Chapter 5160:1-5 Medicaid Special Covered Groups

5160:1-5-01 Breast and cervical cancer project (BCCP) medicaid.

The rules in Chapter 5101:1-41 of the Administrative Code set forth the application and eligibility requirements for implementation of the federal Breast and Cervical Cancer Prevention and Treatment Act of 2000 (BCCPTA) ( Public Law 106-354, 42 U.S.C. 1396a ) in Ohio. The BCCPTA authorizes a new 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. Section 5111.0110 of the Revised Code authorizes this optional category of medicaid. The goals of the BCCPTA are as follows:

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

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

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

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

Eff 7-1-02
Rule promulgated under: RC 111.15
Rule authorized by: RC 5111.0110
Rule amplifies: RC 5111.0110
R.C. 119.032 review dates: 07/01/2007

5160:1-5-02 Breast and cervical cancer project (BCCP) medicaid: definitions.

(A) "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.

(B) "The National Breast and Cervical Cancer Early Detection Program (NBCCEDP)" means the program of the centers for disease control and prevention (CDC) established under Title XV of the Public Health Service Act.

(C) "The Ohio Department of Health (ODH) Breast and Cervical Cancer Project (BCCP)" means the national breast and cervical cancer early detection program (NBCCEDP) funded by the centers for disease control and prevention (CDC) and administered by the Ohio department of health (ODH).

(1) "ODH BCCP enrollee" means an individual determined by the 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.

(2) "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.

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

(D) "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 job and family services (ODJFS) in coordination with the ODH.

(E) "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)" means that a breast or cervical cancer screening was provided all or in part by CDC Title XV funds.

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

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

(F) For the purposes of BCCP medicaid, "breast or cervical cancer diagnosis" 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.

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

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

(3) "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.

(G) "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.

(1) "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 woman is in need of treatment for breast or cervical cancer. Woman who are determined to require only monitoring services (e.g., Papanicolaou smears, pelvic examinations, clinical breast examinations, mammograms) are not considered to need treatment.

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

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

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

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

(4) "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.

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

(1) For the purposes of determining eligibility under BCCP medicaid, the following are considered creditable coverage unless one of the exceptions in paragraph (H)(2) of this rule is applicable:

(a) 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;

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

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

(d) Medicaid.

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

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

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

(c) 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;

(d) Delayed spenddown eligibility under the spenddown process provided in rule 5110:1-39-10 of the Administrative Code;

(e) Disability assistance (DA) Medical coverage, including, for example, coverage obtained by an individual who is medication dependent, as provided in rule 5101:1-5-20 of the Administrative Code; or

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

Eff 7-1-02
Rule promulgated under: RC 111.15
Rule authorized by: RC 5111.0110
Rule amplifies: RC 5111.0110
R.C. 119.032 review dates: 07/01/2007

5160:1-5-03 Breast and cervical cancer project (BCCP) medicaid: eligibility requirements.

An individual must meet all of the following criteria to be eligible for BCCP medicaid:

(A) The Ohio department of health (ODH) or its designated local agencies or subgrantees must determine the individual eligible for the ODH breast and cervical cancer project (BCCP).

(B) The individual must be 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).

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

(2) Individuals screened for breast or cervical cancer under the CDC 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 5101:1-41-05 of the Administrative Code.

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

(D) The individual must be uninsured as defined in rule 5101:1-41-02 of the Administrative Code.

(E) The individual must not meet the eligibility criteria of any other category of medicaid.

(1) The ODJFS shall screen, as described in rule 5101:1-41-05 of the Administrative Code, all BCCP medicaid applicants for potential eligibility in other categories of medicaid.

(2) While there are no income or resource limitations for BCCP medicaid, ODJFS may require BCCP medicaid applicants to provide information regarding income and/or resources to screen the applicant for potential eligibility in other categories of medicaid.

(F) The individual must be under sixty-five years of age.

(G) The individual must meet all other general nonfinancial and nonresource eligibility requirements applicable to medicaid applicants (e.g., citizenship/immigration status, Ohio residency, etc.) as delineated in Chapters 5101:1-38, 5101:1-39, and 5101:1-40 of the Administrative Code

(1) Individuals not meeting citizenship or immigration status eligibility requirements may be eligible for coverage for an emergency medical condition as described in rule 5101:1-30-80 of the Administrative Code.

Eff 7-1-02
Rule promulgated under: RC 111.15
Rule authorized by: RC 5111.0110
Rule amplifies: RC 5111.0110
R.C. 119.032 review dates: 07/01/2007

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

(A) Ohio shall not provide eligibility or coverage for BCCP medicaid, including retroactive eligibility and coverage, for any reason, prior to July 1, 2002.

(B) Eligibility for BCCP medicaid is effective the month that the Ohio department of job and family services (ODJFS) receives an application for this medicaid category and the applicant meets all relevant eligibility requirements described in rule 5101:1-41-03 of the Administrative Code. The first day of eligibility is the earliest day of the month in which ODJFS receives the application that the applicant meets all relevant eligibility requirements described in rule 5101:1-41-03 of the Administrative Code.

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

(2) ODJFS shall 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 5101:1-41-02 of the Administrative Code.

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

(C) ODJFS may extend eligibility for BCCP medicaid retroactively to the third month prior to the month of application if the applicant satisfies the following conditions:

(1) The individual met all relevant eligibility requirements described in rule 5101:1-41-03 of the Administrative Code for each of the three months in which retroactive coverage is sought.

(2) ODJFS shall not provide BCCP medicaid coverage, including retroactive coverage, for any period of time preceding the applicant's fortieth birthday or following the applicant's sixty-fifth birthday.

(3) ODJFS shall 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 5101:1-41-02 of the Administrative Code.

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

(5) BCCP medicaid will not cover an expense for a medical service which is incurred outside an eligible timeframe.

(D) BCCP medicaid shall be terminated in accordance with pre-termination review requirements outlined in rule 5101:1-38-011 of the Administrative Code under the following circumstances:

(1) If the individual no longer meets one or more of the eligibility criteria for BCCP medicaid identified in rule 5101:1-41-03 of the Administrative Code.

(2) If a finding is made that the individual was determined eligible for 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 the centers for disease control and prevention's (CDC) "National Breast and Cervical Cancer Early Detection Program (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 5101:1-41-02 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 ODJFS.

(a) ODJFS 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 ODJFS to perform a review of the individual's continuing medicaid eligibility, in accordance with rule 5101:1-41-05 of the Administrative Code.

(6) If the individual obtains creditable health coverage as defined in rule 5101:1-41-02 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 rule 5101:1-41-02(H)(2) 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 women 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 was approved.

(10) If the individual no longer meets other general non-financial and non-resource eligibility requirements applicable to medicaid recipients (e.g., citizenship/immigration status, Ohio residency, etc.) as delineated in rule 5101:1-41-03(G) of the Administrative Code.

Eff 7-1-02
Rule promulgated under: RC 111.15
Rule authorized by: RC 5111.0110
Rule amplifies: RC 5111.0110
R.C. 119.032 review dates: 07/01/2007

5160:1-5-05 Breast and cervical cancer project (BCCP) medicaid: application process.

(A) The BCCP medicaid application process shall:

(1) Be coordinated between ODJFS, 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 5101:1-41-01 of the Administrative Code.

(B) ODJFS shall make available to the ODH BCCP and its designated local agencies or subgrantees the JFS 07161 "Ohio Breast and Cervical Cancer Project (BCCP) Medicaid Application" (rev. 10/2006) and the JFS 07160 "Ohio breast and cervical cancer project (BCCP) medicaid health care provider's revision of treatment plan" (2/2002).

(C) Provision of the JFS 07161 to potential applicants.

(1) Effective July 1, 2002, ODH BCCP designated local agencies or subgrantees shall provide the JFS 07161 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.

(a) ODH BCCP enrollees screened for breast or cervical cancer under the CDC NBCCEDP and referred for breast or cervical cancer diagnostic evaluation on or after July 1, 2002 will be provided the JFS 07161 by the ODH BCCP designated local agency or subgrantee at the time of the enrollee's diagnostic referral.

(b) ODH BCCP enrollees screened for breast or cervical cancer under the CDC NBCCEDP and referred for breast or cervical cancer diagnostic evaluation prior to July 1, 2002 will be provided the JFS 07161 by the ODH BCCP designated local agency or subgrantee no later than the date the ODH BCCP designated local agency or subgrantee is notified by an ODH BCCP breast and cervical cancer screening provider that the ODH BCCP enrollee is found to need treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(c) 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 as of July 1, 2002 will be provided the JFS 07161 by the ODH BCCP designated local agency or subgrantee no later than September 1, 2002.

(2) The ODH BCCP designated local agency or subgrantee will notify in writing ODH BCCP enrollees described in paragraph (C)(1) of this rule to return the completed BCCP medicaid application to the designated ODH BCCP regional case manager.

(D) The ODH BCCP enrollee must submit the JFS 07161 to the designated ODH BCCP regional case manager. The "Ohio Breast and Cervical Cancer Project (BCCP) Medicaid Application (JFS 07161)" shall supply all requested information necessary for ODH BCCP regional subgrantees and ODJFS to fulfill their responsibilities in processing BCCP medicaid applications.

(E) Submission of completed JFS 07161 to ODJFS.

(1) If the ODH BCCP enrollee submits the JFS 07161 to the designated ODH BCCP regional case manager and if subsequently the ODH BCCP breast and cervical cancer 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 that the ODH BCCP enrollee needs treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer, the designated ODH BCCP regional case manager shall provide, within five business days of receipt of the diagnostic information, ODJFS with the completed JFS 07161, which includes:

(a) The JFS 07161 signed by the applicant or authorized representative, which includes

(b) The ODH BCCP regional case manager verification of receipt of diagnostic results. ODH BCCP breast and cervical cancer screening providers must provide diagnostic results of NBCCEDP funded screenings to designated ODH BCCP case manager(s).

(2) If the ODH BCCP enrollee has not submitted the JFS 07161 to the designated ODH BCCP regional case manager and the ODH BCCP breast and cervical cancer 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 that the ODH BCCP enrollee needs treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer, the designated ODH BCCP regional case manager shall notify the ODH BCCP enrollee in writing within five business days of receipt of the diagnostic information, that the JFS 07161 must be submitted to the designated ODH BCCP regional case manager for the BCCP medicaid application to be processed.

(3) If the ODH BCCP enrollee submits the BCCP medicaid application to the designated ODH BCCP regional case manager and if 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, the designated ODH BCCP regional case manager will notify the individual in writing within five business days that the JFS 07161 will not be submitted to ODJFS.

(F) ODJFS is responsible for all determinations of BCCP medicaid eligibility (including retroactive eligibility).

(1) ODJFS shall use available sources of information, including the following, in the eligibility determination process:

(a) Information contained in the BCCP medicaid application,

(b) CRIS-E history to determine if the applicant is currently enrolled in medicaid or has a pending medicaid application.

(2) ODJFS shall utilize the eligibility criteria set forth in rules 5101: 1-41-03 and 5101:1-41-04 of the Administrative Code.

(3) ODJFS will complete all determinations of eligibility within forty-five days of receipt of a complete application. A delay in the determination or redetermination shall not be a basis for granting eligibility nor shall pendency beyond forty-five days be the sole basis for denial.

(4) Determinations of eligibility shall include:

(a) BCCP medicaid eligibility,

(b) BCCP medicaid eligibility for a time limited period (if information on the BCCP medicaid application indicates possible eligibility in any other category of medicaid), or

(c) BCCP medicaid ineligibility.

(5) All decisions are to be documented.

(G) ODJFS is responsible for all redeterminations of BCCP medicaid eligibility.

(1) ODJFS will 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 enrollment in BCCP medicaid.

(b) When ODJFS is notified of a change in the individual's circumstances (e.g., completion of treatment prior to the originally determined treatment period).

(2) ODJFS will provide written notice to the BCCP medicaid recipient:

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

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

(3) The BCCP medicaid recipient must submit the required completed redetermination materials to the designated ODH BCCP regional case manager.

(4) Submission of BCCP medicaid redetermination documents to ODJFS.

(a) If the BCCP medicaid recipient submits the completed BCCP medicaid redetermination documents to the designated ODH BCCP regional case manager and subsequently the treating health professional notifies the designated ODH BCCP 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, the designated ODH BCCP regional case manager shall provide ODJFS completed BCCP medicaid redetermination materials to ODJFS within five business days of receipt of both the completed BCCP medicaid redetermination documents and notification from the treating health professional.

(b) BCCP medicaid redetermination documents include:

(i) JFS 07161 signed by the applicant or authorized representative, and

(ii) JFS 07160.

(c) If the BCCP medicaid recipient has not submitted the completed BCCP medicaid redetermination documents to the designated ODH BCCP regional case manager and the treating health professional notifies the designated ODH BCCP 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, the designated ODH BCCP regional case manager shall notify the BCCP medicaid recipient in writing within five business days of receiving diagnostic notification, that the BCCP medicaid redetermination documents must be completed and submitted to the designated ODH BCCP regional case manager for continued BCCP medicaid eligibility to be determined.

(d) If the BCCP medicaid recipient submits the completed BCCP medicaid redetermination documents to the designated ODH BCCP regional case manager and if the treating health professional notifies the designated ODH BCCP case manager that the individual has been found to not need continued treatment for either breast or cervical cancer, pre-cancerous conditions, or early stage cancer, the designated ODH BCCP regional case manager will notify the individual in writing within five business days that the BCCP medicaid redetermination documents will not be submitted to ODJFS.

(5) Determinations of continued BCCP medicaid eligibility shall be based on:

(a) All required information as supplied by the recipient to the ODH BCCP regional case manager, and

(b) A review of CRIS-E history to determine if the recipient is currently receiving medicaid benefits or has a pending medicaid application.

(6) All decisions are to be documented.

(7) Determinations of continuing BCCP medicaid eligibility:

(a) Eligibility continued for the duration of a new certified treatment period which the treating health professional states is needed for continued treatment,

(b) Termination of eligibility based on the individual's failure to submit reapplication materials by required deadline,

(c) No longer meets the eligiblity criteria for continued eligibility and ineligible for any other category of medicaid, or

(d) Termination of BCCP medicaid, in accordance with rule 5101:1-38-01.1 of the Administrative Code.

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

(1) A period of BCCP medicaid eligibility will commence each time an individual:

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

(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,

(c) Submits a completed BCCP medicaid application in accordance with paragraphs (C) and (D) of this rule, and

(d) Is determined by ODJFS to meet all eligibility criteria for BCCP medicaid as described in rule 5101:1-41-03 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 must meet the BCCP medicaid eligibility requirements defined in rule 5101:1-41-03 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) Must submit a new JFS 07161 to reestablish BCCP medicaid eligibility.

(I) Screening for potential eligibility for other categories of medicaid by ODJFS at application and redetermination.

(1) If information on the JFS 07161 indicates the applicant is not potentially eligible for any other category of medicaid, neither income nor asset information is not needed.

(2) If information on the JFS 07161 indicates the applicant is potentially eligible for any other category of medicaid, the applicant must provide income and/or asset information to screen for eligibility under any other category of medicaid.

(a) If income or asset information indicates the applicant does not appear eligible for any other category of medicaid, no additional income or asset information is needed.

(b) If income or asset information indicates the applicant appears eligible for any other category of medicaid, the applicant must be:

(i) Notified of potential eligibility; and

(ii) Given the opportunity to and instructions for submission of additional information required to make a determination of eligibility in other categories of medicaid.

(a) ODJFS will notify the applicant in writitng to complete and submit additional information required to the CDJFS in the applicant's county of residence,

(b) ODJFS will notify the applicant in writing to complete and submit additional information required to the CDJFS in the applicant's county of residence,

(i) If the CDJFS determines the applicant eligible for any other category of medicaid, ODJFS will terminate BCCP medicaid and transfer the case information to the CDJFS in accordance with paragraph (D) (8) of rule 5101:1-41-04 of the Administrative Code.

(ii) If the CDJFS determines the applicant ineligible for any other category of medicaid, the CDJFS will notify ODJFS and ODJFS will maintain the BCCP medicaid case.

Effective: 10/01/2006
R.C. 119.032 review dates: 07/14/2006 and 10/01/2011
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011
Rule Amplifies: 5111.011
Prior Effective Dates: 7/1/2002

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 Medicaid: medicaid buy-in for workers with disabilities (MBIWD).

(A) This rule governs the eligibility requirements for two medicaid covered groups authorized under sections 1902(a)(10)(A)(ii)(XV) and (XVI) of the Social Security Act (as in effect on April 1, 2008). 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) "Administrative agency" means the county department of job and family services (CDJFS), Ohio department of job and family services (ODJFS), or other entity determining eligibility for a medical assistance program.

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

(3) "Blind work expense (BWE)" has the same meaning as in rule 5101:1-39-18 of the Administrative Code.

(4) "Countable income", for the purpose of this rule, means income less disregards.

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

(6) "Earned income", for the purpose of this rule, means salary, wages, royalties, honoraria, or "net earnings from self-employment" as defined in rule 5101:1-39-15 of the Administrative Code.

(7) "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.

(8) "Impairment-related work expense (IRWE)" has the same meaning as in rule 5101:1-39-18 of the Administrative Code.

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

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

(11) "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.

(12) "Medicaid buy-in for workers with disabilities (MBIWD)" means the component of the medicaid program established under sections 5111.70 to 5111.7010 of the Revised Code and includes the basic covered group and the medically improved covered group.

(13) "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.

(14) "Medical insurance premiums" has the same meaning as in rule 5101:1-39-10 of the Administrative Code.

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

(16) "Premium" means a periodic payment required under section 5111.704 of the Revised Code and described in paragraph (E) of this rule.

(17) "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.

(18) "Resource eligibility limit for MBIWD", means countable resources limited to the amount specified under section 5111.702 of the Revised Code. The resource eligibility limit for MBIWD is ten thousand dollars in calendar year 2008 and is adjusted annually with the consumer price index for urban areas (CPI-U) beginning calendar year 2009.

(19) "Social security disability insurance (SSDI)" means the program established under Title II of the Social Security Act (as in effect on January 1, 2008).

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

(21) "Supplemental security income program (SSI)" means the program established under Title XVI of the Social Security Act (as in effect on January 1, 2008).

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

(23) "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 5101:1-38-02.3 of the Administrative Code;

(b) Be a resident of Ohio as set forth in rule 5101:1-39-54 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 eligible for MBIWD under the basic or medically improved group 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 exemptions and disregards in accordance with rule 5101:1-39-18 of the Administrative Code, but earned income disregards 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 must be disregarded.

(ii) The twenty thousand dollar earned income disregard 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 disregard 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 5101:1-39-05 of the Administrative Code.

(b) For the purposes of determining resource eligibility for MBIWD, resources in accordance with rule 5101:1-39-26 of the Administrative Code are exempt.

(c) Retirement and income supplementing accounts (RISAs) are evaluated in accordance with rule 5101:1-39-22.7 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 must 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 must 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 5101:1-38 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 5101:1-38-01.3 of the Administrative 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 5101:1-39-24 or 5101:1-39-24.1 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 5101:1-39-36 and 5101:1-39-07 of the Administrative Code apply.

(I) Individuals eligible for MBIWD are not subject to a spenddown as described in rule 5101:1-39-10 of the Administrative Code.

(J) Individual responsibilities. The individual must:

(1) Provide the information necessary to establish eligibility, cooperate in the verification process, and report changes in accordance with rule 5101:1-38-02 of the Administrative Code.

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

(K) Administrative agency's responsibility. The administrative agency must:

(1) Process the application for MBIWD in accordance with Chapter 5101:1-38 of the Administrative Code, except a face to face interview is not required.

(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) Redetermine eligibility for MBIWD annually in accordance with Chapter 5101:1-38 of the Administrative Code.

(6) Complete a pre-termination review (PTR) of continuing medicaid eligibility in accordance with Chapter 5101:1-38 of the Administrative Code prior to MBIWD termination.

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

(8) Explore retroactive eligibility for MBIWD as defined in Chapter 5101:1-38 of the Administrative Code.

(a) Retroactive eligibility for MBIWD exists when the individual meets all eligibility criteria defined in this rule.

(b) Retroactive eligibility for MBIWD is not available for any month prior to the effective date of this rule.

(9) Explore eligibility for qualified medicare beneficiary (QMB) and specified low income medicare beneficiary (SLMB) programs in accordance with Chapter 5101:1-39 of the Administrative Code. MBIWD individuals are not eligible for qualified individual (QI-1) or qualified working disabled individual (QWDI) medicare premium assistance programs.

Effective: 04/01/2008
R.C. 119.032 review dates: 04/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.01 , 5111.708
Rule Amplifies: 5111.01 , 5111.70 to 5111.708

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

(A) This rule describes the state option medicaid covered group eligibility criteria for an individual seeking family planning services as described in section 1902(a)(10)(A)(ii)(XXI) of the Social Security Act (as in effect March 23, 2010). There is no resource limit for individuals described in this rule.

(B) Definitions.

(1) "Family planning related services" has the same meaning as in Chapter 5101:3-21 of the Administrative Code.

(2) "Family planning services" has the same meaning as in Chapter 5101:3-21 of the Administrative Code.

(C) Eligibility criteria. To be eligible for family planning services or family planning related services under this rule, the individual shall:

(1) Be a male or female.

(2) Meet the conditions of eligibility outlined in rule 5101:1-38-01.8 of the Administrative Code.

(3) Meet the financial eligibility requirements described in paragraph (D) of this rule.

(4) Not be otherwise eligible for medicaid.

(5) Not have creditable coverage as defined in rule 5101:1-37-01 of the Administrative Code.

(D) Financial eligibility.

(1) The net countable family income is no more than two hundred per cent of the federal poverty level (FPL) for the appropriate family size plus one.

(a) If the individual is married and living with the individual's spouse, the spouse's income shall be counted.

(b) If the individual is younger than eighteen, unmarried, and living with the individual's parent(s), the income of the parent(s) shall be counted.

(2) To determine net countable family income:

(a) Total the individual's gross, non-exempt income.

(b) Allocate income of a step-parent, parent of a minor parent, spouse of a specified relative, or non-qualified alien parent as described in rule 5101:1-38-02.3 of the Administrative Code, who is living with the individual, but is not a member of the covered group.

(i) From the step-parent, parent of a minor parent, spouse of a specified relative, or non-qualified alien parent's income, deduct the following:

(a) The first ninety dollars of the gross earned income.

(b) An amount equal to the allocation allowance standard, in accordance with Chapter 5101:1-23 of the Administrative Code, for the step-parent, parent of a minor parent, spouse of a specified relative, or a non-qualified alien parent and any other individuals living with but not members of the covered group, who are or could be claimed by the stepparent, parent of a minor parent, spouse of a specified relative, or non-qualified alien parent as dependents.

(c) The amount of verifiable payments made to those who are or could be claimed by the step-parent, parent of a minor parent, spouse of a specified relative, or non-qualified alien parent, as dependents for federal personal income tax liability, but are not living in the home.

(d) The amount of alimony or child support payments made for those not living in the home.

(ii) The remaining amount of earned and unearned income is allocated to the individual as unearned income.

(c) Apply the income exemptions and disregards described in rule 5101:1-38-01.9 of the Administrative Code, and

(d) Apply the following additional exemptions:

(i) The first fifty dollars of court-ordered child support received by the covered group.

(ii) Court-ordered child support and alimony payments made to individuals not living in the household.

(iii) Earned income of a child, who is a fulltime student as defined by the educational facility, for up to six months per calendar year, and

(e) Disregard from earned income of each employed covered group member:

(i) Up to ninety dollars for each employed covered group member.

(ii) Out of pocket dependent care costs, paid to an individual who is not a member of the covered group, for a dependent child or incapacitated adult, up to but not exceeding:

(a) Two hundred dollars per infant, under two years of age, in full-time care at twenty-five hours of care per week.

(b) One hundred seventy-five dollars per child over two years of age, or incapacitated adult, in full-time care at least twenty-five hours of care per week.

(c) One hundred twenty dollars per child or incapacitated adult, in part-time care less than twenty-five hours of care per week.

(f) Earned income disregard penalties. The disregards of earned income do not apply when:

(i) An individual terminated employment or reduced earned income without good cause within the preceding month.

(ii) An individual refused a bona fide offer of employment within the preceding month without good cause.

(iii) An individual failed to timely report income in accordance with rule 5101:1-38-01.2 of the Administrative Code, without good cause.

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

(1) Compare the net countable family income to two hundred per cent of the federal poverty level (FPL) for the appropriate family size plus one.

(2) Redetermine eligibility for family planning services annually in accordance with rule 5101:1-38-01.2 of the Administrative Code.

(3) Complete a pre-termination review (PTR) of continuing medicaid eligibility in accordance with rule 5101:1-38-01.2 of the Administrative Code.

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

(F) Individuals receiving services under this covered group shall receive a fee-for-service medicaid card. Individuals eligible under this rule shall receive a limited benefit package described in rules 5101:3-21-02 and 5101:3-21-02.3 of the Administrative Code and shall not be covered by a managed care plan described in Chapter 5101:3-26 of the Administrative Code.

(G) Retroactive coverage is available for this program in accordance with rule 5101:1-38-01.2 of the Administrative Code, but coverage shall not begin prior to the effective date of this rule and shall not provide reimbursement of services rendered prior to the effective date of this rule.

Effective: 01/08/2012
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