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

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

(A) This rule describes the responsibilities of an individual, or someone acting on his or her behalf, who is applying for or receiving medical assistance.

(B) Individual responsibilities.

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

(a) Sign, under penalty of perjury, and submit an application for medical assistance. The individual's signature may be written (original or a copy), electronic, or telephonic.

(b) Cooperate with the administrative agency in any eligibility determination for initial or continuing coverage, audit, and quality control process set out in this chapter of the Administrative Code. The individual must:

(i) In completing an application or renewal for medical assistance, answer all required questions and provide documentation requested by the administrative agency necessary to verify the conditions of eligibility as described in rule 5160:1-2-10 of the Administrative Code and any other relevant eligibility criteria required under Chapter 5160:1-3, 5160:1-4, 5160:1-5, or 5160:1-6 of the Administrative Code.

(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 any:

(a) One-time gifts or payments;

(b) Change in hourly wage or salary;

(c) Change in full-time or part-time status; or

(d) Gain 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 5160-1-33 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.

Effective: 8/1/2017
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, 08/01/2016