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

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

(B) Calculation of time periods. All calculations of time periods used in the determination and redetermination of eligibility shall be computed as follows:

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

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

(C) Request for application. When an individual requests an application, the administrative agency shall:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(E) Assistance with application.

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

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

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

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

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

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

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

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

(a) An eligibility worker shall, at the individual's request, assist in completing the application by asking the individual for answers needed to complete the application, then recording the individual's answers on the application form or in the electronic eligibility system.

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

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

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

(F) Receipt of initial application.

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

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

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

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

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

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

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

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

(1) Initial determination:

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

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

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

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

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

(iv) The individual's reporting responsibilities; and

(v) The confidential nature of:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(xvii) Upon request, the administrative agency will help the individual register to vote or update voter registration as outlined in rule 5101:1-2-15 of the Administrative Code; and

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

(c) The administrative agency shall:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(a) The administrative agency cannot reach a decision because the examining physician delays or fails to take a required action; or

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

(ii) The administrative agency shall not:

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

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

(e) Retroactive coverage. The administrative agency shall approve eligibility for medical assistance (except for a recipient of transitional medicaid as described in rule 5101:1-40-05 of the Administrative Code or a qualified medicare beneficiary as described in rule 5101:1-38-03 of the Administrative Code) effective no later than the first day of the third month before the month of application if the individual:

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

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

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

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

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

(3) Annual redetermination. The administrative agency shall:

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

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

(i) Every twelve months; or

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(2) The administrative agency shall explain:

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

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

(3) If the information or verification required to establish the individual's eligibility for assistance is not received by the administrative agency by the stated date, the administrative agency shall contact the individual in writing, mailed or personally delivered no more than twenty days from the date of the application. The contact letter shall state that the required information or verification has not been received, and that if the information or verification is not received within ten days the administrative agency shall deny the application for medical assistance. This written follow-up letter:

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

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

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

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

(b) Deny or terminate medical assistance if:

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

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

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

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

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

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

(a) Confirm the accuracy of the statement; and

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

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

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

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

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

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

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

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

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

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

(J) Effective date of termination of coverage.

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

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

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

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

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

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

Effective: 01/09/2012
R.C. 119.032 review dates: 10/01/2014
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011 , 5111.012
Rule Amplifies: 5111.01 , 5111.011 , 5111.012 , 2913.401 , 3501.01 , 3503.10 , 5101.58 , 329.051
Prior Effective Dates: 8/1/75, 10/1/75, 6/1/76, 7/14/77, 9/3/77, 12/31/77, 9/1/82, 9/24/83, 8/1/84, 10/20/84, 11/1/84, 12/1/84 (Emer.), 2/10/85, 4/1/86, 8/1/86 (Emer.), 10/3/86, 7/1/87 (Emer.), 8/3/87, 10/1/87 (Emer.), 12/24/87, 3/24/88 (Emer.), 4/1/88 (Emer.), 6/10/88, 6/30/88, 7/1/88 (Emer.), 9/1/88, 9/24/88, 10/1/88 (Emer.), 10/25/88 (Emer.), 12/20/88, 3/1/89 (Emer.), 5/28/89, 12/1/89, 1/1/90 (Emer.), 4/1/90, 6/22/90, 8/1/90 (Emer.), 10/25/90, 1/1/91 (Emer.), 2/21/91, 4/1/91 (Emer.), 6/1/91, 7/1/91 (Emer.), 9/15/91, 10/1/91 (Emer.), 12/20/91, 4/1/92, 7/1/92, 1/1/93, 1/1/93 (Emer.), 2/11/93, 3/18/93, 5/1/93, 9/1/93, 1/1/94, 3/1/94 (Emer.), 4/18/94, 1/1/95, 1/1/95 (Emer.), 4/1/95, 7/1/95, 10/1/95, 6/1/96, 10/1/96 (Emer.), 10/1/96, 12/15/96, 5/1/97, 10/1/97 (Emer.), 10/30/97, 12/30/97, 7/1/98, 10/1/99, 11/1/99 (Emer.), 2/1/00, 5/4/00, 7/1/00, 10/1/02, 6/1/03, 6/1/03 (Emer.), 9/20/03, 10/6/03, 9/25/06, 10/1/06, 6/1/07, 10/1/09, 7/17/11