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Ohio Laws and Rules
(A) This rule describes the conditions under which a child may receive time-limited medical assistance as a result of an initial, simplified determination of eligibility by a county department of job and family services (CDJFS), as described in section 1920A of the Social Security Act (as in effect on April 1, 2010).
(B) Definitions.
(1) “Child,” for the purpose of this rule, means a person younger than age nineteen.
(2) “Qualified alien” is defined in rule 5101:1-38- 02.3 of the Administrative Code.
(3) “Qualified entity,” for the purpose of this rule, means the CDJFS.
(C) Eligibility criteria for presumptive coverage.
(1) A child who receives presumptive coverage is ineligible for a new presumptive coverage period for one year from the date on which the presumptive coverage began.
(2) Except as set forth in paragraph (C)(1) of this rule, a child is eligible for presumptive coverage if the child:
(a) Is younger than age nineteen; and
(b) Is a resident of the state of Ohio; and
(c) Is a United States citizen or qualified alien; and
(d) Has gross family income no more than two hundred per cent of the federal poverty level for the family size.
(3) The eligibility criteria set forth in paragraph (C)(2) of this rule are verified by self-declared statements made on an ODJFS application for medical assistance. The application shall be signed and dated by:
(a) The child, if the child is at least eighteen years of age, married, serving in the armed forces, or emancipated by court order in a state that recognizes emancipation; or
(b) The child’s adult representative, regardless of the child’s age.
(D) Duration of presumptive coverage.
(1) Presumptive coverage begins on the date the CDJFS determines a child is presumptively eligible. No retroactive coverage may be provided as a result of a presumptive eligibility determination.
(2) Presumptive coverage ends on the date the CDJFS determines, pursuant to rule 5101:1-38- 01.2 of the Administrative Code, the child is eligible or ineligible for medical assistance.
(E) CDJFS responsibilities.
(1) No later than the end of the business day after receipt of a signed and dated application for medical assistance on behalf of a child, the CDJFS shall determine whether the child is eligible for presumptive coverage under this rule.
(2) For the purpose of the presumptive eligibility determination, the CDJFS shall accept the family’s self-declaration of the presumptive eligibility criteria unless the CDJFS has contradictory information.
(3) If a child is eligible for presumptive coverage, the CDJFS shall:
(a) Approve presumptive coverage for the child.
(b) Inform the child’s representative of:
(i) The presumptive coverage, and
(ii) That failure to cooperate with the eligibility determination process set forth in rule 5101:1-38- 01.2 of the Administrative Code will result in a denial of medical assistance, which will trigger the termination of presumptive coverage.
(c) Not make an absent parent referral described in rule 5101:1-3-10 of the Administrative Code as a part of the approval of presumptive eligibility coverage.
(4) If a child is not eligible for presumptive coverage, the CDJFS shall inform, on a form designated by the Ohio department of job and family services (ODJFS), the child’s representative of the denial and that the child’s eligibility for medical assistance will be reviewed.
(5) Whether or not a child is eligible for presumptive coverage, the CDJFS shall determine whether the child is eligible for medical assistance pursuant to rule 5101:1-38- 01.2 of the Administrative Code.
(F) Denial of presumptive coverage is not grounds for a state hearing under division 5101:6 of the Administrative Code.
Effective: 07/01/2010
R.C. 119.032 review dates: 07/01/2015
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011
Rule Amplifies: 5111.01, 5111.011
Prior Effective Dates: 4/1/2010 (Emer.)