Chapter 5160:1-5 Medicaid for Other Covered Groups

5160:1-5-01 Medicaid: the residential state supplement (RSS) program.

(A) RSS provides cash assistance to medicaid-eligible aged, blind, or disabled adults who have increased needs due to a medical condition which is not severe enough to require institutionalization. The RSS cash payment is used together with the individual personal income to help prevent institutionalization, and to deinstitutionalize those aged, blind, or disabled adults who have been placed in long term care facilities and who can return to the community through alternative living arrangement.

(B) Definitions.

(1) "Countable income," for the purposes of this rule, means income remaining after exclusions.

(2) "Income standard," for the purposes of this rule, means the aggregate of the allowable fee standard and the personal needs allowance.

(3) "Individual," for the purposes of this rule, means a person who is applying for or receiving RSS benefits.

(4) "Institutional placement," for the purposes of this rule, means placement, in a public medical institution, a public psychiatric institution, a hospital which has a provider agreement with the Ohio department of medicaid, or a Title XIX certified long term care facility (LTCF).

(5) "OhioMHAS," means the Ohio department of mental health and addiction services or the entity designated by OhioMHAS pursuant to division (C) of section 5119.41 of the Revised Code.

(6) "RSS living arrangement," means an arrangement listed under division (D)(1) of section 5119.41 of the Revised Code.

(7) "RSS," means the residential state supplement program described in section 5119.41 of the Revised Code.

(8) "RSS protected date," for the purposes of this rule, means the signature date on the form of a completed "Residential State Supplement" ODM 07120 (rev. 7/2014) referral form, electronic equivalent, or a "Residential State Supplement (RSS) Program Application" DMHAS 7046 (rev. 11/14).

(9) "Temporary institutional placement," for the purposes of this rule, means placement, not likely to exceed ninety days, in a public medical institution, a public psychiatric institution, a hospital which has a provider agreement with the Ohio department of medicaid, or a Title XIX certified long term care facility (LTCF).

(C) Eligibility criteria:

(1) To be eligible for the RSS program an individual must:

(a) Be determined eligible for medicaid in accordance with Chapter 5160:1-3 of the Administrative Code; and

(b) Meet the financial and resource requirements described in paragraph (E) of this rule; and

(c) Have at least a protective level of care as defined in rule 5160-3-06 of the Administrative Code; and

(d) Meet the non-financial requirements described in paragraph (H) of this rule; and

(e) Not require more than one hundred twenty days of skilled nursing care within a twelve month period.

(2) If at any time, an individual no longer meets all the criteria of this rule, the individual is no longer eligible for the RSS program, unless, according to division (G) of section 5119.41 of the Revised Code, the individual no longer meets the criteria solely by reason of his or her living arrangement, so long as he or she has continued to reside in the same living arrangement since November 15, 1990.

(D) RSS registration and enrollment process. The RSS application process is initiated upon receipt of all of the following:

(1) A completed ODM 07120 or electronic equivalent from OhioMHAS verifying that the individual has been selected for placement in the RSS program;

(a) If the individual submits a completed ODM 07120 either at the CDJFS or by mail, a copy of the ODM 07120 will be forwarded to OhioMHAS to register the individual for the RSS program.

(b) If a completed ODM 07120 or electronic equivalent has been submitted to OhioMHAS, it shall be made available to the department of medicaid and the CDJFS for the determination of eligibility in accordance with paragraph (C) of this rule.

(c) The signature date on the ODM 07120 or electronic equivalent shall be the RSS application date.

(2) A medicaid application, if the individual is not currently in receipt of medicaid;and

(3) Non-financial verifications from OhioMHAS as described in paragraph (H) of this rule.

(E) Financial eligibility.

(1) The definitions of earned and unearned income in Chapter 5160:1-2 of the Administrative Code are applicable to the RSS program.

(2) When an individual and his/her spouse reside in the same RSS living arrangement and both have appropriate levels of care, the CDJFS shall determine their RSS financial and resource eligibility collectively utilizing the appropriate couple income standard as defined in rule 5160:1-3-03.5 of the Administrative Code.

(3) When an individual and his/her spouse reside in the same RSS living arrangement and only one of them has an appropriate level of care, the CDJFS shall determine RSS financial and resource eligibility utilizing the appropriate individual income standard as defined in rule 5160:1-3-03.5 of the Administrative Code.

(4) The spouse who does not have the necessary level of care shall have medicaid eligibility determined in accordance with rule 5160:1-2-10 of the Administrative Code as an individual, except that income cannot be deemed to or from the RSS eligible spouse

(5) The financial eligibility methodologies for RSS shall be the same as the financial eligibility methodology for medicaid, with the following exceptions:

(a) SSI income is countable income in the RSS program.

(b) If an individual has countable income equal to or in excess of the income standard in rule 5122-36-05 of the Administrative Code, the individual is ineligible for RSS.

(c) The RSS program has no deeming provision.

(6) Twenty dollars of any earned or unearned income is disregarded. Only one twenty dollar disregard is applied per couple if both spouses are eligible for RSS and both reside in the same RSS living arrangement.

(7) The disregard allowed from an eligible individual's earned income is sixty-five dollars plus one-half of the remaining income. Only one sixty-five dollar plus one-half of the remaining income disregard is applied per couple if both spouses are eligible for RSS and both reside in the same RSS living arrangement.

(8) Earnings which are used to pay for blind work expenses and/or impairment-related work expenses may be deducted from the earned income in accordance with rule 5160:1-3-03.11 of the Administrative Code.

(9) If the RSS individual countable income is less than the income standard for the appropriate RSS living arrangement, but the individual RSS enrollment is not yet completed, the CDJFS shall pend the RSS application until the RSS enrollment determination is completed.

(10) If the RSS individual countable income is less than the income standard for the appropriate RSS living arrangement, the individual is eligible for an RSS payment.

(11) The CDJFS shall determine retroactive medicaid eligibility in accordance with rule 5160:1-2-01 of the Administrative Code for coverage of non-RSS medicaid services.

(12) The CDJFS shall explore eligibility for qualified medicare beneficiary (QMB), specified low-income medicare beneficiary (SLMB), and qualified individual (QI-1) in accordance with rule 5160:1-3-02.1 of the Administrative Code.

(F) Determination of RSS payment.

(1) The RSS payment to the assistance group shall be equal to the difference between the countable income and the income standard for an RSS living arrangement. This payment calculation includes all allowable deductions and disregards as described in paragraph (E) of this rule.

(2) The approval date for the RSS payment cannot precede the signature date on the ODM 07120 or electronic equivalent, the date of placement in an appropriate RSS living arrangement, or the date when all financial and non-financial eligibility requirements are met including appropriate level of care, whichever occurs last.

(3) When an individual leaves an RSS living arrangement after the monthly RSS payment has been made, and does not begin residence in another eligible RSS living arrangement, the individual shall be responsible for returning the RSS payment. The return amount shall be pro-rated from the date the individual leaves the RSS living arrangement.

(4) If an individual leaves an RSS living arrangement and moves to another RSS living arrangement and the monthly RSS payment has been made to the individual, a second monthly RSS payment will not be made for the new living arrangement.

(5) When an individual leaves an RSS living arrangement the CDJFS must determine the individual's continued medicaid eligibility. If an adverse action is required, the individual must be afforded hearing rights in accordance with division 5101:6 of the Administrative Code.

(6) When an individual moves from a nursing facility or a personal residence into an RSS living arrangement on the first day of the month and is otherwise eligible for RSS, the individual is eligible for a full month's RSS payment.

(7) When an individual moves into an RSS living arrangement on a date other than the first day of the month and is otherwise eligible for RSS, the first month's payment is calculated according to the following formula:

(a) Determine the regular monthly RSS payment in accordance with paragraph (F)(1) of this rule.

(b) Divide the monthly RSS payment amount by the number of days in the month to arrive at the daily supplement amount. Round amounts up to the nearest whole dollar.

(c) Multiply the daily supplement amount by the actual number of days of RSS placement in the month. The actual number of days of RSS placement in the month includes the day that the individual moves into the RSS living arrangement through the last day of the month.

(d) The resulting product is the pro-rated RSS payment.

(G) Temporary institutional placement.

(1) RSS benefits are intended to allow an individual to maintain and pay for the RSS living arrangement in which he/she intends to live when discharged from temporary institutional placement.

(2) Individuals in a temporary institutional placement are potentially eligible to receive full uninterrupted RSS benefits during the first ninety days of institutional placement.

(3) Individuals are eligible for continued RSS benefits thereafter provided the following criteria are met:

(a) The individual must be eligible for an RSS payment both the month prior to and the first month of institutional placement.

(b) The individual period of institutional placement is not likely to exceed ninety consecutive days, beginning the day after the day of admission.

(c) The individual needs to maintain residency in the RSS living arrangement during the temporary institutional placement.

(d) OhioMHAS shall submit written documentation to the CDJFS that the criteria listed in paragraphs (G)(3)(a), (G)(3)(b), and (G)(3)(c) of this rule has been met by the earlier of:

(i) Ninety days after the date of admission for the temporary institutional placement; or

(ii) The date of release from the temporary institutional placement.

(4) RSS payments and personal income are exempt from consideration as income in the long term care patient liability calculation for individuals temporarily entering a LTCF.

(a) This income exemption continues through the last day of the month in which the temporary period of institutional placement ends, not to exceed ninety days.

(b) Effective the month following the month in which the temporary period of institutional placement ends, if the RSS individual remains in an institutional placement, the CDJFS must stop the RSS payment and count the individual income in the patient liability calculation.

(5) The CDJFS shall continue RSS payments to all individuals meeting the criteria in paragraph (G) of this rule.

(6) Any RSS payments made under paragraph (G) of this rule are not overpayments if the recipient's actual stay exceeds the expected stay of ninety days or less.

(7) Prior notice in accordance with division 5101:6 of the Administrative Code is required to stop RSS payments and start vendor payments to a long term care facility.

(8) Upon notification from OhioMHAS that the RSS living arrangement or provider's license or certification has expired or has been suspended or revoked, the CDJFS must provide prior notice that the individual RSS eligibility will be terminated because the individual no longer resides in an RSS living arrangement and hearing rights must be provided in accordance with division 5101:6 of the Administrative Code.

(9) When the CDJFS receives notice from OhioMHAS that the RSS living arrangement or provider's license or certification has been renewed, the RSS payment may be made retroactive to the effective date of the RSS living arrangement's or provider's recertification, as long as all other RSS eligibility factors are met.

(H) OhioMHAS responsibilities. OhioMHAS shall:

(1) Determine the non-financial eligibility for the RSS program, for the individual in accordance with rule 5122-36-02 of the Administrative Code.

(2) Determine that the individual is residing in an appropriate living arrangement in accordance with division (D)(1) of section 5119.41 of the Revised Code and rule 5122-36-04 of the Administrative Code. The appropriate living arrangements are:

(a) A "residential care facility" that is licensed by the department of health under Chapter 3721. of the Revised Code and approved by OhioMHAS;

(b) A "residential facility" that is licensed by OhioMHAS and defined in section 5119.34 of the Revised Code;

(3) Document that the individual meets at least a protective level of care pursuant to rule 5122-36-02 of the Administrative Code.

(4) Participate in state hearings resulting from non-financial RSS eligibility criteria decisions.

(5) Provide non-financial verifications as described in paragraphs (G) and (H) of this rule to the CDJFS in order for the CDJFS to determine RSS financial eligibility for the individual.

(6) Inform the CDJFS of any change in the individual or couple's RSS non-financial eligibility criteria, or RSS placement.

(7) Maintain a census of all individuals who receive RSS payment and the RSS living arrangement in which each individual currently resides.

(8) Confirm that the individuals who receive RSS payment are residing in the RSS living arrangement on record.

(I) CDJFS responsibilities. The CDJFS shall:

(1) Inform OhioMHAS of the individual eligibility for medicaid and the amount of the RSS payment that can be authorized.

(2) Verify that the individual is not a consumer of any home and community-based services (HCBS) waiver.

(3) Verify that the individual is not a participant in a program of all-inclusive care for the elderly (PACE).

(4) Verify that the individual is not enrolled in a medicare or medicaid-certified hospice program.

(5) For an individual who is not already receiving medicaid, determine medicaid eligibility and RSS financial eligibility upon the receipt of the ODM 07120 or electronic equivalent.

(6) For an individual who is receiving medicaid, upon the receipt of ODM 07120 or electronic equivalent, determine if the individual meets the RSS financial eligibility criteria. The CDJFS must notify OhioMHAS of the results of the RSS and medicaid eligibility determination.

(7) Not delay the determination of eligibility for other assistance programs when RSS eligibility is still pending.

(8) Not treat the level of care determination for RSS eligibility as evidence that the limiting physical factor requirement for medicaid eligibility as defined in rule 5160:1-3-02 of the Administrative Code has been met.

(9) If RSS income or resource eligibility is not met in accordance with Chapter 5160:1-3 of the Administrative Code, the CDJFS shall deny the RSS application. The denial notice shall be sent to the individual and authorized representative, or legal guardian, if one has been indicated on the application. A copy of the denial notice shall also be issued to OhioMHAS.

(10) Inform OhioMHAS of any change in the individual or couple's medicaid and/or RSS financial eligibility.

(11) Terminate the individual and/or couple from the RSS program, if the CDJFS is notified by OhioMHAS that the individual no longer meets the non-financial eligibility requirements or if the CDJFS determines that the individual no longer meets the financial eligibility requirements for the RSS program.

(12) Confirm in the case record that the individual has received an appropriate level of care determination for the RSS program, document that OhioMHAS has confirmed that the individual is residing in an appropriate RSS living arrangement, and document the approved RSS payment amount.

(J) Individual responsibilities.

(1) The individual shall cooperate with the CDJFS in order to determine financial eligibility for RSS.

(2) The individual shall cooperate with OhioMHAS in order to determine non-financial eligibility for RSS.

(3) The individual is responsible for reporting changes within ten days to the CDJFS in accordance with rule 5160:1-2-08 of the Administrative Code.

Replaces: 5160:1-5-01

Effective: 8/1/2016
Five Year Review (FYR) Dates: 08/01/2021
Promulgated Under: 111.15
Statutory Authority: 5163.02
Rule Amplifies: 5162.03, 5163.02, 5119.41
Prior Effective Dates: 7/15/82 (Emer.), 12/1/82, 7/1/83 (temp.), 9/24/83, 9/1/84, 1/1/89 (Emer.), 3/6/89, 4/1/89, 10/1/90, 9/12/91 (Emer.), 12/2/91, 11/1/93 (Emer.), 1/30/94, 5/1/94 (Emer.), 7/24/94, 7/1/95 (Emer.), 9/24/95, 4/1/96, 10/1/02, 7/1/11 (Emer.), 9/29/11, 1/1/2016

5160:1-5-02 Medicaid: breast and cervical cancer project (BCCP).

(A) This rule describes breast and cervical cancer project medicaid.

(B) The rules in Chapter 5160:1-5 of the Administrative Code set forth the eligibility requirements for participation in the breast and cervical cancer project. The Breast and Cervical Cancer Prevention and Treatment Act of 2000 (BCCPTA), in accordance with Pub. L. No. 106-354 and 42 U.S.C. 1396 a(a)(10)(A)(ii) (as in effect on September 1, 2014), authorizes an optional category of medicaid to provide full medicaid benefits to certain individuals who need treatment for breast or cervical cancer, breast or cervical pre-cancerous conditions, and/or breast or cervical early stage cancer. The goals of the BCCPTA are as follows:

(1) To improve access to needed breast and cervical cancer treatment for uninsured individuals identified under the national breast and cervical cancer early detection program as needing such treatment;

(2) To facilitate the prompt enrollment in medicaid and immediate access to services for individuals who are in need of treatment for breast or cervical cancer;

(3) To ensure that needed treatment begins as early as possible; and

(4) To coordinate activities between medicaid and public health agencies, including but not limited to application procedures and case management.

Replaces: 5160:1-5-01

Effective: 3/23/2015
Five Year Review (FYR) Dates: 03/23/2020
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5160.02, 5163.02
Prior Effective Dates: 7/1/02

5160:1-5-02.1 Medicaid: breast and cervical cancer project (BCCP) definitions.

(A) This rule contains definitions generally used for BCCP.

(B) Definitions.

(1) "Breast and Cervical Cancer Project (BCCP) medicaid" means the category of medicaid for qualified individuals in need of treatment for breast or cervical cancer, including pre-cancerous conditions and early stage cancer. BCCP medicaid is administered by the Ohio department of medicaid (ODM) in coordination with the Ohio department of health (ODH).

(2) "Breast or cervical cancer diagnosis", for the purpose of BCCP medicaid, means that a treating health professional has made a general determination that breast or cervical cancer(s) or pre-cancerous condition(s) exists. For the purposes of BCCP medicaid, breast or cervical cancer diagnosis does not require the determination of the specific stage or grade of cancer or pre-cancerous conditions.

(a) "Breast or cervical cancer diagnosis" includes metastasized cancer known or presumed by a treating health professional as a complication of breast or cervical cancer.

(b) "Date of diagnosis" is the date of the screening or diagnostic service which the treating health professional utilized to determine the individual's breast or cervical cancer diagnosis.

(c) "Pre-cancerous" means a condition, which, if left untreated is known or presumed by a treating health professional to develop into cancer.

(3) "Centers for Disease Control and Prevention (CDC) Title XV grantee" means an entity receiving funds under a cooperative agreement with CDC to support activities related to the national breast and cervical cancer early detection program.

(4) "Individual", for the purpose of BCCP medicaid, means men or women in need of or receiving treatment for breast or cervical cancer, breast or cervical pre-cancerous conditions, and/or breast or cervical early stage cancer or eligible for BCCP medicaid.

(5) "The National Breast and Cervical Cancer Early Detection Program (NBCCEDP)" means the program of the CDC established under Title XV of the Public Health Service Act.

(6) "The Ohio Department of Health Breast and Cervical Cancer Project (ODH BCCP)" means NBCCEDP funded by the CDC and administered by the Ohio department of health (ODH).

(a) "ODH BCCP breast and cervical cancer screening provider" means an entity which has entered into a written agreement with the ODH BCCP to provide specified breast and cervical cancer screening and diagnostic services for ODH BCCP enrollees.

(b) "ODH BCCP designated local agency or subgrantee" means an entity which has received a grant from ODH to implement specified activities of the ODH BCCP.

(c) "ODH BCCP enrollee" means an individual determined by ODH BCCP, or its designated local agencies or subgrantees, to meet the eligibility requirements (e.g., age and income) for participation in the ODH BCCP.

(d) "ODH BCCP regional case manager" means an individual who determines an individual's eligibility for BCCP, enrolls individuals, schedules services with health care providers, and provides case management to individuals.

(7) "Screened for breast or cervical cancer under NBCCEDP" means that a breast or cervical cancer screening was provided, all or in part, by CDC Title XV funds.

(a) For the purposes of BCCP medicaid, breast or cervical cancer screening includes diagnostic test(s) following a breast or cervical cancer screen.

(b) For the purposes of BCCP medicaid, case management services provided by a CDC Title XV grantee are not considered breast or cervical cancer screening.

(8) "Treatment" means the provision of medical services to control, minimize, or eliminate cancer or pre-cancerous cells of the breast or cervix. "Treatment" includes the provision of hormonal therapies to prevent recurrence of cancer following breast cancer surgery, radiation, and/or chemotherapy. Monitoring services alone (e.g., Papanicolaou smears, pelvic examinations, clinical breast examinations, mammograms) for recurrence or new primary cancers are not considered treatment.

(a) "Needs treatment" means that according to a written certification by the individual's treating health professional, which is documented by the ODH BCCP, a breast or cervical cancer screening indicates that the individual is in need of treatment for breast or cervical cancer. Individuals who are determined to require only monitoring services (e.g., Papanicolaou smears, pelvic examinations, clinical breast examinations, mammograms) are not considered to need treatment.

(b) "No longer receives treatment for breast or cervical cancer" means:

(i) The individual's course of treatment of breast or cervical cancer is completed, or

(ii) The individual chooses to delay or decline available treatment options.

(c) "Treating health professional" means an individual licensed to provide breast or cervical cancer diagnosis and/or treatment services.

(d) "Treatment period" means the period of time, according to a written certification by the individual's treating health professional, needed for the completion of treatment of the individual's breast or cervical cancer or pre-cancerous condition. A treatment period lasting more than twelve months from initial eligibility requires both a review of continuing medicaid eligibility and verification of need for continued treatment.

(9) "Uninsured" means not having creditable coverage for health care services.

(a) For the purposes of determining eligibility under BCCP medicaid, the following are considered creditable coverage unless one of the exceptions in paragraph (B)(8)(b) of this rule is applicable:

(i) Health insurance benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care) under any hospital or medical service policy or certificate, hospital or medical service plan contract;

(ii) Health maintenance organization contract offered by a health insurance issuer;

(iii) Medicare, parts A and B; and,

(iv) Medicaid.

(b) For the purposes of determining eligibility under BCCP medicaid, creditable coverage does not include:

(i) Limited scope coverage such as those which only cover dental, vision, or long term care;

(ii) Coverage for only a specified disease or illness;

(iii) Coverage which excludes treatment for breast or cervical cancer, including situations whereby a period of exclusion has been applied, such as for a pre-existing condition or the individual has exhausted the health insurance plan's covered benefits;

(iv) Delayed spenddown eligibility under the spenddown process provided in rule 5160:1-3-04.1 of the Administrative Code;

(v) Medicare part A only or medicare part B only.

Replaces: 5160:1-5-02

Effective: 3/23/2015
Five Year Review (FYR) Dates: 03/23/2020
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5160.02, 5163.02
Prior Effective Dates: 7/1/02

5160:1-5-02.2 Medicaid: breast and cervical cancer project (BCCP): eligibility requirements.

(A) This rule describes the eligibility criteria for BCCP medicaid.

(B) An individual shall meet all of the following criteria to be eligible for BCCP medicaid:

(1) Be screened for breast or cervical cancer under the national breast and cervical cancer early detection program (NBCCEDP).

(a) An individual is not required to obtain screening for both breast and cervical cancer as a condition of eligibility for participation in the NBCCEDCP.

(b) Individuals screened for breast or cervical cancer under the NBCCEDP in a state other than Ohio must be determined eligible for the ODH BCCP and must utilize the ODH BCCP case management services and Ohio 's BCCP medicaid application process as outlined in rule 5160:1-5-02.4 of the Administrative Code.

(2) Be uninsured as defined in rule 5160:1-5-02.1 of the Administrative Code.

(3) Must not meet the eligibility criteria of any other medicaid program.

(4) Be under sixty-five years of age.

(5) Meet all other general nonfinancial and nonresource eligibility requirements applicable to medicaid applicants described in Chapters 5160:1-1, 5160:1-2, 5160:1-3, 5160:1-4, 5160:1-5, and 5160:1-6 of the Administrative Code.

(C) There are no income or resource limitations for BCCP medicaid.

(D) The CDC NBCCEDP funded screening shall indicate to a treating health professional that the individual needs treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(E) The Ohio department of health (ODH) or its designated local agencies or subgrantees shall:

(1) Determine the individual eligible for the ODH BCCP.

(2) Screen for all other medicaid programs before determining the individual eligible for ODH BCCP.

(F) The Ohio department of medicaid (ODM) shall:

(1) Screen all BCCP medicaid applicants for potential eligibility in other medicaid programs as described in rule 5160:1-5-02.4 of the Administrative Code.

(2) Require BCCP medicaid applicants to provide information regarding income and/or resources to screen the applicant for potential eligibility in other medicaid programs.

(G) Individuals not meeting citizenship or immigration status eligibility requirements may be eligible for coverage for an emergency medical condition as described in rule 5160:1-1-91 of the Administrative Code.

Replaces: 5160:1-5-03

Effective: 3/23/2015
Five Year Review (FYR) Dates: 03/23/2020
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5160.02, 5163.02
Prior Effective Dates: 7/1/02

5160:1-5-02.3 Medicaid: breast and cervical cancer project (BCCP) eligibility period.

(A) This rule describes the eligibility period for breast and cervical cancer project medicaid.

(B) Effective date of BCCP medicaid.

(1) Eligibility for BCCP medicaid is effective the first day of the month that the Ohio department of medicaid (ODM) receives an application for this medicaid category and the applicant meets all relevant eligibility requirements described in rule 5160:1-5-02.2 of the Administrative Code.

(2) BCCP medicaid shall not cover an expense for a medical service incurred outside the eligibility period unless the individual is eligible for retroactive eligibility described in paragraph (D)(3) of this rule.

(3) The first month of BCCP medicaid coverage may be a partial month of coverage.

(C) BCCP medicaid shall be terminated:

(1) If the individual no longer meets one or more of the eligibility criteria for BCCP medicaid identified in rule 5160:1-5-02.2 of the Administrative Code.

(2) If a finding is made that the individual was determined eligible for Ohio department of health (ODH) BCCP when such determination was made in error and ODH BCCP eligibility did not exist.

(3) If a finding is made that the individual was not screened for breast or cervical cancer under NBCCEDP.

(4) If the individual no longer receives treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer. "Treatment" and "no longer receives treatment of breast or cervical cancer" are defined in rule 5160:1-5-02.1 of the Administrative Code.

(5) If the treatment period has ended and required redetermination documents with verification of continued need for treatment has not been received by ODM.

(a) ODM may presume that an individual is receiving treatment for the duration of the treatment period.

(b) A treatment period lasting more than twelve months from the beginning month of BCCP eligibility requires the ODM to perform a review of the individual's continuing medicaid eligibility, in accordance with rule 5160:1-5-02.4 of the Administrative Code.

(6) If the individual obtains creditable health coverage as defined in rule 5160:1-5-02.1 of the Administrative Code.

(7) If the individual reaches sixty-five years of age.

(8) If the individual meets eligibility criteria of any other category of medicaid, except as described in paragraph (B)(8)(b) of rule 5160:1-5-02.1 of the Administrative Code. If the individual is determined eligible for any other category of medicaid, the last day of BCCP medicaid coverage will be the last day of the month prior to the month the new category of medicaid begins.

(9) If the individual fails to cooperate in the eligibility determination process, including the determination of eligibility for other categories of medicaid.

(a) To facilitate immediate access to services for individuals who are in need of treatment for breast or cervical cancer, BCCP medicaid coverage will be allowed for a period of time while an eligibility determination for other categories of medicaid is conducted.

(b) If the individual fails to cooperate in the determination of eligibility for other categories of medicaid as required, the last day of BCCP medicaid coverage will be the last day of the month following the month in which eligibility for BCCP medicaid coverage was approved, in accordance with paragraph (C)(9)(a) of this rule.

(10) If the individual no longer meets other non-financial and non-resource eligibility requirements applicable to medicaid as described in pparagraph (B)(6) of rule 5160:1-5-02.2 of the Administrative Code.

(D) Ohio department of medicaid (ODM) responsibilities. ODM shall:

(1) Not provide BCCP medicaid coverage, including retroactive coverage, for any period of time preceding the individual's fortieth birthday or following the individual's sixty-fifth birthday.

(2) Not provide BCCP medicaid coverage, including retroactive coverage, for any period of time preceding the date of diagnosis of breast or cervical cancer, pre-cancerous conditions, or early stage cancer. "Date of diagnosis" is defined in rule 5160:1-5-02.1 of the Administrative Code.

(3) Extend eligibility for BCCP medicaid retroactively to the third month prior to the month of application if the individual met all relevant eligibility requirements described in rule 5160:1-5-02.2 of the Administrative Code for each of the three months in which retroactive coverage is sought

Replaces: 5160:1-5-04

Effective: 3/23/2015
Five Year Review (FYR) Dates: 03/23/2020
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5160.02, 5163.02
Prior Effective Dates: 7/1/02

5160:1-5-02.4 Medicaid: breast and cervical cancer project (BCCP): application and redetermination process.

(A) This rule describes the application and redetermination process for the breast and cervical cancer project (BCCP).

(B) The BCCP medicaid application and redetermination process shall:

(1) Be coordinated between Ohio department of medicaid (ODM), Ohio department of health (ODH) BCCP, and ODH BCCP designated local agencies and/or subgrantees,

(2) Be coordinated with ODH BCCP case management services, and

(3) Support the goals of the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (BCCPTA), identified in rule 5160:1-5-02 of the Administrative Code.

(C) ODH BCCP and its designated local agencies or subgrantee responsibilities. The ODH BCCP and its designated local agencies or subgrantee shall:

(1) Provide the ODM 07161 "Ohio Breast and Cervical Cancer Project (BCCP) Medicaid Application" (rev. 7/2014) to ODH BCCP enrollees screened for breast or cervical cancer under the centers for disease control and prevention's (CDC) national breast and cervical cancer early detection program (NBCCEDP) and referred for breast or cervical cancer diagnostic evaluation.

(2) Provide the ODM 07161 to ODH BCCP enrollees screened for breast or cervical cancer under the CDC NBCCEDP who are receiving treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(3) Notify in writing ODH BCCP enrollees described in paragraphs (C)(1) and(C)(2) of this rule to return the completed ODM 07161 to the designated ODH BCCP regional case manager.

(D) ODH BCCP regional case manager responsibilities.

(1) The application process. The ODH BCCP regional case manager shall:

(a) Provide to ODM the completed ODM 07161 within five business days of receipt of the diagnostic information if:

(i) The ODH BCCP enrollee has submited the ODM 07161; and

(ii) The ODH BCCP screening provider notifies the designated ODH BCCP regional case manager that, as a result of the NBCCEDP funded screening, a treating health professional has determined the ODH BCCP enrollee needs treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(b) Notify the ODH BCCP enrollee in writing within five business days of the receipt of the diagnostic information, that the ODM 07161 must be submitted to the designated ODH BCCP regional manager if:

(i) The enrollee has not submitted the ODM 07161; and

(ii) The ODH BCCP screening provider notifies the designated ODH BCCP regional case manager that, as a result of the NBCCEDP funded screening, a treating health professional has determined the ODH BCCP enrollee needs treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(c) Notify the ODH BCCP enrollee in writing within five business days that the ODM 07161 will not be submitted to ODM if:

(i) The ODH BCCP enrollee submits the ODM 07161; and

(ii) The diagnostic results indicate that the ODH BCCP enrollee does not need treatment for either breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(2) The redetermination process. The ODH BCCP regional case manager shall:

(a) Provide to ODM the completed ODM 07160 "Healthcare Provider's Revision of Treatment Plan" (7/2014) and ODM 07161 within five business days of receipt of both documents and notification from the treating health professional if:

(i) The individual submitted the ODM 07160 and ODM 07161; and

(ii) The treating health professional notifies the designated ODH BCCP regional case manager that the individual has been found to need continued treatment for either breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(b) Notify the individual in writing within five business days of receipt of the diagnostic information, that the ODM 07160 and ODM 07161 must be submitted to the designated ODH BCCP case manager for continued BCCP medicaid eligibility if:

(i) The individual has not submitted the ODM 07160 and ODM 07161; and

(ii) The treating health professional notifies the designated ODH BCCP regional case manager that the individual has been found to need continued treatment for either breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(c) Notify the individual in writing within five business days that the ODM 07160 and ODM 07161 will not be submitted to ODM if:

(i) The individual submitted the ODM 07160 and ODM 07161; and

(ii) The treating health professional notifies the designated ODH BCCP case manager the individual has been found to not need continued treatment for either breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(E) ODM responsibilies. ODM shall:

(1) Make available to the ODH BCCP and its designated local agencies or subgrantees the ODM 07161 and the ODM 07160.

(2) Be responsible for all determinations of BCCP medicaid eligibility, including retroactive eligibility.

(3) Use available sources of information in the eligibility determination including:

(a) Information contained in the ODM 07160 and ODM 07161; and

(b) Information in the case record to determine if the individual is currently enrolled in medicaid or has pending medicaid application.

(4) Use the eligibility criteria set forth in rules 5160:1-5-02.2 and 5160:1-5- 02.3 of the Administrative Code.

(5) Complete all determinations of eligibility within forty-five days of receipt of a completed ODM 07161.

(a) A delay in the determination of redetermination shall not be a basis for granting eligibility; or

(b) An application pending beyond forty-five days shall not be the sole basis for denial.

(6) Redetermine BCCP medicaid eligibility either:

(a) Prior to the completion of the lesser of:

(i) The individual's treatment period; or

(ii) Twelve months continuous eligibility in BCCP medicaid.

(b) When ODM receives an ODM 07160 indicating a change in the individual's circumstances, including completion of treatment prior to the original determined treatment period.

(7) Provide written notice to the BCCP medicaid recipient:

(a) That information is required for the determination of BCCP medicaid eligibility, and

(b) To return required completed redetermination materials to the assigned ODH BCCP regional case manager.

(F) Individual responsibilities. The individual shall:

(1) Submit a completed ODM 07160 (if applicable) and ODM 07161 to the designated ODH BCCP regional case manager.

(G) BCCP medicaid is terminated when the individual:

(1) Fails to submit the ODM 07160 and ODM 07161 by the required deadline, or

(2) No longer meets the eligibility criteria for continued BCCP medicaid and is ineligible for any other medicaid program.

(H) An individual may apply for a new period of BCCP medicaid eligibility after BCCP medicaid termination.

(1) A period of BCCP medicaid eligibility shall begin each time an individual:

(a) Is screened for breast or cervical cancer under the CDC NBCCEDP, and

(b) Is found, as a result of the CDC NBCCEDP screening, to need treatment of breast or cervical cancer, pre-cancerous condition, or early stage cancer, and

(c) Submits a completed ODM 07161 in accordance with paragraph (F) of this rule, and

(d) Is determined by ODM to meet all eligibility criteria for BCCP medicaid as described in rule 5160:1-5-02.2 of the Administrative Code.

(2) Individuals who have completed a treatment period, have had their BCCP medicaid eligibility terminated, and subsequently have been found to have new, recurrent, or metasticized breast or cervical cancer, pre-cancerous condition, or early stage cancer shall meet the BCCP medicaid eligibility requirements defined in rule 5160:1-5-02.2 of the Administrative Code to be determined eligible for an additional period of BCCP medicaid coverage.

(3) Individuals who have not completed their treatment period, have had their BCCP medicaid eligibility terminated, and have been found to have new, recurrent, or metasticized breast or cervical cancer:

(a) Do not need to be recertified as eligible for the ODH BCCP to reestablish BCCP medicaid eligibility; and

(b) Shall submit a new ODM 07161 to reestablish BCCP medicaid eligibility.

(I) Screening for potential eligibility for other medicaid programs by ODM at application and redetermination.

(1) If information on the ODM 07161 indicates the individual is not potentially eligible for any other medicaid program, income and asset information is not needed and ODM shall notify the individual in writing of ineligibility for other medicaid programs.

(2) If information on the ODM 07161 indicates the individual is potentially eligible for any other medicaid program, the individual shall provide income and asset information to screen for eligibility for other medicaid programs.

(a) If income or asset information indicates the individual does not appear eligible for any other medicaid program, no additional income or asset information is needed and ODM shall notifiy the individual in writing of ineligibility for other medicaid programs.

(b) If income or asset information indicates the individual appears eligible for any other medicaid programs, the individual shall be:

(i) Notified of potential eligibility;

(ii) Given instructions for submission of additional information required to make a determination of eligibility for other medicaid programs.

(iii) Notified by ODM in writing to complete and submit additional information required to the CDJFS in the individual's county of residence.

(a) If the CDJFS determines the applicant eligible for any other category of medicaid, ODM will terminate BCCP medicaid and transfer the case information to the CDJFS in accordance with paragraph (C)(8) of rule 5160:1-5-02.3 of the Administrative Code.

(b) If the CDJFS determines the individual ineligible for any other medicaid program, the CDJFS will notify ODM and ODM will maintain the BCCP medicaid case.

Replaces: 5160:1-5-05

Effective: 3/23/2015
Five Year Review (FYR) Dates: 03/23/2020
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5160.02, 5163.02
Prior Effective Dates: 7/1/02, 10/1/06

5160:1-5-03 Medicaid: medicaid buy-in for workers with disabilities (MBIWD).

(A) This rule governs the eligibility requirements for two medicaid programs authorized under sections 1902(a)(10)(A)(ii)(XV) and (XVI) of the Social Security Act (as in effect on September 1, 2014). Medicaid buy-in for workers with disabilities (MBIWD) enables certain individuals to increase their income and resources without the risk of losing health care coverage.

(B) Definitions.

(1) "Basic covered group" means the medicaid covered group of individuals meeting all criteria in paragraph (C)(1) of this rule.

(2) "Blind work expense (BWE)" has the same meaning as in rule 5160:1-3-03.11 of the Administrative Code.

(3) "Countable income", for the purpose of this rule, means income less exclusions.

(4) "Countable resources", for the purpose of this rule, means those resources remaining after all exclusions have been applied.

(5) "Earned income", for the purpose of this rule, means salary, wages, royalties, honoraria, or "net earnings from self-employment" as defined in rule 5160:1-2-01.9 of the Administrative Code.

(6) "Family", for the purpose of this rule, means an individual, the individual's spouse, and dependent children living in the household of the individual. If an individual is younger than eighteen years of age, "family" also means the individual's parents.

(7) "Impairment-related work expense (IRWE)" as defined in 20 C.F.R. 404.1576 (as in effect on September 1, 2014).

(8) "Income", for the purpose of this rule, means gross earned income and gross unearned income.

(9) "Individual", for the purpose of this rule, means the applicant for or participant in MBIWD.

(10) "Individual with a medically improved disability" means an individual who is participating in the MBIWD basic covered group at the time of a regularly scheduled continuing disability review, but who no longer meets the disability criterion as defined in paragraph (C)(1)(c) of this rule.

(11) "Medicaid buy-in for workers with disabilities (MBIWD)" means the component of the medicaid program established under sections 5163.09 to 5163.099 of the Revised Code and includes the basic covered group and the medically improved covered group.

(12) "Medical and remedial expense (MRE)" means an incurred expense for care, services, or goods prescribed or provided by a licensed medical practitioner within the scope of practice as defined under state law. This expense is the responsibility of the individual, and cannot be reimbursed by any other source, such as medicaid, private insurance, or an employer.

(13) "Medical insurance premiums" has the same meaning as in rule 5160:1-3-04.1 of the Administrative Code.

(14) "Medically improved covered group" means the individuals meeting all criteria in paragraph (C)(2) of this rule.

(15) "Premium" means a periodic payment required under section 5163.094 of the Revised Code and described in paragraph (E) of this rule.

(16) "Resource" means cash, personal property, and real property an individual has an ownership interest in and legal ability to access in order to convert to cash.

(17) "Resource eligibility limit for MBIWD", means countable resources limited to the amount specified under section 5163.092 of the Revised Code.

(18) "Social security disability insurance (SSDI)" means the program established under Title II of the Social Security Act (as in effect on September 1, 2014).

(19) "Spouse" means a person legally married under Ohio law.

(20) "Supplemental security income program (SSI)" means the program established under Title XVI of the Social Security Act (as in effect on September 1, 2014).

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

(22) "Work" or "working", for the purpose of this rule, means full or part-time employment or self-employment from which state or federal income and payroll taxes are paid or withheld.

(C) Eligibility criteria.

(1) To be eligible for the MBIWD basic covered group an individual must:

(a) Meet the citizenship requirements outlined in rule 5160:1-1-58.2 of the Administrative Code;

(b) Be a resident of Ohio as set forth in rule 5160:1-1-58 of the Administrative Code;

(c) Meet the definition of disability used by the social security administration (SSA), except that employment, earnings, and substantial gainful activity must not be considered when determining whether the individual meets the disability criterion for MBIWD. An individual may be eligible for MBIWD regardless of whether the individual is receiving SSI or SSDI;

(d) Be at least sixteen years of age but younger than sixty-five years of age;

(e) Meet the financial eligibility requirements described in paragraph (D) of this rule;

(f) Pay the premium, as calculated in paragraph (E) of this rule; and

(g) Be working.

(2) To be eligible for the MBIWD medically improved covered group an individual must:

(a) Have participated in the MBIWD basic covered group as defined in paragraph (C)(1) of this rule the previous calendar month and continue to meet all eligibility criteria described in paragraph (C) of this rule except that the individual no longer meets the disability criterion defined in paragraph (C)(1)(c) of this rule; and

(b) Work at least forty hours per month earning at least state or federal minimum wage, whichever is lower.

(3) An individual participating in MBIWD with a medically improved disability, whose medical condition is determined, at the time of a regularly scheduled continuing disability review, to have regressed may be reevaluated for the MBIWD basic covered group in accordance with paragraph (C)(1) of this rule.

(4) If the individual is eligible for MBIWD under the basic or medically improved group and ceases to work, the individual may continue to participate in MBIWD for up to six months beginning the first day of the month after the month the individual is no longer working when:

(a) The individual intends to return to work or look for a new job; and

(b) The individual continues to pay MBIWD premiums, if applicable; and

(c) The individual continues to meet all other eligibility requirements for MBIWD.

(D) Financial eligibility.

(1) For the purpose of determining whether an individual is income eligible for MBIWD, the administrative agency must compare the individual's countable income to the two hundred fifty per cent federal poverty level (FPL) for one person. Only the individual's income is considered when determining eligibility for MBIWD.

(a) From the individual's income, apply exclusions in accordance with rule 5160:1-3-03.11 of the Administrative Code, but earned income exclusions must be applied in the following order:

(i) Earned income tax credits and child tax credits;

(ii) Infrequent or irregular income;

(iii) Earned income of student children;

(iv) Any portion of the twenty dollar monthly general income exclusion which has not been excluded from unearned income;

(v) Sixty-five dollars of earned income;

(vi) Impairment-related work expenses;

(vii) One-half of remaining earned income;

(viii) Blind work expenses; and then

(ix) Any earned income used to fulfill an approved plan to achieve self-support (PASS).

(b) If the amount determined in paragraph (D)(1)(a) of this rule is no more than two hundred fifty per cent of the FPL, the individual meets the income eligibility requirement for MBIWD.

(c) If the amount determined in paragraph (D)(1)(a) of this rule exceeds two hundred fifty per cent of the FPL:

(i) An additional annual amount up to twenty thousand dollars of earned income shall be excluded.

(ii) The twenty thousand dollar earned income exclusion may be applied wholly or in part in any month to reduce the individual's countable income below two hundred fifty per cent of the FPL. This exclusion begins the first month the individual would otherwise be eligible for MBIWD and continues within the year until the twenty thousand dollars is exhausted.

(2) For the purpose of determining whether an individual meets the resource eligibility requirement for MBIWD, an individual's countable resources must not exceed the resource eligibility limit for MBIWD as defined in paragraph (B) of this rule.

(a) Only the individual's resources are considered when determining resource eligibility for MBIWD. In the case of resources which are jointly owned, the administrative agency must consider the total amount of the resource available to the individual in accordance with rule 5160:1-3-05.1 of the Administrative Code.

(b) For the purposes of determining resource eligibility for MBIWD, resources in accordance with rule 5160:1-3-05.14 of the Administrative Code are excluded.

(c) Retirement and income supplementing accounts (RISAs) are evaluated in accordance with rule 5160:1-3-03.10 of the Administrative Code.

(E) Premium calculation. An individual eligible for MBIWD whose individual income exceeds one hundred fifty per cent of the FPL for one person must pay a premium determined as follows (rounded down to the nearest dollar at each step):

(1) From the gross annual family income at the time of application and subsequent redeterminations for MBIWD, the administrative agency shall subtract one hundred fifty per cent of the FPL for the family size;

(2) From the amount determined in paragraph (E)(1) of this rule, the administrative agency shall subtract the individual's IRWE, BWE, and/or MRE;

(3) Multiply the amount determined in paragraph (E)(2) of this rule by ten per cent.If the family's income is less than four hundred fifty per cent of the FPL (applicable to the family size), the premium cannot exceed seven and one half per cent of the individual's income;

(4) From the amount determined in paragraph (E)(3) of this rule, the administrative agency must subtract the amount of medical insurance premiums, including medicare premiums, paid by the family; and

(5) Divide the amount determined in paragraph (E)(4) of this rule by twelve and round down to the nearest whole dollar. This is the individual's monthly premium.

(F) The individual's monthly premium obligation begins the month following the month MBIWD coverage is authorized, and is due and payable in full no later than the due date established by the administrative agency.

(1) Partial payments do not satisfy the eligibility criterion in paragraph (C)(1)(f) of this rule.

(2) Partial payments and payments in full received after the due date established by the administrative agency are applied to the most delinquent premium.

(3) An individual who fails to pay a premium in full for two consecutive months will be subject to eligibility termination for MBIWD in accordance with Chapter 5160:1-1 of the Administrative Code.

(4) An individual who loses eligibility for MBIWD due to non-payment of premiums and reapplies for MBIWD must:

(a) Meet all criteria in paragraph (C)(1) of this rule; and

(b) Pay all delinquent premiums for those months prior to MBIWD termination.

(5) Individuals who are eligible for retroactive coverage in accordance with rule 5160:1-1-51oftheAdministrative Code are not required to pay a monthly premium for the months of retroactive coverage.

(G) Receipt of long-term care services in a long-term care facility, under a home and community-based services (HCBS) waiver program, or under the program of all-inclusive care for the elderly (PACE) is not a cause for termination or denial of an individual's eligibility for MBIWD.

(H) Related long term care rules:

(1) Individuals eligible for MBIWD are not subject to a patient liability as described in rule 5160:1-3-04.3 or 5160:1-3- 04.4 of the Administrative Code.

(2) When an individual eligible for MBIWD, or the individual's spouse, becomes institutionalized, the resource assessment and transfer of asset provisions of rules 5160:1-3-06.3 and 5160:1-3- 07.2 of the Administrative Code apply.

(I) Individuals eligible for MBIWD are not subject to a spenddown as described in rule 5160:1-3-04.1 of the Administrative Code.

(J) Individual responsibilities. The individual shall:

(1) Provide the information necessary to establish eligibility, cooperate in the verification process, and report changes in accordance with rule 5160:1-1-55 of the Administrative Code.

(2) Pay premiums determined by the administrative agency in accordance with this rule.

(K) Administrative agency responsibilies. The administrative agency shall:

(1) Process the application for MBIWD in accordance with Chapter 5160:1-1 of the Administrative Code.

(2) Determine eligibility for MBIWD as described in this rule.

(3) Determine the premium for MBIWD as identified in paragraph (E) of this rule, and redetermine this premium during the individual's annual redetermination or whenever the individual reports a decrease in income.

(4) Verify disability in accordance with paragraph (C)(1)(c) of this rule.

(5) Explore eligibility for qualified medicare beneficiary (QMB) and specified low income medicare beneficiary (SLMB) programs in accordance with Chapter 5160:1-3 of the Administrative Code. MBIWD individuals are not eligible for qualified individual (QI-1) or qualified working disabled individual (QWDI) medicare premium assistance programs.

Replaces: 5160:1-5-30

Effective: 3/23/2015
Five Year Review (FYR) Dates: 03/23/2020
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5160.02, 5163.02, 5163.091, 5163.092, 5163.093, 5163.094, 5163.095, 5163.096, 5163.097, 5163.098
Prior Effective Dates: 4/1/08

5160:1-5-04 [Rescinded] Breast and cervical cancer project (BCCP) medicaid: eligibility period.

Effective: 3/23/2015
Five Year Review (FYR) Dates: 12/12/2014
Promulgated Under: 111.15
Statutory Authority: 5111.0110
Rule Amplifies: 5111.0110
Prior Effective Dates: None

5160:1-5-05 Medicaid: refugee medical assistance (RMA).

(A) This rule describes a time-limited medical assistance program, funded through the office of refugee resettlement (ORR), that provides a medical screening through contracted refugee health screening providers, and other medical services. There is no resource limit for individuals described in this rule.

(B) Definitions.

(1) "Household income" is defined in rule 5160:1-1-61 of the Administrative Code.

(2) "Derivative T visa" means either a T-2, T-3, T-4, or T-5 visa issued to certain family members of victims of a severe form of trafficking who may be eligible for RMA benefits if the visa holder meets refugee program eligibility requirements.

(3) "Individual", for the purpose of this rule, means an applicant for or a recipient of RMA or refugee cash assistance (RCA) who is not a U.S. citizen and who meets one of the following definitions of immigration status under the Immigration and Nationality Act (INA) (as in effect on September 1, 2014), as verified by documentation issued by the U.S. department of state, U.S. department of homeland security, or U.S. department of justice:

(a) Paroled as a refugee or asylee under section 212(d)(5) of the INA (as in effect on September 1, 2014).

(b) Admitted to the U.S. as a refugee under section 207 of the INA (as in effect on September 1, 2014).

(c) Granted asylum under section 208 of the INA (as in effect on September 1, 2014).

(d) Cuban and Haitian entrants in accordance with requirements in 45 C.F.R.part 401 (as in effect on September 1, 2014).

(e) Certain Amerasians from Vietnam who are admitted to the U.S. as immigrants pursuant to section 584 of the Foreign Operations, Export Financing, and Related Programs Appropriations Act of 1988 (as contained in section 101(e) of Public Law 100-202 ) (as in effect on September 1, 2014), and amended by the 9th proviso under migration and refugee assistance in title II of the Foreign Operations, Export Financing, and Related Programs Appropriations Act, 1989, Public Law 100-461, as amended) (as in effect on September 1, 2014).

(f) Victims of a severe form of trafficking as identified in 22 U.S.C.7105(b)(1) (as in effect on September 1, 2014) and certain family members, as identified in the Trafficking Victims Protection Reauthorization Act of 2003 (TVPRA) ( Pub. L. No. 108-193 ) (as in effect September 1, 2014). Victims of a severe form of trafficking are awarded a certification letter from ORR and are potentially eligible for RMA as described in 28 C.F.R. 1100.33 (as in effect on September 1, 2014). Certain family members are awarded "Derivative T" visas and are potentially eligible for RMA.

(g) Admitted as an Afghan or Iraqi special immigrant under section 101(a)(27) of the INA (as in effect on September 1, 2014).

(4) "RMA need standard" means one hundred per cent of the federal poverty level (FPL) based on family size.

(C) Eligibility criteria.

(1) The individual shall be neither:

(a) Eligible for medicaid; nor

(b) A full-time student in an institution of higher education, except where such enrollment is approved by the state, or its designee, as part of an individual employability plan as described in rules to 5101:1-2- 40.5 of the Administrative Code.

(2) The individual meets the income requirements for RMA when:

(a) The individual's household income is no more than the RMA need standard, or

(b) The individual whose household income is more than the RMA need standard spends down household income to the RMA need standard, in accordance with the methods set forth in rule 5160:1-3-04.1 of the Administrative Code.

(3) Initial and ongoing eligibility for RMA is based on the applicant's income on the date of application.

(D) Eligibility period. An individual who meets the eligibility requirements of this rule may receive RMA for a time-limited period not to exceed eight months from the individual's date of entry or from the date status is granted, as listed on the individual's U.S. citizenship and immigration services' (USCIS) documentation.

(E) Individual responsibilities. The individual shall:

(1) Provide:

(a) USCIS documentation of alien status;

(b) The name of the resettlement agency, if any, that resettled the individual;

and

(c) The information necessary to establish eligibility, cooperate in the verification process, and report changes in accordance with rule 5160:1-1-58.2 of the Administrative Code.

(2) Spend down to the RMA need standard if the household income exceeds the RMA need standard; and

(3) Cooperate in providing verification of any third-party liability or coverage of medical expenses as defined in Chapter 5160:1-1-58 of the Administrative Code.

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

(1) Accept an application, or electronic equivalent, for medical assistance as an application for RMA;

(2) Not require an individual to apply for or receive RCA;

(3) Not require a face-to-face interview;

(4) Use actual countable family income for the month of application. Do not average income prospectively in determining income eligibility for RMA;

(5) Determine medicaid eligibility, as described in Chapters 5160:1-1 to 5160:1-5 of the Administrative Code, prior to determining eligibility for RMA;

(6) Call the trafficking verification line to confirm the validity of the certification letter or letter for children and to notify ORR of the benefits for which the individual has applied;

(7) Make eligible an individual who receives RCA and who meets the eligibility requirements of this rule;

(8) Obtain third-party liability information from an individual who has other health insurance; and

(9) Explore retroactive eligibility for RMA, as defined in Chapter 5160:1-1-51 of the Administrative Code. Retroactive eligibility cannot begin prior to the individual's date of entry or from the date status is granted.

Replaces: 5160:1-6-90

Effective: 3/23/2015
Five Year Review (FYR) Dates: 03/23/2020
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5160.02, 5163.02
Prior Effective Dates: 7/1/76, 12/31/77, 11/22/81, 10/21/82, 11/1/82, 2/9/84 (Temp.), 5/1/84, 7/1/84, 7/2/84, 10/1/84 (Emer.), 12/27/84, 1/1/85 (Emer.), 4/1/85, 8/1/86 (Emer.), 10/3/86, 7/1/88, 1/1/89 (Emer.), 4/1/89, 11/1/89, 1/1/90 (Emer.), 4/1/90, 10/1/91 (Emer.), 12/20/91, 4/1/92, 10/1/93 (Emer.), 12/21/92, 9/1/94, 10/1/95, 1/1/96, 5/1/97, 7/1/98, 7/1/00, 10/8/00, 10/1/02, 5/7/09

5160:1-5-06 Medicaid: alien emergency medical assistance (AEMA).

(A) This rule describes eligibility criteria for coverage of treatment of an emergency medical condition for certain individuals who do not meet the medicaid citizenship or satisfactory immigration status requirements described in rule 5160:1-2-11 or 5160:1-2-12 of the Administrative Code.

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

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

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

(b) Serious impairment to bodily functions; or

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

(2) Including labor and delivery, but

(3) Not including either:

(a) Routine prenatal or postpartum care, or

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

(C) Eligibility criteria. The individual must:

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

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

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

(a) Does not meet the medicaid citizenship or non-citizen requirements set forth in rules 5160:1-2-11 and 5160:1-2-12 of the Administrative Code. The individual is not required to verify the individual's:

(i) Social security number, or

(ii) Citizenship or immigration status.

(b) Is not required to apply for social security administration (SSA) benefits.If the individual is otherwise eligible for a category of medicaid that requires a disability determination, the administrative agency shall submit a disability determination packet to the disability determination area (DDA) in accordance with rule 5160:1-3-02.9 of the Administrative Code.

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

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

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

(a) Includes labor and delivery, but

(b) Does not include ongoing treatment.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Replaces: 5160:1-1-91

Effective: 8/1/2016
Five Year Review (FYR) Dates: 08/01/2021
Promulgated Under: 111.15
Statutory Authority: 5162.031, 5163.02
Rule Amplifies: 5163.02
Prior Effective Dates: 01/01/2014

5160:1-5-07 Medicaid: Specialized Recovery Services (SRS) program.

(A) This rule sets forth the eligibility criteria for a State plan home and community-based services (HCBS) benefit authorized under section 1915(i) of the Social Security Act (as in effect on October 1, 2015). Section 1915(i) of the Act allows states the flexibility to provide HCBS to individuals who require less than an institutional level of care (LOC) and who would, therefore, not be eligible for HCBS under the more restrictive criteria of section 1915(c) waivers. The Specialized Recovery Services (SRS) program provides targeted services to individuals with severe and persistent mental illness (SPMI) as described in Chapter 5160-43 of the Administrative Code. Eligibility for this program shall be determined for applications for medical assistance filed on or after the effective date of this rule.

(B) Eligibility for the SRS program State plan HCBS benefit. An individual must:

(1) Be at least twenty-one years of age; and

(2) Have been determined to meet the definition of disability used by the social security administration (SSA) for purposes of supplemental security income (SSI) or social security disability insurance (SSDI) benefits; and

(3) Be in receipt of SSI benefits authorized by the SSA under Title XVI of the Social Security Act (as in effect on October 1, 2015) or SSDI benefits authorized by the SSA under Title II of the Social Security Act (as in effect on October 1, 2015); and

(4) Meet the clinical diagnostic, needs assessment, and risk criteria described in rule 5160-43-02 of the Administrative Code; and

(5) Reside in a home and community-based setting consistent with the qualities identified in 42 C.F.R. 441.710 (as in effect on October 1, 2015); and

(6) Meet the financial and nonfinancial eligibility requirements of one of the following groups:

(a) Group one.

(i) Be in receipt of medicaid, as described in Chapters 5160:1-1 to 5160:1-5 of the Administrative Code; and

(ii) Have countable income that does not exceed one hundred fifty percent of the federal poverty level (FPL), as determined using the same rules used for determining the individual's medicaid eligibility.

(b) Group two.

(i) Meet the conditions of eligibility outlined in rule 5160:1-2-10 of the Administrative Code; and

(ii) Not be otherwise eligible for medicaid; and

(iii) For the purpose of determining whether an individual is income eligible for the SRS program, the administrative agency must compare the individual's countable income to one hundred fifty percent of the FPL, as determined in accordance with Chapter 5160:1-3 of the Administrative Code.

(a) If the individual's countable income exceeds one hundred fifty percent of the FPL, apply additional disregards in the following order:

(i) Twenty dollar personal needs disregard; then

(ii) Disregard income in the amount of the difference between one hundred fifty percent of the FPL for an individual and three hundred percent of the current supplemental security income (SSI) federal benefit rate (FBR) for an individual.

(b) If the amount determined in subparagraph (B)(6)(b)(iii) of this rule is no more than one hundred fifty percent of the FPL, the individual meets the income eligibility requirement for the SRS program.

(iv) There is no resource limit for individuals described in subparagraph (B)(6)(b) of this rule.

(C) There is no retroactive eligibility for the SRS program State plan HCBS benefit.Coverage under this rule cannot begin prior to the first day of the month in which all financial, nonfinancial, and programmatic criteria are met.

(D) An individual who is receiving the State plan HCBS benefit cannot be concurrently enrolled in another HCBS authority, such as a section 1915(c) waiver. Subject to the individual's choice, he or she will be enrolled in the HCBS authority best meeting the totality of his or her needs regardless of the order in which the individual applied for or became eligible for HCBS.

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

5160:1-5-20 Medicaid: alien emergency medical assistance (AEMA).

(A) Alien emergency medical assistance (AEMA) is a category of medicaid that provides coverage for the treatment of an emergency medical condition for certain individuals who do not meet the medicaid citizenship requirements outlined in rule 5101:1-38-02.3 of the Administrative Code.

(B) Definitions.

(1) "Administrative agency" is the county department of job and family services (CDJFS), Ohio department of job and family services (ODJFS) or other entity that determines eligibility for a medical assistance program.

(2) "Covered dates of service" is the term used by the county medical services (CMS) unit for the time period of the emergency medical condition episode.

(3) "Eligibility span" is the time period of eligibility within the covered dates of service.

(4) "Emergency medical condition" means after sudden onset, a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. An emergency medical condition does not include care and services related to either an organ transplant procedure or routine prenatal or postpartum care.

(5) "Emergency medical condition episode" is defined as the period of time that starts with the day on which the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part; and stops on the day on which the absence of immediate medical attention could no longer reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. The emergency medical condition episode includes labor and delivery, but does not include ongoing treatment.

(6) "Individual" is the applicant or recipient of a medical assistance program.

(7) "Non-qualified alien" as defined in rule 5101:1-38-02.3 of the Administrative Code.

(8) "Optional qualified alien" is an alien who has completed the five-year period of ineligibility for medicaid. Optional-qualified aliens are not eligible for medicaid in accordance with rule 5101:1-38-02.3 of the Administrative Code.

(9) "Qualified alien within the five-year period of ineligibility for medicaid", as outlined in rule 5101:1-38-02.3 of the Administrative Code.

(10) "Resident of Ohio" as defined in rule 5101:1-39-54 of the Administrative Code.

(C) Eligibility criteria.

(1) The individual must have received treatment for an emergency medical condition.

(2) The individual must submit an application for medical assistance. A new medical assistance application is required for each emergency medical assistance episode.

(3) The individual must be otherwise eligible for a category of medicaid. If the individual would be eligible for a category of medicaid that requires a disability determination, the administrative agency shall submit a CMS packet to the CMS unit in accordance with rule 5101:1-39-03 of the Administrative Code.

(4) The individual must be one of the following:

(a) Non-qualified alien;

(b) Optional qualified alien; or

(c) Qualified alien within the five-year period of ineligibility for medicaid.

(5) The individual must be a resident of Ohio.

(D) Exceptions to eligibility criteria.

(1) The individual is not required to meet the medicaid citizenship requirements in accordance with rule 5101:1-38-02.3 of the Administrative Code.

(2) If the individual would be eligible for a category of medicaid that requires a disability determination, the individual is not required to apply for social security administration (SSA) benefits.

(3) The individual is not required to participate in a face-to-face interview in accordance with rule 5101:1-38-01.2 of the Administrative Code.

(4) The individual is not subject to alien-sponsor deeming provisions.

(5) The individual is not required to provide verification of a social security number in accordance with rule 5101:1-38-02 of the Administrative Code.

(6) The individual is not required to provide verification of immigration/alien status.

(E) Administrative agency responsibilities.

(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) The administrative agency shall determine eligibility for AEMA as identified in paragraphs (C) and (D) of this rule.

(3) Upon request, the administrative agency shall assist the individual in obtaining medical documentation to support the AEMA claim. When assistance is requested, the administrative agency shall request from the medical provider, medical documentation to support the emergent nature of the AEMA claim including physician progress notes and discharge summary. The administrative agency shall then forward the medical documentation to the CMS unit.

(4) The administrative agency shall determine the eligibility span for labor and delivery and enter it into the electronic eligibility system in accordance with the following policy.

(a) The eligibility span begins on the date of admission for labor and includes:

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

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

(b) The time period from date of admission for labor until delivery shall not exceed two days or forty-eight hours.

(c) The eligibility span ends at midnight on the last day in which the forty-eight or ninety-six hour time-period following delivery falls. If the labor and delivery episode exceeds the timeframes as outlined in paragraph (E)(4), the administrative agency shall forward the medical documentation to the CMS unit for the determination of the covered dates of service.

(5) The administrative agency shall enter the eligibility span into the electronic eligibility system for the emergency medical condition episode within the covered dates of service as determined by the CMS unit.

(6) The administrative agency shall issue proper notice and hearing rights as outlined in division level designation 5101:6 of the Administrative Code.

(F) County medical services (CMS) unit responsibilities.

(1) The CMS unit shall make all emergency medical condition determinations, except for labor and delivery, as outlined in paragraph (E) of this rule.

(2) The CMS unit shall determine if the individual received treatment for an emergency medical condition.

(3) The CMS unit shall determine covered dates of service for the emergency medical condition episode.

(4) The CMS unit shall notify the administrative agency of the AEMA determination and the covered dates of service via the electronic eligibility system.

Eff 3-1-05
Replaces: 5101:1-42-02
Rule promulgated under: RC 111.15
Rule authorized by: RC 5111.01
Rule amplifies: RC 5111.01, 5111.012
Prior Effective Dates: 3-1-88 (Emer.), 5-15-88, 3-1-94 (Emer.), 4-18-94, 3-1-98 (Emer.), 5-1-98, 10-1-01 (Emer.), 12-29-01, 12-1-03, 12-1-04 (Emer.).
R.C. 119.032 review dates: 03/01/2010

5160:1-5-30 [Rescinded] Medicaid: medicaid buy-in for workers with disabilities (MBIWD).

Effective: 3/23/2015
Five Year Review (FYR) Dates: 12/12/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.708
Rule Amplifies: 5111.01, 5111.70 , 5111.701, 5111.702, 5111.703, 5111.704, 5111.705, 5111.706, 5111.707, 5111.708
Prior Effective Dates: .

5160:1-5-40 [Rescinded] Medicaid: covered group eligibility for family planning services.

Effective: 1/1/2016
Five Year Review (FYR) Dates: 10/16/2015
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02
Prior Effective Dates: 1/8/12