5101:1-37-01 Medicaid: definitions.

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

(B) Definitions.

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

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

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

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

(b) The spouse of an individual.

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

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

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

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

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

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

(10) "CPA" means combined programs application.

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

(a) This includes:

(i) A group health plan.

(ii) Health insurance coverage.

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

(iv) Coverage under medicaid, as set forth in Title XIX of the Social Security Act, other than coverage consisting solely of benefits under the pediatric vaccine program set forth in 42 U.S.C. 1396s (as in effect on February 1, 2010).

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

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

(vii) A state health benefits risk pool.

(viii) A federal employee health plan offered under 5 U.S.C. 8901 to 5 U.S.C. 8992 (as in effect on January 7, 2011).

(ix) A public health plan.

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

(b) Creditable insurance does not include:

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

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

(iii) Workers' compensation or similar insurance.

(iv) Automobile medical payment insurance.

(v) Credit-only insurance.

(vi) Coverage for on-site medical clinics.

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

(viii) Limited-scope dental or vision benefits.

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

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

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

(xii) Medicare supplemental health insurance as defined under 42 U.S.C. 1395ss (as in effect on February 1, 2010), coverage supplemental to the coverage provided to military or former military personnel under 10 U.S.C. Chapter 55 (as in effect on January 7, 2011), and similar supplemental coverage provided to coverage under a group health plan.

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

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

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

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

(a) The individual;

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

(c) The spouse of any person listed in paragraph (B)(15)(a) or

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

(d) Minor dependent children of persons listed in paragraph

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

(16) "FPL" means the federal poverty level determined annually by the office of management and budget as required by 42 U.S.C. 9902(2) (as in effect on February 1, 2010).

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

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

(19) "HCB services" or "HCBS" means specific home and community-based services furnished under the provision of 42 C.F.R. 441, subpart G (as in effect on October 1, 2011), that provide specific individuals an alternative to placement in a hospital, a nursing facility (NF), or an intermediate care facility for persons with mental retardation (ICF/MR) as set forth in rule 5101:3-1-06 of the Administrative Code.

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

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

(ii) Only to certain individuals.

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

(i) Be eligible for medicaid; and

(ii) Apply separately for HCB services; and

(iii) Be found eligible to receive HCB services.

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

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

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

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

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

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

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

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

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

(b) Conceal an interest in property; or

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

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

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

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

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

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

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

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

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

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

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

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

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

(a) The individual;

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

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

(d) The individual's authorized representative.

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

(39) "Residential care facility" (RCF) means a home that provides either of the following:

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

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

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

(41) "Specified relative" means the following individuals who are age eighteen or older:

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

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

(ii) Siblings;

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

(iv) First cousins and first cousins once removed.

(b) Stepparents and stepsiblings;

(c) Spouses and former spouses of individuals named in paragraph (B)(41)(a) or (B)(41)(b) of this rule.

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

(43) "SSN" means social security number.

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

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

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

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

(c) The absent individual shared the place of residence with the family immediately prior to the absence, except for individuals described in paragraph (B)(6) of rule 5101:1-40-02.2 of the Administrative Code.

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

(46) "Terminate" or "terminated" means a determination by the administrative agency that an individual is no longer eligible, or has failed to cooperate with verification of eligibility, for one or more categories of assistance currently being received by that individual, resulting in a written notice of the administrative agency's intention to cease coverage under that category and providing notice of hearing rights as required by 42 C.F.R. 435.919 (as in effect on October 1, 2011).

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

(48) "United States citizen or national" means any individual who is:

(a) A citizen or national through birth or collective naturalization as set forth in 8 U.S.C. Chapter 12, Subchapter III, Part I (as in effect on January 7, 2011); or

(b) A naturalized citizen or national as set forth in 8 U.S.C. Chapter 12, Subchapter III, Part II (as in effect on January 7, 2011).

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

Effective: 01/09/2012
R.C. 119.032 review dates: 10/01/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011
Rule Amplifies: 5111.01 , 5111.011 , 5101.58
Prior Effective Dates: 9/3/71, 9/3/77, 10/26/78, 5/1/79, 9/21/79, 2/21/80, 7/3/80, 7/1/82, 12/1/82, 10/14/83 (Temp.), 12/22/83, 2/15/85 (Emer.), 3/12/85, 6/10/85, 8/1/86 (Emer.), 10/3/86, 7/1/87 (Emer.), 8/3/87, 10/1/02, 10/1/09, 7/17/11