but are not limited to, title XX, enhanced medicaid transportation, and other community transportation programs.

(2) Consumers enrolled in MCPs shall be advised to contact their MCP’s member services for options in obtaining the support services listed in paragraphs (H)(1)(a) to (H)(1)(c) of this rule.

(3) The CDJFS shall coordinate the delivery of support and medical services with other agencies and programs such as maternal and child health clinics, local health departments, women, infants and children (WIC), and head start.

(I) Tracking newborns.

(1) The CDJFS shall assign priority status for tracking to assistance groups with newborns, particularly in cases where the MCPs have identified parents/caretakers who are not keeping appointments for well-child care or are not following other medical recommendations from their providers. At a minimum, tracking of newborns shall include the following:

(a) The identification of newborns and their parent/caretaker or the PCSA using existing records in the CDJFS;

(b) Contacting the parent/caretaker to assist in securing an ongoing primary care provider for the newborn;

(c) Offering and providing assistance with scheduling and transportation to medical appointments as requested by the parent/caretaker; and

(d) Coordination of the activity in paragraphs (I)(1)(a) to (I)(1)(c) of this rule with the assistance group’s MCP, other agencies, and programs where applicable.

(2) Medicaid-contracting MCPs are responsible for follow-up of their enrollees’ missed appointments. However, when the MCP’s attempts to contact the eligible parents are unsuccessful, the MCP should contact the healthchek coordinator or the case manager in the parents’ county of residence for assistance.

(J) Assistance with treatment outside of the medicaid plan.

To assure that treatment not covered by the medicaid plan is provided, the CDJFS is encouraged to provide referral assistance by providing the assistance group or healthchek eligible consumer a list with the names, addresses, and telephone numbers of medical providers who have expressed a willingness to furnish services at little or no cost to low-income families, where available.

(K) Provider recruitment.

(1) The CDJFS is encouraged to take steps to recruit and maintain a network of fee-for-service providers of medical, dental, vision, and hearing services that is adequate to meet the screening and treatment needs of the healthchek consumers. The CDJFS may make use of a variety of methods including personal visits, telephone calls, and letters to recruit providers.

(2) In counties with medicaid-contracting MCPs, the CDJFS is encouraged to maintain current listings of participating MCPs.

(L) Follow-up of children with elevated blood lead levels.

(1) Upon receiving notification of children who are identified as having high lead levels according to the standards set by the centers for disease control and prevention, the CDJFS must refer their names to the Ohio department of health for an environmental assessment.

(2) The CDJFS shall verify medicaid eligibility at the time the environmental assessment is conducted; and inform the Ohio department of health of such eligibility.

(3) The CDJFS must educate assistance groups relative to the following:

(a) The purpose of the environmental assessment;

(b) The responsibility of the assistance group or landlord in removing the source of lead or removing the child from the contaminated environment; and

(c) The responsibility of the assistance group in informing the state health department staff who conduct the environmental assessment of places the child visits regularly.

(4) If, after the environmental assessment, the health department identifies a lead source, and the landlord refuses to remove the lead from the environment, the CDJFS shall make referrals to other agencies that can assist the assistance group to secure lead free housing.

(5) The CDJFS is responsible for maintaining records of environmental assessment recommendations made by the Ohio department of health and any action taken as a result of those recommendations. If as a result of CDJFS efforts the family relocates, the CDJFS must inform the Ohio department of health of the family’s new address.

(6) In geographic areas with Ohio childhood lead poisoning prevention regional resource centers or local arrangements for environmental assessments and follow-up, the requirements of those programs supersede this rule.

(M) Documentation requirements.

The CDJFS shall submit in writing, under signature of the CDJFS director, a description of the process and structure of the management of the local healthcheck program including the contact person and/or coordinator for the program.

The description shall include the following:

(1) Identify where in the CDJFS table of organization the responsibility for the healthchek program is located and name the title of the contact person or coordinator.

(2) A description of the staff/unit responsible for informing the following medicaid eligible individuals or caretakers as defined in paragraph (D)(6) of this rule.

(a) Newly eligible individuals,

(b) Pregnant women,

(d) Hearing, vision, or speech impaired individuals,

(e) Individuals who have difficulty reading, and

(f) Non-English speaking individuals.

(3) In counties with medicaid-contracting managed care plans (MCPs), the information submitted under the CDJFS director’s signature shall include plans for coordination of efforts between the CDJFS and the MCPs. This can include written agreements between the CDJFS and the medicaid-contracting MCPs with provisions for regularly scheduled meetings, as well as other ideas for county and plan coordination.

(4) Description of the process for follow up of children with elevated blood lead levels.

(N) All changes or amendments to the CDJFS’s description of the process and/or structure shall be submitted in writing to ODJFS under the signature of the CDJFS director within ten working days of the change.

(O) The information submitted under the signature of the CDJFS director can be combined or included with the information submitted as per paragraph (K) of rule 5101:1-38-06 of the Administrative Code.

Effective: 10/15/2005

R.C. 119.032 review dates: 07/29/2005 and 10/01/2010

Promulgated Under: 111.15

Statutory Authority: 5111.01

Rule Amplifies: 5111.01, 5111.016

Prior Effective Dates: 12/24/79, 7/1/88, 5/1/92, 5/1/93, 1/1/94, 10/1/98, 5/1/02, 10/6/03

5101:1-38-06 Medicaid: pregnancy related services (PRS).

(A) All medicaid eligible pregnant women are able to receive enhanced pregnancy related services from their medical providers. These services include extensive counseling and education, nutrition counseling, nutrition intervention, and care coordination.

(1) Care coordination services are delivered by the medical provider and are intended to facilitate the pregnant woman’s access to necessary medical, social, educational, nutritional, and other services. Care coordination is also intended to minimize fragmentation of care without limiting the pregnant woman’s freedom of choice of participating medicaid providers. If the pregnant woman is enrolled in a medicaid-contracting managed care plan(MCP), she will access the services through her MCP’s network of providers.

(2) From the date of identification of pregnancy through sixty days after the end of the pregnancy (i.e., date of delivery, date of spontaneous abortion, or date of federally funded induced abortion), the county department of job and family services (CDJFS), in cooperation with the woman’s MCP, when applicable, shall provide support services to complement medical services when the woman makes a request or the CDJFS is made aware of the woman’s need.

(B) Pregnancy related services (PRS) definitions.

(1) “Potentially eligible women” are all medicaid eligible recipients identified as pregnant who do not have medical verification of pregnancy.

(2) “Eligible women” are all medicaid eligible pregnant recipients who have been medically verified as pregnant.

(3) “Date of identification of pregnancy” is the date that the medicaid eligible recipient states verbally or in writing that she is pregnant or is reported to be pregnant, or the date the CDJFS otherwise learns of the pregnancy.

(4) “Medical providers” are physicians, hospitals, clinics, home health agencies, rural health clinics, outpatient health facilities, federally qualified health centers, nurse midwives, and nurse practitioners who are medicaid enrolled service providers or are part of a medicaid-contracting MCP’s provider network.

(5) “Support services” are non-medical services offered or provided by the CDJFS to assist the medicaid eligible recipient and may include arranging or providing transportation, making appointments, accompanying the woman to her appointment with her medical provider, and making referrals to community and other social services. Support services will be coordinated with the pregnant woman’s medicaid-contracting MCP where applicable.

(6) “Pregnancy related services unit/worker” is the staff person or primary liaison within a unit in the CDJFS responsible for the implementation of the pregnancy related services program.

(1) The CDJFS shall take steps to maintain a community network that is adequate to identify, recruit, and refer potentially eligible women for early prenatal care in both fee-for-service and managed care counties.

(2) CDJFS staff must refer as soon as possible all potentially eligible women to the PRS unit/worker.

(3) Referrals must be made through a standardized procedure developed by the CDJFS as described in paragraph (K) of this rule.

(4) The referral procedure shall utilize the healthchek and pregnancy assessment form (JFS 03528, effective 6/2003) whenever available; or, at a minimum, shall include the woman’s name, case number, estimated date of delivery (when known), and the name and telephone number of the PRS worker.

(D) Recruitment to early prenatal care.

(1) The CDJFS shall take steps to ensure that every potentially eligible woman is under a medical provider’s care as soon as possible after her pregnancy has been identified.

(2) A woman enrolled in a medicaid-contracting MCP shall be advised to contact her MCP’s member services for options in obtaining her prenatal care services.

(3) For every potentially eligible and every eligible woman, the following steps are to be taken:

(a) Inform the woman of the importance of early prenatal care. A copy of the “Healthy Start For a Healthy Baby” brochure (JFS 08062, effective 4/2005) or other written material approved by the bureau of consumer and program support (BCPS) must be given to the woman or her parent or caretaker.

(b) The following benefits of early prenatal care shall be explained using clear and non-technical language:

(i) Increasing the mother’s well-being during pregnancy;

(ii) Reducing the risk to the mother’s health;

(iii) Helping prevent complications and minimize discomfort;

(iv) Helping identify danger signals for early labor or miscarriage;

(v) Increasing the likelihood of having a healthy baby;

(vi) Reducing the risk of birth defects; and

(vii) Providing education on how to take care of the baby.

(4) For each eligible woman, the CDJFS should complete the JFS 03528 to identify her own and her children’s needs for services, or the form may be mailed to the woman for completion. In managed care counties, the CDJFS will share the assessment form information with the medicaid-contracting MCP in which the woman chooses to enroll.

(5) If needed, the CDJFS shall provide a list of medicaid prenatal care providers available to the community and/or information about medicaid-contracting MCPs in managed care counties.

(6) The CDJFS shall provide, assist, or offer the following support services:

(a) Transportation or arranging transportation in accordance with paragraph (H) of this rule through the CDJFS or medicaid-contracting MCP, if available;

(b) Making an appointment with a medical provider. If the pregnant woman chooses to enroll or is already enrolled in a medicaid-contracting MCP, she must go to a provider in her MCP;

(d) Making referrals as needed for non-medical services (e.g., women, infants and children (WIC), social services, community services) and (where applicable) coordinating these services with the pregnant woman’s medicaid-contracting MCP;

(e) To ensure the enrollment of an infant born to an eligible woman, all pregnant women shall be informed of the healthchek program in accordance with rule 5101:1-38-05 of the Administrative Code; and

(f) When a woman’s medical provider contacts the CDJFS by telephone or in writing that the woman has a non-medical need (e.g., child care, clothing, etc.), appropriate referrals shall be made and assistance provided with appointments, when necessary.

(g) If the CDJFS needs additional medical information from the assistance group, it may be necessary to obtain a signed authorization which is health insurance portability and accountability act of 1996 (HIPAA) compliant, as outlined in rule 5101:1-37-01.1 of the Administrative Code.

(E) Identification of pregnant women not receiving prenatal care.

(1) The CDJFS shall develop ways to identify potentially eligible and eligible women who are not receiving prenatal care. The system shall be described as per the guidelines in paragraph (K) of this rule and approved by ODJFS/BCPS. In counties with medicaid-contracting MCPs, the guidelines should include plans for coordination of efforts between the CDJFS and the MCPs to identify and monitor which pregnant women are not receiving prenatal care services.

(2) When the CDJFS identifies any potentially eligible women or eligible women who are not receiving prenatal care services, they shall as soon as possible attempt to make contact with them. Contacts shall be made face-to-face, by telephone, or by home visits. As a final step, when efforts to make personal contact have been unsuccessful, written correspondence shall be sent to inform the woman about the importance of prenatal care and to request that she contact the CDJFS or, when applicable, her MCP’s member services for assistance.

(3) Support services listed in paragraph (D)(6) of this rule are also available for the potentially eligible woman’s initial pregnancy related visit.

(F) Care compliance.

(1) When problems have developed in the delivery of care to eligible women, care compliance services can facilitate patient access to the services recommended in order to promote a healthy pregnancy.

(2) The CDJFS can be notified by telephone or by a written report from an eligible woman’s medical provider when the woman has missed appointments or other problems have developed in the delivery of her care.

(3) Medicaid-contracting MCPs are responsible for follow-up of their enrollees’ missed appointments. However, when the MCP’s attempts to contact the eligible woman are unsuccessful, the MCP should contact the PRS coordinator in the woman’s county of residence for assistance. Upon notification that the woman has missed appointments or there were other problems in the delivery of her care, the CDJFS shall establish contact with the woman according to paragraph (E) of this rule. The CDJFS shall inform the woman’s medical provider or her MCP about the outcome of the contact.

(G) Support services documentation and reports.

(1) Documentation shall be maintained in a case file for each potentially eligible and eligible woman. The file shall consist of permanent records, either hard copy or computer stored, containing the following information, when appropriate:

(a) The CDJFS’s copy of the prenatal risk assessment form (JFS 03535, effective 2/2003) or other prenatal risk assessment form, when available from the woman’s medical provider;

(b) Copies of correspondence received and sent;

(d) Documentation of the MCP in which the pregnant woman is enrolled, if applicable;

(e) Information received from another county when the woman is an intercounty transfer;

(f) Documentation of all service requests made by the woman’s medical provider, steps taken by the CDJFS to assure these services are provided, and whether the woman received the services; and

(g) Records of transportation provided.

(2) The CDJFS shall complete quarterly data collection reports in an ODJFS-approved format on the number of support services provided to medicaid eligible pregnant women. The report shall be submitted to ODJFS by the fifteenth day of the month following the end of each quarter.

(H) Transportation.

Transportation shall be provided, as needed, to the initial prenatal medical provider visit for all potentially eligible women. Transportation shall be provided to all eligible women to any medicaid reimbursable service, if needed, from the date of medical verification of pregnancy through the postpartum period, sixty days after the end of the pregnancy. All transportation shall be provided in accordance with the following criteria:

(1) Transportation shall be provided to the medical provider of the woman’s choice when the medical provider is generally available or used by other residents of the community. The CDJFS shall also provide needed transportation to any medical provider when referred by another medical provider.

(2) If the woman is enrolled in a medicaid-contracting MCP that provides transportation for its members, the woman shall be referred to her MCP for transportation arrangements. The transportation services shall be provided by the CDJFS if not available from the MCP.

(3) The CDJFS shall provide transportation at the woman’s request, at the request of the woman’s medical provider, or if the CDJFS staff worker identifies a need.

(I) Infant referrals.

For every infant born to an eligible woman, the following steps shall be taken to assure that the infant is enrolled in the healthchek program, in cooperation with the woman’s medicaid-contracting MCP, if applicable:

(1) A pregnant woman shall first be informed about healthchek when she completes the JFS 03528;

(2) She shall be reinformed as soon as possible after the infant’s birth or during her or the infant’s next reapplication.

(J) Provider recruitment.

(1) The CDJFS shall take steps to recruit and maintain a provider network that is adequate to meet the prenatal care needs of medicaid eligible women. The CDJFS must maintain on file current lists of all participating prenatal providers.

(2) In counties with medicaid-contracting MCPs, the network of participating providers will be contracted through and maintained by the MCP.

(3) It is recognized that the ability of the CDJFS to recruit and maintain an adequate provider network depends on the existence of appropriate providers within a reasonable geographic area.

(K) Documentation requirements.

The CDJFS shall submit in writing, under signature of the CDJFS director, a description of the process and structure of the management of the local PRS program including the name of the contact person and/or coordinator for the program.

The information submitted, shall include the following:

(1) Identify where in the CDJFS table of organization the responsibility for the PRS program is located and the name and title of the contact person or coordinator.

(2) A description of the staff/unit responsible for informing women identified as pregnant of the following:

(a) The PRS program,

(b) The importance of prenatal care,

(3) How the CDJFS tracks identified pregnant women,

(4) Identification of the staff/unit responsible for submission of the pregnancy related services quarterly report (JFS 03539, effective 1/2002) to ODJFS.

(5) Information as to whether the agency will provide transportation to infants during the first year of life.

(6) In counties with medicaid-contracting MCPs, the information submitted under the CDJFS director’s signature shall include plans for coordination of efforts between the CDJFS and the MCPs. This may include written agreements between the CDJFS and the medicaid-contracting MCPs with provisions for regularly scheduled meetings, as well as other ideas for county and plan coordination.

(7) All changes or amendments to the CDJFS’s description of the process and/or structure shall be submitted in writing to ODJFS under the signature of the CDJFS director within ten working days.

(8) Information submitted under the signature of the CDJFS director can be combined or included with the information submitted as per paragraph (M) of rule 5101:1-38-05 of the Administrative Code.

Effective: 10/15/2005

R.C. 119.032 review dates: 07/29/2005 and 10/01/2010

Promulgated Under: 111.15

Statutory Authority: 5111.01

Rule Amplifies: 5111.01, 5111.016

Prior Effective Dates: 4/1/88 (emer.), 6/30/88, 10/1/88 (emer.), 12/20/88, 4/1/91, 2/1/92, 5/1/93, 10/1/98, 5/1/02, 10/6/03

5101:1-38-10 Medicaid estate recovery.

(A) This rule describes Ohio’s medicaid estate recovery program and the undue hardship waiver request process.

(B) Definitions.

(1) “Estate” includes both of the following:

(a) All real and personal property and other assets to be administered under Title XXI of the Revised Code and property that would be administered under that title if not for section 2113.03 or 2113.031 of the Revised Code; and

(b) Any other real and personal property and other assets in which an individual had any legal title or interest at the time of death (to the extent of the interest), including assets conveyed to a survivor, heir, or assign of the individual through joint tenancy, tenancy in common, survivorship, life estate, living trust, or other arrangement.

(2) “Home” is defined in rule 5101:1-39-31 of the Administrative Code.

(3) “Individual,” for the purpose of this rule, means a past or current recipient of medicaid.

(4) “Permanently institutionalized individual” is defined in section 5111.11 of the Revised Code.

(5) “Person responsible for the estate” is defined in section 2117.061 of the Revised Code.

(6) “Personal property” is defined in rule 5101:1-39-05 of the Administrative Code.

(7) “Qualified long term care partnership (QLTCP)” is defined in rule 5101:1-38-11 of the Administrative Code.

(8) “Real property” is defined in rule 5101:1-39-05 of the Administrative Code.

(9) “Time of death” is defined in section 5111.11 of the Revised Code.

(C) The Ohio attorney general (AGO) will seek recovery or adjustment, on behalf of the Ohio department of job and family services (ODJFS), from the estates of the following individuals:

(1) A permanently institutionalized individual of any age, in the amount of all medicaid benefits correctly paid; or

(2) An individual fifty-five years of age or older who is not a permanently institutionalized individual, in the amount of all medicaid benefits correctly paid after the individual attained such age.

(D) Any adjustment or recovery under paragraph (C) of this rule may be sought only:

(1) After the death of the individual’s surviving spouse, if any; and

(2) When the individual has no surviving child who either is under age twenty-one or is blind or permanently and totally disabled as defined in Chapter 5101:1-39 of the Administrative Code; and

(3) If recovery is sought against a permanently institutionalized individual under paragraph (C)(1) of this rule, no recovery may be made against the individual’s home while either of the following lawfully resides in the home:

(a) The permanently institutionalized individual’s sibling who:

(i) Resided in the home for at least one year immediately before the date of the individual’s admission to the institution, and

(ii) Has resided in the home on a continuous basis since that time.

(b) The permanently institutionalized individual’s son or daughter who:

(i) Provided care to the permanently institutionalized individual that delayed the individual’s institutionalization, and

(ii) Resided in the home for at least two years immediately before the date of the individual’s admission to the institution, and

(iii) Has resided in the home on a continuous basis since that time, and

(iv) Documents that he or she has fulfilled these requirements by submitting the following:

(a) A written statement of the date that he or she moved into the home;

(b) A level of care assessment showing that the individual would have become institutionalized earlier without care provided by the adult son or daughter;

(c) A written statement from the individual’s attending physician, stating the kind and duration of care that was required to delay the individual’s institutionalization; and

(d) All relevant documentation of the care that delayed institutionalization and the role the adult son or daughter played in that care. This documentation shall include (but is not limited to) one or more of the following:

(i) A written statement of the number of hours per day during which the adult son or daughter provided personal care, specifying the extent and type of care provided;

(ii) A written statement of any part-time or full-time jobs performed by the adult son or daughter, and any schools or other similar institutions attended by the adult son or daughter, while providing care; or

(iii) Written documentation from a service agency which provided care to the individual, the dates on which care was provided, and the extent and type of care provided.

(E) Notice requirements.

(1) When an individual was age fifty-five or older or was permanently institutionalized at the time of death, the person responsible for the estate must give notice to the AGO, as required by section 2117.061 of the Revised Code.

(2) After the individual’s death, whenever adjustment or recovery is sought by ODJFS or its designee, a claim for recovery must be presented by the AGO.

(a) The claim must include all information required by Chapter 2117. of the Revised Code and must be served on the person responsible for the estate or, if there is no person responsible for the estate, any person who received or controls probate or non-probate assets inherited from the individual.

(b) The claim must include the following:

(i) That this rule defines undue hardship in paragraph (H) of this rule, and sets out the process for requesting an undue hardship waiver in paragraph (I) of this rule;

(ii) What form (as specified by the ODJFS director) must be completed to request an undue hardship, and where that form can be obtained; and

(iii) The date by which that form must be submitted in order to request an undue hardship waiver.

(3) The person responsible for the estate must notify any person who received or controls probate or non-probate assets, inherited from the individual, affected by the proposed recovery.

(F) If the person responsible for the estate from which recovery is sought requests to satisfy the claim without selling a non-liquid asset subject to recovery, the AGO may establish a payment schedule, promissory note, or lien.

(G) Qualified long term care partnership disregard.

(1) The amount of resources disregarded at eligibility determination (as established in rule 5101:1-38-11 of the Administrative Code) will be disregarded during estate recovery.

(2) The following resources, which are not considered a resource at eligibility determination, will not be disregarded during estate recovery:

(a) Special needs trusts as established in rule 5101:1-39-27.1 of the Administrative Code;

(b) Pooled trusts as established in rule 5101:1-39-27.1 of the Administrative Code; and

(3) The QLTCP disregard at estate recovery is reduced to the extent that an individual made a transfer (that would otherwise have been considered an improper transfer under rule 5101:1-39-07 of the Administrative Code) without a restricted medicaid coverage period.

(H) The ODJFS director, or designee, may grant an undue hardship waiver on a case-by-case basis when there are compelling circumstances.

(1) ODJFS may, at the sole discretion of the ODJFS director or the director’s designee, waive estate recovery when recovery would work an undue hardship on an individual’s survivors. Undue hardship may be found in the following cases.

(a) The estate subject to recovery is the sole income-producing asset of the survivor, such as a family farm or other family business, which:

(i) Produces a limited amount of income, or

(ii) Is the sole asset of the survivor.

(b) Without receipt of the estate proceeds, the survivor would become eligible for public assistance.

(c) Recovery would deprive the survivor of necessary food, shelter or clothing. Deprivation does not include situations in which the survivor is merely inconvenienced but would not be at risk of serious harm.

(d) The survivor provides clear and convincing evidence of substantial personal financial contributions to the deceased individual, creating an equity interest in the property.

(e) The survivor is age sixty-five or older and financially dependent upon receipt of the estate proceeds.

(f) The estate proceeds are preserved for the benefit of a survivor who:

(i) Is totally and permanently disabled as defined in Chapter 5101:1-39 of the Administrative Code; and

(ii) Is financially dependent upon receipt of the estate proceeds.

(2) The following situations do not, without additional showing of hardship, show undue hardship:

(a) When recovery will prevent heirs from receiving an anticipated inheritance.

(b) When recovery results in loss of a pre-existing standard of living, or prevents the establishment of a source of maintenance that did not exist prior to the individual’s death.

(3) Regardless of actual hardship, an undue hardship waiver will not be granted in the following situations:

(a) When the individual created the hardship by using estate planning methods under which the individual divested, transferred, or otherwise encumbered assets in whole or in part to avoid estate recovery.

(b) When an undue hardship waiver will result in the payment of claims to other creditors with lower priority standing under Ohio’s probate law.

(I) Request for undue hardship waiver.

(1) Within thirty calendar days after notice of the estate recovery claim was mailed by the AGO, an undue hardship waiver may be requested (upon such form as may be designated by the ODJFS director) by an heir or potential heir who would suffer an undue hardship if a waiver is not granted, a person with an interest in assets of the estate, or a representative of such persons. An undue hardship waiver may not be requested by a creditor of the estate, unless such creditor is also a potential heir of the estate.

(2) Within sixty calendar days of receipt of the request for an undue hardship waiver, ODJFS must notify the applicant whether the waiver request has been approved (in full, in part, or for a limited time) or denied. Failure to meet this sixty day deadline does not result in an automatic decision on the request.

(3) If the waiver request was not approved in full, or if the approval was time-limited, the applicant may, within thirty calendar days, request (on such form as the director designates) that the ODJFS director, or designee, review the undue hardship waiver decision.

(a) The ODJFS director, or designee, will review only those portions of the undue hardship waiver request that were denied or time-limited. The director will not deny or limit any portion of the undue hardship waiver request that has already been granted.

(b) The ODJFS director, or designee, must review the undue hardship waiver request and notify the applicant within sixty calendar days whether (at the director’s sole discretion) the director, or designee, has approved (in full, in part, or for a limited time) or denied the request for an undue hardship waiver. Failure to meet this sixty day deadline does not result in an automatic decision on the request.

(J) Within thirty days after notice of the estate recovery claim was mailed by the AGO, a person with an interest in assets of the estate (or a representative of any such person) may (upon such form as may be designated by the ODJFS director) present a claim showing evidence that assets of the estate are exempt assets under one of the following categories.

(1) Government reparation payments to special populations are exempt from medicaid estate recovery.

(2) Certain American Indian and Alaska native income and resources, including:

(a) American Indian and Alaska native income and resources which are exempt from medicaid estate recovery by other laws and regulations;

(b) Ownership interest (when ownership would pass from an Indian to one or more relatives; to a tribe or tribal organization; and/or to one or more Indians) in trust or non-trust property, including real property and improvements:

(i) Located on a reservation (any federally recognized Indian tribe’s reservation, pueblo, or colony, including former reservations in Oklahoma, Alaska native regions established by Alaska native claims settlement act and Indian allotments) or near a reservation as designated and approved by the bureau of Indian affairs of the U.S. department of the interior; or

(ii) For any federally-recognized tribe not described in paragraph (J)(2)(b)(i) of this rule, located within the most recent boundaries of a prior federal reservation; or

(c) Income left as a remainder in an estate derived from property protected in paragraph (J)(2)(b) of this rule, that was either collected by an Indian, or by a tribe or a tribal organization and distributed to an Indian, as long as the income clearly comes from protected sources;

(d) Ownership interests left as a remainder in an estate in rents, leases, royalties, or usage rights related to natural resources (including extraction of natural resources or harvesting of timber, other plants and plant products, animals, fish, and shellfish) resulting from the exercise of federally-protected rights, and income either collected by an Indian, or by a tribe or tribal organization and distributed to an Indian derived from these sources the income or ownership interest clearly comes from protected sources; and

(e) Ownership interests in or usage rights to items that have unique religious, spiritual, traditional, and/or cultural significance or rights that support subsistence or a traditional life style according to applicable tribal law or custom.

Replaces: 5101:1-38-10

Effective: 09/01/2007

R.C. 119.032 review dates: 09/01/2012

Promulgated Under: 119.03

Statutory Authority: 5111.11

Rule Amplifies: 5111.11, 5111.12, 5111.111, 5111.18

Prior Effective Dates: 7/1/00

5101:1-38-11 Medicaid: treatment of qualified long-term care insurance policies.

(A) This rule describes the qualified long-term care partnership (QLTCP) program under which an individual’s resources are disregarded in eligibility determinations and at estate recovery in the amount of benefits paid to or on behalf of the consumer by a QLTCP policy.

(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 administering the medicaid program.

(2) “Estate recovery” means the program set out in rule 5101:1-38-10 of the Administrative Code.

(3) “Qualified long-term care partnership (QLTCP)” means the program established under section 5111.18 of the Revised Code, under which an individual’s resources are disregarded in eligibility determination(s) and at estate recovery in the amount of benefits paid to or on behalf of the consumer by a QLTCP policy.

(4) “Third party” is defined in rule 5101:1-38-02.2 of the Administrative Code.

(1) On the date the policy was issued, the state in which the insured resided had in place an approved state plan amendment which provides, pursuant to 42 U.S.C. 1396p(b) (as in effect on May 1, 2007), for the disregard of resources in an amount equal to the insurance benefit payments made to or on behalf of an individual who is a beneficiary of a QLTCP policy; and

(2) The policy is a qualified long-term care insurance policy, as defined in section 7702B(b) of the Internal Revenue Code of 1986; and

(3) The policy meets the requirements set forth by the Ohio department of insurance or, if purchased outside Ohio, meets the requirements of an approved state plan amendment, as described in paragraph (C)(1) of this rule, in the state of purchase.

(D) At application or reapplication (as established in Chapter 5101:1-39 of the Administrative Code) for long-term care services, a home and community-based services (HCBS) waiver, or the program of all inclusive care for the elderly (PACE), an individual’s resources will be disregarded up to the dollar amount of benefits paid to or on behalf of the individual by a QLTCP policy.

(1) The administrative agency shall determine medicaid eligibility in accordance with the eligibility rules contained in Chapters 5101:1-37 to 5101:1-42 of the Administrative Code.

(2) An individual may apply for long term care services before exhausting the benefits of a QLTCP policy. If an individual applies for and is eligible to receive medicaid coverage before the QLTCP policy is exhausted, the QLTCP insurer must make payment for medical care to the maximum extent of their liability before medicaid funds may be used to pay providers for covered services as established in rule 5101:1-38-02.2 of the Administrative Code.

(3) If an individual has applied for and been found eligible to receive medicaid, and then receives additional resources, the individual continues to be eligible for medicaid to the extent the total value of all disregarded resources does not exceed the individual’s QLTCP disregard plus the applicable resource allowance.

(4) A QLTCP disregard does not affect post-eligibility income calculations under Chapters 5101:1-38 to 5101:1-41 of the Administrative Code; the disregard cannot reduce patient liability or cost of care.

(E) Transfers of resources.

(1) If an individual becomes eligible for medicaid through the application of a QLTCP disregard, then makes a transfer (of disregarded resources) that would otherwise be considered an improper transfer (under rule 5101:1-39-07 of the Administrative Code), no restricted medicaid coverage period applies. The disregarded value of the transferred resource continues to be considered part of the individual’s QLTCP disregard.

(2) If an individual becomes eligible for medicaid through the application of a QLTCP disregard after making a transfer that would otherwise be considered an improper transfer (per rule 5101:1-39-07 of the Administrative Code):

(a) If the individual’s QLTCP disregard plus resource limit equals or exceeds the individual’s countable resources plus the value of the transferred resource, no restricted medicaid coverage period applies. The disregarded value of the transferred resource is considered part of the individual’s QLTCP disregard.

(b) If the individual’s QLTCP disregard plus resource limit is less than the individual’s countable resources plus the value of the transferred resource:

(i) The individual’s available QLTCP disregard is determined by adding the individual’s QLTCP disregard to the individual’s resource limit, then subtracting the individual’s current countable resources and any amounts that have previously been transferred without a restricted medicaid coverage period as a result of a QLTCP disregard.

(ii) The individual’s available QLTCP disregard is subtracted from the amount that would otherwise have been considered improperly transferred. The remainder is the amount improperly transferred; a restricted medicaid coverage period is calculated for the remainder as per rule 5101:1-39-07 of the Administrative Code.

Effective: 09/01/2007

R.C. 119.032 review dates: 09/01/2012

Promulgated Under: 119.03

Statutory Authority: 5111.11, 5111.18

Rule Amplifies: 5111.11, 5111.18

5101:1-38-20 Medicaid and covered families and children medicaid: overpayments.

(A) Definitions

(1) “Overpayment” – any unnecessary cost to the medicaid program caused by an assistance group’s or authorized representative’s error in reporting changes, failure to report changes, or misrepresentation, that affects the assistance group’s or a member(s) of the assistance group’s eligibility for medicaid.

(2) “Fraud” – an intentional deception or misrepresentation made by an assistance group, a member of the assistance group or authorized representative with the knowledge that the deception could result in some unauthorized benefit to the assistance group, a member of the assistance group, or another person.

(3) “Non-fraud” – a misunderstanding or unintended error on the part of the assistance group, a member of the assistance group, or authorized representative.

(4) “Overpayment period” – the period beginning with the first month in which eligibility would have ended or changed, the recipient’s spenddown liability or patient liability would have increased, or vendor payment would have stopped had the assistance group or authorized representative properly reported the assistance group’s circumstances, and continuing until the medicaid case is properly terminated, the spenddown or patient liability is corrected, or all eligibility requirements are met or as further defined by rule. An assistance group may have more than one overpayment period.

(5) “Date of determination of an overpayment” – the date all necessary documentation was reviewed and the decision made that an overpayment occurred.

(B) The county department of job and family services (CDJFS) is responsible for making the initial determination of whether an overpayment has occurred and whether to pursue recovery of an overpayment.

(1) The policy for determining the amount of the medicaid overpayment will differ depending on whether the overpayment was due to an improper transfer of assets as determined in accordance with rule 5101:1-39-07 of the Administrative Code, or excessive income or resources.

(2) A determination must be made whether any individuals within the assistance group would have remained eligible for medicaid under the same or another category of medicaid.

(3) In all situations involving children, the liability for any overpayment rests with the responsible adult(s).

(4) If an individual within the assistance group would have remained eligible for medicaid under another category, without any spenddown liability or patient liability, then claims paid for that individual during the overpayment period are not recoverable.

(5) Medicaid overpayments cannot be recovered by a reduction in benefits or services. Overpayments can be recovered only through reimbursement.

(6) An overpayment that occurs as a result of an error that was not caused by the assistance group cannot be recovered.

(7) An overpayment period may include both an assistance group error and an error not cause by the assistance group.

(a) Only the period that was the result of an assistance group error is recoverable.

(b) When an assistance group error has been discovered, the CDJFS must take the appropriate action to determine the assistance group’s continued eligibility. Failure to take corrective action within a reasonable period of time following discovery of the error will result in any additional overpayment incurred by the assistance group during the overpayment period being considered an error not caused by the assistance group.

(D) Overpayment – non-financial eligibility requirement not met

(1) The full amount of medicaid claims paid on behalf of the assistance group or member of the assistance group is recoverable if the assistance group or individual failed to report a change that resulted in their no longer meeting the non-financial eligibility requirements for any category of medicaid (e.g., citizenship, residence, etc.)

(2) The overpayment period begins with the first month that the individual would no longer have been eligible for medicaid had the change been reported in accordance with rule 5101:1-38-02 of the Administrative Code and the expiration of the prior notice period as required in rule 5101:6-2-04 of the Administrative Code.

(3) For an assistance group that was erroneously approved for medicaid as a result of the assistance group’s failure to report information accurately, the overpayment period begins with the first month that medicaid was authorized and continues until the medicaid case is closed or the assistance group meets the non-financial eligibility requirements.

(E) Overpayment – excess resources

(1) The amount of the overpayment is the maximum amount by which the assistance group exceeded the applicable resource limit during the overpayment period or the amount paid by medicaid, during that period, whichever is less.

(2) If some members of the assistance group would have qualified under another category of medicaid that does not have a resource limit during the overpayment period, the overpayment claim shall not include the amount of medical services paid for those members of the assistance group.

(3) For an assistance group that was erroneously approved for medicaid as a result of the assistance group’s failure to report information accurately, the overpayment begins the first month that medicaid was authorized and continues until the medicaid case is closed or the assistance group meets the eligibility requirements.

(F) Overpayment – excess income

(1) For all categories of covered families and children (CFC) medicaid, if some members of the assistance group would have qualified under another category of CFC medicaid during the overpayment period, the overpayment claim shall not include the amount of medical services paid for those members of the assistance group.

(a) The amount of the overpayment is the total amount of medicaid dollars paid by medicaid during the overpayment period.

(b) The beginning date of the overpayment period can be no earlier than the date the medicaid assistance group would no longer have been eligible for medicaid had the change been reported in accordance with rule 5101:1-38-02 of the Administrative Code and the expiration of the prior notice period as required in rule 5101:6-2-04 of the Administrative Code.

(c) For an assistance group that was erroneously approved for medicaid as a result of the assistance group’s failure to report information accurately, the overpayment begins the first month that medicaid was authorized and continues until the medicaid case is closed or the assistance group meets the eligibility requirements.

(2) For medicaid cases in which the assistance group remained eligible with a spenddown liability, the beginning date of the overpayment period can be no earlier than the date the assistance group would no longer have been eligible for medicaid with a lower or no spenddown liability had the change been reported in accordance with rule 5101:1-38-02 of the Administrative Code and the expiration of the prior notice period as required in rule 5101:6-2-04 of the Administrative Code.

(3) For medicaid cases in which the individual remained eligible for spenddown medicaid with a higher liability, the amount of the overpayment is the difference between the spenddown liability that was in effect during the overpayment period and the correct amount of the spenddown liability.

(4) For medicaid cases in which the assistance group remained eligible with a patient liability, the beginning date of the overpayment period can be no earlier than the date the assistance group would no longer have been eligible for medicaid with a lower or no patient liability had the change been reported in accordance with rule 5101:1-38-02 of the Administrative Code and the expiration of the prior notice period as required in rule 5101:6-2-04 of the Administrative Code. The amount of the overpayment is the difference between the patient liability that was in effect during the overpayment period and the corrected amount of the patient liability.

(5) For residential state supplement (RSS) cases in which the individual remained eligible for medicaid with a spenddown liability, the amount of the medicaid overpayment is the amount of the spenddown liability that should have been in effect during the overpayment period.

(6) For RSS individuals, the amount of the RSS overpayment is the difference between the RSS payment that was in effect during the overpayment period and the corrected amount of the RSS payment.

(G) Whenever an overpayment is caused by a combination of excess income and excess resources during the overpayment period, the greater of the two overpayment amounts is subject to recovery.

(H) Overpayment – medicaid recipients who reside in a nursing facility or long term care facility for the mentally retarded (ICF-MR)

(1) For overpayments that occur as a result of an improper transfer of assets as determined under rule 5101:1-39-07 of the Administrative Code, the amount of the overpayment is the amount of the vendor payment that was paid by medicaid during the period that should have been established as restricted coverage.

(2) The overpayment period begins with the first month of the correctly determined period of restricted coverage and continues until the period of restricted coverage has expired or should have expired.

(3) Prior notice is not required before the period of restricted coverage begins.

(I) Cases that are suspected to be fraud, except RSS overpayments, must be referred to the county prosecutor or the prosecutor’s designee.

(1) The assistance group case record and claims record must contain documentation regarding the decision of the county prosecutor or his or her designee.

(2) The record must contain documentation of the amount of the overpayment.

(3) If the county prosecutor requests additional information, the CDJFS must cooperate with the request.

(4) If the county prosecutor pursues the case as fraud, any out-of-court settlement or court order is binding on the CDJFS.

(5) If the county prosecutor determines that fraud does not exist or elects not to prosecute, the CDJFS shall proceed to recover the overpayment as a non-fraud overpayment.

(J) Overpayment recovery

(1) Medicaid overpayments can be recovered only through reimbursement.

(2) RSS overpayments cannot be recovered through a RSS grant reduction.

(3) For cases determined to be fraud, the CDJFS shall accept any reimbursement plan ordered by a court or agreed to by the county prosecutor.

(4) In all non-fraud recoveries, the CDJFS must first seek a recovery agreement.

(a) The CDJFS shall send a completed JFS 07335 “Notice of Medicaid Overpayment” to the assistance group.

(b) If the assistance group does not agree to repay the overpayment, the CDJFS shall determine if any further action is necessary.

(c) The CDJFS may pursue recovery through a civil court action or determine that the overpayment is not recoverable at the present time. A CDJFS may change its decision based on additional information or a change in circumstances.

(5) In overpayment recoveries caused by excess resources, where the excess resources are still available to the assistance group, the CDJFS shall attempt to convince the assistance group to use the excess resources to repay the overpayment.

(6) In resource overpayment recoveries involving nursing facility recipients, the recipient may choose to increase his or her patient liability through payment of a lump sum to the nursing facility if the increase will reduce the resources to the appropriate limit. If the reduction in resources cannot be accomplished in one month, this option is not available.

HISTORY: Eff 10-1-87 (Emer.); 12-24-87; 11-7-02

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.12

Rule amplifies: RC 5111.01, 5111.011, 5111.12

Replaces: 5101:1-39-66, 5101:1-39-66.1, 5101:1-39-67, 5101:1-39-67.1

R.C. 119.032 review dates: 11/07/2007