Chapter 5160:1-2 Medicaid Application Procedures

5160:1-2-01 [Rescinded] Medicaid: individual and administrative agency responsibilities.

Effective: 1/15/2015
Five Year Review (FYR) Dates: 10/30/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011, 5111.012
Rule Amplifies: 5111.01, 5111.011, 5111.012, 329.051
Prior Effective Dates: 11/1/74, 8/1/75, 10/1/75, 6/1/76, 7/14/77, 12/31/77, 9/1/82, 9/24/83, 8/1/84, 10/20/84, 11/1/84, 12/1/84 (Emer.), 2/10/85, 7/1/85, 4/1/86, 8/1/86 (Emer.), 10/3/86, 10/1/87 (Emer.), 12/24/87, 4/1/88 (Emer.), 6/10/88, 6/30/88, 7/1/88 (Emer.), 8/1/88 (Emer.), 9/1/88, 9/24/88, 10/1/88 (Emer.), 10/15/88, 10/25/88 (Emer.), 12/20/88, 3/1/89 (Emer.), 5/28/89, 12/1/89, 4/1/90 (Emer.), 6/22/90, 8/1/90 (Emer.), 10/25/90, 1/1/91 (Emer.), 2/21/91, 4/1/91 (Emer.), 6/1/91, 7/1/91 (Emer.), 9/15/91, 10/1/91 (Emer.), 12/20/91, 4/1/92, 7/1/92, 1/1/93, 1/1/93 (Emer.), 2/11/93, 3/18/93, 5/1/93, 9/1/93, 1/1/94, 3/1/94 (Emer.), 4/18/94, 1/1/95, 1/1/95 (Emer.), 4/1/95, 7/1/95, 10/1/95, 6/1/96, 10/1/96, 10/1/96 (Emer.), 12/15/96, 5/1/97, 10/1/97 (Emer.), 10/30/97, 12/30/97, 7/1/98, 7/1/99, 10/1/99, 5/4/00, 7/1/00, 6/1/03, 6/1/03 (Emer.), 9/20/03, 10/6/03, 9/25/06, 10/1/06, 6/1/07, 8/1/07, 10/1/09, 7/17/11

5160:1-2-01.2 [Rescinded] Medicaid: application, determination, and redetermination processes.

Effective: 1/15/2015
Five Year Review (FYR) Dates: 10/30/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011, 5111.012
Rule Amplifies: 5111.01, 5111.011, 5111.012, 2913.401, 3501.01, 3503.10, 5101.58, 329.051
Prior Effective Dates: 8/1/75, 10/1/75, 6/1/76, 7/14/77, 9/3/77, 12/31/77, 9/1/82, 9/24/83, 8/1/84, 10/20/84, 11/1/84, 12/1/84 (Emer.), 28/10/85, 4/1/86, 8/1/86 (Emer.), 10/3/86, 7/1/87 (Emer.), 8/3/87, 10/1/87 (Emer.), 12/24/87, 3/24/88 (Emer.), 4/1/88 (Emer.), 6/10/88, 6/30/88, 7/1/88 (Emer.), 9/1/88, 9/24/88, 10/1/88 (Emer.), 10/25/88 (Emer.), 12/20/88, 3/1/89 (Emer.), 5/28/89, 12/1/89, 1/1/90 (Emer.), 4/1/90, 6/22/90, 8/1/90 (Emer.), 10/25/90, 1/1/91 (Emer.), 2/21/91, 4/1/91 (Emer.), 6/1/91, 7/1/91 (Emer.), 9/15/91, 10/1/91 (Emer.), 12/20/91, 4/1/92, 7/1/92, 1/1/93, 1/1/93 (Emer.), 2/11/93, 3/18/93, 5/1/93, 9/1/93, 1/1/94, 3/1/94 (Emer.), 4/18/94, 1/1/95, 1/1/95 (Emer.), 4/1/95, 7/1/95, 10/1/95, 6/1/96, 10/1/96, 10/1/96 (Emer.), 12/15/96, 5/1/97, 10/1/97 (Emer.), 10/30/97, 12/30/97, 7/1/98, 10/1/99, 11/1/99 (Emer.), 2/1/00, 5/4/00, 7/1/00, 10/1/02, 6/1/03, 6/1/03 (Emer.), 9/20/03, 10/6/03, 9/25/06, 10/1/06, 6/1/07, 10/1/09, 7/17/11

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

Effective: 01/01/2014
R.C. 119.032 review dates: 10/15/2013
Promulgated Under: 111.15
Statutory Authority: 5162.031, 5163.02
Rule Amplifies: 5162.031, 5163.02
Prior Effective Dates: 10/1/98, 10/6/03, 11/1/09

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

Effective: 3/23/2015
Five Year Review (FYR) Dates: 12/08/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011, 5111.871
Rule Amplifies: 5111.01, 5111.011, 5111.012, 5111.87 , 5111.871, 5111.91
Prior Effective Dates: 6/1/88 (Emer.), 8/1/88 (Emer.), 10/30/88, 1/1/90 (Emer.), 3/1/90 (Emer.), 3/30/90 (Emer.), 4/1/90, 6/29/90, 7/1/90, 10/1/90, 1/1/91 (Emer.), 4/1/91, 1/1/92 (Emer.), 3/20/92, 3/30/92, 5/1/92 (Emer.), 7/1/92, 8/14/92 (Emer.), 1/1/92, 5/1/93, 9/1/93, 7/1/94, 10/1/02, 10/1/04

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

Effective: 1/15/2015
Five Year Review (FYR) Dates: 10/30/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011
Rule Amplifies: 5111.01, 5111.011
Prior Effective Dates: 8/1/09

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

Effective: 1/15/2015
Five Year Review (FYR) Dates: 10/30/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011, 5111.02
Rule Amplifies: 5111.01, 5111.011, 5111.02
Prior Effective Dates: 10/1/75, 9/30/76, 9/3/77, 7/18/78, 2/1/79, 4/19/79, 1/1/81, 2/1/82, 7/1/82, 9/1/82, 11/1/84, 11/3/84, 1/1/86, 8/1/86 (Emer.), 9/1/86 (Emer.), 10/3/86, 11/16/86, 4/9/87, 7/1/87 (Emer.), 8/3/87, 10/1/87 (Emer.), 12/24/87, 3/24/88 (Emer.), 4/1/88 (Emer.), 6/10/88, 6/30/88, 10/1/88 (Emer.), 12/20/88, 3/1/89 (Emer.), 4/1/89 (Emer.), 5/28/89, 6/18/89, 1/1/90 (Emer.), 4/1/90, 10/1/91 (Emer.), 12/20/91, 7/1/92, 7/1/92 (Emer.), 9/21/92, 1/1/93, 5/1/93, 9/1/93, 3/1/95, 10/30/95, 5/1/97, 7/1/98, 7/1/00, 10/1/02, 1/1/03, 10/6/03, 7/1/06, 9/25/06, 8/1/07, 7/1/08, 10/15/09, 7/17/11

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

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

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

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

(B) Definitions.

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

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

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

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

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

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

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

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

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

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

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

(ii) Estimated net income.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(3) Income tax refunds.

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

(5) SSI payments.

(6) Residential state supplement (RSS) payments.

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

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

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

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

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

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

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

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

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

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

(c) A partnership interest.

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

(e) An interest in a settlement trust.

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

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

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

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

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

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

(a) Proceeds from the sale of initial purchases.

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

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

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

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

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

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

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

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

(27) Payments to victims of Nazi persecution.

(28) Principal of a bona-fide loan.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Effective: 1/15/2015
Five Year Review (FYR) Dates: 10/30/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011, 5111.012
Rule Amplifies: 5111.01, 5111.011, 5111.012
Prior Effective Dates: 10/1/75, 9/1/82, 8/1/86 (Emer.), 10/3/86, 10/1/87 (Emer.), 12/24/87, 4/1/88 (Emer.), 6/30/88, 10/1/88 (Emer.), 12/20/88, 3/1/89 (Emer.), 5/28/89, 10/1/91 (Emer.), 12/20/91, 5/1/97, 7/1/00, 10/6/03, 9/25/06, 8/1/07, 7/1/08, 10/15/09

5160:1-2-02.3 [Rescinded] Medicaid: qualified aliens.

Effective: 1/15/2015
Five Year Review (FYR) Dates: 10/30/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011
Rule Amplifies: 5111.01, 5111.011
Prior Effective Dates: 6/1/93, 10/1/95, 7/1/98, 10/1/02, 4/1/03 (Emer.), 9/20/03

5160:1-2-03 Medicaid: application for home and community-based (HCB) services.

(A) This rule sets forth the process for determining whether an individual is eligible for medicaid payments for services under the HCB services waivers set out in agency 5160 of the Administrative Code.

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

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

(2) Be in need of HCB services under a waiver described in agency 5160 of the Administrative Code; and

(3) Be enrolled in an HCB services waiver described in agency 5160 of the Administrative Code.

(C) Determination of eligibility for HCB services. The administrative agency shall approve HCB services for an individual in receipt of medicaid only upon:

(1) Approval by the HCB services waiver operational agency, as defined in rule 5160:1-1- 50.1 of the Administrative Code; and

(2) If services under the waiver are available only to a specific number of individuals, notification that the individual may be enrolled in the waiver from the Ohio department of medicaid (ODM), its designee, or a HCB services waiver operational agency.

(D) Coverage period. The HCB services coverage period can have a different beginning date or ending date from the medicaid eligibility period.

(1) HCB services cannot:

(a) Begin before an individual's medicaid eligibility period or before an individual's retroactive medicaid eligibility period;

(b) Extend beyond the termination date of an individual's medicaid coverage;

and

(c) Be provided during any period of medicaid ineligibility.

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

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

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

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

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

(b) The date the individual meets all criteria for coverage of an HCB services waiver described in agency 5160 of the Administrative Code.

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

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

(a) The administrative agency determines the individual no longer meets medicaid conditions of eligibility as described in rule 5160:1-1-58 of the Administrative Code or the criteria for coverage of HCB services; or

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

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

(1) Submit a ODM 02399 "Request for Medicaid Home and Community-Based Services (HCBS)" (rev. 7/2014), signed by the individual, to the administrative agency within five days of the signature date, if assisting an individual with an application for HCB services.

(2) Determine, in accordance with this rule and agency 5160 of the Administrative Code, whether the individual requesting medicaid coverage of HCB services meets the requirements of the applicable HCB services waiver program.

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

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

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

(1) Determine an individual's eligibility for HCB services in accordance with this rule.

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

(b) If an individual who applies for HCB services is not currently in receipt of medicaid, the administrative agency shall begin the application process described in rule 5160:1-1-51 of the Administrative Code.

(c) If the administrative agency determines that an individual who applies for HCB services is not eligible for any category of medical assistance, the administrative agency shall deny both medical assistance and HCB services for that individual.

(2) Notify the applicable HCB services waiver operational agency, within five days of the receipt of a signed ODM 02399, via the electronic eligibility system of the receipt of the application. If the HCB services waiver operational agency is not known or if multiple waiver agencies are indicated on the application, the administrative agency shall submit the ODM 02399 to ODM.

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

Replaces: 5160:1-2- 01.6

Effective: 3/23/2015
Five Year Review (FYR) Dates: 03/23/2020
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02, 5166.20, 5166.21
Rule Amplifies: 5160.02, 5163.02, 5166.21, 5162.35
Prior Effective Dates: 6/1/88 (Emer.), 8/1/88 (Emer.), 10/30/88, 1/1/90 (Emer.), 3/1/90 (Emer.), 3/30/90 (Emer.), 4/1/90, 6/29/90, 7/1/90, 10/1/90, 1/1/91 (Emer.), 4/1/91, 1/1/92 (Emer.), 3/20/92, 3/30/92, 5/1/92 (Emer.), 7/1/92, 8/14/92 (Emer.), 1/1/92, 5/1/93, 9/1/93, 7/1/94, 10/1/02, 10/1/04, 10/1/09

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(1) Written informing.

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

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

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

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

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

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

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

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

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

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

(i) Increased well-being;

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

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

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

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

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

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

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

(f) The prior authorization process, including that:

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

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

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

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

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

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

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

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

(iii) Verification requirements, if any; and

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

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

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

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

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

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

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

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

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

(D) Provision of support services.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(E) Custodial agency responsibility.

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

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

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

(a) After the initial informing process;

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

(c) After completion of each annual review.

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

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

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

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

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

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

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

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

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

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

(v) The JFS 03528 or other documentation.

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

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

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

(b) Copies of all correspondence received and sent;

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

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

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

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

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

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

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

(iii) Records of transportation requested and provided; and

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

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

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

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

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

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

(1) Complete the JFS 03528;

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

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

(4) Attend scheduled appointments for healthchek services.

Replaces: 5101:1-38-05

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

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

Effective: 1/15/2015
Five Year Review (FYR) Dates: 10/14/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01
Rule Amplifies: 5111.01, 5111.016
Prior Effective Dates: 4/1/88 (Emer.), 6/30/88, 10/1/88 (Emer.), 12/20/88, 4/1/91, 2/1/92, 5/1/93, 10/1/98, 5/1/02, 10/6/03

5160:1-2-07 Medicaid: estate recovery.

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

(B) Definitions.

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

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

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

(2) "Home" is defined in rule 5160:1-3- 05.13 of the Administrative Code.

(3) "Individual," for the purpose of this rule, means someone with past or current medicaid eligibility.

(4) "Permanently institutionalized individual" is defined in section 5162.21 of the Revised Code.

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

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

(7) "Qualified long- term care partnership (QLTCP)" is defined in rule 5160:1-3- 02.8 of the Administrative Code.

(8) "Real property" means land, including buildings or immovable objects, attached permanently to the land.

(9) "Time of death" is defined in section 5162.21 of the Revised Code.

(C) The Ohio attorney general (AGO) will seek recovery or adjustment, on behalf of the Ohio department of medicaid (ODM), from the estates of the following individuals:

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

(2) An individual fifty-five years of age or older who is not permanently institutionalized, in the amount of all medicaid benefits correctly paid (other than benefits paid on or after January 1, 2010, under the medicare premium assistance programs set forth in rules 5160:1-3- 02.6 and 5160:1-3- 02.1 of the Administrative Code) after the individual attained such age.

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

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

(2) When the individual has no surviving child who either is under age twenty-one or is blind or permanently and totally disabled as defined in Chapter 5160:1-3 of the Administrative Code; and

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(E) Notice requirements.

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

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

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

(b) The claim must include the following:

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

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

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

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

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

(G) Qualified long-term care partnership disregard.

(1) The amount of resources disregarded at eligibility determination (as established in rule 5160:1-3- 02.8 of the Administrative Code) will be disregarded during estate recovery.

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

(a) Special needs trusts as established in rule 5160:1-3- 05.2 of the Administrative Code;

(b) Pooled trusts as established in rule 5160:1-3- 05.2 of the Administrative Code; and

(c) Annuities as described in rule 5160:1-3- 05.3 of the Administrative Code.

(3) The QLTCP disregard at estate recovery is reduced to the extent that an individual made a transfer (that would otherwise have been considered an improper transfer under rule 5160:1-3- 07.2 of the Administrative Code) without a restricted medicaid coverage period.

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

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

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

(i) Produces a limited amount of income, or

(ii) Is the sole asset of the survivor.

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

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

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

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

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

(i) Is totally and permanently disabled as defined in Chapter 5160:1-3 of the Administrative Code; and

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

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

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

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

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

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

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

(I) Request for undue hardship waiver.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Replaces: 5160:1-2-10

Effective: 1/15/2015
Five Year Review (FYR) Dates: 01/15/2020
Promulgated Under: 111.15
Statutory Authority: 5162.21
Rule Amplifies: 5162.21, 5162.211, 5162.23, 5164.86
Prior Effective Dates: 7/1/00, 9/1/07, 1/1/10

5160:1-2-10 [Rescinded] Medicaid estate recovery.

Effective: 1/15/2015
Five Year Review (FYR) Dates: 10/30/2014
Promulgated Under: 111.15
Statutory Authority: 5111.11
Rule Amplifies: 5111.11, 5111.111, 5111.12, 5111.18
Prior Effective Dates: 7/1/00, 9/1/07

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

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

(B) Definitions.

(1) "Administrative agency" means the county department of job and family services (CDJFS), Ohio department of job and family services (ODJFS) or other entity administering the medicaid program.

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

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

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

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

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

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

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

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

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

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

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

(4) A QLTCP disregard does not affect post-eligibility income calculations under Chapters 5101:1-38 to 5101:1-41 of the Administrative Code; the disregard cannot reduce patient liability or cost of care.

(E) Transfers of resources.

(1) If an individual becomes eligible for medicaid through the application of a QLTCP disregard, then makes a transfer (of disregarded resources) that would otherwise be considered an improper transfer (under rule 5101:1-39-07 of the Administrative Code), no restricted medicaid coverage period applies. The disregarded value of the transferred resource continues to be considered part of the individual's QLTCP disregard.

(2) If an individual becomes eligible for medicaid through the application of a QLTCP disregard after making a transfer that would otherwise be considered an improper transfer (per rule 5101:1-39-07 of the Administrative Code):

(a) If the individual's QLTCP disregard plus resource limit equals or exceeds the individual's countable resources plus the value of the transferred resource, no restricted medicaid coverage period applies. The disregarded value of the transferred resource is considered part of the individual's QLTCP disregard.

(b) If the individual's QLTCP disregard plus resource limit is less than the individual's countable resources plus the value of the transferred resource:

(i) The individual's available QLTCP disregard is determined by adding the individual's QLTCP disregard to the individual's resource limit, then subtracting the individual's current countable resources and any amounts that have previously been transferred without a restricted medicaid coverage period as a result of a QLTCP disregard.

(ii) The individual's available QLTCP disregard is subtracted from the amount that would otherwise have been considered improperly transferred. The remainder is the amount improperly transferred; a restricted medicaid coverage period is calculated for the remainder as per rule 5101:1-39-07 of the Administrative Code.

Effective: 09/01/2007
R.C. 119.032 review dates: 09/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.11, 5111.18
Rule Amplifies: 5111.11, 5111.18

5160:1-2-16 Medicaid: pregnancy related services (PRS).

(A) The purpose of this rule is to outline the responsibilities of the administrative agency to inform medicaid-eligible pregnant women about the benefits and importance of pregnancy related services (PRS), to make requested or needed referrals to support services, and to provide non-medical services promoting healthy birth outcomes in accordance with 42 C.F.R. 440.210 (as in effect January 1, 2014).

(B) Definitions.

(1) "Individual" for the purpose of this rule, means a medicaid-eligible individual who is pregnant, as verified by either self-declaration or medical verification, including the sixty days post-partum period.

(2) ODM 03515 "Pregnancy Related Services Implementation Plan" (PRSIP) (rev.1/2015) means the document submitted by an administrative agency describing how it delivers PRS to pregnant women in its county and which entity is responsible for ensuring the delivery of PRS.

(3) "PRS coordinator" means the administrative agency employee who is responsible for the implementation of PRS.

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

(C) The individual (or the individual's parent(s), guardian or legal custodian, as applicable) may:

(1) Complete and sign the ODM 03528, "Healthchek and Pregnancy Related Services Information Sheet" (rev. 7/2014) to verify understanding of PRS and Healthchek services;

(2) Complete, sign, and return the ODM 03528 to identify her own and her children's need for services.

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

(1) Inform individuals in its county about PRS within sixty days of the eligibility determination. Informing methods shall be written, oral or a combination of written and oral methods, as described below:

(a) Provide the ODM 03528, "Healthchek and Pregnancy Related Services Information Sheet" (rev. 7/2014).

(b) Provide information about:

(i) The benefits and importance of early and continual prenatal and postpartum care.

(ii) The services covered by PRS as described in Chapter 5160-4 of the Administrative Code.

(iii) The benefits of healthchek services as described in 5160:1-2-05 of the Administrative Code.

(iv) Transportation services and scheduling assistance available to individuals, if needed and upon request, in accordance with Chapter 5160-15 of the Administrative Code.

(v) Availability of transportation services through the individual's MCP. The transportation services shall be provided by the administrative agency if not available from the MCP.

(vi) Transportation services and scheduling assistance available to infants during the first year of life.

(vii) Medical and non-medical support services to include but not limited to:

(a) "The Help Me Grow" (HMG) program;

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

(c) Maternal and child health clinics;

(d) Local health departments;

(e) Social services and other community services.

(viii) Availability of assistance for scheduling medical appointments, as requested by the individual.

(ix) A list of medicaid prenatal care providers, if requested, available to the community and/or information about medicaid-contracting MCPs.

(2) Inform individuals enrolled in a MCP that they should contact the MCP for medical care options and referrals.

(3) Re-inform the individual of the benefits of healthchek services as soon as possible after the infant's birth.

(4) Refer the individual to support services as requested verbally, in writing, or via the ODM 03528 and ensure:

(a) Referrals are made, as needed, for medical and non-medical support services.

(b) Coordination between the individual, medical provider, MCP or other entity where the referral is made.

(c) Transportation assistance is provided to individuals, as requested.

(d) Individuals in need of non-medicaid covered medical services are referred to community, medical or other social services. This includes providers who have expressed a willingness to furnish non-medicaid covered services at little or no expense to the individual.

(5) Establish contact with the individual upon notification from the medical provider or MCP that the individual has missed appointments or there are other problems in the delivery of care and inform the individual's medical provider or MCP about the outcome of the contact.

(6) Provide a copy of the ODM 03528 (if applicable) and the ODM 03535 "Prenatal Risk Assessment Form" (if applicable) (rev. 7/2014) to the individual's MCP.

(7) Make a second attempt to contact the individual by alternate means if written information about PRS sent to the individual is returned as undeliverable.

(8) Submit a new or amended ODM 03515 "Pregnancy Related Services Implementation Plan" (rev. 1/2015) to Ohio department of medicaid (ODM), including but not limited to, when there has been a change of agency address, director, PRS coordinator or where the responsibility for PRS is organizationally located within the agency. The ODM 03515 shall be submitted to ODM within ten business days of the change.

(9) Obtain a HIPAA compliant signed authorization for release of information, ODM 03397 "Authorization for the Release or Use of Protected Health Information (PHI) or Other Confidential Information" (rev. 8/2014), when additional medical information is needed from the individual.

(10) Maintain a listing of fee-for-service providers who have expressed a willingness to furnish non-medicaid covered services at little or no expense to the individual. It is recognized that the ability of the administrative agency to recruit and maintain an adequate provider network depends on the existence of appropriate providers within a reasonable geographic area.

(11) Maintain documentation in a case file for each eligible individual. The file shall consist of permanent records, either hard copy or electronically stored, containing the following information, when appropriate:

(a) Copy of the ODM 03528, ODM 03535, or other referral forms received by the county;

(b) Copy of correspondence received and sent;

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

(d) Documentation of the MCP in which the individual is enrolled;

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

(f) Documentation of all service requests, steps taken by the administrative agency, and whether the individual received services; and

(g) Records of transportation services provided.

(E) Each administrative agency PRS coordinator, or such coordinator's designee(s), shall attend annual and other pertinent trainings offered by ODM. Verification of attendance shall consist of documentation of roll call and sending an evaluation form to the state email box within three days of the video conference or training. Verification of attendance at onsite training shall be documented by the PRS coordinator or such coordinator's designee(s) by signing the attendance log.

Replaces: 5160:1-2-06

Effective: 1/15/2015
Five Year Review (FYR) Dates: 01/15/2020
Promulgated Under: 111.15
Statutory Authority: 5160.02
Rule Amplifies: 5160.02, 5164.26
Prior Effective Dates: 4/1/88 (Emer.), 6/30/88, 10/1/88 (Emer.), 12/20/88, 4/1/91, 2/1/92, 5/1/93, 10/1/98, 5/1/02, 10/6/03, 10/15/05

5160:1-2-20 [Rescinded] Medicaid consumer fraud and erroneous payments.

Effective: 1/15/2015
Five Year Review (FYR) Dates: 10/30/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011
Rule Amplifies: 2913.401, 5111.01, 5111.011, 5111.12
Prior Effective Dates: 10/1/87 (Emer.), 12/24/87, 11/7/02

5160:1-2-30 [Rescinded] Medicaid: continuous eligibility for children younger than age nineteen.

Effective: 01/01/2014
R.C. 119.032 review dates: 10/15/2013
Promulgated Under: 111.15
Statutory Authority: 5162.031, 5163.02
Rule Amplifies: 5163.02
Prior Effective Dates: 4/1/10 (Emer.), 7/1/10, 10/15/10

5160:1-2-40 [Rescinded] Medicaid: presumptive eligibility for children younger than age nineteen.

Effective: 1/15/2015
Five Year Review (FYR) Dates: 10/30/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011
Rule Amplifies: 5111.01, 5111.011, 5111.0125
Prior Effective Dates: 4/1/10 (Emer.), 7/1/10, 4/1/12 (Emer.)

5160:1-2-50 [Rescinded] Medicaid: presumptive eligibility for pregnant women.

Effective: 1/15/2015
Five Year Review (FYR) Dates: 10/30/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011
Rule Amplifies: 5111.01, 5111.011
Prior Effective Dates: 4/1/91 (Emer.), 6/1/91, 9/1/92, 9/1/93, 7/1/00