5101:1-38-50 Medicaid: presumptive eligibility for pregnant women.

(A) This rule describes the conditions under which a pregnant woman may receive time-limited medical assistance as a result of an initial, simplified determination of eligibility, as described in section 1920 of the Social Security Act (as in effect on April 1, 2012). There can be no eligibility for this program prior to the effective date of this rule.

(B) Definitions.

(1) "Qualified entity," for the purpose of this rule, means a county department of job and family services (CDJFS).

(2) "Qualified provider," for the purpose of this rule, means:

(a) A qualified entity as defined in paragraph (B)(1) of this rule; and

(b) A hospital, federally qualified health center (FQHC) or FQHC look-alike as described in Chapter 5101:3-28 of the Administrative Code, that has requested to serve as a qualified provider and has been determined by the state medicaid agency to be capable of making presumptive eligibility determinations.

(C) Eligibility criteria. To be eligible for coverage under this rule, an applicant must be:

(1) Pregnant;

(2) In a family with gross family income that is no more than two hundred percent of the federal poverty level;

(3) An Ohio resident; and

(4) A U.S. citizen or qualified alien as defined in rule 5101:1-38-02.3 of the Administrative Code.

(D) Duration and scope of presumptive coverage.

(1) Presumptive coverage begins on the date the pregnant woman is determined to be presumptively eligible. No retroactive coverage may be provided as a result of a presumptive eligibility determination.

(2) Presumptive coverage ends with the earlier of (and includes):

(a) The date the CDJFS determines, pursuant to rule 5101:1-38-01.2 of the Administrative Code, that the pregnant woman is eligible or ineligible for ongoing medical assistance.

(b) If the woman has not applied for ongoing medicaid, the last day of the month following the month in which the woman was determined to be presumptively eligible.

(3) A pregnant woman shall only receive one presumptive medicaid eligibility period per pregnancy.

(4) Services under this program are restricted to ambulatory prenatal care.

(E) State medicaid agency responsibilities. The state medicaid agency shall provide qualified providers with:

(1) Such forms as are necessary for a pregnant woman to apply for presumptive medical assistance under the state plan; and

(2) Information on how to assist such women in completing and filing such forms.

(F) Qualified provider responsibilities. The qualified provider shall:

(1) If the qualified provider is the CDJFS:

(a) Upon receipt of a signed and dated application for medical assistance on behalf of a pregnant woman, determine whether the pregnant woman is presumptively eligible under this rule.

(b) For the purpose of the presumptive eligibility determination, accept self-declaration of the presumptive eligibility criteria unless contradictory information is provided to or maintained by the qualified provider.

(c) If the pregnant woman is presumptively eligible:

(i) Approve presumptive coverage for the pregnant woman; and

(ii) Inform the pregnant woman within twenty-four hours of the eligibility determination that:

(a) She is eligible for presumptive coverage, and

(b)Failure to cooperate with the eligibility determination process set forth in rule 5101:1-38-01.2 of the Administrative Code will result in denial of ongoing medical assistance and termination of presumptive coverage on the date described in paragraph (D) of this rule.

(d) If the pregnant woman is not presumptively eligible, inform her that her ineligibility for presumptive coverage does not necessarily mean that she is ineligible for other medical assistance, and that her eligibility for other categories of medical assistance will be reviewed.

(2) If the qualified provider is a hospital, FQHC, or FQHC look-alike:

(a) Upon request, or if the qualified provider believes the patient may meet the criteria for presumptive eligibility for pregnant women, determine whether the patient is presumptively eligible under this rule.

(b) Accept self-declaration of the presumptive eligibility criteria unless contradictory information is provided to or maintained by the qualified provider.

(c) If the pregnant woman is presumptively eligible:

(i) Approve presumptive coverage for the pregnant woman; and

(ii) Provide her at the time of determination with a notice of her presumptive eligibility. Such notice shall include the patient's:

(a) Presumptive eligibility determination date;

(b) Name, date of birth, and address;

(c) Expected due date;

(d) MITS billing number; and

(e)A reminder that she is required to make application for ongoing medical assistance by not later than the last day of the following month.

(iii) Notify the state medicaid agency of the presumptive eligibility determination within five working days after the date on which determination is made.

(iv) Take all reasonable steps to help the consumer complete her application for ongoing medicaid or make contact with the CDJFS.

(d) If the pregnant woman is not presumptively eligible, inform her that there may be other categories of medical assistance available to her, and that she should contact her local CDJFS for an eligibility determination.

(G) Denial of presumptive eligibility is not grounds for a state hearing under division 5101:6 of the Administrative Code.

Replaces: 5101:1-40-60

Effective: 04/01/2012
R.C. 119.032 review dates: 03/31/2017
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011
Rule Amplifies: 5111.0124
Prior Effective Dates: 4/1/91 (Emer.), 6/1/91, 9/1/92, 9/1/93, 7/1/00