Chapter 5160:1-2 Medicaid Application Procedures

5160:1-2-01 Medicaid: individual and administrative agency responsibilities.

(A) This rule sets forth responsibilities of the individual and the administrative agency that apply at all times: at application; at the initial eligibility determination; at a scheduled or unscheduled redetermination; and between redeterminations.

(B) Individual responsibilities. The individual shall:

(1) Provide verification of all eligibility criteria as requested by the administrative agency.

(2) Report to the administrative agency, within ten days of the change, any change in the following:

(a) Household composition, living arrangements, or address.

(b) Earned or unearned income, including:

(i) The receipt of a non-recurring lump-sum payment; or

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

(c) Third-party liability for health care costs, including:

(i) New coverage under a health insurance policy, regardless of who is paying for the coverage; or

(ii) A change in health insurers; or

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

(iv) Any accident or injury for which another person or entity may be responsible, such as a work-related injury or an injury sustained in an automobile collision; or

(v) Any insurance information as it relates to paragraph (B)(2)(c)(iv) of this rule.

(vi) Termination of a health insurance policy.

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

(e) An improvement of the individual's condition, if the individual is receiving medicaid for the blind or medicaid for the disabled.

(f) For any category of medical assistance with a resource limitation:

(i) A change in the ownership of a resource; or

(ii) A change in the amount or value of any available resource; or

(iii) Any change in ownership an individual or spouse has in an annuity, or any change to the remainder beneficiary designation.

(3) Cooperate with the application, determination, redetermination, auditing, and quality control processes, including:

(a) Completing, signing, and dating an initial application; and

(b) Answering all relevant questions and providing the necessary verifications to establish initial or continued eligibility; and

(c) Requesting assistance from the administrative agency if the individual is unable to obtain requested information, and providing the information necessary for the administrative agency to assist.

(4) Select a managed care plan (MCP) in accordance with rule 5101:3-26-02 of the Administrative Code, unless the individual falls within one of the exceptions listed in that rule.

(5) Cooperate with third-party insurance companies.

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

(1) Render assistance and determine eligibility and benefits without discrimination on account of race, religion, disability, national origin, political beliefs, age, or sex.

(2) Determine or redetermine an individual's eligibility for medical assistance within the application processing time limits set forth in rule 5101:1-38-01.2 of the Administrative Code.

(3) Not approve medical assistance to an individual merely because of an agency error or delay in determining eligibility, unless all eligibility factors are met.

(4) Determine eligibility for medical assistance promptly upon receipt of required information and verifications. The administrative agency shall not delay the approval of medical assistance due to the lack of information or verifications necessary to determine eligibility for other public assistance programs.

(5) Upon request, provide assistance to individuals having difficulty completing an application or gathering verifications.

(6) Advise applicants, authorized representatives, and individuals of:

(a) The effect of any delay in completing an application upon the starting date of potential medical coverage; and

(b) Verification requirements and time lines; and

(c) The requirement that the individual or authorized representative cooperate with the eligibility determination and redetermination process; and

(d) The penalties for medicaid eligibility fraud set forth in section 2913.401 of the Revised Code.

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

(8) Determine whether the individual's eligibility for medical assistance is affected by a change. This determination shall be made within ten days of learning of the change through data systems, a report from an individual, or by other means.

(9) If an individual reports a new address in the state of Ohio, the administrative agency shall:

(a) Give or mail to the individual a notice meeting the requirements of section 3503.10 of the Revised Code; and

(b) Give or mail to the individual a voter registration form as required by section 329.051 of the Revised Code; and

(c) 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.

(10) Obtain verification of reported information that is new, has changed or is subject to change. Verification shall be obtained as set forth in Chapter 5101:1-38 of the Administrative Code.

(11) Issue an itemized, dated receipt when an application for medical assistance or a verification document related to eligibility for medical assistance is received.

(12) Document and record determinations of eligibility. The administrative agency shall:

(a) 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.

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

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

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

(e) 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.

(f) If information is verified through a telephone contact, record the following data:

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

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

(iii) The date of the contact; and

(iv) An accurate summary of the information provided.

(13) Approve medical assistance for an individual who:

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

(b) Has provided all necessary verifications as set forth in rule 5101:1-38-01.2 of the Administrative Code; and

(c) Meets all conditions of eligibility for a covered group set forth in rule 5101:1-38-01.8 of the Administrative Code.

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

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

(b) Withdraws the application; or

(c) Fails to cooperate in the application or determination process or fails to provide all necessary verifications, as set forth in paragraph (H)(4) of rule 5101:1-38-01.2 of the Administrative Code; or

(d) Does not meet all conditions of eligibility for any covered group as set forth in rule 5101:1-38-01.8 of the Administrative Code.

(15) Suspend medical assistance upon notification that an individual meets any of the criteria for ineligibility for payment of services set forth in rule 5101:1-37-20 of the Administrative Code. Redetermine eligibility upon notification that an individual no longer meets the previously cited criteria.

(16) Terminate medical assistance for an individual who:

(a) Requests that assistance be terminated; or

(b) Is deceased; or

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

(d) No longer meets the conditions of eligibility for any covered group as set forth in rule 5101:1-38-01.8 of the Administrative Code.

(17) Notify individuals of all determinations and proposed changes in coverage or benefits, including any applicable premium, patient liability, or spenddown.

(18) Follow the safeguarding guidelines set forth in rule 5101:1-37-01.1 of the Administrative Code when providing or gathering information by telephone, in person, or in electronic or written form.

(19) Process an intercounty transfer (ICT) upon receipt of a report (verbal or written) that an individual has changed residence from one county to another within the state of Ohio. 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:

(i) Transfer the case in its current status in the electronic eligibility system within five working days of the reported change.

(ii) 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 application for medical assistance benefits; and

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

(iii) Complete a JFS 03900 "Notice of Intercounty Transfer" (rev. 5/2010), attach a copy of the JFS 03900 to the records being transferred to the county of new residence, and keep a copy of the JFS 03900 in the retained case record.

(iv) Maintain a copy of transferred documents for future reference, while making originals available, 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 rule 5101:1-38-01.2 of the Administrative Code.

(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) A potential claim, which has not yet been established, may be transferred to the CDJFS in the county of new residence, for that CDJFS to establish, only if the CDJFS of both counties agree that the county of new residence shall establish the claim.

(20) Advise potentially eligible individuals of the supplemental nutrition program for women, infants and children (WIC) and refer them to the WIC agency by forwarding a copy of the individual's medicaid 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 shall advise the individual of the WIC program at least annually.

(21) Report to the Ohio department of job and family services (ODJFS) any available information about a third party liable for an individual's health care costs.

(a) When determining an individual's eligibility for medical assistance coverage, the agency shall report any potential third-party liability (TPL) to the ODJFS using:

(i) The JFS 06612 "Health Insurance Information Sheet" (rev. 5/2001), or its electronic equivalent, to report possible health insurance coverage. A separate JFS 06612 shall be completed for each possible health insurance policy.

(ii) The JFS 06613 "Accident/Injury Insurance Information Form" (rev. 6/2009), or its electronic equivalent, to report potential TPL due to an injury, disability or court order.

(b) At a redetermination, or upon any reported change, the administrative agency shall compare the individual's current information to the information on the most recent JFS 06612 or JFS 06613. If any information has changed, the administrative agency shall report the changes to ODJFS by submitting a new JFS 06612 or JFS 06613, or an electronic equivalent.

(c) Upon a request by ODJFS, the administrative agency shall contact the individual to obtain information about potential TPL. If the individual fails to cooperate, the agency shall propose to terminate or deny the individual's medical assistance for failure to cooperate, as set forth in rule 5101:1-38-01.2 of the Administrative Code.

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

Effective: 09/09/2012
R.C. 119.032 review dates: 10/01/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011 , 5111.012
Rule Amplifies: 5111.01 , 5111.011 , 5111.012 , 329.051
Prior Effective Dates: 11/1/74, 8/1/75, 10/1/75, 6/1/76, 7/14/77, 12/31/77, 9/1/82, 9/24/83, 8/1/84, 10/20/84, 11/1/84, 12/1/84 (Emer.), 2/10/85, 7/1/85, 4/1/86, 8/1/86 (Emer.), 10/3/86, 10/1/87 (Emer.), 12/24/87, 4/1/88 (Emer.), 6/10/88, 6/30/88, 7/1/88 (Emer.), 8/1/88 (Emer.), 9/1/88, 9/24/88, 10/1/88 (Emer.), 10/15/88, 10/25/88 (Emer.), 12/20/88, 3/1/89 (Emer.), 5/28/89, 12/1/89, 4/1/90 (Emer.), 6/22/90, 8/1/90(Emer.), 10/25/90, 1/1/91 (Emer.), 2/21/91, 4/1/91 (Emer.), 6/1/91, 7/1/91 (Emer.), 9/15/91, 10/1/91 (Emer.), 12/20/91, 4/1/92, 7/1/92, 1/1/93, 1/1/93 (Emer.), 2/11/93, 3/18/93, 5/1/93, 9/1/93, 1/1/94, 3/1/94 (Emer.), 4/18/94, 1/1/95, 1/1/95 (Emer.), 4/1/95, 7/1/95, 10/1/95, 6/1/96, 10/1/96, 10/1/96 (Emer.), 12/15/96, 5/1/97, 10/1/97 (Emer.), 10/30/97, 12/30/97, 7/1/98, 7/1/99, 10/1/99, 5/4/00, 7/1/00, 6/1/03, 6/1/03 (Emer.), 9/20/03, 10/6/03, 9/25/06, 10/1/06, 6/1/07, 8/1/07, 10/1/09, 7/17/11

5160:1-2-01.2 Medicaid: application, determination, and redetermination processes.

(A) This rule sets forth the processes for determining an individual's eligibility for medical assistance at initial application or redetermination. Any reference to an application or form in this rule also means its non-English or electronic equivalent.

(B) Calculation of time periods. All calculations of time periods used in the determination and redetermination 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) Request for application. When an individual requests an application, the administrative agency shall:

(1) Inform the individual that the beginning date of benefits is dependent upon the date the signed and dated application is received by the administrative agency.

(2) Neither deny an individual's right to apply nor discourage an individual from applying.

(3) Give or mail an application on the day the request is received. The proper application to provide to an individual depends upon the category of medical assistance for which the individual is applying.

(a) The JFS 07200 "Request for Cash, Food Stamp, and Medical Assistance" (rev. 3/2010) is an application for cash and food assistance and for all forms of medical assistance except for the Ohio breast and cervical cancer project (BCCP) outlined in rule 5101:1-41-05 of the Administrative Code.

(b) If the individual wishes to apply for medical assistance for a child or children, a low-income family, a pregnant woman, or an adult up to age twenty-one described in Chapter 5101:1-40 of the Administrative Code, the administrative agency shall provide the JFS 07216 "Combined Programs Application" (CPA) (rev. 2/2010).

(i) The JFS 07216 may also be used to apply for or to refer to the following Ohio department of health programs:

(a) The special supplemental food program for women, infants, and children (WIC); and

(b) The child and family health services program (CFHS);

(c) The bureau for children with medical handicaps program (BCMH); and

(d) "The Help Me Grow" (HMG) program.

(ii) If an individual requests WIC, CFHS, or HMG assistance, the administrative agency shall forward copies of the CPA to the appropriate local health department office. If an individual requests BCMH assistance, a copy shall be sent to the bureau for children with medical handicaps.

(c) If the individual wishes to apply for assistance with medicare expenses, the administrative agency shall provide the JFS 07103 "Application for Help with Medicare Expenses" (rev. 9/2009), and inform the individual that additional information is needed to explore eligibility for other medical assistance programs.

(d) If the individual wishes to apply only for coverage under BCCP, the administrative agency shall provide the JFS 07161 "Ohio Breast and Cervical Cancer Project Medicaid Application" (rev. 9/2009), and inform the individual that this is not an application for other medical assistance programs.

(D) Documents. The administrative agency shall give or send the following documents to every applicant at initial application and at every redetermination of eligibility for medical assistance:

(1) Pamphlet describing the local service programs available; and

(2) Preaddressed, postage-paid envelope for return to the administrative agency; and

(3) JFS 07501 "Program Enrollment and Benefit Information" (rev. 07/2011); and

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

(E) Assistance with application.

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

(2) Authorized representative. Unless otherwise stated in the documents authorizing a representative, an authorized representative shares all responsibilities of an individual. The acts or omissions of an authorized representative shall be deemed to be the acts or omissions of the individual.

(a) An individual who wishes to designate an authorized representative shall, in writing, identify the authorized representative and the duties the authorized representative may perform on the individual's behalf.

(i) The individual shall notify the administrative agency in writing of any change in the authorized representative or the duties the authorized representative may perform.

(ii) When written authorization cannot be obtained due to the individual's incompetence, the administrative agency shall waive the written statement and assist in naming a responsible party to act as authorized representative for the individual.

(b) When the individual has an authorized representative, all notices and correspondence issued by the administrative agency for the individual shall be issued to both the authorized representative and the individual.

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

(3) The administrative agency shall help complete the application if assistance is needed.

(a) An eligibility worker shall, at the individual's request, assist in 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.

(i) The eligibility worker shall not alter any answers given by the individual.

(ii) If an eligibility worker assists or helps to complete an application, the worker shall sign the application form and include the worker's title.

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

(F) Receipt of initial application.

(1) An application for medical assistance, or a printed copy of an electronic equivalent, must be signed under penalty of perjury by the applicant, an authorized representative, or, if the applicant is incompetent or incapacitated, someone acting responsibly for the applicant.

(2) Upon receipt of any signed application for medical assistance or for specific medicaid services or programs, the administrative agency shall issue a receipt to the individual showing the date of application.

(3) The administrative agency shall accept and register an application on the day a signed application is received, whether it is an original, a facsimile, or an electronic signature ("e-signature") submitted after the approval of an e-signature policy by the Ohio office of information technology and ODJFS. An original signature is not required.

(a) If the application is received by the administrative agency on a day when the administrative agency is closed, the administrative agency must register the application on the next business day and back date the registration date to the date the application was actually received by the administrative agency.

(b) If an application is received from a local WIC clinic, CFHS clinic, or BCMH office within five days of the signature date, the application shall be registered using the signature date. If the application is not received within five days of the signature date, the application shall be registered using the date it was received by the administrative agency.

(c) An application taken by an outstationed worker assigned to a federally qualified health center (FQHC) or a disproportionate share hospital (DSH) must immediately be submitted to the appropriate administrative agency. The administrative agency must register the application using the signature date.

(d) The administrative agency shall not delay the registration or processing of an application due to the lack of a signed JFS 07236.

(G) Determination of eligibility. The CDJFS shall determine eligibility for all medical assistance programs except BCCP.

(1) Initial determination:

(a) Unless an interview is requested by the applicant, the agency shall not schedule a face-to-face interview.

(b) The administrative agency shall advise the individual of or explain the following, either during an interview, by telephone, electronically or in writing:

(i) The eligibility requirements for relevant medical assistance programs; and

(ii) What information and verifications must be provided in order to determine the individual's eligibility for medical assistance, and the consequences of failing to provide information or verifications in a timely fashion; and

(iii) How the administrative agency will assist in securing the required verifications and information if assistance is requested; and

(iv) The individual's reporting responsibilities; and

(v) The confidential nature of:

(a) All information given to the administrative agency; and

(b) The income and eligibility verification system (IEVS) program described in rule 5101:1-37-03.1 of the Administrative Code; and

(c) The use of a social security number; and

(vi) The individual's right to view the contents of the individual's case record; and

(vii) A quality control review may be undertaken with or without the full knowledge of the individual, and the individual's responsibility to cooperate with the review; and

(viii) The availability, purpose, and provision of relevant social service programs within and outside the agency including WIC, pregnancy-related services (PRS) described in rule 5101:1-38-06 of the Administrative Code, and early and periodic screening, diagnosis and treatment(EPSDT) described in rule 5101:1-38-05 of the Administrative Code; and

(ix) The right to request a state hearing, including a description of the state hearing process; and

(x) The responsibility under medical assistance programs of a parent for minor children and spouses for each other; and

(xi) The issuance and use of medical assistance cards, including the ability of providers to verify eligibility, and that the individual need not wait for receipt of a health care card to receive services if medical assistance is approved; and

(xii) The responsibility to select an MCP in accordance with rule 5101:3-26-02 of the Administrative Code, unless the individual falls within one of the exceptions listed in that rule; and

(xiii) The automatic assignment of third-party medical payments and medical support and the good cause exemption that may be claimed for medical support; and

(xiv) The availability of free legal services through legal aid; and

(xv) An explanation of transitional medicaid as outlined in rule 5101:1-40-05 of the Administrative Code; and

(xvi) An explanation of the medicaid estate recovery program as outlined in rule 5101:1-38-10 of the Administrative Code; and

(xvii) 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; and

(xviii) For individuals who apply for or receive long-term care services, home and community-based (HCB) services, or services under the program of all inclusive care for the elderly (PACE), an explanation of the annuity disclosure requirements outlined in rule 5101:1-39-22.8 of the Administrative Code. For individuals disclosing such ownership interest in any annuity, the administrative agency shall explain the remainder beneficiary requirements outlined in rule 5101:1-39-22.8 of the Administrative Code.

(c) The administrative agency shall:

(i) Determine an individual's eligibility for all categories of medical assistance for which the individual has applied, and issue notice of the determination.

(a) If an individual may be eligible for, or has applied for, a category of medical assistance for which the application completed by the individual does not gather sufficient information, the administrative agency shall request the information from the individual. The administrative agency shall not deny, or fail to explore, a category of medical assistance for failure to complete an application specific to that category. The following documents are applications for medical assistance:

(i) JFS 07200 "Request for Cash, Food Stamp, and Medical Assistance"; or

(ii) JFS 07216 "Combined Programs Application" (CPA); or

(iii) JFS 07103 "Application for Help with Medicare Expenses"; or

(iv) JFS 07161 "Ohio Breast and Cervical Cancer Project Medicaid Application"; or

(v) JFS 01137 "Child Care/Healthy Start and Healthy Families Supplement" (rev. 10/2006), if accompanied by the JFS 01138 "Application for Child Care Benefits" (rev. 1/2010).

(b) At the time of determination, if notice is not issued through the electronic eligibility system, the administrative agency shall immediately issue one of the following forms:

(i) To approve medical assistance, the JFS 04074 "Notice of Approval of Your Application for Assistance" (rev. 2/2009); or

(ii) To deny medical assistance, the JFS 07334 "Notice of Denial of Your Application for Assistance" (rev. 2/2009).

(ii) If an individual is eligible for more than one medical assistance covered group, inform the individual of the options and, unless the individual chooses otherwise, approve coverage that provides the most family members with assistance.

(iii) Approve medical assistance beginning on the first day of the month in which the administrative agency received the application if an individual is eligible for medical assistance as described in Chapters 5101:1-37 to 5101:1-40 or rule 5101:1-41-30 of the Administrative Code, except:

(a) Coverage for an individual born during a month cannot precede the individual's date of birth.

(b) Coverage for an individual who became an Ohio resident during a month cannot precede the date the individual became an Ohio resident.

(c) Coverage for an individual eligible through the spenddown process is addressed in rule 5101:1-39-10 of the Administrative Code.

(d) Timely determination. Within thirty calendar days from the date of application, the administrative agency shall determine if the individual meets the conditions of eligibility, as described in rule 5101:1-38-01.8 of the Administrative Code. The administrative agency shall provide for a ninety day timely determination when an individual alleges blindness or disability, as described in Chapter 5101:1-39 of the Administrative Code, who otherwise meets the conditions of eligibility, as described in rule 5101:1-38-01.8 of the Administrative Code.

(i) The application processing timely determination may be exceeded if:

(a) The administrative agency cannot reach a decision because 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.

(ii) The administrative agency shall not:

(a) Use application processing time limits as a waiting period before approving medical assistance benefits; or

(b) Approve or deny an application because the time limits have been reached before an individual's eligibility has been determined.

(e) Retroactive coverage. The administrative agency shall approve eligibility for medical assistance (except for a recipient of transitional medicaid as described in rule 5101:1-40-05 of the Administrative Code or a qualified medicare beneficiary as described in rule 5101:1-38-03 of the Administrative Code) 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 medicaid 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.

(2) Redetermination upon change. The administrative agency shall promptly determine whether a reported or discovered change affects the individual's eligibility for a medical assistance program, and shall issue written notice of any denial, termination or change in benefits.

(a) An administrative agency may redetermine eligibility at any time based upon a reasonable belief that circumstances that may affect eligibility have changed.

(b) The administrative agency shall document in the case record the reasons for requiring or performing a redetermination at a time other than the scheduled redetermination date.

(3) Annual redetermination. The administrative agency shall:

(a) Contact the individual by telephone, mail, or electronic means to determine whether there have been any changes that may affect the individual's eligibility for medical assistance. At the individual's request, a face-to-face interview may be scheduled.

(b) Determine whether any changes affect the individual's eligibility for medical assistance no less often than:

(i) Every twelve months; or

(ii) The time frames specified in rule 5101:1-40-05 of the Administrative Code for recipients of transitional medical assistance.

(c) Not require an individual complete or sign an application unless all individuals who signed the initial application, or signed an application at a prior redetermination, no longer reside in the household. In this case, an application will need to be completed for the individuals currently residing in the household.

(d) Not require a face-to-face interview.

(e) Provide to the individual the documents set forth in paragraph (D) of this rule.

(f) Inform the individual of or explain the items set forth in paragraph (G)(1)(c) of this rule.

(g) Follow the process set forth in paragraph (H) of this rule for requesting verification documents as at an initial application.

(h) Not perform an annual redetermination of a pregnant woman's eligibility during her pregnancy or postpartum period or of a deemed newborn during the year of deemed eligibility.

(i) Not terminate eligibility due to a delay in redetermination or an inability to complete the redetermination of eligibility on time unless the individual fails to cooperate with the redetermination.

(H) Request for information or verification. If information needed to determine an individual's initial or continuing eligibility for a medical assistance program must be verified, but was not submitted with the application:

(1) The administrative agency shall provide the applicant with a JFS 07105 "Application/Reapplication Verification Request Checklist" (rev. 12/2009), a JFS 07220 "Medicaid Eligibility Review Verification Request Checklist (rev. 2/2010), or an equivalent written checklist including:

(a) A list of information that must be verified in order to determine eligibility; and

(b) The date by which the information must be provided to the administrative agency; and

(c) The eligibility worker's name and contact information; and

(d) A clear statement that, upon request, the administrative agency will assist in obtaining the required information or verification.

(2) The administrative agency shall explain:

(a) Where and how to obtain the required verifications; and

(b) When and how the administrative agency will assist the individual in securing verifications.

(3) 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 shall contact the individual in writing, mailed or personally delivered no more than twenty days from the date of the application. The contact letter shall 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. This written follow-up letter:

(a) Shall include a clear statement that the administrative agency will assist in obtaining the required information or verification if the request for assistance is received on or prior to the given deadline.

(b) Does not serve as a notice of denial of application. If the requested information or verification is not received, the administrative agency shall propose a denial or termination of benefits.

(4) The administrative agency shall deny an application for medical assistance or terminate eligibility if an individual fails or refuses, without good cause, to cooperate by providing necessary verifications or by providing consent for the administrative agency to obtain the verifications. The administrative agency shall:

(a) Allow the individual the timely determination period, not to exceed the time limits for timely determination of eligibility, to obtain verifications and resolve discrepancies prior to determining the individual's eligibility.

(b) Deny or terminate medical assistance if:

(i) An individual provides incomplete or inconsistent information, is non-cooperative, or is unable to clarify information; and

(ii) The administrative agency is unable to verify a required eligibility factor.

(c) Not deny or terminate current or future medical assistance:

(i) If the individual is otherwise eligible for medicaid but meets the requirements of rule 5101:1-38-01.7 of the Administrative Code; or

(ii) For a failure or refusal to cooperate in verifying past eligibility.

(5) Verification is not required if an individual's own statement establishes an individual is ineligible for medical assistance. The administrative agency shall:

(a) Confirm the accuracy of the statement; and

(b) If it is correct, deny or terminate eligibility; and

(c) Advise the individual of the right to reapply at any time.

(6) If an individual does not reside in a permanent dwelling or does not have a fixed home or mailing address, the administrative agency shall:

(a) Approve the individual's application for medicaid if the individual is eligible for a category of medical assistance based upon the individual's statements, an affidavit, or the best available evidence. If the individual is applying for medicaid for the blind, or disabled, the individual must be determined to be blind or disabled pursuant to rule 5101:1-39-03 of the Administrative Code.

(b) Attempt to obtain verification of all eligibility factors for the case record, and record all attempts to obtain verification.

(I) Pre-termination review (PTR). Pursuant to 42 C.F.R. 435.930 (as in effect on October 1, 2011) the administrative agency shall determine whether the individual is eligible for any other category of medical assistance before proposing to terminate an individual's medical assistance for any reason.

(1) If there is sufficient information in the physical or electronic records available to the administrative agency to complete the PTR, the administrative agency shall determine the individual's eligibility for medicaid based upon that information.

(2) If there is insufficient information in the physical or electronic records available to the administrative agency to complete the PTR, the administrative agency shall take reasonable steps to obtain the needed information before proposing termination.

(3) If the individual fails to cooperate by providing requested information, the administrative agency shall determine eligibility based on available information.

(4) If the individual is eligible for another category of medical assistance, the administrative agency shall approve assistance under that category for the individual; if the individual is not eligible for any category of assistance, the agency shall propose to terminate the individual's medical assistance benefits.

(J) Effective date of termination of coverage.

(1) A change in circumstances (other than death) during the month cannot adversely affect eligibility for the month during which the change occurred.

(a) If an individual is no longer eligible for medical assistance, the administrative agency shall propose to terminate coverage on the last day of the month, if there are enough days remaining in the month for prior notice and an opportunity to request a hearing to be given to the consumer before the next month begins.

(b) A change occurring too late in a month for prior notice and an opportunity to request a hearing to be given to the consumer before the next month begins shall be effective the first of the second month following the month of change.

(2) If an individual was incorrectly determined to be eligible for medical assistance, the administrative agency shall propose to terminate coverage and explore the possibility of overpayment recovery as set forth in rule 5101:1-38-20 of the Administrative Code.

(3) An individual's eligibility, once it has been approved and a notice has been generated, can not be retroactively deleted or rescinded.

(4) An established termination date for an individual can be changed to an earlier date only in the case of the individual's death. Coverage for an individual shall terminate on the date of the individual's death.

Effective: 01/09/2012
R.C. 119.032 review dates: 10/01/2014
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
Prior Effective Dates: 8/1/75, 10/1/75, 6/1/76, 7/14/77, 9/3/77, 12/31/77, 9/1/82, 9/24/83, 8/1/84, 10/20/84, 11/1/84, 12/1/84 (Emer.), 2/10/85, 4/1/86, 8/1/86 (Emer.), 10/3/86, 7/1/87 (Emer.), 8/3/87, 10/1/87 (Emer.), 12/24/87, 3/24/88 (Emer.), 4/1/88 (Emer.), 6/10/88, 6/30/88, 7/1/88 (Emer.), 9/1/88, 9/24/88, 10/1/88 (Emer.), 10/25/88 (Emer.), 12/20/88, 3/1/89 (Emer.), 5/28/89, 12/1/89, 1/1/90 (Emer.), 4/1/90, 6/22/90, 8/1/90 (Emer.), 10/25/90, 1/1/91 (Emer.), 2/21/91, 4/1/91 (Emer.), 6/1/91, 7/1/91 (Emer.), 9/15/91, 10/1/91 (Emer.), 12/20/91, 4/1/92, 7/1/92, 1/1/93, 1/1/93 (Emer.), 2/11/93, 3/18/93, 5/1/93, 9/1/93, 1/1/94, 3/1/94 (Emer.), 4/18/94, 1/1/95, 1/1/95 (Emer.), 4/1/95, 7/1/95, 10/1/95, 6/1/96, 10/1/96 (Emer.), 10/1/96, 12/15/96, 5/1/97, 10/1/97 (Emer.), 10/30/97, 12/30/97, 7/1/98, 10/1/99, 11/1/99 (Emer.), 2/1/00, 5/4/00, 7/1/00, 10/1/02, 6/1/03, 6/1/03 (Emer.), 9/20/03, 10/6/03, 9/25/06, 10/1/06, 6/1/07, 10/1/09, 7/17/11

5160:1-2-01.5 [Rescinded] Medicaid: Certificate of creditable coverage and privacy notice.

Effective: 01/01/2014
R.C. 119.032 review dates: 10/15/2013
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

5160:1-2-01.6 Medicaid: application for home and community-based (HCB) services.

(A) This rule sets forth the process for determining whether an individual is eligible for medicaid payments for services under the HCB services waivers set out in division 5101:3 of the Administrative Code.

(B) Eligibility for HCB services. To receive HCB services, the individual shall:

(1) Be in receipt of medicaid, as described in Chapters 5101:1-37 to 5101:1-40 or rule 5101:1-41-30 of the Administrative Code;

(2) Be in need of HCB services under a waiver described in division 5101:3 of the Administrative Code; and

(3) Be enrolled in an HCB services waiver described in rule 5101:3-1-06 of the Administrative Code.

(C) Determination of eligibility for HCB services. The county department of job and family services (CDJFS) shall approve HCB services for an individual in receipt of medicaid only upon:

(1) Approval by the HCB services waiver operational agency; and

(2) If services under the waiver are available only to a specific number of individuals, notification that the individual may be enrolled in the waiver from the Ohio department of job and family services (ODJFS), its designee, or a waiver operating agency.

(D) Coverage period. The HCB services coverage period can have a different beginning date or ending date from the medicaid eligibility period. However, HCB services cannot begin before an individual's medicaid eligibility period or before an individual's retroactive medicaid eligibility period as determined under rule 5101:1-38-01.2 of the Administrative Code; HCB services cannot extend beyond the termination date of an individual's medicaid coverage; and HCB services cannot be provided during any period of medicaid ineligibility.

(1) Medicaid coverage of HCB services begins on the latest of the following dates:

(a) The process date for application for HCB services. The process date is:

(i) The date the CDJFS receives a signed application for HCB services from an individual; or

(ii) The signature date, if the CDJFS receives a signed and dated HCB services application from a waiver operational agency no more than five working days after the date of signature; or

(iii) The date the CDJFS receives the signed application for HCB services, if the application was received from a waiver operational agency more than five working days after the date of signature.

(b) The date the individual meets all criteria for coverage of an HCB services waiver described in rule 5101:3-1-06 of the Administrative Code.

(c) The date the individual is authorized, by the waiver operational agency, to receive HCB services.

(2) Medicaid coverage of HCB services terminates when either:

(a) The CDJFS determines the individual no longer meets medicaid conditions of eligibility as described in rule 5101:1-38-01.8 of the Administrative Code or the criteria for coverage of HCB services; or

(b) The waiver operational agency notifies the CDJFS that it no longer authorizes the individual to receive its HCB services.

(E) HCB services waiver operational agency responsibilities. HCB services waiver operational agencies shall:

(1) Submit a JFS 02399 "Request for Medicaid Home and Community-Based Services (HCBS)" (rev. 1/2006), signed by the individual, to the CDJFS within five days of the signature date, if assisting an individual with an application for HCB services.

(2) Determine, in accordance with this rule and division 5101:3 of the Administrative Code, whether the individual requesting medicaid coverage of HCB services meets the requirements of the applicable HCB services waiver program.

(3) Provide written notification of determinations to individuals, including to whom any patient liability must be paid, if applicable.

(4) Notify the CDJFS of determinations and subsequent changes regarding approval of HCB services.

(F) Administrative agency responsibilities. The CDJFS shall:

(1) Determine an individual's eligibility for HCB services in accordance with this rule and Chapters 5101:1-37, 5101:1-38, 5101:1-39, 5101:1-40, 5101:1-41, and 5101:1-42 of the Administrative Code.

(a) If an individual who applies for HCB services is currently in receipt of medicaid, the CDJFS shall process the individual's application for HCB services.

(b) If an individual who applies for HCB services is not currently in receipt of medicaid, the CDJFS shall begin the application process described in rule 5101:1-38-01.2 of the Administrative Code.

(c) If the CDJFS determines that an individual who applies for HCB services is not eligible for any category of medical assistance under Chapters 5101:1-37 to 5101:1-40 or rule 5101:1-41-30 of the Administrative Code, the agency shall deny both medical assistance and HCB services for that individual.

(2) Within five days of the receipt of a signed JFS 02399, notify the applicable waiver agency via the electronic eligibility system of the receipt of the application. If the waiver agency is not known or if multiple waiver agencies are indicated on the application, the CDJFS shall submit the JFS 02399 to the Ohio department of job and family services (ODJFS) bureau administering HCB waiver services.

(3) Notify the applicable HCB services waiver operational agency of changes in the individual's eligibility for medicaid coverage of HCB services.

Replaces: 5101:1-38- 01.6

Effective: 10/01/2009
R.C. 119.032 review dates: 10/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.01 , 5111.011 , 5111.871
Rule Amplifies: 5111.01 , 5111.011 , 5111.012 , 5111.87 , 5111.871 , 5111.91
Prior Effective Dates: 6/1/1988 (Emer.), 8/1/1988 (Emer.), 10/30/1988, 1/1/1990 (Emer.), 3/1/1990 (Emer.), 3/30/1990 (Emer.), 4/1/1990, 6/29/1990, 7/1/1990, 10/1/1990, 1/1/1991 (Emer.), 4/1/1991, 1/1/1992 (Emer.), 3/20/1992, 3/30/1992, 5/1/1992 (Emer.), 7/1/1992, 8/14/1992 (Emer.), 1/1/1992, 5/1/1993, 9/1/1993, 7/1/1994, 10/1/2002, 10/1/2004

5160:1-2-01.7 Medicaid: assisting individuals unable to access verifications due to a physical or mental impairment.

(A) The purpose of this rule is to establish the procedures the administrative agency must follow when processing an application for medical assistance for an individual unable to access verifications or means of self-support due to a physical or mental impairment, in order to prevent any physical or mental disability from negatively impacting the eligibility determination process. This rule applies to all medical assistance programs administered by the Ohio department of job and family services.

(B) Definitions.

(1) "Administrative agency" means the county department of job and family services, the Ohio department of job and family services, or other entity determining eligibility for a medical assistance program.

(2) "Durable power of attorney" means power of attorney established in accordance with section 1337.09 of the Revised Code.

(3) "Guardian" means any person, association, or corporation appointed by the probate court to have responsibility for the care and management of an incompetent individual and/or their assets under Title XXI of the Revised Code.

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

(5) "Means of self-support" means all countable income, assets and resources attributable to the individual.

(C) Administrative agency responsibilities.

(1) For an individual having a physical or mental impairment substantially limiting the individual's ability to access verifications or access a known means of self-support, and who has not granted any person with durable power of attorney, and 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 shall:

(a) Determine eligibility in accordance with Chapters 5101:1-37 to 5101:1-42 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.

(b) Determine if another person is available to assist in obtaining verifications or accessing the individual's means of self-support, and, if such a person is available, request the person assist in obtaining the verifications or accessing the individual's means of self-support. 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 shall consider those factors in the eligibility determination process.

(c) If no person is available to assist the individual, 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 shall also:

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

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

(d) Redetermine the individual's eligibility:

(i) If a means of access to verifications or means of self-support is obtained or established, or

(ii) During the next regularly-scheduled redetermination using the best evidence available, whichever occurs sooner.

(2) The administrative agency shall not delay the eligibility determination if a case is referred to the administrative agency's legal counsel, adult protective services, or another entity deemed by the administrative agency's legal counsel to be appropriate. Instead, the administrative agency shall complete the eligibility determination using the best evidence available.

Effective: 08/01/2009
R.C. 119.032 review dates: 08/01/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011
Rule Amplifies: 5111.01 , 5111.011

5160:1-2-01.8 Medicaid: conditions of eligibility for each applicant or recipient.

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

(B) Definitions:

(1) "Assignment" means the medicaid-eligible individual has transferred the right to collect and retain third-party and medical support payments only to the extent of medical services which are paid under the medicaid program.

(2) "Medical support" means a requirement by court order or an administrative child support order for an absent parent to make payment for medical care.

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

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

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

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

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

(ii) Adheres to the tenets or teachings of the sect or division of the sect and for that reason is conscientiously opposed to applying for or using a national identification number.

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

(3) Be a:

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

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

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

(ii) Applying for AEMA.

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

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

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

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

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

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

(d) Is receiving transitional medical assistance.

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

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

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

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

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

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

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

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

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

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

(F) Individual responsibilities. The individual shall:

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

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

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

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

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

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

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

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

5160:1-2-01.9 Medicaid: income, exemptions, and disregards.

(A) This rule sets forth guidelines for general income, exemptions and disregards applying to all medicaid covered groups for determining eligibility. Income guidelines that apply to a specific covered group will be addressed in that specific covered group's rule.

(1) Unless otherwise stated, income and resources of a spouse are considered available to the other spouse, and income and resources of a parent are considered available to children under age twenty-one.

(2) The administrative agency shall count as income to the covered group the income, after appropriate exemptions and disregards, of a minor's own parent(s) living in the same household as the minor and the minor's dependent child.

(B) Definitions.

(1) "Deduction" means a verifiable amount the individual pays for an expense. It is subtracted, after any income disregards, from the medicaid eligibility budget.

(a) Up to a specified maximum amount, the actual amount paid, including cents, is disregarded.

(b) Garnishments or liens placed against earned or unearned income of an individual are not considered a deduction, regardless of the reason for the garnishment or lien.

(2) "Disregard" means the amount subtracted from gross non-exempt income in the medicaid eligibility budget.

(3) "Earned income" means gross income in cash or in kind, prior to any deductions received as payment for services performed as an employee or as a self-employed individual. Earned income includes but is not limited to wages, salary, commissions, or "net income from self-employment" from which state or federal income and payroll taxes are paid or withheld.

(4) "Exempt income" means income that state or federal law prohibits from consideration in determining medicaid eligibility.

(5) "Gross, non-exempt income" means any income that is not exempt income.

(6) "Gross countable income from self-employment" means the gross income from a business minus the expenses directly related to producing the goods or services, and without which the goods or services could not be produced. For self-employed home day-care providers, it is fifty per cent of the provider's gross income or the gross income minus verifiable actual operating expenses.

(a) If the individual has filed taxes for the previous year, use all tax forms that were filed with the internal revenue service (IRS).

(b) If the individual has not filed taxes for the previous year, the following may be used:

(i) Business records including receipts for the costs of doing business, or

(ii) Estimated net income.

(c) Items that cannot be used as expenses for the purpose of determining medicaid eligibility include depreciation, personal business and entertainment expenses, personal transportation, purchase of capital equipment and payments on the principal of loans for capital assets or durable goods.

(7) "Home produce" means farm and garden produce grown by the individual or family.

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

(9) "In-kind" means any benefit received other than cash.

(10) "Lump-sum" means a non-recurring payment made, in a single amount, as opposed to smaller payments over time. A lump-sum payment is considered unearned income, unless otherwise exempted, in the month received.

(11) "Net countable family income" means the amount of income remaining after any appropriate exemptions, disregards, or deductions are applied.

(12) "Non-exempt income" means income (earned and unearned) that is not exempt.

(13) "Unearned income" means all income that is not earned income.

(C) Calculating monthly income. The amount of gross monthly non-exempt income must be established first. Disregards and deductions, when applicable, will then be subtracted.

(1) Determining the gross monthly income (earned and unearned). The amount shall be rounded down by dropping the cents.

(2) To correctly calculate income that is not received on a monthly basis, use the following conversion factors:

(a) Income received weekly shall be multiplied by 4.3.

(b) Income received bi-weekly (every two weeks) shall be multiplied by 2.15.

(c) Income received semi-monthly (twice a month) shall be multiplied by 2.0.

(d) Gross annual income received shall be divided by 12.0.

(e) For contract employees, divide the gross payment amount by the number of calendar months the contract covers. This also applies when a one-time payment is made for work that is done over a period.

(D) Exempt income. The administrative agency shall exempt the following:

(1) Grants, loans, and/or scholarships to any undergraduate student for educational purposes made or insured under any programs administered by the secretary of education.

(a) Student financial assistance provided by the Perkins loan will be exempt only when the funds are used for the following attendance costs:

(i) Tuition, fees, book, and supplies normally assessed by the institute of higher education.

(ii) Costs for rental or purchase of equipment, materials or supplies required by students in the same course of study. This can also include transportation and dependent care for a student attending at least half-time as determined by the institution.

(b) Grants or loans to any undergraduate student for educational purposes made or insured under any programs administered by the secretary of education under section 507 of the Higher Education Amendments of 1968.

(c) Any student financial assistance provided under programs in title IV of the Higher Education Act of 1965, as amended, and under bureau of Indian affairs education assistance programs.

(2) Home produce of an individual, utilized by the individual and the household for consumption.

(3) Income tax refunds.

(4) Small, non-recurring gifts, not to exceed thirty dollars per quarter.

(5) SSI payments.

(6) Residential state supplement (RSS) payments.

(7) Federal, state, and local foster care payments received under title IV-E, for a child currently living in the household.

(8) Federal, state, and local adoption assistance payments received under title IV-E.

(9) The value of foods donated by the U.S. department of agriculture (surplus commodities).

(10) Any relocation assistance paid by a public agency to a public assistance recipient, who has been relocated as a result of redevelopment, urban renewal, freeway construction, or any other public development involving condemnation or demolition of the existing residence.

(11) Payments for supporting services or reimbursement of out-of-pocket expenses to volunteers serving as foster grandparents, senior health aides, or senior companions, and to persons serving in the service corps of retired executives (SCORE), active corps of executives (ACE), and any other programs under 42 U.S.C 5044 (as in effect February 1, 2010).

(12) Payments to individuals participating in the volunteers in service to america (VISTA) program and any other program under Section 404, 42 U.S.C. 5044 (as in effect February 1, 2010) so long as the amount does not exceed the equivalent of state or federal minimum wage, whichever is higher.

(13) The value of supplemental food assistance received under the Child Nutrition Act of 1966 described in 42 U.S.C. 1771 (as in effect February 1, 2010) and the special food service program for children under the national school lunch act described in 42 U.S.C. 1751 (as in effect February 1, 2010).

(14) Any of the following distributions made to a household, an individual native, or a descendant of a native by a native corporation established pursuant to the Alaska Native Claims Settlement Act (ANCSA), section 3, 43 U.S.C. 1602 (as in effect February 1, 2010):

(a) Cash distributions (including dividends on stock from a native corporation) received by an individual up to two-thousand dollars per year.

(b) Stock (including stock issued or distributed by a native corporation as a dividend or distribution on stock).

(c) A partnership interest.

(d) Land or an interest in land (including that received from a native corporation as a dividend or distribution on stock).

(e) An interest in a settlement trust.

(15) Benefits paid to eligible households under the Low-Income Home Energy Assistance Act of 1981, section 2605, 42 U.S.C. 8624 (as in effect February 1, 2010).

(16) Any funds and judgment funds distributed per capita or held in trust for members of the Blackfoot and Grosventre Tribes under Pub. L. 92-254 or the Grand River Band of Ottawa Indians under Pub. L. 92-540, up to two-thousand dollars per individual per year.

(17) Pursuant to 25 U.S.C. 459e (as in effect January 7, 2011), receipts distributed to members of certain indian tribes which are referred to in 25 U.S.C. 459d (as in effect January 7, 2011).

(18) Indian judgment funds held in trust by the secretary of the interior (including interest and investment income accrued while funds are held in trust), or distributed per capita to a household or a member of an indian tribe pursuant to a plan prepared by the secretary of the interior and not disapproved by a joint resolution of the congress, and any initial purchases made with these funds in accordance with 25 U.S.C. 1407 (as in effect January 7, 2011).

(19) All funds held in trust by the secretary of the interior for an indian tribe (including interest and investment income accrued while funds are held in trust) and distributed per capita to a household or member of an indian tribe, and initial purchases made with the funds in accordance with Section 2, 25 U.S.C. 117b (as in effect January 7, 2011).

(20) The exemptions in paragraphs (D)(18) and (D)(19) of this rule do not apply to:

(a) Proceeds from the sale of initial purchases.

(b) Subsequent purchases made with funds derived from the sale or conversion of initial purchases.

(c) Funds or initial purchases which are inherited or transferred.

(21) Payments received on or after January 1, 1989, as a result of the Agent Orange Compensation Exclusion Act (Pub. L. 101-201).

(22) Restitution payments under the Civil Liberties Act of 1988, to U.S. citizens of Japanese ancestry and permanent resident Japanese non-citizens who were interned during World War II, or their survivors, section 105, 50 U.S.C. 1989b (as in effect February 1, 2010).

(23) Restitution payments for Aleutian and Pribilof Island Restitution Act under section 206, 50 U.S.C. 1989c (as in effect February 1, 2010).

(24) Payments under the Radiation Exposure Compensation Act, 42 U.S.C. 2210 (as in effect February 1, 2010)

(25) Earned income tax credit payments in the form of a refund of federal income tax or in the form of an advance payment by an employer.

(26) Payments made from any fund established pursuant to a class settlement in the case of Susan Walker v. Bayer Corporation, et al, 96-C-5024 (N.D. 111).

(27) Payments to victims of Nazi persecution.

(28) Principal of a bona-fide loan.

(29) Exemptions of income from paragraphs (D)(16) to (D)(28) of this rule do not apply to interest earned on these funds. Any interest earned is counted as unearned income in the month received and a resource thereafter.

(30) Any federal major disaster and emergency assistance described in 42 U.S.C. 5170 (as in effect on February 1, 2010), including comparable disaster assistance provided by states, local governments and disaster assistance organizations.

(31) Nutrition program benefits provided for the elderly under Title VII of the Older Americans Act of 1965, as amended.

(32) Housing and urban development (HUD) payments covering rent and utility bills which do not exceed the twenty-five per cent payment limitations stipulated by the Brooke Amendment of 1987.

(33) Retroactive payments paid to the individual as the result of a state hearing.

(34) Retroactive payments paid as a result of reconsideration of SSI benefits.

(35) Experimental housing allowance program payments made under annual contributions contracts entered into prior to January 1975, as described in 42 U.S.C. 1437 (as in effect February 1, 2010).

(36) Payments to crime victims from a federal or federally funded state or local program including Washington state crime victims compensation program under title XXIII of the Violent Crime Control and Law Enforcement Act of 1994.

(37) Effective March 1, 1995, basic health insurance, child care or child care allowances, auxiliary aid and services for disabled individuals and the national service educational award provided for individuals participating in a national service program established under the National and Community Services Trust Act of 1993. Payments received as a living allowance are considered income.

(E) Income disregards. The administrative agency shall disregard the following:

(1) Fifty per cent of a home daycare provider's gross earned income.

(2) Income received for temporary employment with the census bureau, related to the ten-year census. Interest received from these funds is not disregarded.

Replaces: 5101:1-39-15, 5101:1-39- 15.3, 5101:1-39-16, 5101:1-39-20, 5101:1-39- 20.1, 5101:1-39- 20.2, 5101:1-40-20, 5101:1-40- 20.1, 5101:1-40- 20.2, 5101:1-40- 20.3, 5101:1-40- 20.4, 5101:1-40- 20.5

Effective: 01/09/2012
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011
Rule Amplifies: 5111.01 , 5111.011 , 5111.012 , 5111.013
Prior Effective Dates: 8/1/75, 7/1/76, 11/1/76, 5/14/77, 9/3/77, 12/31/77, 10/26/78, 3/1/79, 4/5/1979, 10/1/79, 12/1/79, 12/7/79, 1/3/80, 2/3/80, 5/29/1980, 9/7/1981, 10/1/81, 5/1/82, 12/1/82, 12/10/82, 12/29/82, 1/13/83, 3/1/84, 6/1/84, 7/1/84(Temp.), 9/1/1984, 9/10/1984, 10/1/1984 (Emer.), 12/27/1984, 1/1/1985 (Emer.), 4/1/1985, 1/1/1986 (Emer.), 1/2/1986, 2/23/86, 4/1/86, 8/1/86 (Emer.), 10/3/86, 10/1/87, 10/1/87 (Emer.), 12/24/87, 4/1/88 (Emer.), 6/30/88, 10/1/88 (Emer.), 12/20/88, 1/1/89 (Emer..), 3/6/89, 4-1-89, 4/1/89 (Emer.), 5/1/89 (Emer.), 6/18/89, 7/1/89 (Emer.), 7/8/89, 9/23/89, 10/1/89 (Emer.), 11/1/89 (Emer.), 12/16/89, 1/1/90, 1/1/1990 (Emer.), 1/21/90, 3/2/90, 3/22/1990, 4/1/90, 4/2/90 (Emer.), 4/23/90, 6/1/90, 6/22/90, 9/1/90 (Emer.), 10/1/1990, 4/1/91 (Emer.), 5/1/91, 5/1/91 (Emer.), 6/17/91, 7/12/91 (Emer.), 7/17/91, 9/12/91, 9/22/91, 10/1/1991 (Emer.), 12/20/1991, 4/1/1992, 10/1/1992 (Emer.), 6/30/92, 12/21/1992, 1/1/93 (Emer.), 3/18/93, 5/1/1993, 3/0194 (Emer.), 4/18/94, 6/20/94, 9/1/94, 11/1/94, 3/1/95, 10/30/95, 10/31/97 (Emer.), 1/26/98, 2/1/99, 10/1/99, 11/19/99, 1/1/00, 5/1/00 (Emer.), 7/1/00, 8/6/00, 6/01/02 (Emer.), 8/30/02, 10/1/02, 1/1/03, 6/1/03 (Emer.), 9/20/03, 1/1/06, 1/1/08, 3/1/08

5160:1-2-02 Medicaid: United States (U.S.) citizenship documentation.

(A) This rule sets forth acceptable documentary evidence of United States (U.S.) citizenship. All individuals applying for or receiving medical assistance and stating they are a U.S. citizen or national shall verify citizenship, in accordance with 42 C.F.R. 435.407 (as in effect on February 8, 2006. An individual who declares under penalty of perjury they are a U.S. citizen may be given a reasonable opportunity to verify U.S. citizenship.

(B) Individuals not subject to documenting their U.S. citizenship are defined in paragraphs (B)(4) to (B)(7) of this rule. An individual who is already receiving medicaid will remain eligible if the individual presents satisfactory evidence of citizenship or birth and identity. All documents must be originals or copies certified by the issuing agency.

(1) Citizenship shall be documented using this list:

(a) 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;

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

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

(d) 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;

(e) A state match with the state data exchange (SDX) for supplemental security income (SSI) or social security disability insurance (SSDI) recipients, for states which do not provide medicaid to individuals by virtue of the individual's receipt of SSI or SSDI;

(f) 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.

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

(i) A Seneca Indian tribal census record;

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

(iii) A certificate of Indian blood;

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

(v) Other native American tribal documents.

(2) If none of the documents from paragraph (B)(1) of this rule are available, the administrative agency shall verify U.S. citizenship using a combination of one birth or nationality document from paragraph (B)(2) of this rule and one identity document from paragraph (B)(3) of this rule. Although some documents may be listed as both birth and nationality documents and identity documents, a 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. 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) An American Indian card (I-872) issued by the department of homeland security (DHS) with the classification code "KIC." This card is issued by DHS to identify U.S. citizen members of the Texas band of Kickapoos living near the United States/Mexican border;

(i) 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;

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

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

(l) 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;

(m) Evidence showing an individual meets the requirements of the Child Citizenship Act of 2000, Pub. L. No. 106-295 (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);

(n) An extract of a hospital record on hospital letterhead which was established at the time of the individual's birth, was created at least five years before the initial medicaid application date, and indicates a U.S. place of birth. For a child under sixteen, the document must have been created near the time of birth or five years before the application;

(o) A life insurance, health insurance, or other insurance record showing a U.S. place of birth and created at least five years before the initial medicaid application date. For a child under sixteen, the document must have been created near the time of birth or five years before the application;

(p) A religious record recorded in the U.S. within three months of birth, showing the birth occurred in the U.S. and showing either the date of the birth or the individual's age at the time the record was made. The record must be an official record recorded with a religious organization;

(q) An early school record showing a U.S. place of birth. The record must show the name of the individual, the date of admission to the school, the date of birth, a U.S. place of birth and the names and places of birth for the individual's parents;

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

(s) An institutional admission paper from a nursing home, skilled nursing care facility or other institution which indicates a U.S. place of birth;

(t) A U.S. vital statistics official notification of birth registration;

(u) A delayed U.S. public birth record which was recorded more than five years after the individual's birth. For the purpose of this rule, in the state of Ohio, a corrected birth record as defined in section 3705.15 of the Revised Code, is the equivalent of a delayed U.S. public birth record;

(v) A statement signed by the physician or midwife who was in attendance at the time of birth;

(w) The roll of Alaska natives maintained by the bureau of Indian affairs;

(x) A medical record from a clinic, doctor, or hospital which was created at least five years before the initial medicaid application date and indicates a U.S. place of birth. For children under sixteen the document must have been created near the time of birth or five years before the date of application;

(y) 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 citizenship from another listing. If the documentation requirement needs to be met through affidavits, the following rules apply:

(i) The administrative agency must obtain a separate affidavit, from the individual or other knowledgeable person, explaining why the evidence does not exist or cannot be obtained; and

(ii) There must be at least two affidavits by people, who are U.S. citizens and who have personal knowledge of the event(s) establishing the individual's claim of citizenship. The two affidavits could be combined in a joint affidavit. At least one of the persons making the affidavit cannot be related to the individual and neither person can be the individual; and

(iii) Persons making the affidavit must be able to provide proof of their own U.S. citizenship and identity. If the persons making the affidavit have information that explains why documentary evidence establishing the individual's claim of citizenship does not exist or cannot be readily obtained, the affidavit should contain this information as well;

(z) 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.

(3) The administrative agency must use one of the following identity documents in combination with a birth or nationality document listed in paragraph (B)(2) of 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;

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

(d) A military dependent's identification card;

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

(f) A school identification card with a photograph;

(g) A cross match with a federal or state governmental office, public assistance agency, law enforcement agency, or corrections agency data system to establish identity, if the agency establishes and certifies true identity of individuals;

(h) An affidavit of identity, signed under penalty of perjury, by a residential care facility director or administrator on behalf of an institutionalized individual in the facility. All other means of verifying identity should be pursued prior to accepting this type of affidavit. The affidavit does not need to be notarized;

(i) Three or more documents that together reasonably corroborate the identity of an individual, provided such documents have not been used to establish the individual's birthplace or nationality. The administrative agency must first ensure no other evidence of identity is available to the individual prior to accepting such documents. Such documents must at a minimum contain the individual's name, plus any additional information establishing the individual's identity. All documents used must contain consistent identifying information. These documents include, but are not limited to: employer identification cards, high school diplomas, general education and high school equivalency diplomas, college diplomas from accredited institutions, marriage certificates, divorce decrees, and property deeds and titles;

(j) An affidavit on behalf of an individual under the age of eighteen years, when school identification cards and drivers' licenses are not available to the individual. The affidavit does not need to be notarized;

(k) In the case of individuals under sixteen years of age, in a state which does not provide for the issuance of an identification document (other than a driver's license) a parent, legal guardian, authorized representative, or representative of a nonprofit organization, association or program may provide documentation for the individual, including:

(i) A school record or report card;

(ii) A childcare or nursery school record;

(iii) A clinic, doctor, or hospital record;

(iv) An affidavit signed under penalty of perjury by a parent, caretaker relative or guardian, stating the date and place of birth of the child. An individual cannot use an affidavit for identity if he or she also submitted an affidavit for proof of birth or nationality. The affidavit does not need to be notarized; or

(l) 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.

(4) The citizenship verification requirement shall not apply to the following groups, because these individuals have already satisfied the citizenship verification requirement in order to receive the following assistance:

(a) Individuals enrolled in medicare;

(b) Individuals who are receiving supplemental security income (SSI);

(c) Individuals receiving social security disability insurance (SSDI);

(d) Individuals to whom adoption or foster care assistance is made available under Title IV-E of the Social Security Act;

(e) Individuals in foster care to whom child welfare services are made available under Title IV-B of the Social Security Act; and

(f) 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.

(5) Individuals who are not applying for medical assistance for themselves, but are applying for medical assistance for other individuals, are not required to verify their own U.S. citizenship.

(6) A child who is deemed eligible under rule 5101:1-40- 02.2 of the Administrative Code is not required to verify citizenship.

(C) Administrative agency responsibilities.

(1) The administrative agency shall first verify U.S. citizenship through the social security administration (SSA) electronic state verification and exchange system (SVES) pursuant to rule 5101:1-38-01.8 of the Administrative Code.

(2) The U.S. citizenship condition of eligibility is met when the:

(a) Administrative agency receives a valid data match from SSA for the individual, or

(b) Individual has provided satisfactory documentation, as described in paragraph (B) of this rule.

(3) The U.S. citizenship condition of eligibility is not met when the administrative agency receives an invalid data match from SSA for an individual.

(a) When the match is invalid, the administrative agency shall give the individual reasonable opportunity to present satisfactory documentation of U.S. citizenship.

(b) The administrative agency shall approve medical assistance for ninety days, provided the individual satisfies all other conditions of eligibility outlined in rule 5101:1-38-01.8 of the Administrative Code.

(c) The administrative agency shall terminate medical assistance for the individual who fails to present satisfactory documentation of U.S. citizenship after the reasonable opportunity period expires.

(4) The administrative agency shall require U.S. citizenship to be verified only once.

(D) Individual responsibility. The individual shall present satisfactory documentation of U.S. citizenship when the administrative agency cannot validate U.S. citizenship through SSA's SVES.

Effective: 07/17/2011
R.C. 119.032 review dates: 10/01/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011 , 5111.02
Rule Amplifies: 5111.01 , 5111.011 , 5111.02
Prior Effective Dates: 10/1/75, 9/1/82, 8/1/86 (Emer.), 10/3/86, 10/1/87 (Emer.), 12/24/87, 4/1/88 (Emer.), 6/30/88, 10/1/88 (Emer.), 12/20/88, 3/1/89 (Emer.), 5/28/89, 10/1/91 (Emer.), 12/20/91, 5/1/97, 7/1/00, 10/6/03, 9/25/06, 8/1/07, 7/1/08, 10/15/09

5160:1-2-02.3 Medicaid: qualified aliens.

(A) The purpose of this rule is to define the criteria qualified aliens shall meet in order to have potential eligibility for medicaid.

(B) Definitions.

(1) "A-number" means the alien registration number, which is issued to the alien 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, and who was fathered by a U.S. citizen.

(4) "Asylee" means a person who has been granted asylum.

(5) "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 is a federal means-tested public benefit, but certain other benefits listed in 8 U.S.C. 1613(c) (as in effect on September 1, 2009) are not considered means-tested.

(6) "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.

(7) "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 his or her 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 either the five-year bar described in paragraph (D) of this rule or the seven-year limit on eligibility described in paragraph (E)(1) of this rule.

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

(9) "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.

(10) "Qualified alien" means an alien whose immigration status is one of the following at the time he or she applies for, receives, or attempts to receive medicaid:

(a) Lawful permanent resident; or

(b) Granted asylum under section 208 of the Immigration and Nationality Act

(INA) (as in effect on September 1, 2009); or

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

(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; or

(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); or

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

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

(h) An Amerasian immigrant; or

(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).

(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.

(11) "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, 2009), and is published annually in the Federal Register.

(12) "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.

(13) "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.

(14) "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 alien who is lawfully residing in the United States as of August 22, 1996, shall continue to meet the citizenship requirements for medicaid. The alien:

(1) Does not have to meet the definition of a qualified alien; and

(2) Did not have to be receiving assistance prior to August 22, 1996.

(D) A qualified alien who enters the United States on or after August 22, 1996 does not meet the citizenship requirement for medicaid for a period of five years beginning on the date of the alien's entry into the United States with a status of "qualified alien."

(E) Exceptions to the five-year period of ineligibility for benefits as set forth in paragraph (D) of this rule are:

(1) An alien whose status meets any of the following criteria, as defined in paragraph (B)(10) of this rule, has potential eligibility for medicaid for seven years from the date status is granted:

(a) Refugee,

(b) Granted asylum,

(c) Deportation is being withheld,

(d) Cuban or Haitian entrant, or

(e) Amerasian immigrant.

(2) Victims of trafficking are potentially eligible for benefits and services to the same extent as an alien admitted to the United States as a refugee under Section 207 of the INA (as in effect on September 1, 2009).

(3) An alien who is an LPR and has forty quarters of coverage under Title II of the Social Security Act or can be credited with such quarters. 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; and

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

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

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

(4) A veteran who is lawfully residing in Ohio and 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).

(5) A military service member who is lawfully residing in Ohio and who is on active duty (other than active duty for training) in the armed forces of the United States.

(6) A spouse or unmarried dependent child of a veteran or active duty service member as described in paragraph (E)(4) or (E)(5) of this rule.

(7) The surviving spouse of a deceased veteran or service member, provided the spouse has not remarried and the marriage fulfills the requirements of 38 U.S.C. 1304 (as in effect on September 1, 2009):

(a) Married for at least one year; or

(b) 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

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

(8) An Afghan or Iraqi special immigrant, as defined in paragraph (B)(10) of this rule, has potential eligibility for medicaid to the same extent and for the same length of time as a refugee described in paragraph (E)(1) of this rule, in accordance with the Department of Defense Appropriations Act of 2010. Eligibility is calculated from the date special immigrant status is granted.

(9) With respect to eligibility for medicaid, paragraph (D) of this rule shall not apply to any individual:

(a) Who is an American Indian born in Canada to whom the provisions of 8 U.S.C. 1359 (as in effect on September 1, 2009) apply; or

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

(F) A qualified alien described in paragraph (D) of this rule who has been in the United States longer than five years shall either become a citizen or meet one or more of the exceptions set forth in paragraph (E) of this rule in order to be potentially eligible for medicaid.

(G) In order to continue being potentially eligible for medicaid , a qualified alien who has potential medicaid eligibility for seven years in accordance with paragraph (E)(1) of this rule and has now been in the United States longer than seven years shall either have become a citizen or meet one or more of the criteria set forth in paragraph (E)(3), (E)(4), (E)(5), (E)(6), or (E)(7) of this rule.

(H) Medicaid eligibility for an indefinite detainee will depend upon the individual's immigration status before the individual became an indefinite detainee.

(I) Individuals who are not qualified aliens, and individuals who are qualified aliens but are ineligible for benefits in accordance with paragraph (D) of this rule, have potential eligibility for alien emergency medical assistance (AEMA) as set forth in rule 5101:1-41-20 of the Administrative Code and are not required to verify alien status.

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

(1) Verify the alien's immigration status. The following are acceptable verifications, and shall be original documents:

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

(e) 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.

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

(i) I-220B (order of supervision), which should 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 should 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.

(2) Verify the validity of the alien's original documents through the SAVE system maintained by USCIS. There are two methods of verifying the immigration documents provided by the alien:

(a) Primary verification through the SAVE system 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 system is used when problems occur in the verification of alien status, and is required in any of the following situations:

(i) Documentation presented by the alien appears to be counterfeit or altered.

(ii) The individual presents unfamiliar USCIS documentation, or a document that indicates an immigration status but does not contain an A-number.

(iii) When an individual has no immigration documentation and is hospitalized, medically disabled or can otherwise show good cause for the inability to present documentation, and when securing such documentation would constitute an undue hardship.

(iv) When an individual presents a foreign passport or form I-94 and the "admission for permanent residence" endorsement is more than one year old.

(v) When an automated check of the SAVE system returns the response "institute additional verification" or when there is a material discrepancy between an alien's documentation and the information given by the SAVE system.

(vi) When an alien claims that he or she obtained lawful permanent (or conditional) resident status because he or she was a battered alien, the parent of a battered child, or the victim of domestic violence.

(3) Verify the veteran status of the applicant or the applicant's spouse or parent, as appropriate, when the applicant's eligibility is based upon the applicant's own, or another person's veteran status. Veteran status is verified by viewing an original or a certified copy of the DD Form 214 (undated).

(4) Verify with the social security administration, when applicable, whether an individual can be credited with forty qualifying quarters.

(5) Obtain the immigration status of an indefinite detainee by contacting ORR.

(6) Not deny or delay the alien's eligibility determination solely on the basis of the alien's immigration status:

(a) If verification cannot be obtained from the SAVE system; or

(b) Until a reasonable opportunity to submit immigration documentation has been provided.

Effective: 10/01/2010
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
Prior Effective Dates: 6/1/93, 10/1/95, 7/1/98, 10/1/02, 4/1/03 (Emer.), 9/20/03, 10/8/09

5160:1-2-03 Medicare buy-in.

(A) This rule sets forth:

(1) The eligibility criteria for benefits under the medicare part B buy-in agreement between the social security administration (SSA) and the Ohio department of job and family services (ODJFS), which allows ODJFS to pay medicare part B (supplemental medical insurance) premiums for certain medicaid-eligible individuals even if those individuals are not eligible for a medicare premium assistance program (MPAP) set out in rule 5101:1-39-01.1 of the Administrative Code; and

(2) The beginning date of payment of medicare part A (part A) or medicare part B (part B) benefits under this rule; and

(3) The date and effect of termination of benefits under the medicare buy-in or an MPAP; and

(4) The process of coordinating enrollment with ODJFS and the SSA.

(B) Definitions.

(1) "Medicare buy-in" means the program and process of paying part A or part B benefits on behalf of an eligible individual.

(2) "MPAP" means any or all of the medicare premium assistance programs defined in rule 5101:1-39-01.1 of the Administrative Code.

(3) "Part B buy-in" means the agreement under which ODJFS pays part B premiums on behalf of individuals even if those individuals are not eligible for benefits under rule 5101:1-39-01.1 or 5101:1-39-01.2 of the Administrative Code.

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

(C) Eligibility criteria. To be eligible for payment of the part B premium under the medicare buy-in agreement, an individual must meet all three of the following requirements:

(1) Be eligible for part B.

(2) Be eligible for a category of medicaid other than:

(a) Medicaid with a spenddown calculated under rule 5101:1-39-10 of the Administrative Code; or

(b) Breast and cervical cancer project medicaid as set forth in rule 5101:1-41-01 of the Adminstrative Code; or

(c) Expedited medicaid as set forth in rule 5101:1-40-60 of the Administrative Code.

(3) Be receiving at least one of the following:

(a) Medicare premium assistance under rule 5101:1-39-01.1 of the Administrative Code.

(b) One of the following kinds of cash assistance:

(i) Ohio works first (OWF); or

(ii) Supplemental security income (SSI); or

(iii) Residential state supplement.

(c) Four-month extended coverage as set forth in Chapter 5101:1-40 of the Administrative Code.

(d) Grandfathered medicaid as set forth in rule 5101:1-39-02 of the Administrative Code.

(e) Foster care maintenance payments or adoption assistance payments as set forth in rule 5101:1-40-03 of the Administrative Code.

(f) Medicaid as a result of section 1619(b) of the Social Security Act (as in effect on January 1, 2010) as set forth in rule 5101:1-39-02.3 of the Administrative Code.

(g) Deemed OWF as set forth in Chapter 5101:1-40 of the Administrative Code.

(h) Long-term care services in a Title XIX certified nursing facility (NF) or intermediate care facility for the mentally retarded (ICF-MR).

(i) Home and community-based (HCB) services, including the program of all inclusive care for the elderly (PACE), under a waiver described in division 5101:3 of the Administrative Code.

(D) Coordination of enrollment. If an individual is eligible for benefits under this rule or rule 5101:1-39-01.1 or 5101:1-39-01.2 of the Administrative Code, or would be eligible if the individual were enrolled in part A or part B, the county department of job and family services(CDJFS) shall coordinate the individual's receipt of benefits.

(1) If the individual:

(a) Is or has ever been in receipt of part A or part B benefits, the CDJFS shall approve MPAP or part B buy-in benefits for the individual in the electronic eligibility system.

(b) Has never received part A or part B benefits, the CDJFS shall:

(i) Inform the individual that the Ohio department of job and family services (ODJFS) can not pay medicare premiums until the individual has enrolled in part A or part B through the SSA; and

(ii) Advise the individual to apply for part A or part B benefits, and advise the individual that the CDJFS will assist upon request; and

(iii) Advise the individual to report the approval of part A or part B benefits to the CDJFS immediately, so payment of premiums can be approved; and

(iv) Approve MPAP or part B buy-in benefits for the individual in the electronic eligibility system upon being informed that the individual has been enrolled by the SSA in part A or part B.

(2) After three weeks, if the electronic submission was not successful, the CDJFS shall submit a completed JFS 07102 "Changes in Medicaid Health Coverage Date and Medicare Buy-In Eligibility" (rev. 11/2007) to the ODJFS buy-in unit.

(E) Coverage period.

(1) Start date.

(a) For MPAP benefits under rule 5101:1-39-01.1 of the Administrative Code or for QDWI under rule 5101:1-39-01.2 of the Administrative Code, the beginning date for payment of premiums is addressed in those rules. If an individual is eligible for MPAP benefits under rule 5101:1-39-01.1 of the Administrative Code and also eligible for part B buy-in under this rule, payment of part B premiums begins on the earlier of the coverage date under rule 5101:1-39-01.1 of the Administrative Code or the coverage date under this rule.

(b) For individuals eligible for payment of premiums under the part B buy-in agreement, eligibility begins:

(i) The first month an individual is eligible for both medicare and cash assistance as defined in paragraph (C)(3)(b) of this rule; or

(ii) The first day of the second month after the administrative agency made the determination the individual was eligible for medicaid, if the individual is not in receipt of cash assistance as defined in paragraph (C)(3)(b) of this rule.

(2) Termination date. Eligibility for payment of medicare premiums under this rule, rule 5101:1-39-01.1 of the Administrative Code, or rule 5101:1-39-01.2 of the Administrative Code ends on the earliest of the following dates:

(a) The last day of the month in which the individual dies; or

(b) The last day of the last month in which the individual is entitled to part B benefits; or

(c) The last day of the last month in which the individual meets the eligibility criteria for MPAP, QDWI, or medicare part B buy-in benefits, if notice was provided to the centers for medicare and medicaid (CMS) no later than the twenty-fifth day of the second month of ineligibility; or

(d) The last day of the second month before CMS received notice the individual was no longer eligible for MPAP, QDWI, or medicare part B buy-in benefits, if notice was not provided within the time limit in paragraph (E)(2)(c) of this rule.

(F) Retroactive termination. An individual's part B premium payment under buy-in can be terminated retroactively for as many as two months before the state's notice to CMS that the individual is no longer eligible.

(1) After CMS receives notice from ODJFS, CMS sends the individual a notice stating the individual is responsible for paying part B premiums beginning with the month following the last month of buy-in coverage. Because of administrative delays, an individual can already be in the third month after buy-in termination and owe three months of part B premiums before receiving notice that buy-in coverage has been terminated.

(2) The individual may request equitable relief from CMS under certain conditions specified by CMS in its notice.

Replaces:

5101:1-38-03

Effective: 01/01/2010
R.C. 119.032 review dates: 01/01/2015
Promulgated Under: 111.15
Statutory Authority: 5111.01
Rule Amplifies: 5111.01 , 5111.011
Prior Effective Dates: 8/15/1982, 10/1/2002

5160:1-2-04 [Rescinded] Medicaid: outstationing workers at disproportionate share hospitals and federally qualified health centers.

Effective: 01/01/2014
R.C. 119.032 review dates: 10/15/2013
Promulgated Under: 111.15
Statutory Authority: 5162.031 , 5163.02
Rule Amplifies: 5163.02 , 5163.40
Prior Effective Dates: 5/1/95, 7/1/00, 1/1/06

5160:1-2-05 County JFS responsibilities regarding healthchek (early and periodic screening, diagnostic and treatment services).

(A) The purpose of this rule is to explain the requirements of healthchek, Ohio's early and periodic screening, diagnostic and treatment (EPSDT) medicaid benefit for all recipients under twenty-one years of age. A separate healthchek application is not required. All medicaid recipients under twenty-one years of age are entitled to all healthchek services that are medically necessary services.

(B) Definitions. For the purposes of this rule, the following terms have the following meanings:

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

(2) "EPSDT" means early and periodic screening, diagnostic and treatment.

(3) "Healthchek" is Ohio's early and periodic screening, diagnostic and treatment benefit for all recipients under twenty-one years of age.

(4) "Healthchek coordinator" is the staff person or primary liaison within a unit in the CDJFS who is responsible for the implementation of EPSDT/healthchek services.

(5) "Healthchek services" are periodic screening services (including a comprehensive medical exam, vision, dental, and hearing screenings) and such other necessary health care, diagnostic services, treatment, and other measures described in 42 U.S.C. section 1396d(a) (eff. 1/1/2011) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the state plan. Healthchek services are identical to "EPSDT services" as defined at 42 U.S.C. section 1396d(r) .

(6) "Healthchek Services Implementation Plan" (HSIP) means the document submitted by a CDJFS describing how it delivers healthchek services to recipients in its county and who in the agency is responsible for ensuring the delivery of healthchek services.

(7) "Managed care plan" (MCP) means a medicaid managed care plan as defined in Chapter 5101:3-26 of the Administrative Code.

(8) "Medically necessary services" has the same meaning as in rule 5101:3-1-01 of the Administrative Code.

(9) "Prior authorization" for a member of a medicaid MCP is the process outlined in Chapter 5101:3-26 of the Administrative Code. For all other recipients, prior authorization is the process outlined in Chapter 5101:3-1 of the Administrative Code.

(10) "Private child placing agency" (PCPA) has the same meaning as in Chapter 5101:2-1 of the Administrative Code.

(11) "Private non-custodial agency" (PNA) has the same meaning as defined in Chapter 5101:2-1 of the Administrative Code (12) "Provider" means "eligible provider" as defined in Chapter 5101:3-1 of the Administrative Code.

(13) "Public children services agency" (PCSA) has the same meaning as in Chapter 5101:2-1 of the Administrative Code.

(14) "Recipient" means an Ohio medicaid recipient under twenty-one years of age.

(15) "Special populations" means recipients who are blind or deaf or who cannot read or understand the English language.

(16) "Substitute caregiver" has the same meaning as in Chapter 5101:2-1 of the Administrative Code.

(17) "Support services" means personal assistance, coordination, referrals, transportation or other services required to be provided by the CDJFS to assist the recipient with accessing healthchek services.

(18) "Title IV-E agency" has the same meaning as in Chapter 5101:2-1 of the Administrative Code.

(C) Informing. County departments of job and family services are responsible for informing recipients in their counties about healthchek. Each CDJFS shall use a combination of written and oral (including telephone calls, office visits, or home visits) methods to effectively inform recipients (or such recipients' parents, guardians or legal custodians, as applicable) in its county about healthchek within sixty days of the eligibility determination and at least once each year thereafter. Appropriate oral and written informing methods are described as followed:

(1) Written informing.

(a) Each CDJFS shall ensure that each recipient (or such recipient's parent, guardian or legal custodian, as applicable) in its county receives JFS 03528 "Healthchek and Pregnancy Related Services Information" (rev. 2/2011) and JFS 08009 "Healthchek - Ohio's EPSDT Services Brochure" (rev. 11/2007) within sixty days after the recipient is determined eligible for medicaid and at least once each year thereafter:

(b) Each CDJFS shall document that each recipient (or such recipient's parent, guardian or legal custodian, as applicable) in its county has received a JFS 03528 and JFS 08009.

(c) If written healthchek information is sent to a recipient (or such recipient's parent, guardian or legal custodian, as applicable) and returned as undeliverable, the CDJFS will make a second attempt to contact the recipient by alternate means. All attempts to contact a recipient (or such recipient's parent, guardian, or legal custodian, as applicable) shall be documented.

(d) Upon the completion of the JFS 03528, the recipient (or such recipient's parent, guardian or legal custodian, as applicable) will be asked to sign the JFS 03528 form to verify understanding of the healthchek services available to the recipient. If the recipient (or such recipient's parent, guardian or legal custodian, as applicable) needs additional information in order to understand healthchek services, the CDJFS shall immediately provide the necessary information.

(e) Each CDJFS shall enter data regarding recipients into electronic information systems, as directed by ODJFS. Such information shall include information from completed JFS 03528 forms.

(f) Each CDJFS shall prominently post JFS 08137 "Healthchek Screenings, Diagnosis, Treatment" (rev. 9/2010) in an area where medicaid applications are accepted and where it can be seen by the maximum number of applicants and recipients.

(g) ODJFS may develop additional written materials containing information about healthchek. Each CDJFS shall distribute such written materials, as directed by ODJFS. All written materials that a CDJFS uses to inform individuals about healthchek shall be submitted to ODJFS for its review and approval. No CDJFS shall use such written materials unless they have been approved by ODJFS.

(h) Each CDJFS shall utilize ODJFS' information systems to monitor the quality of data regarding recipients, monitor the CDJFS' healthchek informing activities, and aid the CDJFS' healthchek informing activities.

(2) Oral informing. Each CDJFS shall ensure that each recipient (or such recipients' parents, guardians, or legal custodians, as applicable), who has a face-to-face meeting or telephone call with CDJFS staff to apply for medicaid, is orally informed about healthchek. The oral informing shall include written informing material distributed to each CDJFS by ODJFS and shall include clear and non-technical language about the following:

(a) The benefits of preventive health care, including without limitation;

(i) Increased well-being;

(ii) Reduced risk to the recipient's health;

(iii) Identification and treatment of health problems early to reduce the possibility of increase in their severity and cost of treatment; and

(iv) Education of the family to allow for optimal health.

(b) The services covered by healthchek and where and how to obtain those services.

(c) That the services covered by healthchek are without cost to recipients.

(d) The recipient's ability to request and schedule dental, vision, and hearing services separately from the healthchek screening visit.

(e) The availability of medically necessary diagnostic and follow-up treatment services, including referrals, for problems discovered during the healthchek screening service.

(f) The prior authorization process, including that:

(i) The prior authorization process, whether fee-for-service or managed care, must be started by the recipient's medicaid provider;

(ii) The prior authorization requirement for some services, products, or procedures applies even if the recipient is under twenty-one years of age;

(iii) The prior authorization process may enable individuals under twenty-one years of age to receive services not available to adults, including services that are limited in number for adults;

(iv) Certain services require prior authorization, which must be requested by a provider and approved by Ohio medicaid before the service is provided; and

(v) The provider of a recipient who is a member of an MCP must submit a prior authorization request to the recipient's MCP.

(g) The CDJFS must explain necessary transportation and scheduling assistance is available to recipients under twenty-one years of age, upon request, in accordance with Chapter 5101:3-15 of the Administrative Code, and the following:

(i) That transportation will be provided to any medicaid reimbursable service;

(ii) How to request transportation and the timeframes for requesting transportation;

(iii) Verification requirements, if any; and

(iv) That for a recipient who is a member of an MCP, transportation is also available through the recipient's MCP.

(3) Informing special populations. Each CDJFS shall use appropriate methods to inform recipients in a special population (or such recipients' parents, guardians, or legal custodians, as applicable) about healthchek. Information provided to special populations shall meet the requirements of paragraphs (C)(2)(a) to (C)(2)(g) of this rule.

(4) Informing pregnant women. A JFS 03528 shall be used to document the informing of pregnant women about healthchek services as outlined in Chapter 5101:1-38 of the Administrative Code. The JFS 03528 shall be used to document informing again upon the birth of the infant.

(5) The CDJFS shall use electronic means to track pregnant women and the births of their infants to accomplish the following:

(a) Identify newborns and the infant's parent, guardian, legal custodian, as applicable, or the PCSA, using the CDJFS' existing records.

(b) Ensure that any infant is added to the assistance group (AG) within thirty days of learning of the birth of the infant;

(c) Inform the infant's parent, guardian, legal custodian, as applicable, of healthchek services within sixty days of the infant's birth;

(d) Contact the infant's parent, guardian, legal custodian, as applicable, to assist in securing an ongoing primary care provider for the newborn;

(e) Coordinate the activity in paragraphs (C)(1) to (C)(3) of this rule with the assistance group's MCP, other agencies, and programs where applicable.

(D) Provision of support services.

(1) The CDJFS will refer the recipient, and/or the recipient's parent, guardian, or legal custodian, as applicable, to entities listed on the JFS 03528 and/or other community services as requested. The CDJFS will ensure:

(a) That referrals are made, as needed, for both medical and other services such as help me grow (HMG); women, infants and children (WIC); maternal and child health clinics; local health departments; head start (HS); child care; clothing and/or other community social services, where applicable.

(b) Coordination between the recipient and the entity where the referral is made.

(c) Coordination between the recipient and the medical provider or MCP.

(d) The recipient enrolled in a MCP (or the recipient's parent, guardian or legal custodian, as applicable) is advised to contact the recipient's MCP for medical care options and/or referrals.

(e) Offering and providing assistance with scheduling medical appointments as requested by the recipient or the recipient's parent, guardian or legal custodian, as applicable.

(2) The CDJFS shall provide recipients with necessary assistance in obtaining transportation to healthchek services as requested by the recipient or the recipient's parent, guardian or legal custodian, as applicable.

(3) Each recipient in a household who requests or is in need of non-medicaid covered medical services as indicated on the JFS 03528 or through other verbal or written communication shall be referred by the CDJFS to community, medical or other social services, as needed, including providers who have expressed a willingness to furnish non-medicaid covered services at little or no expense to the family. Community and medical service requests will be documented and forwarded to the appropriate community provider, medical provider and/or MCP.

(4) Elevated blood lead level services for assisting families of recipients identified as having elevated blood lead levels when notified by the family, provider or the county or city department of health shall be provided by the CDJFS and include:

(a) Referral of the recipient to the Ohio department of health (ODH) for an environmental assessment.

(b) Verification of medicaid eligibility at the time the environmental assessment is conducted and informing the ODH agent of such eligibility, when asked and after receiving proper verification of whom, is requesting the information;

(c) Education of the family about the purpose of the environmental assessment by:

(i) Informing the family of the need to remove the source of lead or removing the recipient from the contaminated environment;

(ii) Explaining the family's responsibility to inform the health department staff who conduct the environmental assessment of places the recipient visits regularly;

(iii) Assisting the family with securing lead-free housing by making any necessary referrals if the source of lead cannot or will not be removed from the environment.

(d) The CDJFS is responsible for maintaining records of environmental assessment recommendations made by the ODH and any action taken as a result of those recommendations. If as a result of CDJFS efforts the family relocates, the CDJFS must inform the ODH of the family's new address.

(e) In geographic areas with Ohio childhood lead poisoning prevention regional resource centers or local arrangements for environmental assessments and follow-up, the requirements of those programs supersede this rule.

(E) Custodial agency responsibility.

(1) The custodial agency of a recipient is responsible for ensuring that healthchek informing requirements are completed as explained in this rule. A custodial agency that has a recipient child placed in a substitute care setting certified by another PCSA, PCPA or PNA, is responsible for complying with this rule.

(2) The PCSA, PCPA and the Title IV-E agency shall inform the substitute caregivers about healthchek services and complete the JFS 03528.

(3) The JFS 03528 shall be submitted by the PSCA, PCPA, or Title IV-E agency to the CDJFS:

(a) After the initial informing process;

(b) When the recipient is moved to a new placement setting; and

(c) After completion of each annual review.

(F) CDJFS healthchek service implementation plan. Each CDJFS shall submit a proposed HSIP to ODJFS within ten business days of a change in director, healthchek coordinator or where the responsibility for healthchek resides in the agency. The proposed HSIP shall include all of the following:

(1) Identification of the CDJFS table of organization, showing where the responsibility for delivery of administrative healthchek support services lies;

(a) The name, title and contact information of the contact person or coordinator for administrative healthchek support services;

(b) A job description of the staff responsible for administration of administrative healthchek support services,

(2) Procedures for coordination of efforts between the CDJFS and the MCPs. The procedures may be in the form of written agreements between the agency and the MCPs and shall include:

(a) Provisions for regularly scheduled meetings to exchange information regarding:

(i) Tracking recipients to ensure they are receiving care and other services as identified as needed;

(ii) Issues recipients may be having in accessing services (such as finding a provider, making appointments, accessing transportation) and identifying remedies to these issues;

(iii) Social support services needed or discovered for recipients (such as housing needs, clothing, increased food needs);

(iv) MCP referrals to other agencies (such as HMG, WIC, and HS) so the healthchek coordinator can follow-up with the family; and

(v) The JFS 03528 or other documentation.

(b) A method for MCPs and the CDJFS to share follow-up and other communication with the recipient (or such recipient's parent, guardian or legal custodian, as applicable) to ensure complete care is delivered.

(3) The CDJFS shall provide a description in the HSIP of the electronic and/or hard-copy methods for ensuring permanent records and documentation are maintained in a case file for each recipient. The case file shall contain the following information, when appropriate:

(a) The agency copy of the signed JFS 03528;

(b) Copies of all correspondence received and sent;

(c) Documentation of agency contacts with recipients (or such recipient's parent, guardian or legal custodian, as applicable) , both attempted and successful;

(d) Documentation of the MCP in which recipients are enrolled, if applicable;

(e) Any communication from or forms provided by the medical provider;

(f) Information received from the other county when a recipient is an inter-county transfer;

(g) Documentation of all support service referrals or requests made by a recipient or on a recipient's behalf, and the CDJFS efforts to fulfill the referrals and/or requests. At a minimum the documentation shall contain:

(i) Steps taken by the CDJFS to assure the requested support services are provided, and whether or not the recipient received the requested support services;

(ii) A copy of all documentation of services requested by a recipient (or such recipient's parents, caretakers, custodians or substitute caregivers, as applicable) and provided or facilitated by the CDJFS.

(iii) Records of transportation requested and provided; and

(iv) Any communication from or forms provided by the medical provider.

(4) The CDJFS shall identify, if applicable, any services or functions required in this rule which are contracted out to other entities. A copy of the contract shall be provided to ODJFS. The CDJFS shall also describe accountability and monitoring measures, along with timeframes when monitoring takes place to ensure the contracted entities are achieving all required functions and that these functions are in accordance with applicable state and federal rules.

(G) Release of information. The CDJFS shall, if necessary, obtain a HIPAA-compliant signed authorization for release of information, form JFS 03397 "Authorization for the Release or Use of Protected Health Information (PHI)" (rev. 7/2003), if and when the CDJFS needs additional medical information from the recipient or the recipient's provider.

(H) Provider recruitment. The CDJFS is required to take steps to recruit and maintain a network of fee-for-service providers of medical, dental, vision, and hearing services that is adequate to meet the screening and treatment needs of the healthchek consumers. The CDJFS may make use of a variety of methods including personal visits, telephone calls, and letters to recruit providers.

(I) Training. Each CDJFS' healthchek coordinator, or such coordinator's designee(s), shall attend annual training and attend any other available healthchek training offered by ODJFS. Recording a training for later viewing does not constitute attendance. Verification of attendance shall consist of documentation roll call and sending an evaluation form to the state e-mail box within three days of the video conference or training for video conferences. Verification of attendance at an on site training shall be documented by the healthchek coordinator or such coordinators' designee(s) by signing the attendance log.

(J) Responsibilities of recipient. A recipient (or the recipient's parent(s), guardian or legal custodian, as applicable) shall:

(1) Complete the JFS 03528;

(2) Return the JFS 03528 to the recipient's healthchek coordinator as soon as it is completed;

(3) As soon as possible, report to the recipient's CDJFS any change in a recipient's address or family or household group; and

(4) Attend scheduled appointments for healthchek services.

Replaces: 5101:1-38-05

Effective: 02/14/2011
R.C. 119.032 review dates: 11/01/2015
Promulgated Under: 111.15
Statutory Authority: 5111.01
Rule Amplifies: 5111.01 , 5111.016
Prior Effective Dates: 1/14/83, 3/20/83, 3/21/83, 11/1/85 (Emer), 1/1/86, 1/29/86 (Emer), 1/31/86, 4/1/86 (Emer), 1/1/87, 3/20/87, 9/28/87 (Emer), 12/23/87 (Emer), 3/15/88, 7/1/88 (Emer), 9/1/88, 1/1/89, 10/1/90, 7/1/92, 9/1/93, 6/1/97, 3/18/99 (Emer), 6/17/99, 4/1/01, 12/1/01, 9/19/05, 3/1/06, 10/1/09, 12/31/10

5160:1-2-06 Medicaid: pregnancy related services (PRS).

(A) All medicaid eligible pregnant women are able to receive enhanced pregnancy related services from their medical providers. These services include extensive counseling and education, nutrition counseling, nutrition intervention, and care coordination.

(1) Care coordination services are delivered by the medical provider and are intended to facilitate the pregnant woman's access to necessary medical, social, educational, nutritional, and other services. Care coordination is also intended to minimize fragmentation of care without limiting the pregnant woman's freedom of choice of participating medicaid providers. If the pregnant woman is enrolled in a medicaid-contracting managed care plan(MCP), she will access the services through her MCP's network of providers.

(2) From the date of identification of pregnancy through sixty days after the end of the pregnancy (i.e., date of delivery, date of spontaneous abortion, or date of federally funded induced abortion), the county department of job and family services (CDJFS), in cooperation with the woman's MCP, when applicable, shall provide support services to complement medical services when the woman makes a request or the CDJFS is made aware of the woman's need.

(B) Pregnancy related services (PRS) definitions.

(1) "Potentially eligible women" are all medicaid eligible recipients identified as pregnant who do not have medical verification of pregnancy.

(2) "Eligible women" are all medicaid eligible pregnant recipients who have been medically verified as pregnant.

(3) "Date of identification of pregnancy" is the date that the medicaid eligible recipient states verbally or in writing that she is pregnant or is reported to be pregnant, or the date the CDJFS otherwise learns of the pregnancy.

(4) "Medical providers" are physicians, hospitals, clinics, home health agencies, rural health clinics, outpatient health facilities, federally qualified health centers, nurse midwives, and nurse practitioners who are medicaid enrolled service providers or are part of a medicaid-contracting MCP's provider network.

(5) "Support services" are non-medical services offered or provided by the CDJFS to assist the medicaid eligible recipient and may include arranging or providing transportation, making appointments, accompanying the woman to her appointment with her medical provider, and making referrals to community and other social services. Support services will be coordinated with the pregnant woman's medicaid-contracting MCP where applicable.

(6) "Pregnancy related services unit/worker" is the staff person or primary liaison within a unit in the CDJFS responsible for the implementation of the pregnancy related services program.

(C) Pregnancy identification.

(1) The CDJFS shall take steps to maintain a community network that is adequate to identify, recruit, and refer potentially eligible women for early prenatal care in both fee-for-service and managed care counties.

(2) CDJFS staff must refer as soon as possible all potentially eligible women to the PRS unit/worker.

(3) Referrals must be made through a standardized procedure developed by the CDJFS as described in paragraph (K) of this rule.

(4) The referral procedure shall utilize the healthchek and pregnancy assessment form (JFS 03528, effective 6/2003) whenever available; or, at a minimum, shall include the woman's name, case number, estimated date of delivery (when known), and the name and telephone number of the PRS worker.

(D) Recruitment to early prenatal care.

(1) The CDJFS shall take steps to ensure that every potentially eligible woman is under a medical provider's care as soon as possible after her pregnancy has been identified.

(2) A woman enrolled in a medicaid-contracting MCP shall be advised to contact her MCP's member services for options in obtaining her prenatal care services.

(3) For every potentially eligible and every eligible woman, the following steps are to be taken:

(a) Inform the woman of the importance of early prenatal care. A copy of the "Healthy Start For a Healthy Baby" brochure (JFS 08062, effective 4/2005) or other written material approved by the bureau of consumer and program support (BCPS) must be given to the woman or her parent or caretaker.

(b) The following benefits of early prenatal care shall be explained using clear and non-technical language:

(i) Increasing the mother's well-being during pregnancy;

(ii) Reducing the risk to the mother's health;

(iii) Helping prevent complications and minimize discomfort;

(iv) Helping identify danger signals for early labor or miscarriage;

(v) Increasing the likelihood of having a healthy baby;

(vi) Reducing the risk of birth defects; and

(vii) Providing education on how to take care of the baby.

(4) For each eligible woman, the CDJFS should complete the JFS 03528 to identify her own and her children's needs for services, or the form may be mailed to the woman for completion. In managed care counties, the CDJFS will share the assessment form information with the medicaid-contracting MCP in which the woman chooses to enroll.

(5) If needed, the CDJFS shall provide a list of medicaid prenatal care providers available to the community and/or information about medicaid-contracting MCPs in managed care counties.

(6) The CDJFS shall provide, assist, or offer the following support services:

(a) Transportation or arranging transportation in accordance with paragraph (H) of this rule through the CDJFS or medicaid-contracting MCP, if available;

(b) Making an appointment with a medical provider. If the pregnant woman chooses to enroll or is already enrolled in a medicaid-contracting MCP, she must go to a provider in her MCP;

(c) Accompanying the woman to the medical provider's office;

(d) Making referrals as needed for non-medical services (e.g., women, infants and children (WIC), social services, community services) and (where applicable) coordinating these services with the pregnant woman's medicaid-contracting MCP;

(e) To ensure the enrollment of an infant born to an eligible woman, all pregnant women shall be informed of the healthchek program in accordance with rule 5101:1-38-05 of the Administrative Code; and

(f) When a woman's medical provider contacts the CDJFS by telephone or in writing that the woman has a non-medical need (e.g., child care, clothing, etc.), appropriate referrals shall be made and assistance provided with appointments, when necessary.

(g) If the CDJFS needs additional medical information from the assistance group, it may be necessary to obtain a signed authorization which is health insurance portability and accountability act of 1996 (HIPAA) compliant, as outlined in rule 5101:1-37-01.1 of the Administrative Code.

(E) Identification of pregnant women not receiving prenatal care.

(1) The CDJFS shall develop ways to identify potentially eligible and eligible women who are not receiving prenatal care. The system shall be described as per the guidelines in paragraph (K) of this rule and approved by ODJFS/BCPS. In counties with medicaid-contracting MCPs, the guidelines should include plans for coordination of efforts between the CDJFS and the MCPs to identify and monitor which pregnant women are not receiving prenatal care services.

(2) When the CDJFS identifies any potentially eligible women or eligible women who are not receiving prenatal care services, they shall as soon as possible attempt to make contact with them. Contacts shall be made face-to-face, by telephone, or by home visits. As a final step, when efforts to make personal contact have been unsuccessful, written correspondence shall be sent to inform the woman about the importance of prenatal care and to request that she contact the CDJFS or, when applicable, her MCP's member services for assistance.

(3) Support services listed in paragraph (D)(6) of this rule are also available for the potentially eligible woman's initial pregnancy related visit.

(F) Care compliance.

(1) When problems have developed in the delivery of care to eligible women, care compliance services can facilitate patient access to the services recommended in order to promote a healthy pregnancy.

(2) The CDJFS can be notified by telephone or by a written report from an eligible woman's medical provider when the woman has missed appointments or other problems have developed in the delivery of her care.

(3) Medicaid-contracting MCPs are responsible for follow-up of their enrollees' missed appointments. However, when the MCP's attempts to contact the eligible woman are unsuccessful, the MCP should contact the PRS coordinator in the woman's county of residence for assistance. Upon notification that the woman has missed appointments or there were other problems in the delivery of her care, the CDJFS shall establish contact with the woman according to paragraph (E) of this rule. The CDJFS shall inform the woman's medical provider or her MCP about the outcome of the contact.

(G) Support services documentation and reports.

(1) Documentation shall be maintained in a case file for each potentially eligible and eligible woman. The file shall consist of permanent records, either hard copy or computer stored, containing the following information, when appropriate:

(a) The CDJFS's copy of the prenatal risk assessment form (JFS 03535, effective 2/2003) or other prenatal risk assessment form, when available from the woman's medical provider;

(b) Copies of correspondence received and sent;

(c) Documentation of agency contacts with the pregnant woman, both attempted and established;

(d) Documentation of the MCP in which the pregnant woman is enrolled, if applicable;

(e) Information received from another county when the woman is an intercounty transfer;

(f) Documentation of all service requests made by the woman's medical provider, steps taken by the CDJFS to assure these services are provided, and whether the woman received the services; and

(g) Records of transportation provided.

(2) The CDJFS shall complete quarterly data collection reports in an ODJFS-approved format on the number of support services provided to medicaid eligible pregnant women. The report shall be submitted to ODJFS by the fifteenth day of the month following the end of each quarter.

(H) Transportation.

Transportation shall be provided, as needed, to the initial prenatal medical provider visit for all potentially eligible women. Transportation shall be provided to all eligible women to any medicaid reimbursable service, if needed, from the date of medical verification of pregnancy through the postpartum period, sixty days after the end of the pregnancy. All transportation shall be provided in accordance with the following criteria:

(1) Transportation shall be provided to the medical provider of the woman's choice when the medical provider is generally available or used by other residents of the community. The CDJFS shall also provide needed transportation to any medical provider when referred by another medical provider.

(2) If the woman is enrolled in a medicaid-contracting MCP that provides transportation for its members, the woman shall be referred to her MCP for transportation arrangements. The transportation services shall be provided by the CDJFS if not available from the MCP.

(3) The CDJFS shall provide transportation at the woman's request, at the request of the woman's medical provider, or if the CDJFS staff worker identifies a need.

(I) Infant referrals.

For every infant born to an eligible woman, the following steps shall be taken to assure that the infant is enrolled in the healthchek program, in cooperation with the woman's medicaid-contracting MCP, if applicable:

(1) A pregnant woman shall first be informed about healthchek when she completes the JFS 03528;

(2) She shall be reinformed as soon as possible after the infant's birth or during her or the infant's next reapplication.

(J) Provider recruitment.

(1) The CDJFS shall take steps to recruit and maintain a provider network that is adequate to meet the prenatal care needs of medicaid eligible women. The CDJFS must maintain on file current lists of all participating prenatal providers.

(2) In counties with medicaid-contracting MCPs, the network of participating providers will be contracted through and maintained by the MCP.

(3) It is recognized that the ability of the CDJFS to recruit and maintain an adequate provider network depends on the existence of appropriate providers within a reasonable geographic area.

(K) Documentation requirements.

The CDJFS shall submit in writing, under signature of the CDJFS director, a description of the process and structure of the management of the local PRS program including the name of the contact person and/or coordinator for the program.

The information submitted, shall include the following:

(1) Identify where in the CDJFS table of organization the responsibility for the PRS program is located and the name and title of the contact person or coordinator.

(2) A description of the staff/unit responsible for informing women identified as pregnant of the following:

(a) The PRS program,

(b) The importance of prenatal care,

(c) The availability to assist eligible pregnant women in receiving an initial physician visit,

(3) How the CDJFS tracks identified pregnant women,

(4) Identification of the staff/unit responsible for submission of the pregnancy related services quarterly report (JFS 03539, effective 1/2002) to ODJFS.

(5) Information as to whether the agency will provide transportation to infants during the first year of life.

(6) In counties with medicaid-contracting MCPs, the information submitted under the CDJFS director's signature shall include plans for coordination of efforts between the CDJFS and the MCPs. This may include written agreements between the CDJFS and the medicaid-contracting MCPs with provisions for regularly scheduled meetings, as well as other ideas for county and plan coordination.

(7) All changes or amendments to the CDJFS's description of the process and/or structure shall be submitted in writing to ODJFS under the signature of the CDJFS director within ten working days.

(8) Information submitted under the signature of the CDJFS director can be combined or included with the information submitted as per paragraph (M) of rule 5101:1-38-05 of the Administrative Code.

Effective: 10/15/2005
R.C. 119.032 review dates: 07/29/2005 and 10/01/2010
Promulgated Under: 111.15
Statutory Authority: 5111.01
Rule Amplifies: 5111.01 , 5111.016
Prior Effective Dates: 4/1/88 (emer.), 6/30/88, 10/1/88 (emer.), 12/20/88, 4/1/91, 2/1/92, 5/1/93, 10/1/98, 5/1/02, 10/6/03

5160:1-2-10 Medicaid estate recovery.

(A) This rule describes Ohio's medicaid estate recovery program and the undue hardship waiver request process.

(B) Definitions.

(1) "Estate" includes both of the following:

(a) All real and personal property and other assets to be administered under Title XXI of the Revised Code and property that would be administered under that title if not for section 2113.03 or 2113.031 of the Revised Code; and

(b) Any other real and personal property and other assets in which an individual had any legal title or interest at the time of death (to the extent of the interest), including assets conveyed to a survivor, heir, or assign of the individual through joint tenancy, tenancy in common, survivorship, life estate, living trust, or other arrangement.

(2) "Home" , for the purpose of this rule, means any property in which an individual has an ownership interest and which serves as the individual's principal place of residence. Home includes the structures and land appertaining to the home property. Appertaining land must be contiguous to the land on which the home property is located and must not be separated by intervening land property owned by others.

(3) "Individual," for the purpose of this rule, means a past or current recipient of medicaid.

(4) "Permanently institutionalized individual" is defined in section 5111.11 of the Revised Code.

(5) "Person responsible for the estate" is defined in section 2117.061 of the Revised Code.

(6) "Personal property"

means any property that is not real property. The term includes, but is not limited to, such things as cash, jewelry, household goods, tools, life insurance policies, automobiles, promissory notes, etc.

(7) "Qualified long- term care partnership (QLTCP)" is defined in rule 5101:1-38-11 of the Administrative Code.

(8) "Real property"

means land, including buildings or immovable objects, attached permanently to the land.

(9) "Time of death" is defined in section 5111.11 of the Revised Code.

(C) The Ohio attorney general (AGO) will seek recovery or adjustment, on behalf of the Ohio department of job and family services (ODJFS), from the estates of the following individuals:

(1) A permanently institutionalized individual of any age, in the amount of all medicaid benefits correctly paid; or

(2) An individual fifty-five years of age or older who is not permanently institutionalized , in the amount of all medicaid benefits correctly paid (other than benefits paid on or after January 1, 2010, under the medicare premium assistance programs set forth in rules 5101:1-38-03 and 5101:1-39-01.1 of the Administrative Code) after the individual attained such age.

(D) Any adjustment or recovery under paragraph (C) of this rule may be sought only:

(1) After the death of the individual's surviving spouse, if any; and

(2) When the individual has no surviving child who either is under age twenty-one or is blind or permanently and totally disabled as defined in Chapter 5101:1-39 of the Administrative Code; and

(3) If recovery is sought against a permanently institutionalized individual under paragraph (C)(1) of this rule, no recovery may be made against the individual's home while either of the following lawfully resides in the home:

(a) The permanently institutionalized individual's sibling who:

(i) Resided in the home for at least one year immediately before the date of the individual's admission to the institution, and

(ii) Has resided in the home on a continuous basis since that time.

(b) The permanently institutionalized individual's son or daughter who:

(i) Provided care to the permanently institutionalized individual that delayed the individual's institutionalization, and

(ii) Resided in the home for at least two years immediately before the date of the individual's admission to the institution, and

(iii) Has resided in the home on a continuous basis since that time, and

(iv) Documents that he or she has fulfilled these requirements by submitting the following:

(a) A written statement of the date that he or she moved into the home;

(b) A level of care assessment showing that the individual would have become institutionalized earlier without care provided by the adult son or daughter;

(c) A written statement from the individual's attending physician, stating the kind and duration of care that was required to delay the individual's institutionalization; and

(d) All relevant documentation of the care that delayed institutionalization and the role the adult son or daughter played in that care. This documentation shall include (but is not limited to) one or more of the following:

(i) A written statement of the number of hours per day during which the adult son or daughter provided personal care, specifying the extent and type of care provided;

(ii) A written statement of any part-time or full-time jobs performed by the adult son or daughter, and any schools or other similar institutions attended by the adult son or daughter, while providing care; or

(iii) Written documentation from a service agency which provided care to the individual, the dates on which care was provided, and the extent and type of care provided.

(E) Notice requirements.

(1) When an individual was age fifty-five or older or was permanently institutionalized at the time of death, the person responsible for the estate must give notice to the AGO, as required by section 2117.061 of the Revised Code.

(2) After the individual's death, whenever adjustment or recovery is sought by ODJFS or its designee, a claim for recovery must be presented by the AGO.

(a) The claim must include all information required by Chapter 2117. of the Revised Code and must be served on the person responsible for the estate or, if there is no person responsible for the estate, any person who received or controls probate or non-probate assets inherited from the individual.

(b) The claim must include the following:

(i) That this rule defines undue hardship in paragraph (H) of this rule, and sets out the process for requesting an undue hardship waiver in paragraph (I) of this rule;

(ii) What form (as specified by the ODJFS director) must be completed to request an undue hardship, and where that form can be obtained; and

(iii) The date by which that form must be submitted in order to request an undue hardship waiver.

(3) The person responsible for the estate must notify any person who received or controls probate or non-probate assets, inherited from the individual, affected by the proposed recovery.

(F) If the person responsible for the estate from which recovery is sought requests to satisfy the claim without selling a non-liquid asset subject to recovery, the AGO may establish a payment schedule, promissory note, or lien.

(G) Qualified long- term care partnership disregard.

(1) The amount of resources disregarded at eligibility determination (as established in rule 5101:1-38-11 of the Administrative Code) will be disregarded during estate recovery.

(2) The following resources, which are not considered a resource at eligibility determination, will not be disregarded during estate recovery:

(a) Special needs trusts as established in rule 5101:1-39-27.1 of the Administrative Code;

(b) Pooled trusts as established in rule 5101:1-39-27.1 of the Administrative Code; and

(c) Annuities as described in rule 5101:1-39-22.8 of the Administrative Code.

(3) The QLTCP disregard at estate recovery is reduced to the extent that an individual made a transfer (that would otherwise have been considered an improper transfer under rule 5101:1-39-07 of the Administrative Code) without a restricted medicaid coverage period.

(H) The ODJFS director, or designee, may grant an undue hardship waiver on a case-by-case basis when there are compelling circumstances.

(1) ODJFS may, at the sole discretion of the ODJFS director or the director's designee, waive estate recovery when recovery would work an undue hardship on an individual's survivors. Undue hardship may be found in the following cases.

(a) The estate subject to recovery is the sole income-producing asset of the survivor, such as a family farm or other family business, which:

(i) Produces a limited amount of income, or

(ii) Is the sole asset of the survivor.

(b) Without receipt of the estate proceeds, the survivor would become eligible for public assistance.

(c) Recovery would deprive the survivor of necessary food, shelter or clothing. Deprivation does not include situations in which the survivor is merely inconvenienced but would not be at risk of serious harm.

(d) The survivor provides clear and convincing evidence of substantial personal financial contributions to the deceased individual, creating an equity interest in the property.

(e) The survivor is age sixty-five or older and financially dependent upon receipt of the estate proceeds.

(f) The estate proceeds are preserved for the benefit of a survivor who:

(i) Is totally and permanently disabled as defined in Chapter 5101:1-39 of the Administrative Code; and

(ii) Is financially dependent upon receipt of the estate proceeds.

(2) The following situations do not, without additional showing of hardship, show undue hardship:

(a) When recovery will prevent heirs from receiving an anticipated inheritance.

(b) When recovery results in the loss of a pre-existing standard of living, or prevents the establishment of a source of maintenance that did not exist prior to the individual's death.

(3) Regardless of actual hardship, an undue hardship waiver will not be granted in the following situations:

(a) When the individual created the hardship by using estate planning methods under which the individual divested, transferred, or otherwise encumbered assets in whole or in part to avoid estate recovery.

(b) When an undue hardship waiver will result in the payment of claims to other creditors with lower priority standing under Ohio's probate law.

(I) Request for undue hardship waiver.

(1) Within thirty calendar days after notice of the estate recovery claim was mailed by the AGO, an undue hardship waiver may be requested (upon such form as may be designated by the ODJFS director) by an heir or potential heir who would suffer an undue hardship if a waiver is not granted, a person with an interest in assets of the estate, or a representative of such persons. An undue hardship waiver may not be requested by a creditor of the estate, unless such creditor is also a potential heir of the estate.

(2) Within sixty calendar days of receipt of the request for an undue hardship waiver, ODJFS must notify the applicant whether the waiver request has been approved (in full, in part, or for a limited time) or denied. Failure to meet this sixty day deadline does not result in an automatic decision on the request.

(3) If the waiver request was not approved in full, or if the approval was time-limited, the applicant may, within thirty calendar days, request (on such form as the director designates) that the ODJFS director, or designee, review the undue hardship waiver decision.

(a) The ODJFS director, or designee, will review only those portions of the undue hardship waiver request that were denied or time-limited. The director will not deny or limit any portion of the undue hardship waiver request that has already been granted.

(b) The ODJFS director, or designee, must review the undue hardship waiver request and notify the applicant within sixty calendar days whether (at the director's sole discretion) the director, or designee, has approved (in full, in part, or for a limited time) or denied the request for an undue hardship waiver. Failure to meet this sixty day deadline does not result in an automatic decision on the request.

(J) Within thirty days after notice of the estate recovery claim was mailed by the AGO, a person with an interest in assets of the estate (or a representative of any such person) may (upon such form as may be designated by the ODJFS director) present a claim showing evidence that assets of the estate are exempt assets under one of the following categories.

(1) Government reparation payments to special populations are exempt from medicaid estate recovery.

(2) Certain American Indian and Alaska native income and resources, including:

(a) American Indian and Alaska native income and resources which are exempt from medicaid estate recovery by other laws and regulations;

(b) Ownership interest (when ownership would pass from an Indian to one or more relatives; to a tribe or tribal organization; and/or to one or more Indians) in trust or non-trust property, including real property and improvements:

(i) Located on a reservation (any federally recognized Indian tribe's reservation, pueblo, or colony, including former reservations in Oklahoma, Alaska native regions established by Alaska native claims settlement act and Indian allotments) or near a reservation as designated and approved by the bureau of Indian affairs of the U.S. department of the interior; or

(ii) For any federally-recognized tribe not described in paragraph (J)(2)(b)(i) of this rule, located within the most recent boundaries of a prior federal reservation; or

(c) Income left as a remainder in an estate derived from property protected in paragraph (J)(2)(b) of this rule, that was either collected by an Indian, or by a tribe or a tribal organization and distributed to an Indian, as long as the income clearly comes from protected sources;

(d) Ownership interests left as a remainder in an estate in rents, leases, royalties, or usage rights related to natural resources (including extraction of natural resources or harvesting of timber, other plants and plant products, animals, fish, and shellfish) resulting from the exercise of federally-protected rights, and income either collected by an Indian, or by a tribe or tribal organization and distributed to an Indian derived from these sources the income or ownership interest clearly comes from protected sources; and

(e) Ownership interests in or usage rights to items that have unique religious, spiritual, traditional, and/or cultural significance or rights that support subsistence or a traditional life style according to applicable tribal law or custom.

Replaces:

5101:1-38-10

Effective: 01/01/2010
R.C. 119.032 review dates: 09/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.11
Rule Amplifies: 5111.11 , 5111.111 , 5111.12 , 5111.18
Prior Effective Dates: 7/1/2000, 9/1/2007

5160:1-2-11 Medicaid: treatment of qualified long-term care insurance policies.

(A) This rule describes the qualified long-term care partnership (QLTCP) program under which an individual's resources are disregarded in eligibility determinations and at estate recovery in the amount of benefits paid to or on behalf of the consumer by a QLTCP policy.

(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 administering the medicaid program.

(2) "Estate recovery" means the program set out in rule 5101:1-38-10 of the Administrative Code.

(3) "Qualified long-term care partnership (QLTCP)" means the program established under section 5111.18 of the Revised Code, under which an individual's resources are disregarded in eligibility determination(s) and at estate recovery in the amount of benefits paid to or on behalf of the consumer by a QLTCP policy.

(4) "Third party" is defined in rule 5101:1-38-02.2 of the Administrative Code.

(C) A QLTCP policy is one that meets all of the following requirements.

(1) On the date the policy was issued, the state in which the insured resided had in place an approved state plan amendment which provides, pursuant to 42 U.S.C. 1396p(b) (as in effect on May 1, 2007), for the disregard of resources in an amount equal to the insurance benefit payments made to or on behalf of an individual who is a beneficiary of a QLTCP policy; and

(2) The policy is a qualified long-term care insurance policy, as defined in section 7702B(b) of the Internal Revenue Code of 1986; and

(3) The policy meets the requirements set forth by the Ohio department of insurance or, if purchased outside Ohio, meets the requirements of an approved state plan amendment, as described in paragraph (C)(1) of this rule, in the state of purchase.

(D) At application or reapplication (as established in Chapter 5101:1-39 of the Administrative Code) for long-term care services, a home and community-based services (HCBS) waiver, or the program of all inclusive care for the elderly (PACE), an individual's resources will be disregarded up to the dollar amount of benefits paid to or on behalf of the individual by a QLTCP policy.

(1) The administrative agency shall determine medicaid eligibility in accordance with the eligibility rules contained in Chapters 5101:1-37 to 5101:1-42 of the Administrative Code.

(2) An individual may apply for long term care services before exhausting the benefits of a QLTCP policy. If an individual applies for and is eligible to receive medicaid coverage before the QLTCP policy is exhausted, the QLTCP insurer must make payment for medical care to the maximum extent of their liability before medicaid funds may be used to pay providers for covered services as established in rule 5101:1-38-02.2 of the Administrative Code.

(3) If an individual has applied for and been found eligible to receive medicaid, and then receives additional resources, the individual continues to be eligible for medicaid to the extent the total value of all disregarded resources does not exceed the individual's QLTCP disregard plus the applicable resource allowance.

(4) A QLTCP disregard does not affect post-eligibility income calculations under Chapters 5101:1-38 to 5101:1-41 of the Administrative Code; the disregard cannot reduce patient liability or cost of care.

(E) Transfers of resources.

(1) If an individual becomes eligible for medicaid through the application of a QLTCP disregard, then makes a transfer (of disregarded resources) that would otherwise be considered an improper transfer (under rule 5101:1-39-07 of the Administrative Code), no restricted medicaid coverage period applies. The disregarded value of the transferred resource continues to be considered part of the individual's QLTCP disregard.

(2) If an individual becomes eligible for medicaid through the application of a QLTCP disregard after making a transfer that would otherwise be considered an improper transfer (per rule 5101:1-39-07 of the Administrative Code):

(a) If the individual's QLTCP disregard plus resource limit equals or exceeds the individual's countable resources plus the value of the transferred resource, no restricted medicaid coverage period applies. The disregarded value of the transferred resource is considered part of the individual's QLTCP disregard.

(b) If the individual's QLTCP disregard plus resource limit is less than the individual's countable resources plus the value of the transferred resource:

(i) The individual's available QLTCP disregard is determined by adding the individual's QLTCP disregard to the individual's resource limit, then subtracting the individual's current countable resources and any amounts that have previously been transferred without a restricted medicaid coverage period as a result of a QLTCP disregard.

(ii) The individual's available QLTCP disregard is subtracted from the amount that would otherwise have been considered improperly transferred. The remainder is the amount improperly transferred; a restricted medicaid coverage period is calculated for the remainder as per rule 5101:1-39-07 of the Administrative Code.

Effective: 09/01/2007
R.C. 119.032 review dates: 09/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.11 , 5111.18
Rule Amplifies: 5111.11 , 5111.18

5160:1-2-20 Medicaid consumer fraud and erroneous payments.

(A) This rule sets out requirements for the identification and referral of consumer fraud and erroneous payments made by a medical assistance program on behalf of a consumer.

(B) Definitions.

(1) "Abuse" means individual practices resulting in unnecessary cost to the medicaid program.

(2) "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.

(3) "Erroneous payments" means 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.

(C) Administrative responsibilities. The administrative agency shall:

(1) Upon notification of a complaint of medicaid fraud, abuse or questionable practices, conduct a preliminary investigation to determine if there is sufficient basis to warrant a full investigation in accordance with 42 C.F.R. 455.15 and 42 C.F.R. 455.16 (as in effect November 1, 2009). If a full investigation is warranted, the investigation shall continue until:

(a) Appropriate legal action is initiated;

(b) The investigation is closed or dropped by the administrative agency due to insufficient evidence of fraud or abuse; or

(c) The matter is resolved by the administrative agency. The resolution may include but is not limited to:

(i) Sending a warning letter to the individual giving notice that continuation of the activity in question will result in further action;

(ii) Seeking recovery of erroneous payments.

(2) Make a determination whether an erroneous payment was made as a result of unreported changes, excess income or excess resources and seek recovery as authorized in section 5111.12 of the Revised Code.

(3) Refer all cases of fraud or suspected fraud to the county prosecutor as described in section 2913.401 of the Revised Code. For cases determined to be fraud, the administrative agency shall accept any reimbursement plan ordered by a court or agreed to by the county prosecutor.

(4) Not recover erroneous claims paid by the administrative agency for an individual that would have remained eligible under another medical assistance program.

(5) Recover erroneous claims for the individual only through reimbursement. Erroneous payments shall not be recovered by reducing benefits or services to the individual.

(6) Not recover erroneous payments for the individual as a result of an administrative error not caused by the individual.

(7) Seek recovery from only the responsible adult or guardian of medicaid eligible children.

(8) Seek a recovery agreement by sending a JFS 07335 "Notice of Medicaid Overpayment" (rev. 4/2002), or electronic equivalent, to the individual.

(9) Follow rule 5101:9-7-06 of the Administrative Code.

(D) Recovery of erroneous payments. The administrative agency shall recover erroneous payments beginning the date the individual would no longer have been eligible for medicaid had the change been reported in accordance with paragraph (B) of rule 5101:1-38-01 of the Administrative Code and the expiration of the prior notice period as required in rule 5101:6-2-04 of the Administrative Code.

(1) For 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.

(2) For excess income, the amount subject to recovery is the total amount of payments made on behalf of the individual during the months of the erroneous payment period.

(3) For combinations of excess resources and excess income, the amount subject to recovery is the greater of either paragraph (D)(1) or paragraph (D)(2).

(4) For spenddown cases, as outlined in rule 5101:1-39-10 of the Administrative Code, the amount subject to recovery is the lesser of:

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

(b) The difference between the amount of the liability in effect during the erroneous period and the correct amount of the liability.

(5) Situations involving individuals receiving long-term care, waiver services or intermediate care facility for the mentally retarded (ICF/MR) services:

(a) Income. Erroneous payments made as a result of incorrect patient liability as outlined in paragraph (B) of rule 5101:1-38-01 of the Administrative Code.

(i) Determine if an erroneous payment was made as a result of an improper transfer of assets by the individual or authorized representative as outlined in rule 5101:1-39-07 of the Administrative Code.

(ii) The amount subject to recovery.

(a)If the individual should not have been made medicaid-eligible, the amount subject to recovery is the amount of payments made on behalf of the individual; or

(b)If the individual was correctly made medicaid-eligible but the patient liability was incorrectly calculated, 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.

(b) Resources. Erroneous payments made as a result of excess resources as outlined in rule 5101:1-39-05 of the Administrative Code.

(i) Determine if an erroneous payment was made as a result of an improper transfer of assets by the individual or authorized representative as outlined in rule 5101:1-39-07 of the Administrative Code.

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

(iii) 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 shall be accomplished in one calendar month and in compliance with paragraph (D) of rule 5101:1-38-01.8 of the Administrative Code.

(E) Individual responsibility. The individual shall complete and return the JFS 07335 "Notice of Medicaid Overpayment" (rev. 4/2002), or its electronic equivalent, within thirty days from the date the form was sent by the administrative agency.

Replaces: 5101:1-38-20

Effective: 02/01/2010
R.C. 119.032 review dates: 02/01/2015
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011
Rule Amplifies: 2913.401 , 5111.01 , 5111.011 , 5111.12
Prior Effective Dates: 10/1/87 (Emer), 12/24/87, 11/7/02

5160:1-2-30 [Rescinded] Medicaid: continuous eligibility for children younger than age nineteen.

Effective: 01/01/2014
R.C. 119.032 review dates: 10/15/2013
Promulgated Under: 111.15
Statutory Authority: 5162.031 , 5163.02
Rule Amplifies: 5163.02
Prior Effective Dates: 4/1/10 (Emer.), 7/1/10, 10/15/10

5160:1-2-40 Medicaid: presumptive eligibility for children younger than age nineteen.

(A) This rule describes the conditions under which a child may receive time-limited medical assistance as a result of an initial, simplified determination of eligibility , as described in section 1920A of the Social Security Act (as in effect on July 1, 2012).

(B) Definitions.

(1) "Child," for the purpose of this rule, means a person younger than age nineteen.

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

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

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

(C) Eligibility criteria for presumptive coverage.

(1) A child who receives presumptive coverage is ineligible for a new presumptive coverage period for one year from the date on which the presumptive coverage began.

(2) Except as set forth in paragraph (C)(1) of this rule, a child is eligible for presumptive coverage if the child:

(a) Is younger than age nineteen; and

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

(c) Is a United States citizen or qualified alien as defined in rule 5101:1-38-02.3 of the Administrative Code; and

(d) Has gross family income no more than two hundred per cent of the federal poverty level for the family size.

(3) The eligibility criteria set forth in paragraph (C)(2) of this rule are verified by self-declared statements.

(D) Duration of presumptive coverage.

(1) Presumptive coverage begins on the date the qualified entity determines a child is presumptively eligible. No retroactive coverage may be provided as a result of a presumptive eligibility determination.

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

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

(b) If an application for ongoing medicaid is not filed on the child's behalf, the last day of the month following the month in which the child was determined to be presumptively eligible.

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

(1) Such forms as are necessary for applications on behalf of children to be submitted for presumptive medical assistance under the state plan; and

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

(F) Qualified entity responsibilities

(1) If the qualified entity is a CDJFS:

(a) No later than the end of the business day after receipt of a signed and dated application for medical assistance on behalf of a child, the CDJFS shall determine whether the child is eligible for presumptive coverage under this rule.

(b) For the purpose of the presumptive eligibility determination, the CDJFS shall accept the family's self-declaration of the presumptive eligibility criteria unless the CDJFS has contradictory information.

(c) If a child is eligible for presumptive coverage, the CDJFS shall:

(i) Approve presumptive coverage for the child ; and

(ii) Inform the child's representative of:

(a)The presumptive coverage, and

(b)That failure to cooperate with the eligibility determination process set forth in rule 5101:1-38-01.2 of the Administrative Code will result in a denial of medical assistance, which will trigger the termination of presumptive coverage.

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

(d) If a child is not eligible for presumptive coverage, the CDJFS shall inform, on a form designated by the Ohio department of job and family services (ODJFS), the child's representative of the denial and that the child's eligibility for medical assistance will be reviewed.

(e) Whether or not a child is eligible for presumptive coverage, the CDJFS shall determine whether the child is eligible for medical assistance pursuant to rule 5101:1-38-01.2 of the Administrative Code.

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

(a) Upon request, or if the qualified entity believes the child may meet the criteria for presumptive eligibility for children, determine whether the child is presumptively eligible under this rule.

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

(c) If the child is presumptively eligible:

(i) Approve presumptive coverage for the child; and

(ii) Provide the child's parent or guardian, as appropriate, at the time of determination, with a notice of the child's presumptive eligibility. Such notice shall include the child's:

(a) Presumptive eligibility determination date;

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

(c) MITS billing number; and

(d)A reminder that the child's parent or guardian is required to make application for ongoing medical assistance for the child no later than the last day of the following month.

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

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

(d) If the child is not presumptively eligible, inform the child's parent or guardian that there may be other categories of medical assistance available to the child, and that the child's parent or guardian should contact the local CDJFS for an eligibility determination.

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

Replaces: 5101:1-38-40

Effective: 07/01/2012
R.C. 119.032 review dates: 07/01/2015
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011
Rule Amplifies: 5111.01 , 5111.011 , 5111.0125
Prior Effective Dates: 4/1/10 (Emer.), 7/1/10, 4/1/12 (Emer.)

5160:1-2-50 Medicaid: presumptive eligibility for pregnant women.

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

(B) Definitions.

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

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

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

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

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

(1) Pregnant;

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

(3) An Ohio resident; and

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

(D) Duration and scope of presumptive coverage.

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

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

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

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

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

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

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

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

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

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

(1) If the qualified provider is the CDJFS:

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

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

(c) If the pregnant woman is presumptively eligible:

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

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

(a) She is eligible for presumptive coverage, and

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

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

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

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

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

(c) If the pregnant woman is presumptively eligible:

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

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

(a) Presumptive eligibility determination date;

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

(c) Expected due date;

(d) MITS billing number; and

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

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

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

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

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

Replaces: 5101:1-40-60

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