Chapter 5160:1-1 General Medicaid Eligibility Policy

5160:1-1-01 Medicaid: definitions.

(A) This rule contains definitions generally used in determining medicaid eligibility.

(B) Definitions.

(1) "Abuse" means any action by an individual or entity that results in unnecessary costs to the medical assistance program.

(2) "Administrative agency" means the Ohio department of medicaid (ODM) and/or an agent of ODM authorized to determine eligibility for a medical assistance program.

(3) "AEMA" means alien emergency medical assistance as established in rule 5160:1-5-06 of the Administrative Code.

(4) "Assignment" means a medicaid-eligible individual has transferred his or her right to collect and retain third-party and/or medical support payments to ODM up to the amount of medical services paid under the medicaid program.

(5) "Authorized representative" means an individual, who is at least eighteen years old or a legal entity who stands in place of the individual. Actions or failures of an authorized representative have the same effect as if the individual did them. If an individual has designated an authorized representative, all references to "individual" in regard to an individual's responsibilities include the individual's authorized representative.

(6) "Caretaker relative" means a relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child's care (as may, but is not required to, be indicated by claiming the child as a tax dependent for federal income tax purposes), and who is one of the following:

(a) The child's father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, or stepsister.

(b) The child's aunt, uncle, nephew, or niece, including such relatives with the prefix great, great-great, grand, or great-grand.

(c) The child's first cousin or first cousin once removed.

(d) The spouse of such parent or relative, even after the marriage is terminated by death or divorce.

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

(8) "Certificate of creditable coverage" means a written certificate, issued by a health plan or health insurance issuer, that states the period of time an individual was or has been covered by the health plan. A certificate of creditable coverage must contain information about the duration of coverage and an educational statement that describes the individual's health insurance portability rights under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

(9) "Community Spouse" means an individual who is not in a medical institution or nursing facility and has an institutionalized spouse. If both spouses request or receive services under a home and community-based services (HCBS) waiver program or program of all inclusive care for the elderly (PACE), neither spouse meets this definition.

(10) "Confined" means serving time for a criminal offense or involuntary placement in a public institution, including a prison, jail, detention facility, or other penal institution. The term "confined":

(a) Includes placement while awaiting trial, sentencing, or other involuntary detainment determination.

(b) Does not include placement in a public institution pending arrangements appropriate to an individual's needs.

(11) "Continuous period of institutionalization" means an admission to a medical institution, receipt of home and community-based waiver services, or receipt of services under the program of all inclusive care for the elderly (PACE), for a period of at least thirty consecutive days.

(12) "Conviction" or "convicted" means a judgment of conviction has been decided by a federal, state, or local court, regardless of whether an appeal from that judgment is pending.

(13) "Creditable insurance" or "creditable coverage" means health insurance coverage as defined in 42 U.S.C. 300gg-3(c) (as in effect on September 1, 2013).

(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 1395i-5. (as in effect on April 1, 2013) or part B, as set forth in 42 U.S.C. 1395j to 1395w-4 (as in effect on April 1, 2013).

(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 April 1, 2013).

(v) Armed forces health insurance as set forth in 10 U.S.C. 1071 to 1110a (as in effect on April 1, 2013).

(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 8992 (as in effect on April 1, 2013).

(ix) A public health plan.

(x) A peace corps volunteer health benefit plan under section 22 U.S.C. 2504 (as in effect on April 1, 2013).

(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 April 1, 2013), coverage supplemental to the coverage provided to military or former military personnel under 10 U.S.C. Chapter 55 (as in effect on April 1, 2013), and similar supplemental coverage provided to coverage under a group health plan.

(14) "Denial" or "deny" means a determination by the administrative agency that an individual is not eligible for one or more categories of assistance applied for by the individual.

(15) "Dependent child" means a person younger than age eighteen living with a parent or caretaker relative.

(16) "Early and periodic screening, diagnostic and treatment" (EPSDT or healthchek) means periodic screening services for individuals under twenty-one years of age.

(17) "Electronic equivalent" means an electronic version of an Ohio department of job family services (ODJFS) or ODM 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 altered.

(18) "Electronic protected health information" (ePHI) means any protected health information (PHI) that is maintained or transmitted in electronic form, regardless of the format.

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

(20) "Erroneous payment" means a medicaid reimbursement made for an individual who was ineligible at the time services were received, regardless of the presence of fraud or abuse.

(21) "Family size" means the number of persons counted as members of an individual's medicaid household.

(22) "Federal adoption assistance" (AA) means the Title IV-E subsidy program as defined by the Adoption Assistance and Child Welfare Act of 1980.

(23) "Federal means-tested public benefit" means a benefit in which eligibility for the benefit or the amount of the benefit, or both, is determined on the basis of income or resources of the individual seeking the benefit. Medicaid, cash assistance, and food assistance are federal means-tested public benefits, but certain other benefits listed in 8 U.S.C. 1613(c) (as in effect on September 1, 2009) are not considered means-tested.

(24) "Federal poverty level" (FPL) means a measure of income level determined annually by the office of management and budget as required by 42 U.S.C. 9902(2) (as in effect on April 1, 2013).

(25) "Foster care maintenance" (FCM) means Ohio's Title IV-E foster care maintenance program, as described in rule 5101:2-47-01 of the Administrative Code.

(26) "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.

(27) "Home and community-based services" (HCB services or HCBS) means services furnished under the provision of 42 C.F.R. 441, subpart G (as in effect on June 1, 2015), that provide specific individuals an alternative to placement in a hospital, a nursing facility (NF), or an intermediate care facility for individuals with intellectual disabilities (IDD) as set forth in rule 5160-1-06 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;

(ii) Apply separately for HCB services; and

(iii) Be found eligible to receive HCB services.

(28) "Home and community-based (HCB) services waiver operational agency" means ODM or its designee that performs administrative functions related to an HCB services waiver program in accordance with agency 5160 of the Administrative Code.

(29) "Household income" is the sum of the MAGI-based income of every person included in an individual's medicaid household.

(30) "Immigrant" means a person who comes to the United States with plans to live here permanently. This term includes refugees, asylees, parolees, and other entrants regardless of whether residing in the United States legally.

(31) "Income" means any benefit in cash or in-kind, received by an individual during a calendar month.

(32) "Income and eligibility verification system" (IEVS) means the electronic system that shares income and asset information among the social security administration (SSA), internal revenue service (IRS), state wage information collection agency (SWICA), agencies administering the state unemployment compensation (UC) laws, and the administrative agency.

(33) "Individual" means a person applying for or receiving medical assistance.

(34) "Individually identifiable health information" means information that is a subset of health information that includes demographic information collected from an individual and:

(a) Is created or received by a health care provider, health plan, employer or health care clearinghouse; and

(b) Relates to the past, present, or future physical condition or mental health condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual and either:

(i) Identifies the individual; or

(ii) There is a reasonable basis to believe the information can be used to identify the individual.

(35) "Initial processing" means taking applications for medical assistance, assisting applicants in completing the application, providing information and referrals, obtaining required documentation needed to complete processing of the application, and assuring completeness of the information contained on the application. Initial processing does not include evaluating the information on the application and supporting documentation, or making a determination of eligibility.

(36) "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 is an IMD, whether or not it is licensed as such, if it is operated primarily for the care and treatment of individuals with mental diseases.

(b) An institution for persons with cognitive impairments or other developmental disabilities is not an IMD.

(37) "Institutionalized" describes an individual who receives long-term care (LTC) services in a medical institution, a long-term care facility, under a home and community-based services (HCBS) waiver program, or under program of all inclusive care for the elderly (PACE) for at least thirty consecutive days.

(38) "Institutionalized spouse" means an individual who receives long-term care services in a medical institution, a long-term care facility, under a home and community-based services (HCBS) waiver program, or under program of all inclusive care for the elderly (PACE) for at least thirty consecutive days.

(39) "Legal custodian" means a person who has legal custody, as defined in section 2151.011 of the Revised Code, and the right to have physical care and control of a minor child.

(40) "Legal guardian" means any guardian, as defined in section 2111.01 of the Revised Code, appointed by the probate court to have the care and management of a minor child.

(41) "Limited English proficiency" (LEP) means the inability of any person or group of persons to speak, read, write or understand the English language at a level that allows them to meaningfully communicate with the administrative agency.

(42) "Long term care facility" (LTCF) is a medicaid-certified nursing facility, skilled nursing facility, or intermediate care facility for individuals with intellectual disabilities (ICF-IDD) as defined in Chapter 5160-3 of the Administrative Code.

(43) "Long term care services" are medicaid-funded, institutional or community-based, medical, health, psycho-social, habilitative, rehabilitative, and/or personal care services, as defined in Chapter 5160-3 of the Administrative Code, that may be provided to medicaid-eligible individuals.

(44) "MAGI-based income" has the same meaning as in 42 C.F.R. 435.603 (as in effect on January 1, 2014).

(45) "MBIWD" means the medicaid buy-in for workers with disabilities category set forth in rule 5160:1-5-03 of the Administrative Code.

(46) "Medical assistance" includes all programs administered by the state medicaid administrative agency

(47) "Medicaid eligibility fraud" means that an individual knowingly:

(a) Made or caused to be made a false or misleading statement; or

(b) Concealed an interest in property or failed to disclose certain transfers of property.

(48) "Medicaid household" means a group of individuals, defined in relationship to one specific medical assistance applicant or recipient, who impact the applicant or recipient's family size or household income.

(49) "Medical support" has the same meaning as in section 5160.35 of the Revised Code.

(50) "Medical verification of pregnancy" means a written statement signed by a licensed medical professional verifying pregnancy and includes the expected date of delivery and, if more than one, the expected number of fetuses.

(51) "Non-applicant" means an individual who is not seeking an eligibility determination for himself or herself but is included in an applicant's or beneficiary's medicaid household to determine eligibility for such applicant or beneficiary

(52) "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.

(53) "Outstationing" means the federal requirement that administrative agencies provide opportunities for low-income pregnant women and children to apply for medicaid at locations other than the local county department of job and family services.

(54) "OWF sanction" means that an adult member of an Ohio works first (OWF) assistance group, as a result of his or her own failure, has become ineligible for OWF payments for at least six months due to a third or subsequent failure or refusal, without good cause, to comply in full with a provision of a self-sufficiency contract related to a work activity.

(55) "Parent" means a natural or adoptive parent, or step-parent.

(56) "Postpartum period" means a span of at least sixty days, beginning on the date a woman's pregnancy ends and ending on the last day of the month in which the sixtieth day falls.

(57) "Pre-termination review" (PTR) is set forth in rule 5160:1-2-01 of the Administrative Code. This is done prior to any termination of medical assistance to determine whether an individual is eligible for any other category of medical assistance.

(58) "Private child placing agency" (PCPA) as defined in rule 5101:2-1-01 of the Administrative Code.

(59) "Protected health information" (PHI) means individually identifiable health information that is transmitted by electronic media, maintained in electronic media or transmitted or maintained in any other form or medium.

(60) "Public children services agency" (PCSA) as defined in rule 5101:2-1-01 of the Administrative Code.

(61) "Public institution" means an institution which is the responsibility of a governmental unit or over which a governmental unit exercises administrative control, as evidenced by final administrative control, including ownership and control of the physical facilities and grounds.

(62) "Qualified entity" means the source of eligibility determinations for the presumptive eligibility program and is limited to the following:

(a) A county department of job and family services (CDJFS); or

(b) A hospital, the department of youth services (DYS), a federally qualified health center (FQHC) or a FQHC look-alike, that meet the requirements described in Chapter 5160-28 of the Administrative Code.

(63) "Refugee" means a person who flees his or her country due to persecution or a well-founded fear of persecution because of race, religion, nationality, political opinion, or membership in a social group.

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

(65) "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, legal custodian, legal guardian, or caretaker relative; and

(d) The individual's authorized representative.

(66) "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.

(67) "Residential care facility" (RCF) means a home that provides accommodations described in section 3721.01 of the Revised Code.

(68) "Safeguarding" means security measures taken to ensure that the information of individuals applying for or receiving medical assistance is protected against unauthorized inspection, disclosure, or use. Safeguarding also refers to the restriction on the use of, or disclosure of, individual information including federal tax information and returns (FTI), any protected health information (PHI), or other confidential information used in the administration of the medicaid program.

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

(70) "Spouse" means a person who is legally married to another under Ohio law.

(71) "State adoption assistance" means the state-only adoption subsidy program as described in rule 5101:2-44-03 of the Administrative Code.

(72) "Support Services" means non-medical services offered or provided by the administrative agency to assist the individual and may include arranging or providing transportation, making medical appointments, accompanying the individual to medical appointments, and making referrals to community and other social services to be coordinated with the individual's medicaid-contracting managed care plan (MCP), where applicable.

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

(74) "Temporary absence" means that an individual who is otherwise considered part of the family is considered not to have changed residence.

(a) An individual is considered to be temporarily absent with no time limit when all of the following conditions are met:

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

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

(iii) The absent individual shared the place of residence with the family immediately prior to the absence, except for individuals described in paragraph (C)(1)(h) of rule 5160:1-4-02 of the Administrative Code.

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

(c) Individuals who are confined are not temporarily absent.

(75) "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 June 1, 2015).

(76) "United States (U.S.)" and "state(s)" mean 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.

(77) "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 Ill, Part I (as in effect on April 1, 2013); 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 April 1, 2013).

(78) "Verification" means a document, statement, or other confirmation of information provided by an individual or by a third party to confirm statements made by the individual about any requirement for eligibility for medical assistance. A verification document or written statement may be an original, photocopy, facsimile (fax), or electronic version of the original, unless otherwise stated.

Replaces: 5160:1-1-01, 5160:1-1- 50.1

Effective: 1/1/2016
Five Year Review (FYR) Dates: 01/01/2021
Promulgated Under: 111.15
Statutory Authority: 5162.031, 5163.02
Rule Amplifies: 5162.031, 5163.02
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, 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, 1/9/12, 10/1/13, 1/1/14

5160:1-1-01.1 [Rescinded] Medicaid: safeguarding and releasing information.

Effective: 1/10/2015
Five Year Review (FYR) Dates: 10/23/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011
Rule Amplifies: 307.981, 329.01, 1347, 3503.10, 5101.30, 5111.01, 5111.011, 5122.31, 5703.211
Prior Effective Dates: 4/14/03 (Emer.), 7/1/03, 11/1/09

5160:1-1-03 Medicaid: restrictions on payment for services.

(A) Medicaid will not pay for services provided under the conditions set out in paragraph (C) of this rule, even if an individual has been found eligible for a medical assistance category and is enrolled in medicaid.

(B) Definitions.

(1) "Administrative control" exists:

(a) When a facility is an organizational part of a governmental unit; or

(b) When a governmental unit owns and controls the physical facilities and grounds; or

(c) When a governmental unit is responsible for the ongoing daily activities of a facility; or

(d) When a private entity is appointed by or contracts with a state, federal, or local governmental entity to act as its agent to manage the incarceration or care of inmates in a prison, jail, detention facility, or other penal facility.

(2) "Inmate" means an individual who is serving time for a criminal offense or who is confined in a state or federal prison, jail, detention facility, or other penal facility.

(3) "Inmate of a public institution" means a person who is living in a public institution.

(a) An individual who is residing in a public institution awaiting criminal proceedings, penal dispositions, or other detainment determinations is considered an inmate. The duration of time that an individual is residing in the public institution awaiting these arrangements does not determine inmate status.

(b) An individual is not considered an inmate if:

(i) He or she is residing in a public educational or vocational training institution for purposes of securing education or vocational training; or

(ii) He or she is residing in a public institution for a temporary period pending other living arrangements appropriate to his or her needs; or

(iii) He or she is residing in a detention center, jail, or county penal facility after his or her case has been adjudicated and other living arrangements are being decided; or

(iv) He or she is on parole or probation.

(4) "Inpatient" means a patient who has been admitted to a medical institution as an inpatient on recommendation of a physician or dentist and who:

(a) Receives room, board, and medical services in the institution for a 24 hour period or longer; or

(b) Is expected by the institution to receive room, board, and medical services in the institution for a 24-hour period or longer even though it later develops that the patient dies, is discharged, or is transferred to another facility and does not actually stay in the institution for 24 hours.

(5) "Inpatient hospital services" is defined in rule 5160-2-02 of the Administrative Code.

(6) "Institution for mental diseases" (IMD) is defined in 42 C.F.R. 435.1010 (as in effect on October 1, 2015).

(7) "Intermediate care facility for individuals with intellectual disabilities"(ICF-IID) is defined in chapter 5160-3 of the Administrative Code.

(8) "Medical institution" means an institution that:

(a) Is organized to provide medical care, including nursing and convalescent care; and

(b) Has the necessary professional personnel, equipment, and facilities to manage the medical, nursing, and other health needs of patients on a continuing basis in accordance with accepted standards; and

(c) Is authorized under state law to provide medical care; and

(d) Is staffed by professional personnel who are responsible to the institution for professional medical and nursing services. The services must include:

(i) Adequate and continual medical care and supervision by a physician; and

(ii) Registered nurse or licensed practical nurse supervision and services and nurses' aid services, sufficient to meet nursing care needs; and

(iii) A physician's guidance regarding the professional aspects of operating the institution.

(9) "Outpatient" means a patient of an organized medical facility or distinct part of that facility who is expected by the facility to receive, and who does receive, professional services for less than a 24-hour period regardless of the hour of admission, whether or not a bed is used, and whether or not the patient remains in the facility past midnight.

(10) "Patient" means an individual who is receiving needed professional services that are directed by a licensed practitioner of the healing arts toward maintenance, improvement, or protection of health, or lessening of illness, disability, or pain.

(11) "Public institution" means an institution that is under the responsibility of a governmental unit or over which a governmental unit exercises administrative control and that is not a medical institution as defined in paragraph (B)(7) of this rule.

(C) As required by 42 C.F.R. 435.1009 (as in effect on October 1, 2015), medicaid will not pay for services provided to:

(1) An individual who is an inmate of a public institution; or

(2) An individual who is a patient in an IMD who is age twenty-two or older, but under age sixty-five.

(D) An exception to the prohibition against medicaid payment for services is permitted during the part of the month in which an individual is not an inmate of a public institution.

(1) An individual is not an inmate of a public institution during such time as he or she is admitted as an inpatient in a hospital, nursing facility, juvenile psychiatric facility, or ICF-IID.

(2) There is no time limit on medicaid payment for services as long as the individual continues to be eligible for medicaid and is receiving services as an inpatient in the medical facility.

(3) An inmate is not considered a patient in a medical institution when:

(a) Services are provided on an outpatient basis at a hospital, nursing facility, juvenile psychiatric facility, ICF-IID, clinic, or physician office; or

(b) Medical care is provided to an inmate in a prison hospital or dispensary.

(E) An individual on conditional release or convalescent leave from an IMD is not considered to be a patient in that institution.

(1) An individual on conditional release is an individual who is on definite leave from the institution, but who is not discharged.

(2) An individual who is released from the institution on the condition that he or she receives outpatient treatment or on other comparable conditions is on conditional release.

(3) An individual who is sent home or to another setting for a trial visit is on convalescent leave.

Replaces: 5160:1-1- 58.1

Effective: 8/1/2016
Five Year Review (FYR) Dates: 08/01/2021
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02, 5163.45
Prior Effective Dates: 10/01/2013

5160:1-1-03.1 [Rescinded] Medicaid: income and eligibility verification system (IEVS).

Effective: 1/10/2015
Five Year Review (FYR) Dates: 10/23/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011
Rule Amplifies: 5111.01, 5111.011
Prior Effective Dates: 1/1/83, 12/1/86, 3/13/87 (Emer.), 5/4/87, 9/1/89 (Emer.), 11/30/89, 1/1/90 (Emer.), 4/1/90, 1/1/93, 9/1/94, 11/1/96, 7/1/98, 7/1/99, 10/1/02, 10/6/03, 11/1/09

5160:1-1-04 Medicaid: income and eligibility verification system (IEVS).

(A) This rule describes the requirements in section 1137 of the Social Security Act (as in effect on May 1, 2014) and in section 42 C.F.R. 435.945 (as in effect on May 1, 2014), requiring state agencies administering certain federally funded, state administered public assistance programs, to establish procedures for obtaining, using and verifying information relevant to determinations of eligibility. The Ohio department of medicaid shall obtain and share income and benefit information with the following sources:

(1) The social security administration (SSA).

(2) The internal revenue service (IRS).

(3) The state wage information collection agency (SWICA).

(4) The agencies administering the State unemployment compensation (UC) laws.

(B) Definition. "IEVS" is defined in rule 5160:1-1-50.1 of the Administrative Code.

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

(1) Provide adequate safeguards in accordance with rule 5160:1-1-51.1 of the Administrative Code.

(2) Inform all individuals in writing at the time of application and reapplication that the agency will obtain and use information available from IEVS to verify an individual's eligibility for medicaid.

(3) Within forty-five days of receipt of the information, review and compare against the case record all information received to determine whether it affects the individual's eligibility. Obtain verification, if appropriate, to determine eligibility and initiate appropriate action in accordance with 42 C.F.R. 435.952(c) (as in effect on May 1, 2014). For applicants, if the information is received during the application period, it must be used to the extent possible to make eligibility determinations, in accordance with 42 C.F.R. 435.952(b) (as in effect on May 1, 2014).

(4) Verify the information, in accordance with 42 C.F.R. 435.948 (as in effect on May 1, 2014) and 42 C.F.R. 435.949 (as in effect on May 1, 2014).

(5) Not terminate, deny, suspend benefits until appropriate steps have been taken to verify the information in accordance with 42 C.F.R. 435.952(d) (as in effect on May 1, 2014). The administrative agency shall verify information relating to:

(a) The amount of the income and resource involved;

(b) Whether the individual actually has or had access and use of the resource, income, or both;

(c) The period of time during which the individual actually has or had access to the resource, income, or both.

(6) Maintain the individual's data in a standardized format that allows the administrative agency to furnish and to obtain eligibility and income information from the agencies or programs referenced in 42 C.F.R. 435.945 and 42 C.F.R. 435.948(a) in accordance with 42 C.F.R. 435.960(a) (as in effect on May 1, 2014).

Replaces: 5160:1-1- 03.1

Effective: 1/10/2015
Five Year Review (FYR) Dates: 01/10/2020
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5160.02, 5163.02
Prior Effective Dates: 1/1/83, 12/1/86, 3/13/87 (Emer.), 5/4/87, 9/1/89 (Emer.), 11/30/89, 1/1/90 (Emer.), 4/1/90, 1/1/93, 9/1/94, 11/1/96, 7/1/98, 7/1/99, 10/1/02, 10/06/03, 11/1/09

5160:1-1-20 [Rescinded] Medicaid: restrictions on payment for services.

Effective: 1/10/2015
Five Year Review (FYR) Dates: 10/23/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011
Rule Amplifies: 5111.01, 5111.011, 5111.0119
Prior Effective Dates: 3/1/09 (Emer.), 5/29/09

5160:1-1-50 Medicaid: administrative code rule migration.

(A) This rule describes the migration of Administrative Code rules regarding eligibility categories and eligibility determination processes as the department of medicaid (ODM) moves to a new Administrative Code title and implements new federal requirements.

(B) Effective dates.

(1) For the determination or redetermination of eligibility for medical assistance, rules 5101:1-37-50 to 5101:1-37-58.3 of the Administrative Code are effective upon publication.

(2) For the determination of eligibility under modified adjusted gross income (MAGI) based or presumptive eligibility categories with coverage beginning on or after January 1, 2014, rules 5101:1-37-61 to 5101:1-37-65 of the Administrative Code are effective October 1, 2013 or the date of publication of the rule, whichever is later.

(3) For the determination or redetermination of eligibility under non-MAGI eligibility categories for the aged, blind, or disabled; alien status; or another non-MAGI eligibility category, with coverage beginning on January 1, 2014, Chapters 5101:1-38, 5101:1-39, 5101:1-41, and 5101:1-42 of the Administrative Code remain in effect.

(C) Conflicts between rules.

(1) Beginning October 1, 2013, or, if later, the effective date of this rule, the administrative agency must comply with Administrative Code rules 5101:1-37-50 to 5101:1-37-58.3 regarding administrative processes and the determination and redetermination of eligibility.

(2) For any benefit month prior to January, 2014, an individual may be found eligible for medical assistance under an eligibility category described in Chapter 5101:1-40 of the Administrative Code.

(3) For January, 2014 or any later benefit month, eligibility for a given category must be determined under the rules appropriate for that category:

(a) For a MAGI-based eligibility group, eligibility must be determined under rules 5101:1-37-61 to 5101:1-37-65 of the Administrative Code; or

(b) For an eligibility category based upon age, blindness, disability, alien status, or other non-MAGI basis, eligibility must be determined under Chapters 5101:1-38, 5101:1-39, 5101:1-41, and 5101:1-42 of the Administrative Code.

Effective: 10/01/2013
R.C. 119.032 review dates: 10/01/2018
Promulgated Under: 111.15
Statutory Authority: 5111.01
Rule Amplifies: 5111.01

5160:1-1-50.1 [Rescinded] Medicaid: definitions.

Effective: 1/1/2016
Five Year Review (FYR) Dates: 10/16/2015
Promulgated Under: 111.15
Statutory Authority: 5162.031, 5163.02
Rule Amplifies: 5162.031, 5163.02
Prior Effective Dates: 10/1/13, 1/1/14

5160:1-1-51 [Rescinded] Medicaid: administrative agency responsibilities.

Effective: 1/1/2016
Five Year Review (FYR) Dates: 10/16/2015
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02, 329.051, 2913.401, 3501.01, 3503.10
Prior Effective Dates: 10/1/13

5160:1-1-51.1 Medicaid: safeguarding and releasing information.

(A) This rule describes the administrative agency's responsibilities regarding disclosing information, maintaining confidentiality and safeguarding information for an individual applying for or participating in a medical assistance program.

(B) "Safeguarded information" includes but is not limited to the following types of information:

(1) Names and addresses; and

(2) Medical services provided; and

(3) Social and economic conditions or circumstances; and

(4) Agency evaluation of personal information; and

(5) Medical data, including diagnosis and past history of disease or disability; and

(6) Any information received in connection with the identification of third party coverage; and

(7) Any information received for verifying income eligibility and amount of medical assistance payments. Income information received from the social security administration (SSA) or the internal revenue service (IRS) must be safeguarded according to the requirements of the agency that furnished the data.

(C) Administrative agency safeguarding responsibilities. The administrative agency must:

(1) Implement administrative, physical and technical safeguards in accordance with 45 CFR 164.308, 45 CFR 164.310, and 45 CFR 164.312 (as in effect on April 1, 2013).

(2) Follow the safeguarding guidelines for protecting federal tax information (FTI) described in the most current version of IRS publication 1075 (rev. 6/2010).

(3) Safeguard information received or maintained about an individual connected with the administration of the medicaid program in accordance with 42 C.F.R. 431.302 (as in effect on March 1, 2013).

(4) Publicize provisions governing the confidential nature of information about individuals, including the legal sanctions imposed for improper disclosure and use, in accordance with 42 C.F.R. 431.304 (as in effect March 1, 2013).

(5) Provide copies of the publicized provisions to individuals and to other persons and agencies to whom information is disclosed, in accordance with 42 C.F.R. 431.304 (as in effect March 1, 2013).

(6) Protect the types of safeguarded information required by 42 C.F.R. 431.305 (as in effect March 1, 2013).

(7) Not release medical, psychiatric or psychological information to an individual or authorized representative if the administrative agency has reason to believe that the release may have an adverse effect on the individual, as provided in section 5122.31 of the Revised Code.

(8) Not publish names of individuals in accordance with 42 C.F.R. 431.306(c) (as in effect March 1, 2013).

(D) Release of information. The administrative agency must:

(1) Obtain permission from an individual or authorized representative before releasing information, unless that information is used to verify income or eligibility, in accordance with 42 C.F.R. 431.306(d) (as in effect on March 1, 2013).

(2) Apply policies to all requests for information from outside sources, including governmental bodies, courts of law, or law enforcement officials, except as provided in sections 5101.26 to 5101.30 of the Revised Code.

(3) Establish criteria specifying the conditions for release and use of information about individuals. The information must be restricted to persons or agency representatives who are subject to standards of confidentiality that are comparable to those of the agency in accordance with 42 C.F.R. 431.306(a) and (b) (as in effect on March 1, 2013).

(4) Limit disclosures of protected health information (PHI) for individuals applying for, or participating in, a medical assistance program to purposes related to payment, treatment, or health care operations. For any other purposes, disclosures of information about the health care of an individual, health care provided to an individual, or payment for the provision of health care for an individual require an authorization compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) in accordance with 45 CFR 164.508 (as in effect April 1, 2013).

(5) Release information as permitted by and in accordance with sections 5101.27 and 5101.271 of the Revised Code.

Effective: 10/01/2013
R.C. 119.032 review dates: 10/01/2018
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011
Rule Amplifies: 307.981, 329.01, 1347, 3503.10, 5101.30, 5111.01, 5111.011, 5122.31, 5703.211

5160:1-1-51.2 [Rescinded] Medicaid: consumer fraud and erroneous payments.

Effective: 8/1/2016
Five Year Review (FYR) Dates: 04/15/2016
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011
Rule Amplifies: 2913.401, 5111.01, 5111.011, 5111.12
Prior Effective Dates: 10/1/2013

5160:1-1-51.3 [Rescinded] Medicaid: certificate of creditable coverage and privacy notice.

Effective: 1/1/2016
Five Year Review (FYR) Dates: 10/16/2015
Promulgated Under: 111.15
Statutory Authority: 5162.031, 5163.02
Rule Amplifies: 5162.031, 5163.02
Prior Effective Dates: 10/1/98, 10/6/03, 11/1/09

5160:1-1-51.4 [Rescinded] Medicaid: outstationing workers at disproportionate share hospitals and federally qualified health centers.

Effective: 8/1/2016
Five Year Review (FYR) Dates: 04/15/2016
Promulgated Under: 111.15
Statutory Authority: 5162.031, 5163.02
Rule Amplifies: 5163.02, 5163.10, 5163.101
Prior Effective Dates: 5/1/95, 7/1/00, 1/1/06

5160:1-1-55 [Rescinded] Medicaid: individual responsibilities.

Effective: 8/1/2016
Five Year Review (FYR) Dates: 04/15/2016
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02, 5160.37, 329.051
Prior Effective Dates: 10/01/2013

5160:1-1-55.1 Medicaid: authorized representative responsibilities.

(A) This rule describes the responsibilities of an authorized representative who is appointed in writing by the individual to stand in the place of the individual and act with authority on behalf of the individual. These responsibilities do not apply to people or organizations who merely help or assist an individual with portions of the application, verification, or redetermination process, unless the individual or organization is granted authority to act on behalf of the individual.

(B) Assistance from individuals who are not authorized representatives. A person may accompany and assist an individual without being an individual's authorized representative.

(1) The administrative agency must not reveal safeguarded information, as described in rule 5101:1-37-51.1 of the Administrative Code, or send notices or correspondence to a person who is assisting an individual, unless the person is designated in writing as an authorized representative.

(2) A person who is assisting an individual must provide accurate information, to the best of his or her knowledge, regardless of whether the person is an authorized representative.

(C) Appointment of an authorized representative.

(1) Any person at least eighteen years old, or a business or other legal entity, may be appointed an authorized representative by an individual.

(2) An authorized representative must be appointed by an individual in order to act on the individual's behalf or have access to the individual's medicaid information. The document appointing an authorized representative must identify what duties the individual is authorizing the representative to perform.

(3) If the appointed authorized representative is unwilling or unable to accept the responsibility of being an authorized representative, the authorized representative must inform the administrative agency and the individual of the refusal or withdrawal.

(D) Responsibilities of an authorized representative. If a person or organization is designated as an individual's authorized representative, the authorized representative:

(1) Must present proper identification, if requested by the administrative agency, prior to representation of the individual by or disclosure of medicaid information to the authorized representative.

(2) Will receive copies of notices and correspondence sent to the individual by the administrative agency.

(3) Stands in the place of the individual. Any responsibility of the individual is a responsibility of the authorized representative. Any action taken by the authorized representative or failure to act will be accepted as the action or lack of action of the individual.

(4) Shares all responsibilities set out in rule 5101:1-37-55 of the Administrative Code.

(E) The administrative agency may contact the 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, 5111.011, 5111.012
Rule Amplifies: 5111.01, 5111.011, 5111.012, 2913.401, 3501.01, 3503.10, 5101.58, 329.051

5160:1-1-58 [Rescinded] Medicaid: conditions of eligibility and verifications.

Effective: 8/1/2016
Five Year Review (FYR) Dates: 04/15/2016
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02, 5164.02
Rule Amplifies: 5162.03, 5163.02, 5164.02
Prior Effective Dates: 10/01/2013

5160:1-1-58.1 [Rescinded] Medicaid: restrictions on payment for services.

Effective: 8/1/2016
Five Year Review (FYR) Dates: 04/15/2016
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02, 5163.45
Prior Effective Dates: 10/01/2013

5160:1-1-58.2 [Rescinded] Medicaid: United States (U.S.) citizenship documentation.

Effective: 8/1/2016
Five Year Review (FYR) Dates: 04/15/2016
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011, 5111.02
Rule Amplifies: 5111.01, 5111.011, 5111.02
Prior Effective Dates: .

5160:1-1-58.3 [Rescinded] Medicaid: non-citizens.

Effective: 8/1/2016
Five Year Review (FYR) Dates: 04/15/2016
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011
Rule Amplifies: 5111.01, 5111.011
Prior Effective Dates: .

5160:1-1-61 [Rescinded] MAGI-based medicaid: income and household income.

Effective: 1/1/2016
Five Year Review (FYR) Dates: 10/16/2015
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02
Prior Effective Dates: 10/1/13

5160:1-1-62 Medicaid: presumptive eligibility.

(A) This rule describes the conditions under which an individual may receive time-limited medical assistance as a result of an initial, simplified determination of eligibility based on the individual's self-declared statements.

(B) Eligibility criteria for presumptive coverage.

(1) Limitations. An individual is ineligible for a subsequent presumptive coverage period for twelve months beginning on the date of a presumptive coverage determination, except that a woman may receive presumptive coverage based on pregnancy once during each pregnancy.

(2) Except as set forth in paragraph (B)(1) of this rule, an individual is eligible for presumptive coverage if the individual:

(a) Is a resident of the state of Ohio; and

(b) Is a U.S. citizen or has an immigration status as defined in rule 5160:1-1-58.3 of the Administrative Code that allows for medicaid eligibility; and

(c) Meets the non-financial eligibility criteria for a group set out in rule 5160:1-1-63, 5160:1-1- 63.1, 5160:1-1-64, or 5160:1-1-65 of the Administrative Code , except that a simplified determination of household composition will be done, whereby household composition comprises the individual and, if living in the home:

(i) The individual's spouse;

(ii) The individual's children under age nineteen; and

(iii) If the individual is under age nineteen:

(a) The individual's parents; and

(b) The individual's siblings under the age of nineteen.

(d) Has gross family income, for the individual's family size, of no more than the eligibility limit set out for the relevant eligibility group in rule 5160:1-1-63, 5160:1-1- 63.1, 5160:1-1-64, or 5160:1-1-65 of the Administrative Code.

(C) Duration and scope of presumptive coverage.

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

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

(a) The date the administrative agency determines that the individual is eligible or ineligible for ongoing medical assistance pursuant to rule 5160:1-1-51 of the Administrative Code; or

(b) If an application for ongoing medical assistance for the individual has not been filed, the last day of the month following the month in which the individual was determined to be presumptively eligible.

(3) Presumptive eligibility services for individuals found presumptively eligible on the basis of pregnancy are restricted to ambulatory prenatal care.

(D) State agency responsibilities. The Ohio department of medicaid (ODM) must:

(1) Provide qualified entities (QEs), as defined in rule 5160:1-1-50.1 of the Administrative Code, with:

(a) Such forms as are necessary for applications to be submitted for medical assistance under the state plan; and

(b) Information on how to assist individuals in completing and filing such forms.

(2) Monitor the performance of each QE, as specified in the presumptive coverage addendum to their operating agreement, to determine that the QE has provided appropriate assistance to presumptively eligible individuals.

(3) Determine if a QE is in compliance with the presumptive coverage addendum to their operating agreement and notify any QE found to be out of compliance that the QE is no longer authorized to determine presumptive eligibility.

(E) Qualified entity (QE) responsibilities.

(1) If the QE is a CDJFS:

(a) No later than the end of the business day after receipt of a signed and dated application for medical assistance on behalf of an individual, the CDJFS must determine, based on the individual's self-declared information, whether an individual is eligible for presumptive coverage under this rule.

(b) If an individual is eligible for presumptive coverage, the CDJFS must:

(i) Approve presumptive coverage for the individual; and

(ii) Inform the individual of:

(a) The presumptive coverage, and

(b) That failure to cooperate with the eligibility determination process set forth in rule 5160:1-1-51 of the Administrative Code will result in a denial of medical assistance, which will trigger the termination of presumptive coverage.

(iii) Not make an absent parent referral described in rule 5101:1-3-10 of the Administrative Code as a part of the approval of presumptive eligibility coverage.

(c) If an individual is not eligible for presumptive coverage, the CDJFS must inform the individual that the individual's eligibility for medical assistance will be determined.

(d) Whether or not an individual is eligible for presumptive coverage, the CDJFS must determine whether the individual is eligible for ongoing medical assistance pursuant to rule 5160:1-1-51 of the Administrative Code.

(2) If the QE is a hospital, department of youth services (DYS), federally-qualified health center (FQHC), or FQHC look-alike, as defined in rule 5160:1-1-50.1 of the Administrative Code:

(a) Upon request, or if the QE believes the individual may meet the criteria for presumptive eligibility, determine whether the individual is presumptively eligible under this rule. Such determination shall not be delegated to a third party, but shall be done by the QE.

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

(c) If the individual is presumptively eligible:

(i) Approve presumptive coverage for the individual using the electronic eligibility system designated by ODM in the presumptive eligibility operating addendum to the QE's provider agreement; and

(ii) Provide the individual, at the time of determination, with a notice of the individual's presumptive eligibility. Such notice must include the individual's:

(a) Presumptive eligibility determination date;

(b) Basis for presumptive eligibility;

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

(d) Medicaid information technology system (MITS) billing number; and

(e) A reminder that the individual must apply for ongoing medical assistance no later than the last day of the following month.

(iii) Take all reasonable steps to help the consumer complete the application for ongoing medical assistance or make contact with the CDJFS.

(d) If the individual is not presumptively eligible, inform the individual that there may be other categories of medical assistance available to the individual, and that the individual should apply for a full determination of eligibility for medical assistance.

(e) Disqualification of QEs. A QE may be disqualified if ODM finds that a QE is not:

(i) Making, or is not capable of making, presumptive eligibility determinations, or

(ii) Complying with the QE responsibilities as described in this rule and in any agreement required by ODM.

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

Effective: 4/25/2015
Five Year Review (FYR) Dates: 03/31/2019
Promulgated Under: 111.15
Statutory Authority: 5163.02
Rule Amplifies: 5163.01, 5163.02, 5163.10, 5163.101
Prior Effective Dates: 4/1/91 (Emer.), 6/1/91, 9/1/92, 9/1/93, 7/1/00, 4/1/10 (Emer.), 7/1/10, 4/1/12 (Emer.), 4/1/12, 7/1/12, 3/31/14

5160:1-1-63 [Rescinded] MAGI-based medicaid: coverage for children younger than age nineteen.

Effective: 3/26/2015
Five Year Review (FYR) Dates: 12/19/2014
Promulgated Under: 111.15
Statutory Authority: 5161.02, 5161.12, 5160.02, 5163.02, 5163.40
Rule Amplifies: 5161.02, 5161.12, 5160.02, 5163.02, 5163.40
Prior Effective Dates: 10/1/13

5160:1-1-63.1 [Rescinded] MAGI-based medicaid: coverage for Ribicoff and former foster care adults.

Effective: 3/26/2015
Five Year Review (FYR) Dates: 12/19/2014
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5160.02, 5163.02
Prior Effective Dates: 10/1/13

5160:1-1-63.2 [Rescinded] Medicaid: continuous eligibility for children younger than age nineteen.

Effective: 8/1/2016
Five Year Review (FYR) Dates: 04/15/2016
Promulgated Under: 111.15
Statutory Authority: 5162.031, 5163.02
Rule Amplifies: 5163.02, 5163.03
Prior Effective Dates: 4/1/10 (Emer.), 7/1/10, 10/15/10

5160:1-1-64 [Rescinded] MAGI-based medicaid: coverage for pregnant women.

Effective: 1/1/2016
Five Year Review (FYR) Dates: 10/16/2015
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02, 5163.40
Prior Effective Dates: 10/1/13

5160:1-1-65 [Rescinded] MAGI-based medicaid: coverage for a parent or caretaker relative residing with a child.

Effective: 1/1/2016
Five Year Review (FYR) Dates: 10/16/2015
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02
Prior Effective Dates: 10/1/13

5160:1-1-91 [Rescinded] Medicaid: alien emergency medical assistance (AEMA).

Effective: 8/1/2016
Five Year Review (FYR) Dates: 04/15/2016
Promulgated Under: 111.15
Statutory Authority: 5162.031, 5163.02
Rule Amplifies: 5163.02
Prior Effective Dates: 01/01/2014