Chapter 5160:1-2 Medicaid Application Processing

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

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

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

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

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

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

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

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

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

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

(2) Inform the individual of the following:

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

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

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

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

(c) The verification requirements and deadlines.

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

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

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

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

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

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

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

(2) Distribute voter information and registration materials as required by 42 C.F.R. 431.307 (as in effect on June 1, 2015).

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

(a) The following individuals are potential WIC recipients:

(i) A woman who is:

(a) Pregnant; or

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

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

(ii) A child younger than five years old.

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

(F) Assistance.

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

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

(b) The administrative agency must not reveal safeguarded information, as described in rule 5160:1-1-03 of the Administrative Code, or send notices or correspondence to the person assisting the individual, unless the person has been designated in writing as an authorized representative.

(c) A person who is assisting an individual must provide accurate information, to the best of his or her knowledge, regardless of whether the person is an authorized representative.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(ii) Determine eligibility in accordance with Chapter 5160:1-2 of the Administrative Code, but without considering eligibility factors for which verification cannot be obtained or means of self-support that cannot be accessed because of the physical or mental impairment. Use the most reliable information available without delaying the determination of eligibility.

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

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

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

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

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

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

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

(4) If not previously provided, give or send a notice meeting the requirements of section 3503.10 of the Revised Code or JFS 07217, voter registration form as required by section 329.051 of the Revised Code.

(H) Verifications. Where manual verifications are required under rule 5160:1-2-10 of the Administrative Code, the administrative agency must:

(1) Follow the safeguarding guidelines set forth in rule 5160:1-1-03 of the Administrative Code when providing or gathering information by telephone, in person, or in electronic or written form.

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

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

(4) To the extent possible, verify relevant eligiblity criteria using electronic records available through the electronic eligibility system. Where electronic verification is not available, or electronic verification data conflicts with the individual's attestation, request verifications as set out in rule 5160:1-2-10 of the Administrative Code.

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

(a) The written request must:

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

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

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

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

(b) When the normal sources of verification described in this rule have been exhausted and no documentation can be obtained, the administrative agency may accept the individual's statement if it is complete and consistent with other facts and statements. The use of such a statement must be on a case by case basis when no other approach is possible, and must be used only in rare circumstances.

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

(i) The follow-up letter:

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

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

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

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

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

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

(i) An individual may reapply at any time.

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

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

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

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

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

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

(c) The date of the contact; and

(d) An accurate summary of the information provided.

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

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

(2) Inform all individuals at the time of application and renewal that the agency will obtain and use information available from IEVS to assist with the determination of eligibility, as required by section 1137 of the Social Security Act (as in effect on June 1, 2015).

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

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

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

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

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

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

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

(c) Approve medical assistance for an individual who:

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

(ii) Has provided all necessary verifications as set forth in rule 5160:1-2-10 of the Administrative Code; and

(iii) Meets all conditions of eligibility for an eligibility category set forth in an approved state plan amendment, Chapter 5160:1-2, 5160:1-3, 5160:1-4, or 5160:1-5 of the Administrative Code. If an individual who attests to U.S. citizenship or qualified alien status meets all conditions of eligibility for an eligibility category except for verification of the individual's citizenship or qualified alien status, the administrative agency must approve time-limited coverage during a reasonable opportunity period (ROP) as required in rule 5160:1-2-11 or 5160:1-2-12 of the Code.

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

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

(ii) Withdraws the application; or

(iii) Fails to cooperate in the application or determination process or fails to provide all necessary verifications set forth in rule 5160:1-2-10 of the Administrative Code; or

(iv) Does not meet all conditions of eligibility for any eligibility category set forth in Chapter 5160:1-2, 5160:1-3, 5160:1-4, or 5160:1-5 of the Administrative Code.

(e) Suspend medical assistance upon notification that an individual meets any of the criteria for ineligibility for payment of services set forth in rule 5160:1-1-05 of the Administrative Code.

(f) Terminate medical assistance for an individual who:

(i) Requests that assistance be terminated; or

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

(iii) Fails to cooperate in the renewal process; or

(iv) Fails to cooperate in the quality control process; or

(v) Fails to provide all necessary verifications; or

(vi) Is eligible as a result of an administrative agency error, or

(vii) Provided fraudulent information or verifications, or

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

(ix) No longer meets the conditions of eligibility for an eligibility category as set forth in Chapter 5160:1-2 of the Administrative Code. Before terminating coverage on this basis, the administrative agency must conduct a pre-termination review (PTR) to determine that the individual is no longer eligible for coverage under any eligibility category.

(J) Reinstatement of medical assistance when an individual cooperates with the renewal process.

(1) The administrative agency must reinstate medical assistance, terminated for failure to cooperate in the renewal process or verfication of a reported change, within ninety calendar days of the termination date without requiring a new application in accordance with 42 C.F.R. 435.916(a)(3)(C)(iii) (as in effect on June 1, 2015).

(2) The administrative agency must accept the renewal form and/or verifications that caused the termination of medical assistance.

(3) The administrative agency must reinstate medical assistance if all eligibility criteria are met.

(4) Reinstated medical assistance coverage shall begin on the first day of the calendar month following the month medical assistance was terminated.

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

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

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

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

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

(3) Forty-five calendar days of receipt of new or changed information from IEVS.

The administrative agency must not terminate, deny, or suspend benefits until appropriate steps have been taken to verify the relevant information in accordance with 42 C.F.R. 435.952(d) (as in effect on June 1, 2015).

(L) Effective dates of eligibility.

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

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

(i) Became a resident of Ohio, or

(ii) Was born.

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

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

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

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

(a) Transitional medicaid as described in rule 5160:1-4-05 of the Administrative Code; or

(b) Medicare premium assistance as described in rule 5160:1-3-02.1 of the Administrative Code; or

(c) Any presumptive eligibility category described in rule 5160:1-2-13 of the Administrative Code.

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

(a) Becomes a resident of another state;

(b) Dies; or

(c) Requests that coverage be terminated.

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

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

(a) Any presumptive eligibility category, described in rule 5160:1-2-13 of the Administrative Code, and

(b) Alien emergency medical assistance, as described in rule 5160:1-5-06 of the Administrative Code, and

(c) Refugee medical assistance, described in rule 5160:1-5-05.

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

(a) Twelve months after the most recent eligibility determination, or

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

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

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

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

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

(2) At a renewal, or upon any reported change, the administrative agency must compare the individual's current information to the information on the most recent ODM 06612 "Health Insurance Information Sheet" (rev. 07/2014) or ODM 06613" Accident/Injury Insurance Information (rev. 07/2014). If any information has changed, the administrative agency must report the changes to ODM by submitting a new ODM 06612 or ODM 06613, or an electronic equivalent.

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

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

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

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

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

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

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

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

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

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

(a) The most recently signed application for medical assistance benefits; and .

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

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

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

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

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

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

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

(e) If the case being transferred is subject to a claim for overpayment as set out in rule 5160:1-2-04 of the Administrative Code:

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

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

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

(1) Must issue proper notice and hearing rights as outlined in division 5101:6 of the Administrative Code.

(2) Must distribute to individuals the ODM 1095-B "Health Coverage" in January of each calendar year and upon an individual's request.

(3) Must distribute materials to individuals in accordance with 42 C.F.R. 431.307 (as in effect on June 1, 2015).

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

Replaces: 5160:1-1-51

Effective: 1/1/2016
Five Year Review (FYR) Dates: 01/01/2021
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02, 329.051, 2913.401, 3501.01, 3503.10
Prior Effective Dates: 10/1/13

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. 459 e (as in effect January 7, 2011), receipts distributed to members of certain indian tribes which are referred to in 25 U.S.C. 459 d (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. 117 b (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. 1989 b (as in effect February 1, 2010).

(23) Restitution payments for Aleutian and Pribilof Island Restitution Act under section 206, 50 U.S.C. 1989 c (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 Medicaid: consumer fraud and erroneous payments.

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

(B) Investigation of complaints. Upon notification of a complaint of medicaid fraud, abuse or questionable practices, the administrative agency must conduct a preliminary investigation in accordance with 42 C.F.R. 455.14 (as in effect on November 1,2015 ) to determine if there is sufficient basis to warrant a full investigation.

(1) If the preliminary investigation finds that a full investigation is warranted in accordance with 42 C.F.R. 455.15 (as in effect on November 1, 2015):

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

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

(2) The investigation must continue until the investigation is resolved in accordance with 42 C.F.R. 455.16 (as in effect on November 1, 2015).

(C) Recovery of erroneous payments is authorized in section 5162.23 of the Revised Code, subject to rule 5101:9-7-06 of the Administrative Code. The administrative agency must:

(1) Not attempt to recover erroneous payments when:

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

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

(c) An individual has received fair hearing benefits pending a state hearing pursuant to rule 5101:6-4-01 of the Administrative Code, and the individual loses the hearing. The administrative agency may recover the benefits if it requests and obtains authorization from ODM prior to taking any action.

(2) Recover erroneous payments from an individual only:

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

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

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

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

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

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

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

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

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

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

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

(5) An incorrect spenddown amount, as calculated according to rule 5160:1-3-04 of the Administrative Code, the amount subject to recovery is the lesser of:

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

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

(6) Receipt of long-term services and supports, waiver services, or intermediate care facilities for individuals with intellectual disabilities (ICFs/IID) services, as a result of:

(a) Improper transfer of resources as outlined in rule 5160:1-3-07.2 of the Administrative Code, the amount subject to recovery is the amount of payments made on behalf of the individual.

(b) Resources in excess of the limit set forth in rule 5160:1-3-05.1 of the Administrative Code:

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

(ii) The individual may choose to increase the patient liability through payment of a lump sum to the nursing facility if the increase will reduce the resources to the appropriate limit. The reduction in resources must be accomplished in one calendar month and in compliance with rule 5160:1-1-58 of the Administrative Code.

(c) Patient liability as outlined in rule 5160:1-3-04.3 and rule 5160:1-3-04.4 of the Administrative Code, the amount subject to recovery is the difference between the amount of the correct patient liability and the amount of the patient liability that was in effect during the erroneous payment period, added up over the months of the erroneous period.

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

Replaces: 5160:1-1- 51.2

Effective: 8/1/2016
Five Year Review (FYR) Dates: 08/01/2021
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 2913.401, 5162.03, 5162.23, 5163.02
Prior Effective Dates: 10/01/2013

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(1) Written informing.

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

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

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

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

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

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

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

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

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

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

(i) Increased well-being;

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

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

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

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

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

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

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

(f) The prior authorization process, including that:

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

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

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

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

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

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

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

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

(iii) Verification requirements, if any; and

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

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

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

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

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

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

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

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

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

(D) Provision of support services.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(E) Custodial agency responsibility.

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

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

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

(a) After the initial informing process;

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

(c) After completion of each annual review.

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

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

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

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

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

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

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

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

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

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

(v) The JFS 03528 or other documentation.

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

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

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

(b) Copies of all correspondence received and sent;

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

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

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

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

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

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

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

(iii) Records of transportation requested and provided; and

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

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

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

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

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

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

(1) Complete the JFS 03528;

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

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

(4) Attend scheduled appointments for healthchek services.

Replaces: 5101:1-38-05

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

5160:1-2-06 Medicaid: outstationing workers at disproportionate share hospitals and federally qualified health centers.

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

(B) Responsibilities of the administrative agency.

(1) Locations. The administrative agency:

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

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

(2) Hours.

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

(i) Containing the following information:

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

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

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

(3) Workers and assistance.

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

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

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

(A) The confidentiality of information rules specified in 42 C.F.R.part 431, subpart F (as in effect on December 1, 2015);

(B) The requirements of 42 C.F.R. section 447.10 (as in effect on December 1, 2015), which prohibit medicaid payments to anyone other than a provider or recipient except under specific circumstances; and

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

(b) The outstationed worker must:

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

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

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

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

Replaces: 5160:1-1- 51.4

Effective: 8/1/2016
Five Year Review (FYR) Dates: 08/01/2021
Promulgated Under: 111.15
Statutory Authority: 5162.031, 5163.02
Rule Amplifies: 5163.02, 5163.10, 5163.101
Prior Effective Dates: 5/1/95, 7/1/00, 1/1/06, 1/1/14

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

5160:1-2-08 Medicaid: individual responsibilities.

(A) This rule describes the responsibilities of an individual applying for or receiving medical assistance, whether on behalf of the individual or someone else.

(B) Individual responsibilities.

(1) When applying for or receiving any medical assistance, an individual must:

(a) Sign and submit an initial application under penalty of perjury. This signature may be electronic, telephonic, a copy or facsimile, or an original ink signature.

(b) Cooperate with the administrative agency in application, verification, determination, redetermination, auditing, and quality control processes set out in this chapter of the Administrative Code. The individual must:

(i) Answer all relevant questions and provide information and documentation necessary to verify the conditions of eligibility as described in rule 5160:1-2-10 of the Administrative Code and the requirements specific to the relevant eligibility category in order to establish initial or continued eligibility.

(ii) Request assistance from the administrative agency when unable to obtain requested information. The individual must provide the information necessary to allow the administrative agency to assist the individual.

(c) Select a managed care plan (MCP) as required by rule 5160-26-02 of the Administrative Code, unless the individual meets one of the exceptions listed in that rule.

(d) Inform the administrative agency within ten calendar days of any change to the following circumstances for the individual or any person living with the individual:

(i) Address.

(ii) Marital status.

(iii) Income, including:

(a) One-time gifts or payments, and

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

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

(v) Third-party responsibility for the individual's health care costs, including:

(a) New coverage under a health insurance policy, no matter who is paying for the coverage;

(b) A change in health insurers;

(c) Loss or ending of other health insurance coverage;

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

(e) Any accident or injury for which another person or entity may be responsible, such as a work-related injury or an injury received in an automobile collision. In addition to reporting the injury or accident, an individual must also report any information received about any involved insurance company.

(e) Cooperate with any third party responsible for an individual's health care costs.

(f) Not commit medicaid eligibility fraud as described in section 2913.401 of the Revised Code.

(2) When applying for or receiving medical assistance on the basis of being blind, disabled, or at least age sixty-five, an individual must also inform the administrative agency of any:

(a) Improvement of the condition for which the benefit is received; or

(b) Change in the ownership or value of a resource owned by the individual or the individual's spouse, including any change in an annuity or an annuity's remainder beneficiary designation.

(C) Authorized representative.

(1) An individual may designate an authorized representative, in writing, to stand in place of the individual and act with authority on behalf of the individual, as described in rule 5160:1-2-09 of the Administrative Code.

(2) If an individual is unable to identify an authorized representative because of incapacity or incompetence, the administrative agency will assist the individual with appointing an authorized representative, as described in rule 5160:1-2-01 of the Administrative Code.

Replaces: 5160:1-1-55

Effective: 8/1/2016
Five Year Review (FYR) Dates: 08/01/2021
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02, 5160.37
Prior Effective Dates: 10/01/2013

5160:1-2-10 Medicaid: conditions of eligibility and verifications.

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

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

(1) Provide a social security number (SSN) in accordance with 42 C.F.R. 435.910 (as in effect March 1, 2016).

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

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

(i) Is applying for or receiving alien emergency medical assistance (AEMA), as described in rule 5160:1-5-06 of the Administrative Code.

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

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

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

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

(2) Be a resident, as defined in 42 C.F.R. 435.403 (as in effect March 1, 2016) of the state of Ohio on the date of application or requested coverage begin date.

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

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

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

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

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

(b) An individual's declaration of U.S. citizenship must be verified as described in rule 5160:1-2-11 of the Administrative Code.

(c) An individual's declaration of qualified non-citizen status must be verified as described in rule 5160:1-2-12 of the Administrative Code.

(d) Verification of alien status is not required when the individual is applying for AEMA, as described in rule 5160:1-5-06 of the Administrative Code.

(4) Take all necessary steps to obtain any annuities, pensions, retirement, and disability benefits for which the individual is eligible, unless the individual can show good cause for not doing so, in accordance with 42 CFR 435.608 (as in effect on March 1, 2016).

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

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

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

(5) In accordance with 42 CFR 435.610 (as in effect on March 1, 2016), assign to the state of Ohio any rights to medical support and payments for medical care from any third party for:

(a) The individual, and

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

(6) Cooperate with the child support enforcement agency (CSEA) in establishing the paternity of any medicaid eligible child, in accordance with 42 C.F.R. 433.147 (as in effect on March 1, 2016), unless the individual:

(a) Is not receiving medical assistance for himself or herself;

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

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

(d) Is receiving transitional medical assistance.

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

(a) From a third-party insurance company to provide additional information that is required to authorize coverage or obtain benefits through the third party insurance company.

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

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

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

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

(8) Meet all eligibility requirements for an eligibility category set out in an approved state plan amendment, Chapters 5160:1-2, 5160:1-3, 5160:1-4, 5160:1-5, or 5160:1-6 of the Administrative Code, including:

(a) Income requirements for the eligibility category.

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

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

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

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

(b) A current pay stub;

(c) An award letter from a certifying agency;

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

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

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

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

(ii) A financial institution statement; or

(iii) Legal documents.

Replaces: 5160:1-1-58

Effective: 8/1/2016
Five Year Review (FYR) Dates: 08/01/2021
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02, 5164.02
Rule Amplifies: 5162.03, 5163.02, 5164.02
Prior Effective Dates: 10/01/2013

5160:1-2-11 Medicaid: United States (U.S.) citizenship documentation.

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

(B) Any individual applying for medical assistance and declaring U.S. citizenship or nationality shall verify citizenship in accordance with 42 C.F.R. 435.407 (as in effect on December 1, 2015).

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

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

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

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

(c) An individual who is:

(i) Enrolled in medicare;

(ii) Receiving supplemental security income (SSI);

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

(iv) Receiving adoption or foster care assistance under Title IV-E of the Social Security Act (as in effect on December 1, 2015 ); or

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

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

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

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

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

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

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

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

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

(a) A Seneca Indian tribal census record;

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

(c) A certificate of Indian blood;

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

(e) Other native American tribal documents.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(ii) A military dependent's identification card;

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

(iv) A school identification card with a photograph;

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

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

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

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

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

(1) The administrative agency shall approve time-limited medical assistance, provided the individual satisfies all other conditions of eligibility outlined in rule 5160:1-2-10 of the Administrative Code. The reasonable opportunity period:

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

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

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

Replaces: 5160:1-1- 58.2

Effective: 8/1/2016
Five Year Review (FYR) Dates: 08/01/2021
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02, 5164.02
Rule Amplifies: 5162.03, 5163.02, 5164.02
Prior Effective Dates: 10/1/13

5160:1-2-12 Medicaid: non-citizens.

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

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

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

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

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

(4) "Asylee" means a person who has been granted asylum under section 208 of the Immigration and Nationality Act (INA) (as in effect on January 1, 2016).

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

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

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

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

(9) "Qualified non-citizen" means:

(a) An LPR;

(b) An asylee;

(c) A refugee admitted to the United States under section 207 of the INA (as in effect on January 1, 2016);

(d) A parolee allowed into the United States under section 212(d)(5) of the INA (as in effect on January 1, 2016) for a period of at least one year;

(e) An alien whose deportation is being withheld under section 243(h) or 241(b)(3) of the INA (as in effect on January 1, 2016);

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

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

(h) An Amerasian immigrant;

(i) An alien or alien's child who has been battered or subjected to extreme cruelty, as defined in 8 U.S.C. 1641(c) (as in effect on January 1, 2016); or

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

(10) "Quarter of coverage" is the basic unit for determining whether a worker is insured under the social security program. The amount of wages and self-employment income which an individual shall have in order to be credited with a quarter of coverage is defined in 42 U.S.C. 413(d) (as in effect on January 1, 2016), and is published annually in the Federal Register.

(11) "Veteran" means an individual who served in the active military service and who was discharged or released from duty under honorable conditions. This term includes military personnel who die during active duty service, as defined in 38 U.S.C. 1101 (as in effect on as in effect on January 1, 2016), and Filipinos described in 38 U.S.C. 107 (as in effect on January 1, 2016). These are individuals who served in the Philippine Commonwealth army during World War II or as Philippine scouts following the war.

(12) "Victim of trafficking" refers to:

(a) Victims of trafficking and certain family members, as identified in the Trafficking Victims Protection Reauthorization Act of 2003 (TVPRA) ( Pub. L. No. 108-193 ), who are eligible for federally funded or administered benefits to the same extent as refugees, per 22 U.S.C. 7105(b)(1)(A) (as in effect on January 1, 2016).

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

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

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

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

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

(1) A non-citizen who was lawfully residing in the United States as of August 22, 1996, and continues to be a lawful resident of the U.S.

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

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

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

(i) Refugee;

(ii) Asylee;

(iii) An alien whose deportation is being withheld under section 243(h) of the INA (as in effect on January 1, 2016);

(iv) Cuban or Haitian entrant;

(v) Amerasian immigrant;

(vi) Victim of trafficking; or

(vii) Afghan or Iraqi special immigrant.

(b) A lawfully residing pregnant woman.

(c) A lawfully residing child.

(d) An LPR who has forty quarters of coverage under Title II of the Social Security Act (as in effect on January 1, 2016) or can be credited with such quarters.

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

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

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

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

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

(e) An individual who:

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

(ii) Is a veteran who received an honorable discharge, not a discharge on account of alienage as described in 8 U.S.C. 1426 (as in effect on January 1, 2016).

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

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

(i) Married for at least one year; or

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

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

(h) An American Indian born in Canada to whom the provisions of 8 U.S.C. 1359 (as in effect on January 1, 2016) apply.

(i) A member of an Indian tribe, as defined in 25 U.S.C. 450B(e) (as in effect on January 1, 2016).

(D) An individual who is not a U.S. citizen or national and not in a satisfactory immigration status may be eligible for alien emergency medical assistance as described in rule 5160:1-5-06 of the Administrative Code, and is not required to verify alien status.

(E) Any individual applying for medical assistance and declaring a satisfactory immigration status shall bear the burden of proof of satisfactory immigration status.

(F) The process for establishing satisfactory immigration status shall include that:

(1) The administrative agency must attempt to verify an individual's immigrant status through the electronic eligibility system.

(2) If the individual's immigrant status cannot be verified through the electronic eligibility system, the individual must present documentary evidence of immigration status. The administrative agency is required to confirm the authenticity of the documentation provided by the individual through the automated systematic alien verification for entitlements (SAVE) system. Documentary evidence of immigration status refers to:

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

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

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

(d) For victims of trafficking:

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

(ii) The SAVE system does not contain information about victims of trafficking.

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

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

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

(ii) I-766 (employment authorization document) which must show 8 U.S.C. 1231(a)(7) (as in effect on January 1, 2016) as the provision of law authorizing employment.

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

(G) Reasonable opportunity period for individuals who self-declare to be in satisfactory immigration status. If the administrative agency has been unable to verify satisfactory immigration status through the electronic eligibility system, and the individual has not provided verification as described in paragraph (E)(2) of this rule, the administrative agency shall give the individual reasonable opportunity to present verification of satisfactory immigration status.

(1) The administrative agency shall approve time-limited medical assistance, provided the individual satisfies all other conditions of eligibility outlined in rule 5160:1-2-10 of the Administrative Code.

(2) The reasonable opportunity period:

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

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

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

Replaces: 5160:1-1- 58.3

Effective: 8/1/2016
Five Year Review (FYR) Dates: 08/01/2021
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02
Prior Effective Dates: 10/1/13

5160:1-2-14 Medicaid: continuous eligibility for children younger than age nineteen.

(A) This rule describes the twelve-month period of continuous eligibility for a child younger than age nineteen, and the conditions under which the child's coverage ends during the twelve-month period, as described in section 1902(e)(12) of the Social Security Act (as in effect on January 1, 2016 ).

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

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

(2) Alien emergency medical assistance as described in rule 5160:1-1-05 or 5160:1-5-06 of the Administrative Code; or

(3) Refugee medical assistance as described in rule 5160:1-5-05 of the Administrative Code.

(C) Duration.

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

(a) On the date that medical assistance began as a result of an initial determination or annual renewal in accordance with rule 5160:1-2-01 or rule 5160:1-2-01.2 of the Administrative Code,

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

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

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

(b) When the child:

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

(ii) Dies; or

(iii) Has not paid the premium amounts required for coverage, if the child is covered under the medicaid buy-in for workers with disabilities category described in rule 5160:1-5-03 of the Administrative Code; or

(iv) Reaches age nineteen.

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

(E) Regardless of a child's status under this rule, payment for services shall not be made if payment is prohibited under rule 5160:1-1-05 of the Administrative Code.

Replaces: 5160:1-1- 63.2

Effective: 8/1/2016
Five Year Review (FYR) Dates: 08/01/2021
Promulgated Under: 111.15
Statutory Authority: 5162.031, 5163.02
Rule Amplifies: 5163.02, 5163.03
Prior Effective Dates: 4/1/10 (Emer.), 7/1/10, 10/15/10, 12/20/13, 1/1/14

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