5101:1-38-01.8 Medicaid: conditions of eligibility for each applicant or recipient.

(A) This rule sets forth the general conditions of eligibility each individual must meet to qualify for any medicaid covered group. Requirements specific to a given covered group are addressed in the rule corresponding to that covered group.

(B) Definitions:

(1) "Assignment" means the medicaid-eligible individual 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 or an administrative child support order for an absent parent to make payment for medical care.

(C) To be eligible for medical assistance, each individual shall meet all of the following non-financial conditions. The individual shall:

(1) Provide a social security number (SSN) in accordance with 42 C.F.R. 435.910 (as in effect September 1, 2009). The individual's self-declaration of SSN meets this condition unless contradictory information is provided to or maintained by the administrative agency. An individual is not required to provide a SSN if the individual is:

(a) Applying for or receiving alien emergency medical assistance (AEMA).

(b) Refusing to obtain a SSN because of well-established religious objections. Well-established religious objections exist when the individual:

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

(ii) 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.

(2) Be a resident of the state of Ohio, effective the date of application or requested coverage begin date, whichever is earlier, in accordance with 42 C.F.R. 435.403 (as in effect September 1, 2009). The individual's self-declaration of residency meets this condition unless contradictory information is provided to or maintained by the administrative agency. An individual who is temporarily absent, as defined in rule 5101:1-37-01 of the Administrative Code, is a resident of the state of Ohio.

(3) Be a:

(a) U.S. citizen, or declare citizenship under penalty of perjury. Citizenship shall be verified through the social security administration (SSA) electronic data exchange system beginning no earlier than January 1, 2010. When citizenship information is not available through the SSA electronic data exchanges system or the data is contradictory, the individual shall provide acceptable documentary evidence, by mail or in person within ninety days, as described in rule 5101:1-38-02 of the Administrative Code; or

(b) Qualified alien and provide documentary evidence as described in rule 5101:1-38-02.3 of the Administrative Code. Verification of alien status is not required when the individual is:

(i) Applying for benefits on behalf of another person.

(ii) Applying for AEMA.

(4) Assign to the state of Ohio rights of self, or the rights of any medicaid-eligible individual for whom the individual is legally able to make an assignment in accordance with 42 C.F.R. 433.145 and 42 C.F.R. 433.146 (as in effect on September 1, 2009), to medical support and payments for medical care from any third party in accordance with 42 CFR 435.610 (as in effect on September 1, 2009).

(5) Agree to cooperate with the child support enforcement agency (CSEA) in establishing paternity of any medicaid eligible child when both the individual and child receive medicaid.

(6) The individual shall not be required to cooperate as described in paragraph (C)(5) of this rule if the individual:

(a) Is not receiving medicaid for himself or herself;

(b) Is a pregnant woman, including her sixty day post-partum period;

(c) Provides good cause as determined by the local CSEA; or

(d) Is receiving transitional medical assistance.

(7) Cooperate with the CDJFS and the state in identifying and providing information to assist the state in pursuing any third party who may be liable to pay for care and services. To meet this condition, the individual shall provide the name of the insurance company, billing address, subscriber identification number, group number, name of policy holder, and a list of covered individuals.

(8) Cooperate with requests from a third-party insurance company to provide additional information that is required to authorize coverage or obtain benefits through the third party insurance company.

(9) Cooperate with requests from a medicaid provider, managed care plan, or a managed care plan's contracted provider to provide additional information that is required for the provider or plan to obtain payments from a third-party insurance company for medicaid covered services.

(10) Cooperate with requests from a third-party insurance company, medicaid provider, managed care plan, or a managed care plan's contracted provider to forward or return to the third-party insurance company, medicaid provider, managed care plan, or managed care plan's contracted provider any payments received from the third-party insurance company for medicaid covered services when:

(a) The provider has billed the third-party insurance company for medicaid covered services provided to the individual, and

(b) The third-party insurance company has sent payment to the individual for medicaid covered services the individual received from the provider.

(11) Take all necessary steps to obtain any benefits for which the individual is eligible, including but not limited to: medicare, annuities, retirement, veterans benefits, supplemental security income (SSI), social security disability income (SSDI), railroad retirement, and unemployment compensation in accordance with 42 CFR 435.608 (as in effect on September 1, 2009). An official letter from the paying entity or financial institution, or information obtained and verified through the electronic eligibility system, meets this condition.

(12) Not be eligible for and receiving medicaid services in another state or U.S. territory.

(D) The individual shall meet resource and asset requirements for the covered group. Acceptable documentation includes, but is not limited to: information maintained as a regular part of business by a government entity, information obtained and verified through the electronic eligibility system, financial institution statement, and legal documents.

(E) The individual shall meet income requirements for the covered group. Acceptable documentation includes, but is not limited to: information maintained as a regular part of business by a government entity, current pay stub; award letter from certifying agency; IRS form 1099; tax documents; information obtained and verified in the electronic eligibility system; wage information provided to the administrative agency through a contracted service, or employer statement including hourly or salary wage, hours worked per pay period, length of pay period and any tax withholdings.

(F) Individual responsibilities. The individual shall:

(1) Provide all information and documentation necessary to meet the conditions of eligibility in paragraphs (C) to (E) of this rule.

(2) Notify the administrative agency of any need for assistance in obtaining required documentation.

(3) Cooperate with the administrative agency in the verification process in accordance with rule 5101:1-38-01 of the Administrative Code.

(4) Report any changes to the administrative agency as established in rule 5101:1-38-01 of the Administrative Code.

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

(1) Not require the individual to apply for Ohio works first (OWF) benefits as a condition of eligibility for medicaid.

(2) Assist the consumer in obtaining the verifications required for eligibility determination. When the normal sources of verification described in paragraphs (C) to (E) of this rule have been exhausted, and no documentation can be obtained, the administrative agency may accept the individual's statement if it is complete and consistent with other facts and statements. The use of such a statement shall be on a case by case basis when no other approach is possible, and shall be used only in rare circumstances.

Effective: 09/09/2012
R.C. 119.032 review dates: 10/01/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011 , 5111.02
Rule Amplifies: 5111.01 , 5111.011 , 5111.02
Prior Effective Dates: 10/1/75, 9/30/76, 9/3/77, 7/18/78, 2/1/79, 4/19/79, 1/1/81, 2/1/82, 7/1/82, 9/1/82, 11/1/84, 11/3/84, 1/1/86, 8/1/86 (Emer.), 9/1/86 (Emer.), 10/3/86, 11/16/86, 4/9/87, 7/1/87 (Emer.), 8/3/87, 10/1/87 (Emer.), 12/24/87, 3/24/88 (Emer.), 4/1/88 (Emer.), 6/10/88, 6/30/88, 10/1/88 (Emer.), 12/20/88, 3/1/89 (Emer.), 4/1/89 (Emer.), 5/28/89, 6/18/89, 1/1/90 (Emer.), 4/1/90, 10/1/91 (Emer.), 12/20/91, 7/1/92, 7/1/92 (Emer.), 9/21/92, 1/1/93, 5/1/93, 9/1/93, 3/1/95, 10/30/95, 5/1/97, 7/1/98, 7/1/00, 10/1/02, 1/1/03, 10/6/03, 7/1/06, 9/25/06, 8/1/07, 7/1/08, 10/15/09, 7/17/11