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

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

(B) Definitions:

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

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

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

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

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

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

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

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

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

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

(a) Is confined.

(b) Lives in a public institution.

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

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

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

Replaces: 5101:1-37-20

Effective: 05/29/2009
R.C. 119.032 review dates: 05/01/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011
Rule Amplifies: 5111.01 , 5111.011 , 5111.0119
Prior Effective Dates: 3/1/2009 (Emer.)