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

(A) This rule describes the conditions under which a child may receive time-limited medical assistance as a result of an initial, simplified determination of eligibility , as described in section 1920A of the Social Security Act (as in effect on July 1, 2012).

(B) Definitions.

(1) "Child," for the purpose of this rule, means a person younger than age nineteen.

(2) "Qualified entity," for the purpose of this rule, means:

(a) A county department of job and family services (CDJFS); and

(b) A hospital, federally qualified health center (FQHC) or FQHC look-alike, as described in Chapter 5101:3-28 of the Administrative Code, that has requested to serve as a qualified entity and has been determined by the state medicaid agency to be capable of making presumptive eligibility determinations.

(C) Eligibility criteria for presumptive coverage.

(1) A child who receives presumptive coverage is ineligible for a new presumptive coverage period for one year from the date on which the presumptive coverage began.

(2) Except as set forth in paragraph (C)(1) of this rule, a child is eligible for presumptive coverage if the child:

(a) Is younger than age nineteen; and

(b) Is a resident of the state of Ohio; and

(c) Is a United States citizen or qualified alien as defined in rule 5101:1-38-02.3 of the Administrative Code; and

(d) Has gross family income no more than two hundred per cent of the federal poverty level for the family size.

(3) The eligibility criteria set forth in paragraph (C)(2) of this rule are verified by self-declared statements.

(D) Duration of presumptive coverage.

(1) Presumptive coverage begins on the date the qualified entity determines a child is presumptively eligible. No retroactive coverage may be provided as a result of a presumptive eligibility determination.

(2) Presumptive coverage ends on the earlier of (and includes):

(a) The date the CDJFS determines, pursuant to rule 5101:1-38-01.2 of the Administrative Code, that the child is eligible or ineligible for ongoing medical assistance ; or

(b) If an application for ongoing medicaid is not filed on the child's behalf, the last day of the month following the month in which the child was determined to be presumptively eligible.

(E) State agency responsibilities. The state medicaid agency shall provide qualified providers with:

(1) Such forms as are necessary for applications on behalf of children to be submitted for presumptive medical assistance under the state plan; and

(2) Information on how to assist individuals in completing and filing such forms.

(F) Qualified entity responsibilities

(1) If the qualified entity is a CDJFS:

(a) No later than the end of the business day after receipt of a signed and dated application for medical assistance on behalf of a child, the CDJFS shall determine whether the child is eligible for presumptive coverage under this rule.

(b) For the purpose of the presumptive eligibility determination, the CDJFS shall accept the family's self-declaration of the presumptive eligibility criteria unless the CDJFS has contradictory information.

(c) If a child is eligible for presumptive coverage, the CDJFS shall:

(i) Approve presumptive coverage for the child ; and

(ii) Inform the child's representative of:

(a)The presumptive coverage, and

(b)That failure to cooperate with the eligibility determination process set forth in rule 5101:1-38-01.2 of the Administrative Code will result in a denial of medical assistance, which will trigger the termination of presumptive coverage.

(iii) Not make an absent parent referral described in rule 5101:1-3-10 of the Administrative Code as a part of the approval of presumptive eligibility coverage.

(d) If a child is not eligible for presumptive coverage, the CDJFS shall inform, on a form designated by the Ohio department of job and family services (ODJFS), the child's representative of the denial and that the child's eligibility for medical assistance will be reviewed.

(e) Whether or not a child is eligible for presumptive coverage, the CDJFS shall determine whether the child is eligible for medical assistance pursuant to rule 5101:1-38-01.2 of the Administrative Code.

(2) If the qualified entity is a hospital, FQHC, or FQHC look-alike:

(a) Upon request, or if the qualified entity believes the child may meet the criteria for presumptive eligibility for children, determine whether the child is presumptively eligible under this rule.

(b) Accept self-declaration of the presumptive eligibility criteria unless contradictory information is provided to or maintained by the qualified entity.

(c) If the child is presumptively eligible:

(i) Approve presumptive coverage for the child; and

(ii) Provide the child's parent or guardian, as appropriate, at the time of determination, with a notice of the child's presumptive eligibility. Such notice shall include the child's:

(a) Presumptive eligibility determination date;

(b) Name, date of birth, and address;

(c) MITS billing number; and

(d)A reminder that the child's parent or guardian is required to make application for ongoing medical assistance for the child no later than the last day of the following month.

(iii) Notify the state medicaid agency of the presumptive eligibility determination within five working days after the date the determination is made.

(iv) Take all reasonable steps to help the consumer complete the application for ongoing medicaid or make contact with the CDJFS.

(d) If the child is not presumptively eligible, inform the child's parent or guardian that there may be other categories of medical assistance available to the child, and that the child's parent or guardian should contact the local CDJFS for an eligibility determination.

(G) Denial of presumptive coverage is not grounds for a state hearing under division 5101:6 of the Administrative Code.

Replaces: 5101:1-38-40

Effective: 07/01/2012
R.C. 119.032 review dates: 07/01/2015
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.)