5101:1-37-55 Medicaid: individual responsibilities.

(A) This rule describes the responsibilities of an individual applying for or receiving medical assistance, whether on behalf of the individual or someone else.

(B) Individual responsibilities.

(1) When applying for or receiving any medical assistance, an individual must:

(a) Sign and submit an initial application under penalty of perjury. This signature may be electronic, telephonic, a copy or facsimile, or an original ink signature.

(b) Cooperate with the administrative agency in application, verification, determination, redetermination, auditing, and quality control processes set out in this chapter of the Administrative Code. The individual must:

(i) Answer all relevant questions and provide information and documentation necessary to verify the conditions of eligibility as described in rule 5101:1-37-58 of the Administrative Code and the requirements specific to the relevant eligibility category in order to establish initial or continued eligibility.

(ii) Request assistance from the administrative agency when unable to obtain requested information. The individual must provide the information necessary to allow the administrative agency to assist the individual.

(c) Select a managed care plan (MCP) as required by rule 5101:3-26-02 of the Administrative Code, unless the individual meets one of the exceptions listed in that rule.

(d) Inform the administrative agency within ten days of any change to the following circumstances for the individual or any person living with the individual:

(i) Address.

(ii) Marital status.

(iii) Income, including:

(a) One-time gifts or payments, and

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

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

(v) Third-party responsibility for the individual's health care costs, including:

(a) New coverage under a health insurance policy, no matter who is paying for the coverage;

(b) A change in health insurers;

(c) Loss or ending of other health insurance coverage;

(d) A court order requiring a person or entity to pay some or all of the individual's medical expenses; or

(e) Any accident or injury for which another person or entity may be responsible, such as a work-related injury or an injury received in an automobile collision. In addition to reporting the injury or accident, an individual must also report any information received about any involved insurance company.

(e) Cooperate with any third party responsible for an individual's health care costs.

(f) Not commit medicaid eligibility fraud as described in section 2913.401 of the Revised Code.

(2) When applying for or receiving medical assistance on the basis of being blind, disabled, or at least age sixty-five, an individual must also inform the administrative agency of any:

(a) Improvement of the condition for which the benefit is received; or

(b) Change in the ownership or value of a resource owned by the individual or the individual's spouse, including any change in an annuity or an annuity's remainder beneficiary designation.

(C) Authorized representative.

(1) An authorized representative may be any person at least eighteen years old, or a business or other legal entity.

(2) An authorized representative must be appointed by an individual to act on the individual's behalf or have access to the individual's medicaid information.

(a) The document appointing an authorized representative must:

(i) Identify what duties the individual is authorizing the representative to perform, and

(ii) Be signed by the individual.

(b) The individual may contact the administrative agency to remove an authorized representative or reduce the authorized representative's authority in person, in writing, or by telephone.

(c) If an individual is unable to identify an authorized representative because of incapacity or incompetence, the administrative agency will assist the individual with appointing an authorized representative, as described in rule 5101:1-37-51 of the Administrative Code.

(3) The administrative agency must request proper identification from the authorized representative prior to disclosure of medicaid information to or representation of the individual by the authorized representative.

(4) All notices and correspondence sent to an individual by the administrative agency will also be sent to the authorized representative.

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

Effective: 10/01/2013
R.C. 119.032 review dates: 10/01/2018
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 111.011, 5111.012
Rule Amplifies: 5111.01 , 5111.011 , 5111.012 , 5101.58 , 329.051