Chapter 5160:1-1 Medicaid General Principles

5160:1-1-01 Medicaid: definitions.

(A) This rule contains the definitions of terms used in Chapters 5101:1-37, 5101:1-38, 5101:1-39, 5101:1-40, 5101:1-41, and 5101:1-42 of the Administrative Code. These definitions apply unless a term is otherwise defined in a specific rule.

(B) Definitions.

(1) "Administrative agency" means the CDJFS, ODJFS, or other entity that determines eligibility for a medical assistance program.

(2) "AEMA" means alien emergency medical assistance as established in rule 5101:1-41-20 of the Administrative Code.

(3) "Allocation" and "deeming" mean the distribution of income or resources from a responsible individual not included in the covered group to members of a covered group for whom they have a legal and/or financial responsibility. Allocation or deeming occurs when the responsible individuals are:

(a) The biological or adoptive parent(s) of an individual; or

(b) The spouse of an individual.

(4) "Authorized representative" means an individual, eighteen years or older, who stands in place of the individual. The authorized representative may include a legal entity assisting in the application process. The administrative agency may request proper identification from the authorized representative.

(5) "BCCP" means the Ohio breast and cervical cancer project.

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

(7) "CDJFS" means county department of job and family services.

(8) "Child" or "minor child" means a person who has not attained eighteen years of age or has not attained nineteen years of age and is a full-time student in a secondary school or in an equivalent level of vocational or technical training.

(9) "Covered group" means an individual or individuals who qualify for medical assistance under Title XIX or Title XXI of the Social Security Act (as in effect on March 1, 2011).

(10) "CPA" means combined programs application.

(11) "Creditable insurance" or "creditable coverage" means health insurance coverage as defined in 42 U.S.C. 300gg(a) to (c) (as in effect on February 1, 2010).

(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 42 U.S.C. 1395i-5 . (as in effect on February 1, 2010) or part B, as set forth in 42 U.S.C. 1395j to 42 U.S.C. 1395w-4 (as in effect on February 1, 2010).

(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 February 1, 2010).

(v) Armed forces health insurance as set forth in 10 U.S.C. 1071 to 10 U.S.C. 1110a (as in effect on January 7, 2011).

(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 5 U.S.C. 8992 (as in effect on January 7, 2011).

(ix) A public health plan.

(x) A peace corps volunteer health benefit plan under section 22 U.S.C. 2504 (as in effect on January 7, 2011).

(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 February 1, 2010), coverage supplemental to the coverage provided to military or former military personnel under 10 U.S.C. Chapter 55 (as in effect on January 7, 2011), and similar supplemental coverage provided to coverage under a group health plan.

(12) "Electronic equivalent" means an electronic version of an ODJFS 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 materially altered.

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

(14) "EPSDT" means early and periodic screening, diagnosis and treatment as described in rule 5101:1-38-05 of the Administrative Code, also referred to as healthchek.

(15) "Family" means the following persons living in the same household as the individual for whom medical assistance is sought or received:

(a) The individual;

(b) If the individual is a minor, the biological, adoptive, step parents, legal guardians, or legal custodians of the individual;

(c) The spouse of any person listed in paragraph (B)(15)(a) or

(B) (15)

(b) of this rule; and

(d) Minor dependent children of persons listed in paragraph

(B)

(15)

(a) , (B)(15)(b), or (B)(15)(c) of this rule.

(16) "FPL" means the federal poverty level determined annually by the office of management and budget as required by 42 U.S.C. 9902(2) (as in effect on February 1, 2010).

(17) "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.

(18) "Home and community-based (HCB) services waiver operational agency" means ODJFS or its designee that performs administrative functions related to an HCB services waiver program in accordance with division 5101:3 of the Administrative Code.

(19) "HCB services" or "HCBS" means specific home and community-based services furnished under the provision of 42 C.F.R. 441, subpart G (as in effect on October 1, 2011), that provide specific individuals an alternative to placement in a hospital, a nursing facility (NF), or an intermediate care facility for persons with mental retardation (ICF/MR) as set forth in rule 5101:3-1-06 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; and

(ii) Apply separately for HCB services; and

(iii) Be found eligible to receive HCB services.

(20) "Income" is defined in rule 5101:1-38-01.9 of the Administrative Code.

(21) "Individual" means an applicant for or recipient of a medical assistance program.

(22) "Institution for mental diseases" (IMD) means a hospital, nursing facility, or other institution of more than sixteen beds primarily providing 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.

(23) "LIF" means low-income families medicaid under section 1931 of the Social Security Act.

(24) "Limited English proficiency" (LEP) means any person or group of persons who cannot speak, read, write or understand the English language at a level that allows them to meaningfully communicate with county agencies or county agency contractors.

(25) "Medicaid eligibility fraud" means a violation of section 2913.401 of the Revised Code, which states that no person, in an application for medicaid benefits or in a document that requires a disclosure of assets for the purpose of determining eligibility to receive medicaid benefits, shall knowingly:

(a) Make or cause to be made a false or misleading statement; or

(b) Conceal an interest in property; or

(c) Fail to disclose a certain transfers of property.

(26) "Medical assistance program" includes all programs administered by the state medicaid administrative agency.

(27) "MBIWD" means the medicaid buy-in for workers with disabilities category set forth in rule 5101:1-41-30 of the Administrative Code.

(28) "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.

(29) "ODJFS" means the Ohio department of job and family services.

(30) "PCPA" means a private child placing agency.

(31) "PCSA" means a public children services agency.

(32) "Pend" or "pending" means the administrative agency has begun to process an individual's application for medical assistance but has not yet determined whether an individual is eligible for a category of medical assistance.

(33) "Personal knowledge" means first-hand knowledge of circumstances of an event. A person verifying an event, based on personal knowledge, should be able to share such details as when and where the event occurred, who was involved and whether there were any special circumstances surrounding the event.

(34) "Postpartum coverage" means a span of medicaid eligibility beginning on the last day of a pregnancy (if the woman was eligible for and receiving medicaid on that date) and ends on the last day of the month in which the sixtieth day (after the last day of the woman's pregnancy) falls.

(35) "PTR" means pre-termination review as set forth in rule 5101:1-38-01.2 of the Administrative Code. This is done prior to any termination of assistance to determine whether a consumer is eligible for any other category of assistance.

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

(37) "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, guardian, or specified relative; and

(d) The individual's authorized representative.

(38) "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.

(39) "Residential care facility" (RCF) means a home that provides either of the following:

(a) Accommodations for seventeen or more unrelated individuals and supervision and personal care services for three or more of those individuals who are dependent on the services of others by reason of age or physical or mental impairment; or

(b) Accommodations for three or more unrelated individuals, supervision and personal care services for at least three of those individuals who are dependent on the services of others by reason of age or physical or mental impairment, and, to at least one of those individuals, any of the skilled nursing care authorized by section 3721.011 of the Revised Code.

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

(41) "Specified relative" means the following individuals who are age eighteen or older:

(a) The following individuals related by blood or adoption:

(i) Grandparents, including grandparents with the prefix great, great-great, or great-great-great;

(ii) Siblings;

(iii) Aunts, uncles, nephews, and nieces, including such relatives with the prefix great, great-great, grand, or great-grand; and

(iv) First cousins and first cousins once removed.

(b) Stepparents and stepsiblings;

(c) Spouses and former spouses of individuals named in paragraph (B)(41)(a) or (B)(41)(b) of this rule.

(42) "SSA" means the social security administration.

(43) "SSN" means social security number.

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

(45) "Temporary absence" means that an individual (parent or child) who is otherwise considered part of the family is considered to be temporarily absent (and not to have changed residence) when all of the following conditions are met:

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

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

(c) The absent individual shared the place of residence with the family immediately prior to the absence, except for individuals described in paragraph (B)(6) of rule 5101:1-40-02.2 of the Administrative Code.

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

(46) "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 October 1, 2011).

(47) "United States (U.S.)" and "state(s)" means 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.

(48) "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 III, Part I (as in effect on January 7, 2011); 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 January 7, 2011).

(49) "Verification" means a document or statement from a third party or collateral contact confirming statements made by the individual about a specific eligibility criterion. A verification document or written statement may be an original, photocopy, facsimile (fax), or electronic version of the original, unless otherwise stated.

Effective: 01/09/2012
R.C. 119.032 review dates: 10/01/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011
Rule Amplifies: 5111.01 , 5111.011 , 5101.58
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, 12/1/82, 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

5160:1-1-01.1 Medicaid: safeguarding and releasing information.

(A) This rule describes the requirements of disclosing information, maintaining confidentiality and safeguarding information for an individual participating in a medical assistance program. No information shall be released to anyone except as provided in sections 5101.26 to 5101.271 of the Revised Code.

(B) Definition of safeguard. "Safeguard" means security measures that need to be taken to ensure that federal tax information (FTI) of medicaid individuals is protected against unauthorized inspection or disclosure and use. Safeguarding also refers to the restriction on the use of, or disclosure of, individual information.

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

(1) Follow the safeguarding guidelines for protecting federal tax returns and federal tax return information as described in the internal revenue service (IRS) publication 1075 (as in effect November 1, 2009).

(2) Safeguard information about individuals by restricting the use of, or disclosure of, information concerning individuals to purposes directly connected with the administration of the medicaid program in accordance with 42 C.F.R. 431.302 (as in effect November 1, 2009). Purposes directly related to the administration of the medicaid program include:

(a) Establishing eligibility;

(b) Determining the amount of medical assistance;

(c) Providing services for individuals; and

(d) Conducting or assisting an investigation, prosecution, or civil or criminal proceeding.

(3) Publicize provisions governing the confidential nature of information about individuals. The agency shall provide copies of these 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 November 1, 2009).

(4) Protect the types of information about individuals that are safeguarded in accordance with 42 C.F.R. 431.305 (as in effect November 1, 2009). The information shall include:

(a) Names and addresses;

(b) Medical services provided;

(c) Social and economic conditions or circumstances;

(d) Administrative agency evaluation of personal information;

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

(f) Any information received for verifying income eligibility and amount of medical assistance payments. Income information received from the social security administration or the internal revenue service shall be safeguarded according to the requirements of the agency furnishing the data.

(g) Any information received in connection with the identification of legally liable third party resources, in accordance with 42 C.F.R. 433.138 (as in effect on November 1, 2009).

(5) Release information as permitted in accordance with sections 5101.27 and 5101.271 of the Revised Code. Information and records, but only the minimum necessary to fulfill the need for the sharing of information concerning an individual, shall be released.

(6) Obtain a Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant authorization form when requests for information are received or when information is provided about the health care of an individual, the health care provided to an individual, or the payment for the provision of health care for an individual, in accordance with 45 C.F.R. 164.508 (as in effect November 1, 2009).

(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) 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 November 1, 2009).

(9) Not publish names of individuals in accordance with 42 C.F.R. 431.306(c) (as in effect November 1, 2009).

(10) Obtain permission from an individual or authorized representative whenever releasing information, unless that information is used to verify income or eligibility (IEVS) in accordance with 42 C.F.R. 431.306(d) (as in effect November 1, 2009).

(11) 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 (as in effect on November 1, 2009).

(12) Distribute materials to individuals in accordance with 42 C.F.R. 431.307 (as in effect November 1, 2009). The materials shall:

(a) Have no political implications except to the extent required to implement the National Voter Registration Act (NVRA) of 1993.

(b) Include voter information and registration materials as provided in section 3503.10 of the Revised Code (as in effect on November 1, 2009).

(c) Contain only the names of individuals directly connected with the administration of the medicaid program and shall identify those individuals only in their official capacity.

(d) Not be materials such as holiday greetings, general public announcements, partisan voting information and alien registration notices.

(13) Have the authority to distribute materials directly related to the health and welfare of individuals, such as announcements of free medical examinations, availability of surplus food, and consumer protection information.

Replaces: 5101:1-37- 01.1

Effective: 11/01/2009
R.C. 119.032 review dates: 11/01/2014
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

5160:1-1-03.1 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 November 1, 2009) and in section 42 C.F.R. 435.940 (as in effect on November 1, 2009), 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 job and family services shall obtain and share income and benefit information with the following sources:

(1) The social security administration (SSA).

(2) The internal revenue service (IRS).

(B) Definition of IEVS. "IEVS" means income and eligibility verification system that shares income and asset information among SSA, IRS and the administrative agency.

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

(1) Provide adequate safeguards in accordance with rule 5101:1-37-01.1 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 assist in the determination of eligibility under section 1137 of the Social Security Act.

(3) Within forty-five days of receipt of the information, review and compare against the case file 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 November 1, 2009). 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 November 1, 2009).

(4) Verify the information, in accordance with 42 C.F.R. 435.955(b) (as in effect on November 1, 2009) by:

(a) Contacting the originating entity, from which the information came, to verify the fact and amount of the income, resources or both; or

(b) Sending the individual a letter which includes the information received and requesting a response within a specified period. The letter must clearly explain what information was received and the relevance to the individual's past, current or future eligibility. The individual shall be given an opportunity to contest such findings.

(c) The number of determinations delayed beyond forty-five days from receipt, must not exceed twenty per cent of the reviews provided the reason for the delay is due to nonreceipt of verifications. Otherwise, all determinations shall be made promptly.

(5) Not terminate, deny, suspend benefits until appropriate steps have been taken to verify the information in accordance with 42 C.F.R. 435.955(a) (as in effect on November 1, 2009). The administrative agency must verify information relating to:

(a) The amount of the income and resource that generated the item 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) Make the decision to exclude duplicate information or earnings information previously researched in accordance with 42 C.F.R. 435.953(c) (as in effect on November 1, 2009).

(7) 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 listed in paragraph (A) of this rule or programs referenced in 42 C.F.R. 435.948(a) in accordance with 42 C.F.R. 435.960(a) (as in effect on November 1, 2009).

Replaces: 5101:1-37- 03.1

Effective: 11/01/2009
R.C. 119.032 review dates: 11/01/2014
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

5160:1-1-04 Medicaid: replacement checks.

(A) The purpose of this rule is to describe how the administrative agency replaces a check that is reported missing or damaged.

(B) Definitions:

(1) "Check" or "checks," for the purposes of this rule, means a payment issued to a payee for the residential state supplement (RSS), for reimbursement for medicaid-covered expenses, or for other payments related to medical assistance programs administered by the Ohio department of job and family services (ODJFS).

(2) "Holder" means the person who acquired possession of the check from the payee and is entitled to receive payment for the check.

(3) "Payee" means the individual to whom the check is payable.

(C) Payee responsibilities and rights. The payee shall:

(1) Notify the administrative agency of the missing or damaged check. The payee should notify the administrative agency in the county in which the recipient resides.

(2) Return the damaged check to the administrative agency.

(3) Complete the necessary forms and paperwork.

(4) Provide identification.

(5) Provide a copy of a police report, if the payee is alleging the check was stolen.

(6) Have the right to request a fair hearing, as described in division 5101:6 of the Administrative Code.

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

(1) Verify the payee has met the requirements of paragraph (C) of this rule.

(2) Check the electronic eligibility system issuance history to complete the following steps. For checks not generated by the electronic eligibility system, contact the ODJFS for assistance in completing the following steps.

(a) Verify that a check was issued to the payee.

(b) Determine if a missing check was mailed to the payee's current address. If it was not, correct the address in the electronic eligibility system. Redirect the check, if possible.

(c) Determine if a check was canceled, redirected, voided, or redeemed. If the issuance history shows the check was:

(i) Canceled, issue a replacement check through the electronic eligibility system benefit issuance subsystem.

(ii) Redirected, advise the payee to allow five working days from the redirect date for delivery.

(iii) Voided, issue a replacement check through the electronic eligibility system benefit issuance subsystem.

(iv) Redeemed,

(a) Instruct the payee to complete forms JFS 02132, "Affidavit in Support of Application for Replacement Warrant" (rev. 11/2000) and the state of Ohio office of budget and management "Handwriting Specimens Claim for Alleged Forgery of Payee(s) Warrant" (rev. 06/2007).

(b) Forward the originals and one copy of each completed form to the ODJFS bureau of accounting, accounts receivable section.

(c) Issue a replacement check through the electronic eligibility system benefit issuance subsystem. If the payee alleges the check was stolen, collect a copy of the police report from the payee prior to issuing the replacement check.

(v) Not canceled, redirected, voided, or redeemed, and it has been five or more working days since the check mailing or redirect date, the administrative agency shall:

(a) Immediately telephone the ODJFS bureau of accounting, accounting information section to request payment be stopped on the check, if the payee had endorsed the check prior to it being lost or stolen, or

(b) Enter a stop payment request in the electronic eligibility system, if the payee had not endorsed the check prior to being lost or stolen.

(c) Instruct the payee to complete forms JFS 02132 and the state of Ohio office of budget and management, "Handwriting Specimens Claim for Alleged Forgery of Payee(s) Warrant". Retain the completed forms in the case record. These forms shall be forwarded to the ODJFS bureau of accounting, accounts receivable section if the original check is cashed.

(d) Issue a replacement check through the electronic eligibility system benefit issuance subsystem. If the payee alleges the original check was stolen, collect a copy of the police report from the payee prior to issuing the replacement check.

(3) Issue a replacement check within fourteen days of when a payee reports a damaged check is unable to be cashed.

(a) Collect the damaged check from the payee. If the check has been torn or mutilated, the payee must be able to surrender the major part of the check.

(b) Instruct the payee to complete and sign the JFS 02132.

(c) Attach the damaged check to the JFS 02132, write the words "damaged check" across the top of the form, and forward them to the ODJFS bureau of accounting, accounts receivable section.

(d) Issue a replacement check through the electronic eligibility system benefits issuance subsystem.

(4) Obtain additional samples of the payee's handwriting when requested by ODJFS. This additional sample can be copies of the payee's existing signatures in the case record or an additional state of Ohio office of budget and management, "Handwriting Specimens Claim for Alleged Forgery of Payee(s) Warrant" completed by the payee. The handwriting sample shall be returned, along with a copy of the ODJFS notice requesting the additional sample, to the ODJFS bureau of accounting, accounts receivable section.

(5) Meet with the payee when notified by ODJFS that the handwriting analysis indicates the payee endorsed the original check. During the interview, if the payee:

(a) Acknowledges endorsing and cashing the original check, the administrative agency shall recover the overpayment in accordance with rule 5101:1-38-20 of the Administrative Code.

(b) Denies endorsing and cashing the original check, the administrative agency may file charges against the payee through the county prosecutor, in accordance with section 2913.02 or 2913.401 of the Revised Code. Prior to referring the case to the county prosecutor, the administrative agency shall submit a written request to ODJFS for a report of the handwriting analysis. The case may be referred to the county prosecutor once the report is received.

(6) Act on any overpayment notifications from ODJFS or the county prosecutor in accordance with rule 5101:1-38-20 of the Administrative Code.

(7) Act on checks reported by the holder as missing after being cashed by the payee. Check the electronic eligibility system issuance history and with the ODJFS to verify the check has not been redeemed by the treasurer of state.

(a) If the check has been redeemed, a replacement check cannot be issued. The administrative agency shall obtain a copy of the redeemed check and forward it to the holder in due course.

(b) If the check does not show in the electronic eligibility system as being redeemed, the administrative agency shall:

(i) Immediately telephone the ODJFS bureau of accounting, accounting information section and order payment on the check stopped.

(ii) Complete an AUD 8184, "Auditor of State Handwriting Specimens Claim for Alleged Forgery of Payee(s) Warrant" (rev. 06/2007), or its equivalent. This form shall be signed by the holder. The administrative agency shall assist the holder in completing the form.

(iii) Forward the original and one copy of the AUD 8184, or its equivalent, to the ODJFS bureau of accounting, accounting information section.

(iv) Issue a replacement check through the electronic eligibility system benefit issuance subsystem. If the holder alleges the original check was stolen, collect a copy of the police report from the holder prior to issuing the replacement check.

Replaces: 5101:1-37-04

Effective: 11/01/2009
R.C. 119.032 review dates: 11/01/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011
Rule Amplifies: 5111.01 , 5111.011 , 2913.02 , 2913.401
Prior Effective Dates: 5/1/71, 5/1/75, 2/1/84 (temp.), 5/1/84, 6/1/84, 4/19/85, 1/1/86 (Emer.), 2/3/86 (Emer.), 4/1/86, 10/1/88 (Emer.), 12/20/88, 10/1/91 (Emer.), 12/20/91, 1/1/94 (Emer.), 3/18/94, 1/1/95, 1/1/96, 7/1/98, 10/1/98, 10/1/02

5160:1-1-20 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.)

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 Medicaid: definitions.

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

(B) Definitions.

(1) "Abuse" means individual practices resulting in unnecessary cost 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 5160:1-5-20 of the Administrative Code.

(4) "Assignment" means a 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.

(5) "Authorized representative" means an individual, at least eighteen years old, or a legal entity who stands in place of the individual and shares the individual's responsibilities. 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) "CDJFS" means a county department of job and family services.

(9) "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).

(10) "Confined" means serving time for a criminal offense or involuntary placement in a prison, jail, detention facility, or other penal facility. 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) "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.

(12) "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.

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

(14) "Electronic equivalent" means an electronic version of an 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 materially altered.

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

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

(17) "EPSDT" means early and periodic screening, diagnosis and treatment as described in rule 5160:1-2-05 of the Administrative Code, also referred to as healthchek.

(18) "Erroneous payment" means a medicaid reimbursement made for an individual who was ineligible at the time services were received. An erroneous payment may occur as a result of fraud or non-fraud.

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

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

(21) "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.

(22) "FPL" means the federal poverty 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).

(23) "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.

(24) "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.

(25) "HCB services" or "HCBS" means specific home and community-based services furnished under the provision of 42 C.F.R. 441, subpart G (as in effect on April 1, 2013), that provide specific individuals an alternative to placement in a hospital, a nursing facility (NF), or an intermediate care facility for persons with mental retardation (ICF/MR) 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.

(26) "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 Chapter 5160-1 of the Administrative Code.

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

(28) "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, both legal and illegal.

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

(30) "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), and the administrative agency.

(31) "Independent living services" has the same meaning as in rule 5101:2-42-19 of the Administrative Code.

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

(33) "Individually identifiable health information" means information that is a subset of health information including 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.

(34) "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.

(35) "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.

(36) "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.

(37) "MAGI-based income" has the same meaning as in 42 C.F.R. 435.603 (as in effect on September 1, 2013).

(38) "MBIWD" means the medicaid buy-in for workers with disabilities category set forth in rule 5160:1-5-30 of the Administrative Code.

(39) "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.

(40) "Medicaid household" means the 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.

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

(42) "Medical verification of pregnancy" means a written statement signed by a doctor or nurse verifying pregnancy and includes the expected date of confinement and, if more than one, the expected number of fetuses.

(43) "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

(44) "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.

(45) "ODJFS" means the Ohio department of job and family services.

(46) "ODM" means the Ohio department of medicaid.

(47) "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.

(48) "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.

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

(50) "PCPA" means a private child placing agency as defined in rule 5101:2-1-01 of the Administrative Code.

(51) "PCSA" means a public children services agency as required by section 5153.02 of the Revised Code.

(52) "Personal knowledge" means first-hand knowledge of circumstances of an event. A person verifying an event, based on personal knowledge, should be able to share such details as when and where the event occurred, who was involved and whether there were any special circumstances surrounding the event.

(53) "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.

(54) "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.

(55) "PTR" means pre-termination review as set forth in rule 5160:1-1-51 of the Administrative Code. This is done prior to any termination of assistance to determine whether an individual is eligible for any other category of assistance.

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

(57) "Qualified entity" means:

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

(b) A hospital, federally qualified health center (FQHC) or FQHC look-alike, as described in Chapter 5160-28 of the Administrative Code, that:

(i) Has requested to serve as a qualified entity, and

(ii) Has been determined by ODM to be capable of making presumptive eligibility determinations, and

(iii) Is currently in compliance, as determined by ODM, with the presumptive eligibility operating addendum to its provider agreement.

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

(59) "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.

(60) "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, guardian, or specified relative; and

(d) The individual's authorized representative.

(61) "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.

(62) "Residential care facility" (RCF) means a home that provides either of the following:

(a) Accommodations for seventeen or more unrelated individuals and supervision and personal care services for three or more of those individuals who are dependent on the services of others by reason of age or physical or mental impairment; or

(b) Accommodations for three or more unrelated individuals, supervision and personal care services for at least three of those individuals who are dependent on the services of others by reason of age or physical or mental impairment, and, to at least one of those individuals, any of the skilled nursing care authorized by section 3721.011 of the Revised Code.

(63) "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.

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

(65) "SSA" means the social security administration.

(66) "SSN" means social security number.

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

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

(69) "Temporary absence" means that an individual (parent or child) who is otherwise considered part of the family is considered not to have changed residence

(a) An individual is considered to be temporarily absent 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 (B)(6) of rule 5160:1-4- 02.2 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.

(70) "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 April 1, 2013).

(71) "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).

(72) "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.

Effective: 01/01/2014
R.C. 119.032 review dates: 10/01/2018
Promulgated Under: 111.15
Statutory Authority: 5162.031 , 5163.02
Rule Amplifies: 5162.031 , 5163.02
Prior Effective Dates: 10/1/13

5160:1-1-51 Medicaid: administrative agency responsibilities.

(A) This rule describes the responsibilities of the administrative agency.

(B) Calculation of time periods for eligibility determinations. All calculations of time periods used in the determination of eligibility, including scheduled redeterminations or a redetermination as a result of a reported change, or any notice sent as a result of a determination of eligibility, shall be computed as follows:

(1) When counting the number of days in a specified time period, the initial day is excluded from the computation and the last day is included.

(2) When the last day of the time period falls on a Saturday, Sunday, or legal holiday, the time period shall end on the next working day.

(C) Effective date of applications, reported information, or requests for applications or assistance. Applications, documents, or information submitted or provided to the administrative agency, or requests made to the administrative agency, are considered received by the administrative agency:

(1) That day, if received before five p.m. on a business day, or if provided to the administrative agency during the administrative agency's office hours.

(2) On the next business day, if received by the electronic eligibility system after five p.m. or on a non-business day when the administrative agency is closed.

(D) Request for application. When an individual requests an application, the administrative agency must:

(1) Not deny an individual's right to apply or discourage an individual from applying.

(2) Inform the individual of the following:

(a) An online application portal is available to complete an application for medical assistance.

(i) Assistance completing the online application is available through the portal.

(ii) Use of the online application portal will likely lead to faster determination of eligibility.

(b) The beginning date of benefits depends on the date the signed application is submitted electronically or received by the administrative agency. The signature may be original, copied, facsimile, or electronic.

(c) The verification requirements and deadlines.

(d) Individuals must cooperate with eligibility determinations, redeterminations, audits and quality control processes as defined in this chapter of the Administrative Code.

(e) The meaning of and penalties for medicaid eligibility fraud as set forth in section 2913.401 of the Revised Code.

(3) Fulfill a request for an application within a business day.

(a) Fulfillment occurs when the administrative agency sends an electronic copy of the application or a link to an electronic copy of the application to the text or email address provided by the individual; hands the application to the individual; or places the application in the U.S. mail. If the application is provided in person or via U.S. mail, the administrative agency must enclose a preaddressed, postage-paid envelope for return of the application.

(b) The application must be accompanied by the following documents. To the extent possible, these documents must be provided in the same manner and in the same format as the application.

(i) The JFS 07501 "Program Enrollment and Benefit Information" (rev. 10/2012).

(ii) The JFS 07217 "Voter Registration Notice of Rights and Declination" (rev. 8/2009), or a notice meeting the requirements of section 3503.10 of the Revised Code, and a voter registration form as required by section 329.051 of the Revised Code.

(E) Upon a request for assistance or receipt of an application, the administrative agency must:

(1) Provide an interpreter at no charge to an individual with limited English proficiency and, when available, provide applications and important forms or brochures in the individual's language.

(2) Distribute voter information and registration materials as required by 42 C.F.R. 431.307 (as in effect on March 1, 2013).

(3) Coordinate with the supplemental nutrition program for women, infants and children (WIC) program. Advise any potential WIC recipient of the WIC program and refer the individual to the WIC agency by forwarding a copy of the individual's medical assistance application and any supplemental application, unless the individual is already receiving WIC assistance.

(a) The following individuals are potential WIC recipients:

(i) A woman who is:

(a) Pregnant; or

(b) Within a six-month period after termination of pregnancy; or

(c) Breastfeeding her infant within the twelve months after the infant's birth; or

(ii) A child younger than five years old.

(b) For any individual in receipt of medical assistance who is a potential WIC recipient, the administrative agency must advise the individual of the WIC program at least annually.

(4) Issue proper notice and hearing rights as outlined in division 5101:6 of the Administrative Code.

(F) Assistance.

(1) The administrative agency must allow a person or persons of the individual's choice to accompany, assist, and represent the individual in the application or redetermination process.

(a) A person may accompany and assist an individual without being an individual's authorized representative.

(b) The adminstrative 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 the person assisting the individual, unless the person has been designated in writing as an authorized representative.

(c) 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.

(2) If an individual has designated an authorized representative, the administrative agency must:

(a) Issue all notices and correspondence to both the authorized representative and the individual.

(b) Contact the individual to clarify or verify information provided by an authorized representative if the information provided on the application seems contradictory, unclear, or unrealistic.

(c) Remove the authorized representative from any correspondence or access to safeguarded information upon receipt of notice that:

(i) The authorized representative is declining or ending representation of the individual, or

(ii) The individual has withdrawn the representative's authority.

(3) The administrative agency must help complete the application if assistance is needed, including assistance through agents of the administrative agency, such as eligibility workers.

(a) At the individual's request, an eligibility worker must assist with completing the application by asking the individual for answers needed to complete the application, then recording the individual's answers on the application form or in the electronic eligibility system. The eligibility worker must not alter any answers given by the individual.

(b) If an eligibility worker assists or helps to complete an application, the worker must sign the application form, and include the worker's title, as a person who assisted in completing the application.

(c) The normal process of inputting data into the electronic eligibility system or determining an individual's eligibility must not be construed as providing assistance.

(4) Upon request, the administrative agency must provide assistance to individuals having difficulty gathering verifications.

(5) When determining eligibility for an individual with a physical or mental impairment that substantially limits the individual's ability to access verifications, and who has not granted any person with durable power of attorney, or who does not have a court-appointed guardian or a person with other legal authority and obligation to act on behalf of the individual, the administrative agency must:

(a) Determine if another person is available to assist with obtaining verifications or accessing the individual's means of self-support.

(i) If such a person is available, request the person assist with obtaining the verifications or accessing the individual's means of self-support.

(ii) If verifications are provided, or if means of self-support are accessed by the individual or on the individual's behalf by another person, the administrative agency must consider the verified criteria or means or self-support in the eligibility determination process.

(b) If no person is available to assist the individual:

(i) Refer the individual's case to the administrative agency's legal counsel and request counsel evaluate whether the matter should be referred to the probate court, adult protective services, or another entity deemed by the administrative agency's legal counsel to be appropriate. For cases referred to counsel for such evaluation, the administrative agency must also:

(a) Note in the individual's case record that verifications or means of self-support are not available and must not be considered a disqualifying factor until a means of access to those items is obtained or established, and

(b) Inform the administrative agency's legal counsel of any eligibility approval or denial.

(ii) Determine eligibility in accordance with Chapter 5101:1-37 of the Administrative Code, but without considering eligibility factors for which verification cannot be obtained or means of self-support that cannot be accessed because of the physical or mental impairment. Use the best evidence available without delaying the determination of eligibility.

(iii) Redetermine eligibility once a means of access to verifications or means of self-support is obtained or established. If such access has not been obtained prior to a regularly-scheduled redetermination, determine continuing eligibility using the best evidence available.

(G) Receipt of application. Upon receipt of any signed application for medical assistance or for specific medical assistance services or programs, the administrative agency must:

(1) Give or send a receipt to the individual showing the date of application.

(2) Accept and register an application within a business day of the time the signed application is received, whether it is an original, a facsimile, a telephonic, or an electronic signature ("e-signature"). An original signature is not required.

(a) If an application is received from a local WIC clinic, child and family health services (CFHS) clinic, or bureau for children with medical handicaps (BCMH) office within five days of the signature date, the application must be registered using the signature date. If the application is not received within five days of the signature date, the application must be registered using the date it was received by the administrative agency.

(b) If an application taken by an outstationed worker assigned to a federally qualified health center (FQHC) or a disproportionate share hospital (DSH) was not directly entered into the electronic eligibility system, it must immediately be submitted to the appropriate administrative agency, which must register the application using the signature date.

(3) The administrative agency must not delay the registration or processing of an application due to the lack of a signed acknowledgement of an individual's rights and responsibilities.

(4) If not previously provided, give or send the following documents to the applicant:

(a) Pamphlet describing the local service programs available through the administrative agency or other county agencies;

(b) A preaddressed, postage-paid envelope for return to the administrative agency;

(c) JFS 07501; and

(d) A notice meeting the requirements of section 3503.10 of the Revised Code or JFS 07217, and a voter registration form as required by section 329.051 of the Revised Code.

(H) Verifications. Where manual verifications are required under rule 5101:1-37-58 of the Administrative Code, the administrative agency must:

(1) Follow the safeguarding guidelines set forth in rule 5101:1-37-51.1 of the Administrative Code when providing or gathering information by telephone, in person, or in electronic or written form.

(2) Not require that an individual provide verification of unchanged information unless the information is incomplete, inaccurate, inconsistent, outdated, or missing from the case record due to record retention limitations.

(3) Not request that an individual provide duplicate copies of previously submitted verifications.

(4) To the extent possible, verify relevant eligiblity criteria using electronic records available through the electronic eligibility system. Where electronic verification is not available, or electronic verification data conflicts with the individual's attestation, request verifications as set out in rule 5101:1-37-58 of the Administrative Code.

(5) If the administrative agency is unable to verify an eligibility criteria through electronic sources, the administrative agency will provide a written (electronic or on paper) request for the necessary information or verification documents.

(a) The written request must:

(i) Include the date by which the information must be provided to the administrative agency;

(ii) Inform the individual that any delay in providing requested information or documents will delay the determination of an individual's eligibility; and

(iii) Provide information on how an individual can request assistance in gathering the requested documents.

(a) The administrative agency must assist the individual in obtaining the verifications required for eligibility determination.

(b) When the normal sources of verification described in 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 must be on a case by case basis when no other approach is possible, and must be used only in rare circumstances.

(b) If the information or verification required to establish the individual's eligibility for assistance is not received by the administrative agency by the stated date, the administrative agency must contact the individual in writing no more than twenty days from the date of the application.

(i) The follow-up letter:

(a) Must be sent via postal mail or personally delivered to the individual;

(b) Must state that the required information or verification has not been received, and that if the information or verification is not received within ten days the administrative agency shall deny the application for medical assistance; and

(c) Must include a clear statement that the administrative agency will assist with obtaining the required information or verification if the request for assistance is received on or prior to the given deadline; and

(d) Does not serve as a notice of denial of application.

(ii) If the requested information or verification is not received by the stated deadline, the administrative agency shall propose a denial or termination of benefits.

(c) The administrative agency must deny the individual's application if the individual fails to provide the necessary information or verifications, or request assistance and cooperate with obtaining verifications, within the time specified in the second verification request. If this happens:.

(i) An individual may reapply at any time.

(ii) An individual should not be asked to re-verify information previously verified by the administrative agency without reason to believe the information may have changed.

(6) Give or send a dated itemized receipt for any verification document received from an individual.

(7) Record receipt of all verification documents, photocopy or scan the documents, and retain copies or images of the documents in the case record.

(8) If information is verified through a telephone contact, record the following details:

(a) The name and telephone number of the person giving the information;

(b) The name of the agency or business contacted, if applicable;

(c) The date of the contact; and

(d) An accurate summary of the information provided.

(I) Determination and redetermination of eligibility. The administrative agency must:

(1) Not schedule an interview except at the request of the applicant.

(2) Inform all individuals at the time of application and reapplication that the agency will obtain and use information available from IEVS to assist with the determination of eligibility, as required by section 1137 of the Social Security Act (as in effect on April 1, 2013).

(3) Using the electronic eligibility system, the administrative agency must:

(a) Determine or redetermine an individual's eligibility for medical assistance within the application processing time limits set forth in this rule.

(i) The administrative agency must not approve medical assistance to an individual merely because of an agency error or delay in determining eligibility. All eligibility factors must be met.

(ii) The administrative agency must not delay the approval of medical assistance due to the lack of information or verifications necessary to determine eligibility for other public assistance programs.

(b) Document and record determinations of eligibility. The administrative agency must:

(i) Record, in physical or electronic case records, any information, action, decision, or delay in the application, eligibility determination, or termination processes, as well as the reasons for any action, decision, or delay.

(ii) Make the case records, physical or electronic, available for compliance audits.

(c) Approve medical assistance for an individual who:

(i) Has signed an application under penalty of perjury; and

(ii) Has provided all necessary verifications as set forth in rule 5101:1-37-58 of the Administrative Code; and

(iii) Meets all conditions of eligibility for an eligibility category set forth in an approved state plan amendment, Chapter 5101:1-37, 5101:1-39, 5101:1-41, or 5101:1-42 of the Administrative Code. If an individual who attests to U.S. citizenship or qualified alien status meets all conditions of eligibility for an eligibility category except for verification of the individual's citizenship or qualified alien status, the administrative agency must approve time-limited coverage during a reasonable opportunity period (ROP) as required in rule 5101:1-37-58.2 or 5101:1-37- 58.3 of the Administrative Code.

(d) Deny an application for medical assistance for an individual who:

(i) Has not signed an application under penalty of perjury; or

(ii) Withdraws the application; or

(iii) Fails to cooperate in the application or determination process or fails to provide all necessary verifications set forth in rule 5101:1-37-58 of the Administrative Code; or

(iv) Does not meet all conditions of eligibility for any eligibility category set forth in Chapter 5101:1-37 of the Administrative Code.

(e) Suspend medical assistance upon notification that an individual meets any of the criteria for ineligibility for payment of services set forth in rule 5101:1-37-58.1 of the Administrative Code.

(f) Terminate medical assistance for an individual who:

(i) Requests that assistance be terminated; or

(ii) Is no longer an Ohio resident, or is deceased; or

(iii) Fails to cooperate in the redetermination or quality control processes, or fails to provide all necessary verifications; or

(iv) Fails or refuses to comply with individual responsibilities as described in this chapter of the Administrative Code, or is subject to an OWF sanction and has not agreed to comply with the work requirements; or

(v) No longer meets the conditions of eligibility for an eligibility category as set forth in Chapter 5101:1-37 of the Administrative Code. Before terminating coverage on this basis, the administrative agency must conduct a pre-termination review (PTR) to determine that the individual is no longer eligible for coverage under any eligibility category.

(J) Timely determinations and redeterminations. The administrative agency must make a timely determination of an individual's eligibility for medical assistance under this chapter of the Administrative Code. The administrative agency must determine or redetermine eligibility, including obtaining verifications when required, within:

(1) Ten days of receiving a report of a change that could affect an individual's on-going eligibility for medical assistance; or

(2) Thirty calendar days from the date of application or scheduled redetermination, unless:

(a) An individual who otherwise meets the conditions of eligibility described in this chapter of the Administrative Code alleges blindness or disability. The administrative agency must determine eligibility within ninety days from the date of application unless the examining physician delays or fails to take a required action; or

(b) There is an administrative or other emergency beyond the administrative agency's control.

(3) Forty-five days of receipt of new or changed information from IEVS. The administrative agency must not terminate, deny, or suspend benefits until appropriate steps have been taken to verify the relevant information in accordance with 42 C.F.R. 435.955(a) (as in effect on April 1, 2013).

(K) Effective dates of eligibility.

(1) Medical assistance coverage begins on the first day of the calendar month in which the application which resulted in eligibility was submitted to the adminstrative agency, except that:

(a) An individual's coverage cannot begin before the date on which the individual:

(i) Became a resident of Ohio, or

(ii) Was born.

(b) The administrative agency must approve retroactive eligibility for medical assistance effective no later than the first day of the third month before the month of application if the individual:

(i) Received medical services of a type covered by medicaid at any time during that period; and

(ii) Would have been eligible for medical assistance at the time the services were provided if an application had been made at that time, regardless of whether the individual was alive when the application actually was made.

(iii) Is eligible for a category of medical assistance other than:

(a) Transitional medicaid as described in rule 5101:1-40-05 of the Administrative Code; or

(b) Medicare premium assistance as described in rule 5101:1-38-03 of the Administrative Code; or

(c) Any presumptive eligibility category described in rule 5101:1-37-62 of the Administrative Code.

(2) Medical assistance coverage terminates on the last day of a calendar month, except that coverage terminates on the date an individual:

(a) Becomes a resident of another state;

(b) Dies; or

(c) Requests that coverage be terminated.

(L) Duration of eligibility span. The administrative agency must:

(1) Terminate coverage under a time-limited eligibility category as described in the Administrative Code rule for the appropriate eligibility category. These time-limited eligibility categories include:

(a) Any presumptive eligibility category, described in rule 5101:1-37-62 of the Administrative Code, and

(b) Alien emergency medical assistance, as described in rule 5101:1-41-20 of the Administrative Code.

(2) Redetermine an individual's eligibility for medical assistance on the earlier of the following:

(a) One year after the most recent eligibility determination, or

(b) Upon receiving a report of a change in circumstances that could affect an individual's eligibility for medical assistance.

(M) Third party liability (TPL). For individuals found eligible for or in receipt of medical assistance, the administrative agency must report to the Ohio department of medicaid (ODM) any available information about a third party liable for an individual's health care costs.

(1) When determining an individual's eligibility for medical assistance coverage, the agency must use the form (or an electronic equivalent) designated by the administrative agency to report:

(a) Possible health insurance coverage of an individual. A separate report must be made for each possible health insurance policy.

(b) Potential TPL due to an injury, disability or court order.

(2) At a redetermination, or upon any reported change, the administrative agency must compare the individual's current information to the information on the most recent JFS 06612 "Health Insurance Information Sheet" (rev. 5/2001) or JFS 06613 "Accident/Injury Insurance Information (rev. 6/2009). If any information has changed, the administrative agency must report the changes to ODM by submitting a new JFS 06612 or JFS 06613, or an electronic equivalent.

(3) Upon a request by ODM, the administrative agency must contact the individual to obtain information about potential TPL. If the individual fails to cooperate, the agency must propose to terminate or deny the individual's medical assistance for failure to cooperate, as set forth in paragraph (I)(3) of this rule.

(N) Upon a report (verbal or written) of a change of address within the state of Ohio, the administrative agency must:

(1) Give or mail to the individual a notice meeting the voter registration requirements of section 3503.10 of the Revised Code, and advise the individual that, upon request, the administrative agency will help the individual register to vote or update voter registration as outlined in rule 5101:1-2-15 of the Administrative Code.

(2) Process an intercounty transfer (ICT) if the individual has changed residence from one county to another. Both the county of original residence and the county of new residence have responsibilities in the ICT process. The ICT process shall be followed whether the individual reporting a change of residence is an applicant or is currently in receipt of medical assistance benefits.

(a) The CDJFS receiving report of a move shall determine whether the move is a change of residence or a temporary absence from the home. If the move is a temporary absence from the home, the county in which the individual is physically located shall provide necessary medical and transportation services.

(b) The CDJFS receiving report of a change of residence shall:

(i) Update the address in the electronic eligibility system. If the individual does not have an address in the new county, use the address of the administrative agency in the new county.

(ii) If the report was made to the administrative agency in the county of new residence, inform the county of original residence.

(c) The CDJFS in the county of original residence shall transfer the case in its current status in the electronic eligibility system within five working days of the reported change. If any case records or physical or electronic documents are maintained by the CDJFS outside of the electronic eligibility system, the CDJFS shall:

(i) Transfer the case records, or a physical or electronic copy of the records, to the county of new residence within fifteen days of the reported change. The case record to be transferred shall contain the original (or, if the administrative agency uses an imaging system, a scanned image) of the following documents:

(a) The most recently signed "Printed Copy of Information" (PCI) or application for medical assistance benefits; and .

(b) Other pertinent documents, such as citizenship, income or resource verifications

(ii) Complete a notice of intercounty transfer, attach a copy of the notice to the records being transferred to the county of new residence, and keep a copy of the notice in the retained case record.

(iii) Maintain a copy of transferred documents for future reference, while providing original documents, to the extent available, to the county of new residence.

(d) The CDJFS in the county of new residence shall:

(i) Not require the individual reapply or cooperate with a redetermination of eligibility for medical assistance merely due to the change in county of residence.

(ii) Provide the medical assistance benefits for which the individual is eligible.

(iii) Perform the periodic redetermination or redetermination upon a change in circumstances as outlined in this rule.

(e) If the case being transferred is subject to a claim for overpayment as set out in rule 5101:1-38-20 of the Administrative Code:

(i) An existing claim shall not be transferred. The records transferred to the CDJFS in the county of new residence shall include copies of the documentation of the claim. The CDJFS establishing the claim remains responsible for any necessary action on the claim.

(ii) If no claim has been established and the CDJFS in each county agrees that the county of new residence shall establish the claim, then a potential claim may be transferred to the CDJFS in the county of new residence to be established by the CDJFS in that county.

(O) Distribution of informational materials. The administrative agency:

(1) Must distribute materials to individuals only in accordance with 42 C.F.R. 431.307 (as in effect on March 1, 2013).

(2) May distribute materials directly related to the health and welfare of applicants and beneficiaries, such as announcements of free medical examinations, availability of surplus food, and consumer protection information.

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 , 329.051 , 2913.401 , 3501.01 , 3503.10 , 5101.58

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 Medicaid: consumer fraud and erroneous payments.

(A) This rule sets out requirements for the administrative agency to identify and refer consumer fraud and erroneous payments made on behalf of an individual by medicaid.

(B) Investigation of complaints. Upon notification of a complaint of medicaid fraud, abuse or questionable practices, the administrative agency must conduct a preliminary investigation in accordance with 42 C.F.R. 455.14 (as in effect on April 1, 2013) to determine if there is sufficient basis to warrant a full investigation.

(1) If the preliminary investigation finds that a full investigation is warranted in accordance with 42 C.F.R. 455.15 (as in effect on April 1, 2013):

(a) And there is reason to believe that a beneficiary has defrauded the medicaid program as described in section 2913.401 of the Revised Code, then the administrative agency must refer the case to the county prosecutor.

(b) And there is reason to believe that a beneficiary has abused the medicaid program, then the agency must conduct a full investigation of the abuse.

(2) The investigation must continue until the investigation is resolved in accordance with 42 C.F.R. 455.16 (as in effect on April 1, 2013).

(C) Recovery of erroneous payments is authorized in section 5111.12 of the Revised Code, subject to rule 5101:9-7-06 of the Administrative Code. The administrative agency must:

(1) Not attempt to recover erroneous payments when:

(a) An individual would have remained eligible under another category of medical assistance even if the individual's circumstances had been reported accurately or a change had been reported promptly; or

(b) The erroneous payment was a result of an administrative error not caused by the individual.

(2) Recover erroneous payments from an individual only:

(a) Through reimbursement. Erroneous payments must not be recovered by reducing benefits or services to the individual.

(b) From the responsible adult or guardian, if the erroneous payment was made on behalf of a child.

(c) To the extent that an actual overpayment resulted. If an individual who reported a change within the ten-day reporting period would have remained eligible for a given month, after allowing a ten-day period to for the administrative agency to act on a change and allowing for the adverse action period, there is no overpayment in that month.

(3) Send a notice of medicaid overpayment to the individual.

(D) Amount subject to recovery. If the erroneous payment resulted from:

(1) Fraud, as determined by a county prosecutor, the administrative agency must accept any reimbursement plan ordered by a court or agreed to by the county prosecutor.

(2) Excess resources, the amount subject to recovery is the lesser of:

(a) The amount of the payment made on behalf of the individual; or

(b) The difference between the actual amount of countable resources and the applicable resource standard.

(3) Excess income, the amount subject to recovery is the total amount of payments made on behalf of the individual during the month or months of the erroneous payment period.

(4) For combinations of excess resources and excess income, the amount subject to recovery is the greater of either paragraph (D)(2) or paragraph (D)(3) of this rule.

(5) An incorrect spenddown amount, as calculated according to rule 5101:1-39-10 of the Administrative Code, the amount subject to recovery is the lesser of:

(a) The total amount of payments made on behalf of the individual; or

(b) The difference between the amount of the spenddown liability in effect during the erroneous period and the correct amount of the spenddown liability, added up over the months of the erroneous period.

(6) Receipt of long-term services and supports, waiver services, or intermediate care facility for the mentally retarded (ICF/MR) services, as a result of:

(a) Improper transfer of resources as outlined in rule 5101:1-39-07 of the Administrative Code, the amount subject to recovery is the amount of payments made on behalf of the individual.

(b) Resources in excess of the limit set forth in rule 5101:1-39-05 of the Administrative Code:

(i) The amount subject to recovery is the difference between the actual amount of countable resources and the applicable resource standard.

(ii) The individual may choose to increase the patient liability through payment of a lump sum to the nursing facility if the increase will reduce the resources to the appropriate limit. The reduction in resources must be accomplished in one calendar month and in compliance with rule 5101:1-38-01.8 of the Administrative Code.

(c) Patient liability as outlined in of rule 5101:1-39-24 of the Administrative Code, the amount subject to recovery is the difference between the amount of the correct patient liability and the amount of the patient liability that was in effect during the erroneous payment period, added up over the months of the erroneous period.

(E) Individual responsibility. The individual must complete and return the notice of medicaid overpayment within thirty days from the date the form was sent by the administrative agency.

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: 2913.401 , 5111.01 , 5111.011 , 5111.12

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

(A) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law requiring the administrative agency to issue a certificate of creditable coverage and a privacy notice.

(B) Administrative agency responsibilities: The administrative agency shall:

(1) Ensure appropriate safeguards are taken in accordance with rule 5160:1-1-51.1 of the Administrative Code.

(2) Issue all individuals of medical assistance programs a privacy notice, as described in 45 C.F.R. 164.520 (as in effect September 1, 2013), outlining the following descriptions of uses and disclosures, and procedures:

(a) A description of the types of uses and disclosures of PHI the administrative agency is permitted with examples for each of the following purposes:

(i) Payment;

(ii) Treatment; and

(iii) Healthcare operations.

(b) A description of uses and disclosures permitted without the individual's written consent or authorization;

(c) A statement that other uses and disclosures will be made only with the individual's written authorization;

(d) Complaint procedure;

(e) Request for restriction procedure;

(f) Request for amendment procedure;

(g) Request for accounting procedure; and,

(h) A name, or title, and telephone number of a person to contact for further information.

(3) Issue the JFS 03748, "Certificate of Group Health Plan Coverage" (rev. 11/2013) or its electronic equivalent, for any medicaid eligible individual, as set forth in 45 C.F.R. 146.115 (as in effect September 1, 2013). The administrative agency may create its own certificate provided it contains all of the following information:

(a) The date the certificate is issued.

(b) The name of the group health plan that provided the coverage.

(c) The name(s) of the individual(s).

(d) The medicaid identification number.

(e) The name, address and telephone number of the administrative agency member who is responsible for issuing certificates and accepting telephone inquiries regarding the certificates.

(f) A statement that an individual has at least eighteen months of creditable coverage before a significant break in coverage or, if less than eighteen months, the beginning date of creditable coverage.

(g) Date the creditable coverage ended.

(h) An educational statement regarding HIPAA explaining:

(i) The restrictions on the ability of a health plan or issuer to impose a pre-existing condition exclusion against an individual including an individual's ability to reduce a pre-existing condition exclusion by creditable coverage;

(ii) Special enrollment rights;

(iii) The prohibitions against discrimination based on any health factor;

(iv) The right to individual health coverage;

(v) The fact that state law may require issuers to provide additional protections to individuals; and

(vi) Where to get more information.

(4) Provide the certificate of coverage to all medicaid-eligible individuals, dependents or to an entity requesting the certificate on behalf of the individual. The certificate shall be available for up to no less than twenty-four months after coverage ceases.

(a) The certificate shall be mailed to the individual's last known address.

(b) If a dependent's last known address is different than the participant's last known address, a separate certificate is required to be provided to the dependent at the dependent's last known address.

Replaces: 5160:1-2- 01.5

Effective: 01/01/2014
R.C. 119.032 review dates: 01/01/2019
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 Medicaid: outstationing workers at disproportionate share hospitals and federally qualified health centers.

(A) This rule describes the administrative agency's role in facilitating outreach services for low-income children and pregnant women through the process of outstationing workers at disproportionate share hospitals and federally qualified health centers.

(B) Responsibilities of the administrative agency.

(1) Locations. The administrative agency:

(a) Must establish and staff outstation locations at each disproportionate share hospital and each federally-qualified health center participating in the medicaid program and providing services to medicaid-eligible children and pregnant women.

(b) May establish additional outstation locations at any other site where potentially eligible children or pregnant women receive services. These additional sites may include additional sites other than the main outstation location of federally-qualified health centers or disproportionate share hospitals.

(2) Hours.

(a) Workers must be available at each outstation location during the administrative agency's regular office operating hours to accept applications and to assist applicants with the application process (b) If the administrative agency determines that an outstation site is infrequently used and does not require a full-time outstationed worker, a notice must be displayed:

(i) Containing the following information:

(a) The hours when an outstationed worker will be available; and

(b)The telephone number of the administrative agency that individuals may call for assistance.

(ii) Providing adequate notice to persons who are blind or deaf or who are unable to read or understand the English language.

(3) Workers and assistance.

(a) The agency may use county employees, provider or contractor employees, or volunteers who have been properly trained to staff outstation locations under the following conditions:

(i) County outstation intake workers may perform all eligibility processing functions, including the eligibility determination, if the worker is authorized to do so at the regular intake office.

(ii) Provider or contractor employees and volunteers may perform only initial processing functions. Provider and contractor employees and volunteers are subject to:

(a) The confidentiality of information rules specified in 42 C.F.R. part 431, subpart F (as in effect on December 31, 2013);

(b) The requirements of 42 C.F.R. section 447.10 (as in effect on December 31, 2013), which prohibit medicaid payments to anyone other than a provider or recipient except under specific circumstances; and

(c)All other Ohio or federal laws concerning conflicts of interest.

(b) The outstationed worker must:

(i) Complete the initial processing of the application for medical assistance.

(a) When authorized by the administrative agency, the outstationed worker may also determine medicaid eligibility.

(b) If the outstationed worker is only performing initial processing duties, the outstationed worker must forward the application to the administrative agency in accordance with Chapter 5160:1-1 and Chapter 5160:1-2 of the Administrative Code.

(ii) Accept and refer applications for other public assistance programs to the administrative agency for processing.

Replaces: 5160:1-2-04

Effective: 01/01/2014
R.C. 119.032 review dates: 01/01/2019
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 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

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 Medicaid: conditions of eligibility and verifications.

(A) This rule describes eligibility criteria that apply to all medical assistance programs, how eligibility criteria will be verified by the administrative agency, and when an individual will be asked to provide manual verification. Eligibility conditions that are specific to a certain eligibility group are addressed in the eligibility rule for that group.

(B) To be determined eligible for medical assistance, an individual must:

(1) Provide a social security number (SSN) in accordance with 42 C.F.R. 435.910 (as in effect September 1, 2013).

(a) The individual's self-declaration of SSN meets this condition unless contradictory information is provided to or maintained by the administrative agency.

(b) An individual is not required to provide a SSN if the individual:

(i) Is applying for or receiving alien emergency medical assistance (AEMA).

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

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

(b) 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.

(c) If the individual has not been issued or cannot recall the individual's SSN, the administrative agency must assist the individual in obtaining or applying for the individual's SSN.

(2) Be a resident, as defined in 42 C.F.R. 435.403 (as in effect April 1, 2013) of the state of Ohio on the date of application or requested coverage begin date.

(a) The individual's self-declaration of residency meets this condition unless contradictory information is provided to or maintained by the administrative agency.

(b) An individual remains a resident despite a temporary absence from the state if the individual intends to return when the purpose of the absence has been accomplished, unless another state has determined that the individual is a resident there for purposes of medicaid eligibility.

(c) The individual must not be eligible for and receiving medical assistance in another state or U.S. territory. An individual who has recently become an Ohio resident is not ineligible for medical assistance merely due to processing delays in terminating medical assistance in the prior state of residence.

(3) Be a U.S. citizen or qualified alien.

(a) An individual is not required to declare or verify citizenship or alien status when the individual is applying for benefits only on behalf of another person.

(b) An individual's declaration of U.S. citizenship must be verified as described in rule 5101:1-37-58.2 of the Administrative Code.

(c) An individual's declaration of qualified non-citizen status must be verified as described in rule 5101:1-37-58.3 of the Administrative Code. Verification of alien status is not required when the individual is applying for AEMA.

(4) Take all necessary steps to obtain any annuities, pensions, retirement, and disability benefits for which the individual is eligible, unless the individual can show good cause for not doing so, in accordance with 42 CFR 435.608 (as in effect on April 1, 2013).

(a) "Good cause", for the purposes of paragraph (B)(4) of this rule, means that to obtain a benefit, the individual would incur any significant disadvantage or detriment, including but not limited to any significant cost or expense.

(b) Benefits that the individual must take steps to obtain include but are not limited to annuities, retirement, veterans benefits, supplemental security income (SSI), social security disability income (SSDI), railroad retirement, and unemployment compensation.

(c) If eligibility or ineligibility for other benefits cannot be verified electronically, an official letter from the paying entity or financial institution is sufficient to verify the benefit.

(5) In accordance with 42 CFR 435.610 (as in effect on April 1, 2013), assign to the state of Ohio any rights to medical support and payments for medical care from any third party for:

(a) The individual, and

(b) Any medicaid-eligible individual for whom the individual is legally able to make an assignment.

(6) Cooperate with the child support enforcement agency (CSEA) in establishing the paternity of any medicaid eligible child, in accordance with 42 C.F.R. 433.147 (as in effect on April 1, 2013), unless the individual:

(a) Is not receiving medical assistance 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 administrative agency 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 must provide the name of the insurance company, billing address, subscriber identification number, group number, name of policy holder, and a list of covered individuals. In addition, the individual must cooperate with requests:

(a) 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.

(b) 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.

(c) 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:

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

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

(8) Meet all eligibility requirements for an eligibility category set out in an approved state plan amendment, Chapter 5101:1-37, 5101:1-39, 5101:1-41 or 5101:1-42 of the Administrative Code, including:

(a) Income requirements for the eligibility category.

(i) If an individual's declared income exceeds the relevant federal poverty level (FPL) threshold, the individual's declared income will be accepted without further verification.

(ii) If an individual's declared income is reasonably compatible with data available through an electronic data source, the individual's declared income will be accepted without further verification.

(iii) If the administrative agency is unable to verify income through an electronic data source, acceptable verification documentation includes, but is not limited to:

(a) Information maintained as a regular part of business by a government entity;

(b) A current pay stub;

(c) An award letter from a certifying agency;

(d) IRS form 1099 or other tax documents; or

(e) Employer statement including hourly or salary wage, hours worked per pay period, length of pay period and any tax withholdings.

(b) Resource and asset requirements for the eligibility category. If the administrative agency is unable to verify the value of an individual's resources through an electronic data source, acceptable verification documentation includes, but is not limited to:

(i) Information maintained as a regular part of business by a government entity;

(ii) A financial institution statement; or

(iii) Legal documents.

Effective: 10/01/2013
R.C. 119.032 review dates: 10/01/2018
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011 , 5111.02
Rule Amplifies: 5111.01 , 5111.011 , 5111.02

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

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

(B) As required by 42 C.F.R. 435.1009 (as in effect on May 1, 2013), medicaid will not pay for services provided while an individual:

(1) Is confined in a public institution; or

(2) Is a patient in an institution for mental diseases (IMD) who is age twenty-two or older, but under age sixty-five.

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: 5111.01 , 5111.011 , 5111.0119

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

(A) This rule sets forth acceptable documentary evidence of United States (U.S.) citizenship and the circumstances under which an individual who declares U.S. citizenship, under penalty of perjury, may be given a reasonable opportunity to verify U.S. citizenship.

(B) Any individual applying for medical assistance and declaring U.S. citizenship or nationality shall verify citizenship in accordance with 42 C.F.R. 435.407 (as in effect on September 1, 2013).

(1) After an individual's U.S. citizenship or nationality is verified by the administrative agency, the administrative agency shall not require the individual to re-verify citizenship.

(2) The following individuals are not required to verify their U.S. citizenship:

(a) An individual applying for medical assistance only for other individuals.

(b) A child who received medicaid as a deemed newborn on or after July 1, 2006.

(c) An individual who is:

(i) Enrolled in medicare;

(ii) Receiving supplemental security income (SSI);

(iii) Receiving social security disability insurance (SSDI);

(iv) Receving adoption or foster care assistance under Title IV-E of the Social Security Act (as in effect on September 1, 2013); or

(v) In foster care and receiving child welfare services under Title IV-B of the Social Security Act.

(d) Other individuals on such other basis as the secretary of the department of health and human services may specify, by regulation, that satisfactory documentary evidence of citizenship or nationality was previously presented.

(e) The administrative agency may rely, without further documentation of citizenship or identity, on a verification of citizenship made by a federal agency or another state agency, if such verification was done on or after July 1, 2006.

(C) If the administrative agency is unable to verify an individual's citizenship through the social security administration (SSA) or department of homeland security (DHS) electronic data exchange in the electronic eligibility system, the following documents must be accepted as satisfactory documentary evidence of citizenship:

(1) A U.S. passport, unless it was issued with a limitation; limited passports are issued through the department of homeland security (DHS) using form I-131. A passport does not have to be currently valid unless it was issued to an individual born in Puerto Rico;

(2) A certificate of naturalization (DHS form N-550 or N-570);

(3) A certificate of U.S. citizenship (DHS form N-560 or N-561);

(4) A valid state-issued driver's license, if the state issuing the license requires proof of U.S. citizenship before issuance of such license or obtains a social security number from the applicant and verifies before certification that such number is valid and assigned to the individual, who is a citizen;

(5) Native American tribal documents, including, but not limited to:

(a) A Seneca Indian tribal census record;

(b) The bureau of Indian affairs tribal census records of the Navajo Indians;

(c) A certificate of Indian blood;

(d) U.S. American Indian or Alaska native tribal document; or

(e) Other native American tribal documents.

(6) Such other documents as the secretary of the department of health and human services may specify, by regulation, provide proof of U.S. citizenship or nationality and that provide a reliable means of personal identity.

(D) If none of the documents from paragraph (C) of this rule are available, the administrative agency shall verify U.S. citizenship using a combination of one birth or nationality document from paragraph (D)(1) of this rule and one identity document from paragraph (D)(2) of this rule. Although some documents may be listed as both birth and nationality documents and identity documents, a particular document may only be used to satisfy either birth and nationality or identity, not both. A birth or nationality document or an identity document alone does not satisfy the citizenship documentation requirement.

(1) Birth or nationality shall be documented using an item from the following hierarchical list:

(a) A U.S. public birth record or birth document, showing birth in one of the fifty states, the District of Columbia, American Samoa, Guam (on or after April 10, 1899), the Northern Mariana Islands (NMI) (after November 4, 1986 NMI local time), Puerto Rico (on or after January 13, 1941), Swain's Island, or the U.S. Virgin Islands (on or after January 17, 1917) and for individuals whose U.S. citizenship may be established for collectively naturalized individuals as designated, by regulation, from the secretary of the department of health and human services. A birth certificate issued by Puerto Rico is valid only if it was issued on or after July 1, 2010;

(b) Birth information obtained through the administrative agency's data exchanges, as authorized by federal regulation or guidance from the secretary of the department of health and human services;

(c) A certification of birth abroad issued by the department of state (DS-1350);

(d) A certification of birth abroad (FS-545);

(e) A U.S. citizen identification card (I-197 or I-179);

(f) A report of birth abroad of a citizen of the U.S. (FS-240);

(g) A Northern Mariana Islands identification card (I-873), issued by the United States citizen and immigration service (USCIS), to a collectively naturalized citizen of the United States who was born in the Northern Mariana Islands before November 3, 1986;

(h) A final adoption decree or a statement from a state-approved adoption agency showing the individual's name and U.S. place of birth. In situations in which the adoption is not finalized and the state will not release a birth certificate prior to a final adoption decree, a statement showing the individual's name and U.S. place of birth, and stating that the source of information regarding the place of birth is an original birth certificate;

(i) Evidence of civil service employment by the U.S. government prior to June 1, 1976;

(j) An official military record of service showing a U.S. place of birth;

(k) A data verification with the systematic alien verification for entitlements (SAVE) program for naturalized citizens, including but not limited to the provision of the individual's alien registration number;

(l) Evidence showing an individual meets the requirements of the Child Citizenship Act of 2000, Pub. L. No. 106-395 (October 30, 2000). The administrative agency must obtain documentary evidence verifying that at any time on or after February 27, 2001, the following conditions have been met:

(i) At least one parent of the child is a U.S. citizen by either birth or naturalization;

(ii) The child is under the age of eighteen years;

(iii) The child is residing in the United States in legal and physical custody of the U.S. citizen parent;

(iv) The child was admitted to the U.S. for lawful permanent residence, as verified under the requirements of 8 U.S.C. 1641 as in effect on July 13, 2007 pertaining to verification of qualified alien status; and

(v) If adopted, the child satisfies the requirements of section 101 (b)(1) of the Immigration and Nationality Act pertaining to international adoptions, as in effect on July 13, 2007 including:

(a) Admission for lawful permanent residence as a child adopted outside the U.S. (IR-3); or

(b) Admission for lawful permanent residence as a child coming to the U.S. to be adopted, with final adoption having subsequently occurred (IR-4);

(m) Medical records, including, but not limited to, hospital, clinic, or doctor records or admission papers from a nursing facility, skilled care facility, or other institution that indicate a U.S. place of birth;

(n) A life insurance, health insurance, or other insurance record showing a U.S. place of birth;

(o) Official religious record recorded in the U.S. showing that the birth occurred in the U.S.;

(p) School records, including pre-school, Head Start and daycare, showing the child's name and U.S. place of birth;

(q) A federal or state census record showing U.S. citizenship or a U.S. place of birth, including the individual's age;

(r) Affidavits made under penalty of perjury. The affidavits do not need to be notarized. Affidavits may be used only in rare circumstances when the administrative agency is unable to secure evidence of birth or nationality from another listing. If the documentation requirement needs to be met through affidavits, the affidavit must be signed by another individual under penalty of perjury who can reasonably attest to the applicant's citizenship, and contain the applicant's name, date of birth, and place of U.S. birth.

(s) Such other documents as the secretary of the department of health and human services may specify, by regulation, that provide proof of U.S. citizenship or nationality.

(2) One of the following identity documents shall be used in combination with a birth or nationality document listed in paragraph (D)(1) of this rule. A document used to verify birth or nationality may not also be used to verify identity, even if the document is listed in this rule.

(a) A driver's license or similar document issued for the purpose of identification by a state, if it contains a photograph of the individual or such other personal identifying information relating to the individual, such as: name, date of birth, gender, height, eye color and address;

(b) An identification card issued by federal, state, or local government agencies or entities, provided it contains a photograph or other information such as: name, date of birth, gender, height, eye color and address:

(i) A U.S. military card or draft record;

(ii) A military dependent's identification card;

(iii) A U.S. coast guard merchant mariner card; or

(iv) A school identification card with a photograph;

(c) For children under age nineteen, a clinic, doctor, hospital or school record, including preschool or day care records;

(d) Two documents containing consistent information that corroborates an applicant's identity. Such documents include, but are not limited to, employer identification cards, high school and college diplomas (including high school equivalency diplomas), marriage certificates, divorce decrees and property deeds or titles;

(e) If the individual does not have any document specified in paragraphs (D)(2)(a) to (D)(2)(d) of this rule, the individual may submit an affidavit signed under penalty of perjury by another person who can reasonably attest to the individual's identity. Such affidavit must contain the individual's name and other identifying information establishing identity, such as date of birth, gender, height, eye color and address. The affidavit does not have to be notarized; or

(f) Such other documents of personal identity as the secretary of the department of health and human services finds, by regulation, provide reliable means of identification.

(E) Reasonable opportunity period. If the administrative agency is unable to verify U.S. citizenship through the social security administration (SSA) electronic state verification and exchange system (SVES), and the individual has not provided satisfactory documentation as described in paragraphs (C) and (D) of this rule, the administrative agency shall give the individual reasonable opportunity to present satisfactory documentation of U.S. citizenship.

(1) The administrative agency shall approve time-limited medical assistance, provided the individual satisfies all other conditions of eligibility outlined in rule 5101:1-37-58 of the Administrative Code. The reasonable opportunity period:

(a) Begins on the date of the individual's application.

(b) Ends ninety-five days after the administrative agency provides the individual (in person, electronically, or by mail) with the notice of the reasonable opportunity period.

(2) If, by the end of the reasonable opportunity period, the individual's citizenship or immigration status has not been verified, the administrative agency must take action within thirty days to terminate eligibility.

Effective: 10/01/2013
R.C. 119.032 review dates: 10/01/2018
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011 , 5111.02
Rule Amplifies: 5111.01 , 5111.011 , 5111.02

5160:1-1-58.3 Medicaid: non-citizens.

(A) This rule sets forth medicaid eligibility criteria for an individual who is not a U.S. citizen or national, acceptable documentary evidence of qualified non-citizen status, and the circumstances under which an individual who declares qualified non-citizen status, under penalty of perjury, may be given a reasonable opportunity to verify that status.

(B) Definitions. For the purposes of this rule:

(1) "A-number" means the alien registration number issued to a non-citizen by the United States citizenship and immigration service (USCIS) or, in limited circumstances, by the United States department of state.

(2) "Active duty" means full-time employment in the military service, and does not include reserve or guard duty. The service member shall serve a minimum of twenty-four months or the period for which the person was called to military service in order to be eligible for benefits that are based on the length of active duty service.

(3) "Amerasian" means an alien born in Cambodia, Korea, Laos, Thailand, or Vietnam after December 31, 1950, and before October 22, 1982, who was fathered by a U.S. citizen.

(4) "Asylee" means a person who has been granted asylum under section 208 of the Immigration and Nationality Act (INA) (as in effect on September 1, 2009).

(5) "Child" means an individual under the age of twenty-one.

(6) "Indefinite detainee" means a non-citizen who has served time for a criminal conviction and has received a final order of removal, but remains indefinitely in the United States because neither the individual's home country nor any other country will accept the individual. Being an indefinite detainee does not confer medicaid eligibility upon an individual nor does it serve as an exemption to the five-year bar described in paragraph (C) of this rule.

(7) "Lawful permanent resident" (LPR) means an individual who has been granted the privilege of living permanently in the United States as an immigrant.

(8) "Parolee" means a person who has been given permission by the United States department of justice or the United States department of homeland security to enter the United States in an emergency or because it serves an overriding public interest. Parolees are granted temporary residence and are not on a predetermined path to permanent resident status.

(9) "Qualified alien" means:

(a) An LPR;

(b) An asylee;

(c) A refugee admitted to the United States under section 207 of the INA (as in effect on September 1, 2009);

(d) A parolee allowed into the United States under section 212(d)(5) of the INA (as in effect on September 1, 2009) for a period of at least one year;

(e) An alien whose deportation is being withheld under section 243(h) or 241(b)(3) of the INA (as in effect on September 1, 2009);

(f) An individual granted conditional entry pursuant to section 203(a)(7) of the INA (as in effect prior to April 1, 1980);

(g) A Cuban or Haitian entrant as defined in section 501(e) of the Refugee Education Assistance Act of 1980;

(h) An Amerasian immigrant;

(i) An alien or alien's child who has been battered or subjected to extreme cruelty, as defined in 8 U.S.C. 1641(c) (as in effect on September 1, 2009); or

(j) An Afghan or Iraqi alien granted special immigrant visa status under section 101(a)(27) of the INA in accordance with the Consolidated Appropriations Act of 2008 and the National Defense Authorization Act for Fiscal Year 2008.

(10) "Quarter of coverage " is the basic unit for determining whether a worker is insured under the social security program. The amount of wages and self-employment income which an individual shall have in order to be credited with a quarter of coverage is defined in 42 U.S.C. 413(d) (as in effect on September 1, 2013), and is published annually in the Federal Register.

(11) "Veteran" means an individual who served in the active military service and who was discharged or released from duty under honorable conditions. This term includes military personnel who die during active duty service, as defined in 38 U.S.C. 1101 (as in effect on September 1, 2009), and Filipinos described in 38 U.S.C. 107 (as in effect on September 1, 2009). These are individuals who served in the Philippine Commonwealth army during World War II or as Philippine scouts following the war.

(12) "Victim of trafficking."

(a) Victims of trafficking and certain family members, as identified in the Trafficking Victims Protection Reauthorization Act of 2003 (TVPRA) ( Pub. L. No. 108-193 ), are eligible for federally funded or administered benefits to the same extent as refugees, per 22 U.S.C. 7105(b)(1)(A) (as in effect on September 1, 2009).

(b) Victims of trafficking are awarded a certification letter from the office of refugee resettlement (ORR) and are potentially eligible for medicaid. Certain family members are awarded "Derivative T" visas and are potentially eligible for medicaid.

(i) ORR makes the certification determinations and issues letters of certification for adult victims of trafficking.

(ii) Victims of trafficking who are younger than eighteen years of age do not need to be certified in order to receive benefits. Instead, ORR issues notarized letters similar to adult certification letters, stating the child is a victim of trafficking.

(c) A victim of trafficking is not required to provide any other documentation of immigration status to receive benefits, unless the victim's immigration status has changed.

(C) An individual who is not a U.S. citizen or national must be in a satisfactory immigration status to be eligible for medical assistance.

(1) An alien who was lawfully residing in the United States as of August 22, 1996, and continues to be a lawful resident of the U.S. shall be considered to be in a satisfactory immigration status.

(2) A non-citizen who was granted qualified non-citizen status on or after August 22, 1996, does not have a satisfactory immigration status for medicaid for a period of five years beginning on the date the status was granted, unless the individual is one of the following:

(a) An individual whose immigration status meets any of the following criteria:

(i) Refugee;

(ii) Asylee;

(iii) An alien whose deportation is being withheld under section 243(h) of the INA (as in effect on September 1, 2009);

(iv) Cuban or Haitian entrant;

(v) Amerasian immigrant;

(vi) Victim of trafficking; or

(vii) Afghan or Iraqi special immigrant.

(b) A lawfully residing pregnant woman.

(c) A lawfully residing child.

(d) An LPR who has forty quarters of coverage under Title II of the Social Security Act (as in effect on September 1, 2013) or can be credited with such quarters.

(i) In determining the number of quarters of coverage, an alien shall be credited as follows:

(a) All of the qualifying quarters of coverage worked by a natural or adoptive parent of such alien before the date the individual attains age eighteen can be credited;

(b) All of the qualifying quarters worked by a spouse of such alien during their marriage shall be credited so long as the alien remains married to such spouse or such spouse is deceased.

(c) A parent or spouse whose quarters are credited to the alien must be a U.S. citizen or an LPR.

(ii) A qualifying quarter does not include any quarter after December 31, 1996, in which the individual also received a federal means-tested public benefit.

(e) An individual who:

(i) Is a military member on active duty (other than active duty for training) in the armed forces of the United States; or

(ii) Is a veteran who received an honorable discharge, not a discharge on account of alienage as described in 8 U.S.C. 1426 (as in effect on September 1, 2009).

(f) A spouse or unmarried dependent child of a veteran or active duty service member as described in paragraph (C)(2)(e) of this rule.

(g) The surviving spouse of a deceased veteran or service member, provided the spouse has not remarried and the marriage fulfills the following requirements:

(i) Married for at least one year; or

(ii) Married before the end of a fifteen-year time span following the end of the period of military service in which the injury or disease was incurred or aggravated; or

(iii) Married for any period if a child was born of or before the marriage.

(h) An American Indian born in Canada to whom the provisions of 8 U.S.C. 1359 (as in effect on September 1, 2009) apply.

(i) A member of an Indian tribe, as defined in 25 U.S.C. 450B(e) (as in effect on September 1, 2009).

(3) An indefinite detainee is in a satisfactory immigration status only if the individual was in a satisfactory immigration status when the individual became an indefinite detainee.

(D) An individual who is not a U.S. citizen or national and not in a satisfactory immigration status may be eligible for alien emergency medical assistance as described in rule 5101:1-41-20 of the Administrative Code, and is not required to verify alien status.

(E) Any individual applying for medical assistance and declaring a satisfactory immigrant status shall verify his or her immigrantion status.

(1) The administrative agency must attempt to verify an individual's immigrant status through the SAVE program using the electronic eligibility system. There are two methods of verifying the immigration documents provided by the individual:

(a) Primary verification through the SAVE program is an electronic verification of alien status provided within seconds of inquiry. This verification is used for most applicants.

(b) Secondary verification through the SAVE program is used when the electronic eligibility system is unable to electronically verify alien status.

(2) If the individual's immigrant status cannot be verified through the SAVE program, the following documents must be accepted as satisfactory documentary evidence of immigrant status:

(a) I-94 (arrival/departure record).

(b) I-551 (permanent resident card).

(c) Visa in passport with a stamp from the appropriate issuing agency showing immigration status.

(d) For victims of trafficking:

(i) The original certification letter or letter for children from ORR is to be used in place of immigration documentation from USCIS. Retain a copy in the case file. Victims of trafficking are not required to provide any other immigration documents to receive benefits.

(ii) The systematic alien verification for eligibility (SAVE) program does not contain information about victims of trafficking.

(e) Other documentation as prescribed or allowed by federal law.

(f) An indefinite detainee most likely will not have documentation of original immigration status, and should instead present the following documentation, available from ORR:

(i) I-220B (order of supervision), which must include the alien's A-number and notation concerning exclusion, deportation or removal; or

(ii) I-766, I-688A or I-688B (employment authorization documents), which must show either 8 C.F.R. 274a.12(c)(18) or 8 U.S.C. 1231(a)(7) (as in effect on September 1, 2009) as the provision of law authorizing employment.

(3) When the individual's eligibility is based upon the veteran status of the individual, the individual's parent, or the individual's spouse, veteran status is verified by viewing an original or a certified copy of the DD Form 214 (undated).

(F) Reasonable opportunity period. If the administrative agency has been unable to verify U.S. citizenship through the SAVE program, and the individual has not provided verification as described in paragraph (E)(2) of this rule, the administrative agency shall give the individual reasonable opportunity to present verification of satisfactory immigration status.

(1) The administrative agency shall approve time-limited medical assistance, provided the individual satisfies all other conditions of eligibility outlined in rule 5101:1-37-58 of the Administrative Code.

(2) The reasonable opportunity period:

(a) Begins on the date of the individual's application.

(b) Ends ninety-five days after the administrative agency provides the individual (in person, electronically, or by mail) with the notice of the reasonable opportunity period.

(3) If, by the end of the reasonable opportunity period, the individual's immigration status has not been verified, the administrative agency must take action within thirty days to terminate eligibility.

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: 5111.01 , 5111.011

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

(A) This rule describes how an individual's or household's income is calculated under 42 C.F.R. 435.603 (as in effect on September 1, 2013) when determining an individual's eligibility for applications for medical assistance filed on or after January 1, 2014. This rule does not apply to determinations for categories of eligibility:

(1) For which an individual must be at least age sixty-five; or

(2) For which an individual must be found to be blind or disabled; or

(3) For which an individual must be found in need of long-term care services, whether in a facility or in a community setting; or

(4) Which cover only an individual's medicare premium or cost-sharing.

(B) Definition. "Person", for the purpose of this rule, means someone in the family or household of an individual applying for or receiving medical assistance.

(C) Determining household composition and family size.

(1) For each individual, the administrative agency must follow the requirements and definitions set out to determine household composition and family size. For the tax year in which the eligibility determination is being made:

(a) If an individual expects to file a tax return and does not expect to be claimed as a tax dependent, the household composition is determined under 42 C.F.R. 435.603(f)(1) (as in effect on September 1, 2013).

(b) If an individual expects to be claimed as a tax dependent, the household composition is determined under 42 C.F.R. 435.603(f)(2) (as in effect on September 1, 2013) unless the individual meets one of the exceptions set out in the subparagraphs of that section.

(c) Household composition is determined under 42 C.F.R. 435.603(f)(3) (as in effect on September 1, 2013) if the individual:

(i) Does not expect to file taxes or to be claimed as a tax dependent, or if it is unclear whether the individual will be claimed as a tax dependent; or

(ii) Meets one of the exceptions set out in a subparagraph of 42 C.F.R. 435.603(f)(2) (as in effect on September 1, 2013).

(2) When determining the family size of a household containing at least one pregnant woman, each pregnant woman is counted as herself plus:

(a) One; or

(b) The number of verified fetuses, if a doctor or nurse has provided a statement verifying a woman's pregnancy, including the expected date of confinement and the number of unborn fetuses.

(3) When determining the household of a married couple who live together, each spouse will always be considered a part of the other spouse's household, regardless of tax filing status and regardless of whether either spouse is claimed as a tax dependent.

(D) Determining household income.

(1) The administrative agency must follow the requirements and definitions set forth in 42 C.F.R. 435.603 (as in effect on September 1, 2013) to determine the MAGI-based income, as set forth in 42 C.F.R. 435.603(e) (as in effect on September 1, 2013) of:

(a) The individual, and

(b) Each person in the individual's household.

(2) The individual's household income is the sum of the individual's MAGI-based income plus the MAGI-based income of each person in the individual's household, excluding only income from an individual who is:

(a) Included in the household of his or her natural, adopted or step parent; and

(b) Not expected to be required to file a tax return under section 6012(a)(1) of the Internal Revenue Code (as in effect on September 1, 2013) for the taxable year in which eligibility for medical assistance is being determined, whether or not the individual files a tax return.

(3) Before comparing an individual's household income to the highest income standard under which the individual may be determined eligible using MAGI-based methodologies, deduct a dollar amount equal to five per cent of the federal poverty level (FPL) for the individual's family size.

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: 5111.01 , 5111.011 , 5111.012

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

(A) This rule describes medicaid eligibility criteria for children from birth until the individual reaches age nineteen for applications for medical assistance filed on or after January 1, 2014.

(B) Definition. "Child", for the purpose of this rule, means an individual younger than age nineteen.

(C) Eligibility criteria for coverage because a newborn child was born to a medicaid-eligible woman. In accordance with section 1902(e)(4) of the Social Security Act (as in effect April 1, 2013), a child is automatically eligible for medicaid, as of the child's date of birth, and remains eligible until the child reaches the age of one, provided the birth mother is eligible for medicaid on the date of the child's birth.

(1) Coverage under this paragraph applies, but is not limited, to newborns of a birth mother:

(a) Whose labor and delivery services were furnished prior to the date of application and whose medicaid eligibility is based on retroactive coverage in accordance with 42 C.F.R. 435.915 (as in effect on January 1, 2014).

(b) Receiving alien emergency medical assistance (AEMA) in accordance with rule 5101:1-41-20 of the Administrative Code.

(c) Residing in a public institution who is both:

(i) In a "suspended for payment but eligible for medicaid" status as described in rule 5101:1-37-58.1 of the Administrative Code, and

(ii) Within twelve months from the date of her most recent medicaid application or redetermination.

(d) In the custody of a public children services agency (PCSA) or private child placing agency (PCPA).

(e) In receipt of adoption or foster care assistance under Title IV-E.

(f) In receipt of state or federal adoption assistance.

(g) Who loses medicaid eligibility after the birth of the newborn.

(h) Who is no longer a member of the newborn's household at any time prior to the newborn reaching the age of one.

(2) For newborns described in this paragraph, the administrative agency must:

(a) Upon verbal or written notification of the newborn's birth from any individual or entity reporting the birth:

(i) Verify, in the electronic eligibility system, that the birth mother was eligible for and received medicaid on the date of the child's birth, and

(ii) Approve the child's eligibility for medicaid without delay and without consideration of household income.

(b) Not require an application for the child or a redetermination prior to the month of the child's first birthday.

(c) Not require verification of U.S. citizenship or identity.

(d) Complete a redetermination when the child reaches the age of one.

(D) Eligibility criteria for coverage because an individual is in foster care, receives adoption assistance, or is in the custody of a PCSA or PCPA or Title IV-E agency.

(1) A child is eligible for medicaid under this rule, regardless of family size, income, or resources, when the child is:

(a) In the custody of a PCSA or a PCPA or Title IV-E agency; or

(b) In receipt of adoption or foster care assistance under Title IV-E of the Social Security Act as in effect January 1, 2008; or

(c) In receipt of state or federal adoption assistance.

(2) Child, individual, or authorized representative responsibilities. The child, the individual, or the authorized representative must:

(a) Sign and date the application;

(b) Cooperate in establishing eligibility; and

(c) Report changes.

(E) Eligibility criteria for coverage because an individual is a child under age nineteen.

(1) Calculate a child's family size and household income as described in rule 5101:1-37-61 of the Administrative Code.

(2) If the child is not covered by other creditable coverage, the child's household income must not exceed two hundred six per cent of the federal poverty level for the family size.

(3) If the child is covered by other creditable coverage, the child's household income for the family size must not exceed one hundred fifty-six per cent.

(4) A child receiving medical coverage under this paragraph remains eligible:

(a) Through the end of the month in which the child turns age nineteen, if the child remains otherwise eligible in accordance with rule 5101:1-37-58 of the Administrative Code; or

(b) Until the end of an inpatient stay during which inpatient services are being furnished, if the child turns age nineteen during the inpatient stay.

Effective: 10/01/2013
R.C. 119.032 review dates: 10/01/2018
Promulgated Under: 111.15
Statutory Authority: 5101.502 , 5101.512 , 5111.01 , 5111.011 , 5111.013
Rule Amplifies: 5101.502 , 5101.512 , 5111.01 , 5111.011 , 5111.013

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

(A) This rule describes medicaid eligibility criteria for applications for medical assistance filed on or after January 1, 2014, for individuals:

(1) Who are age nineteen or twenty, or

(2) Who aged out of foster care on their eighteenth birthday and are younger than age twenty-six.

(B) Eligibility criteria for coverage because an individual is age nineteen or twenty.

(1) The individual must be age nineteen or twenty.

(2) Calculate the individual's family size and household income as described in rule 5101:1-37-61 of the Administrative Code.

(3) The individual's household income must not exceed fourty-four per cent of the federal poverty level for the family size.

(C) Eligibility criteria for coverage because an individual aged out of foster care.

(1) The individual must:

(a) Be at least eighteen years old and younger than twenty-six years old;

(b) Have been in foster care under the responsibility of the state on the individual's eighteenth birthday;

(c) Have received foster care maintenance (FCM) payments or independent living services furnished by a program funded under Title IV-E of the Social Security Act of 1935 (as in effect January 1, 2008), before the individual reached age eighteen; and

(d) Cooperate in establishing eligibility, which includes signing and dating the application.

(2) There is no income test for coverage because an individual aged out of foster care.

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: 5111.01 , 5111.011

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

(A) This rule describes the twelve-month period of continuous eligibility for a child younger than age nineteen, and the conditions under which the child's coverage ends during the twelve-month period, as described in section 1902(e)(12) of the Social Security Act (as in effect on October 1, 2013).

(B) Eligibility criteria. A child remains eligible for coverage despite changes in the child's circumstances for a period of twelve months if the child was found to be eligible for a category of medical assistance other than:

(1) Presumptive eligibility as described in Chapter 5160:1-1 or Chapter 5160:1-2 of the Administrative Code;

(2) Alien emergency medical assistance as described in rule 5160:1-5-20 or 5160:1-1-91 of the Administrative Code; or

(3) Refugee medical assistance as described in rule 5160:1-6-90 of the Administrative Code.

(C) Duration.

(1) A child's twelve-month period of continuous eligibility begins:

(a) On the date that medical assistance began as a result of an initial determination or annual redetermination in accordance with rule 5160:1-2-01.2 or rule 5160:1-1-51 of the Administrative Code,

(b) Without regard to any months of retroactive eligibility.

(2) The child's coverage shall be terminated during the continuous eligibility period only:

(a) Upon oral or written request of the child (if the child is at least eighteen years old) or the child's representative; or

(b) When the child:

(i) No longer resides in the state of Ohio; or

(ii) Dies; or

(iii) Has not paid the premium amounts required for coverage, if the child is covered under the medicaid buy-in for workers with disabilities category described in rule 5160:1-5-30 of the Administrative Code; or

(iv) Reaches age nineteen.

(D) Spenddown, patient liability, or premium.

(1) A spenddown, patient liability, or premium calculated for a child in accordance with Chapters 5160:1-3 to 5160:1-6 of the Administrative Code shall not increase during the child's continuous coverage period. Any decrease in a child's spenddown, patient liability, or premium results in a new maximum amount, which will not increase for the remainder of the child's continuous coverage period.

(2) If a child is eligible for medical assistance only through the spenddown process set forth in Chapter 5160:1-3 of the Administrative Code, the child will not receive medical assistance in any month until the child's spenddown has been satisfied for that month.

(E) Regardless of a child's status under this rule, payment for services shall not be made if payment is prohibited under rule 5160:1-1-58.1 of the Administrative Code.

Replaces: 5160:1-2-30

Effective: 01/01/2014
R.C. 119.032 review dates: 01/01/2019
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 MAGI-based medicaid: coverage for pregnant women.

(A) This rule describes eligibilty for pregnant women as described in 42 C.F.R. 435.116 (as in effect on April 1, 2013) for applications for medical assistance filed on or after January 1, 2014.

(B) Eligibility criteria for coverage because a woman is pregnant.

(1) The individual must be female and pregnant. Unless the administrative agency has information contradicting an individual's statement, the individual's statement is sufficient verification of her pregnancy.

(2) The woman's household income must not exceed two hundred per cent of the federal poverty level for the family size.

(C) Eligibility span for pregnant women.

(1) Once established, eligibility for a pregnant woman continues throughout her pregnancy and postpartum period.

(2) A woman is eligible for postpartum coverage if she was eligible for medicaid on the date her pregnancy ends. This includes a birth mother whose labor and delivery services were furnished prior to the date of application and who is determined eligible for retroactive coverage of the labor and delivery services as described in rule 5101:1-37-51 of the Administrative Code.

(D) Administrative agency responsibilities. The administrative agency must:

(1) Calculate a pregnant woman's family size and household income as described in rule 5101:1-37-61 of the Administrative Code.

(2) Inform a pregnant woman who has indicated that she is carrying more than one fetus whether medical verification of her pregnancy might, by increasing her family size, cause her to be income-eligible for medicaid.

(3) Not terminate eligibility for a pregnant woman during her pregnancy or postpartum period unless the woman dies, moves out of state, or requests that coverage be terminated.

(E) Individual responsibilities. The individual must provide medical verification of pregnancy, only if necessary for income eligibility by increasing the family size.

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: 5111.01 , 5111.011 , 5111.013 , 5111.014

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

(A) This rule describes eligibilty for parents and caretaker relatives residing with children as described in 42 C.F.R. 435.110 (as in effect on April 1, 2013) for applications for medical assistance filed on or after January 1, 2014.

(B) Eligibility criteria for coverage because an individual is a parent or caretaker relative residing with a child.

(1) The individual must be residing with a dependent child under the age of eighteen. An individual is considered to be residing with the child even if the child is temporarily absent with the intent to return home.

(2) The individual must be the child's parent or caretaker relative, or a spouse residing with the child's parent or caretaker relative.

(3) An individual must not be subject to an OWF sanction, unless the individual has agreed to comply with the work activity. The sanctioned individual shall regain medicaid eligibility beginning on the first day of the month in which the individual agrees to comply with the work activity.

(4) The individual's household income must not exceed ninety per cent of the federal poverty level for the family size.

(C) Transitional medical assistance (TMA) or extended medical assistance (EMA).

(1) To be eligible for TMA or EMA an individual must have:

(a) Been eligible for and enrolled in medicaid:

(i) For at least three of the six months immediately preceding the loss of eligibility.

(ii) As a parent or caretaker relative, or as the minor child of a parent or caretaker relative, eligible under paragraph (B) of this rule.

(b) Become ineligible for medicaid under this rule as a result of an increase in:

(i) Earned income, to be eligible for TMA. Verification of increased income is not required and can be self-declared.

(ii) Increased collection of spousal support, to be eligible for EMA. Verification of increased income is not required and can be self-declared.

(2) Duration of eligibility.

(a) A parent or caretaker relative is eligible for:

(i) Four months of EMA beginning the month immediately following the last month the individual had income below the threshold for coverage as a parent or caretaker relative. Any months of medicaid received in error due to unreported income are counted as months of EMA.

(ii) Twelve months of TMA beginning the month immediately following the last month the individual had income below the threshold for coverage as a parent or caretaker relative. Any months of medicaid received in error due to unreported income are counted as months of TMA.

(b) A child remains eligible under rule 5101:1-37-63 of the Administrative Code for a continuous period of twelve months. At the end of that twelve-month period, the child becomes eligible for any remaining months of TMA or EMA for which the parent or caretaker relative is eligible, ending in the same month as TMA or EMA ends for the parent or caretaker relative.

(3) Resuming interrupted spans of eligibility. If an individual whose span of TMA was interrupted because the individual became eligible for coverage under paragraph (B) of this rule subsequently loses eligiblity under paragraph (B) of this rule due to an increase in earned income, the individual is eligible for any remaining months or the original TMA span.

(4) Repeated spans of eligibility. There is no limit to the number of times an individual may receive coverage under TMA or EMA, provided that the individual meets all of the relevant criteria for the coverage each time.

(D) Administrative agency responsibilities. The administrative agency must:

(1) Calculate a parent's or caretaker relative's family size and household income as described in rule 5101:1-37-61 of the Administrative Code.

(2) Consider an individual's eligibility for TMA or EMA as part of the redetermination and pre-termination review processes described in rule 5101:1-37-51 of the Administrative Code.

(a) Verify in the electronic eligibility system the individual was receiving medicaid in previous months. Approve TMA or EMA if an individual meets the requirements in paragraph (C) of this rule;

(b) Deny or terminate TMA or EMA when:

(i) There is no longer a child residing with the parent or caretaker relative, or

(ii) All individuals become eligible for another medicaid covered group.

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: 5111.01 , 5111.011

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

(A) This rule describes eligibility criteria for coverage of treatment of an emergency medical condition for certain individuals who do not meet the medicaid citizenship or satisfactory immigration status requirements described in rule 5160:1-1-58.2 or 5160:1-1- 58.3 of the Administrative Code.

(B) Definition. "Emergency medical condition", for the purposes of this rule, means a medical condition with a sudden onset:

(1) Manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

(a) Placing the patient's health in serious jeopardy;

(b) Serious impairment to bodily functions; or

(c) Serious dysfunction of any bodily organ or part;

(2) Including labor and delivery, but

(3) Not including either:

(a) Routine prenatal or postpartum care, or

(b) Care and services related to an organ transplant procedure.

(C) Eligibility criteria. The individual must:

(1) Have received treatment for an emergency medical condition.

(2) Submit an application for medical assistance for the dates of a particular emergency medical episode.

(3) Meet eligibility criteria for a category of medicaid, except that the individual:

(a) Does not meet the medicaid citizenship or non-citizen requirements set forth in rules 5160:1-1-58.2 and 5160:1-1- 58.3 of the Administrative Code. The individual is not required to verify the individual's:

(i) Social security number, or

(ii) Citizenship or immigration status.

(b) Is not required to apply for social security administration (SSA) benefits. If the individual is otherwise eligible for a category of medicaid that requires a disability determination, the administrative agency shall submit a disability determination packet to the disability determination area (DDA) in accordance with rule 5101:1-39-03 of the Administrative Code.

(D) Eligibility span. Coverage for an individual who meets the criteria in paragraph (C) of this rule:

(1) Begins on the day on which the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part, and

(2) Ends on the day on which the absence of immediate medical attention could no longer reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. The emergency medical condition episode:

(a) Includes labor and delivery, but

(b) Does not include ongoing treatment.

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

(1) Determine the eligibility span for routine labor and delivery without submitting medical documentation to the DDA for a determination, and enter it into the electronic eligibility system in accordance with the following policy:

(a) The eligibility span begins on the date of admission for labor, and ends at midnight of the day in which one of the following time periods falls:

(i) A maximum of two days (forty-eight hours) following a vaginal delivery; and

(ii) A maximum of four days (ninety-six hours) following a caesarian section delivery.

(b) The time period beginning on the date of admission for labor and ending on the date of delivery shall not exceed two days (forty-eight hours).

(2) Submit medical documentation to the DDA for a determination of the covered dates of service when:

(a) The time period beginning on the date of admission for labor and ending on the date of delivery is greater than two days (forty-eight hours); or

(b) The labor and delivery episode from admission through discharge exceeds the timeframes described in paragraph (E)(1)(a) of this rule.

(3) For emergency medical conditions other than routine labor and delivery as described in paragraph (E)(1) of this rule, enter the eligibility span determined by the DDA into the electronic eligibility system.

(4) Upon request, assist the individual in obtaining medical documentation to support the AEMA claim.

(F) Disability determination area (DDA) responsibilities. The DDA shall:

(1) Make all emergency medical condition determinations except for routine labor and delivery cases, as described in paragraph (E)(1) of this rule.

(2) Determine if the individual received treatment for an emergency medical condition.

(3) Determine the eligibility span for the emergency medical condition episode.

(4) Notify the administrative agency of the AEMA determination and the eligibility span via the electronic eligibility system.

Effective: 01/01/2014
R.C. 119.032 review dates: 01/01/2019
Promulgated Under: 111.15
Statutory Authority: 5162.031 , 5163.02
Rule Amplifies: 5163.02