5160:1-5-05 Breast and cervical cancer project (BCCP) medicaid: application process.

(A) The BCCP medicaid application process shall:

(1) Be coordinated between ODJFS, ODH BCCP, and ODH BCCP designated local agencies and/or subgrantees,

(2) Be coordinated with ODH BCCP case management services, and

(3) Support the goals of the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (BCCPTA), identified in rule 5101:1-41-01 of the Administrative Code.

(B) ODJFS shall make available to the ODH BCCP and its designated local agencies or subgrantees the JFS 07161 "Ohio Breast and Cervical Cancer Project (BCCP) Medicaid Application" (rev. 10/2006) and the JFS 07160 "Ohio breast and cervical cancer project (BCCP) medicaid health care provider's revision of treatment plan" (2/2002).

(C) Provision of the JFS 07161 to potential applicants.

(1) Effective July 1, 2002, ODH BCCP designated local agencies or subgrantees shall provide the JFS 07161 to ODH BCCP enrollees screened for breast or cervical cancer under the centers for disease control and prevention's (CDC) national breast and cervical cancer early detection program (NBCCEDP) and referred for breast or cervical cancer diagnostic evaluation.

(a) ODH BCCP enrollees screened for breast or cervical cancer under the CDC NBCCEDP and referred for breast or cervical cancer diagnostic evaluation on or after July 1, 2002 will be provided the JFS 07161 by the ODH BCCP designated local agency or subgrantee at the time of the enrollee's diagnostic referral.

(b) ODH BCCP enrollees screened for breast or cervical cancer under the CDC NBCCEDP and referred for breast or cervical cancer diagnostic evaluation prior to July 1, 2002 will be provided the JFS 07161 by the ODH BCCP designated local agency or subgrantee no later than the date the ODH BCCP designated local agency or subgrantee is notified by an ODH BCCP breast and cervical cancer screening provider that the ODH BCCP enrollee is found to need treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(c) ODH BCCP enrollees screened for breast or cervical cancer under the CDC NBCCEDP who are receiving treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer as of July 1, 2002 will be provided the JFS 07161 by the ODH BCCP designated local agency or subgrantee no later than September 1, 2002.

(2) The ODH BCCP designated local agency or subgrantee will notify in writing ODH BCCP enrollees described in paragraph (C)(1) of this rule to return the completed BCCP medicaid application to the designated ODH BCCP regional case manager.

(D) The ODH BCCP enrollee must submit the JFS 07161 to the designated ODH BCCP regional case manager. The "Ohio Breast and Cervical Cancer Project (BCCP) Medicaid Application (JFS 07161)" shall supply all requested information necessary for ODH BCCP regional subgrantees and ODJFS to fulfill their responsibilities in processing BCCP medicaid applications.

(E) Submission of completed JFS 07161 to ODJFS.

(1) If the ODH BCCP enrollee submits the JFS 07161 to the designated ODH BCCP regional case manager and if subsequently the ODH BCCP breast and cervical cancer screening provider notifies the designated ODH BCCP regional case manager that, as a result of the NBCCEDP funded screening, a treating health professional has determined that the ODH BCCP enrollee needs treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer, the designated ODH BCCP regional case manager shall provide, within five business days of receipt of the diagnostic information, ODJFS with the completed JFS 07161, which includes:

(a) The JFS 07161 signed by the applicant or authorized representative, which includes

(b) The ODH BCCP regional case manager verification of receipt of diagnostic results. ODH BCCP breast and cervical cancer screening providers must provide diagnostic results of NBCCEDP funded screenings to designated ODH BCCP case manager(s).

(2) If the ODH BCCP enrollee has not submitted the JFS 07161 to the designated ODH BCCP regional case manager and the ODH BCCP breast and cervical cancer screening provider notifies the designated ODH BCCP regional case manager that, as a result of the NBCCEDP funded screening, a treating health professional has determined that the ODH BCCP enrollee needs treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer, the designated ODH BCCP regional case manager shall notify the ODH BCCP enrollee in writing within five business days of receipt of the diagnostic information, that the JFS 07161 must be submitted to the designated ODH BCCP regional case manager for the BCCP medicaid application to be processed.

(3) If the ODH BCCP enrollee submits the BCCP medicaid application to the designated ODH BCCP regional case manager and if diagnostic results indicate that the ODH BCCP enrollee does not need treatment for either breast or cervical cancer, pre-cancerous conditions, or early stage cancer, the designated ODH BCCP regional case manager will notify the individual in writing within five business days that the JFS 07161 will not be submitted to ODJFS.

(F) ODJFS is responsible for all determinations of BCCP medicaid eligibility (including retroactive eligibility).

(1) ODJFS shall use available sources of information, including the following, in the eligibility determination process:

(a) Information contained in the BCCP medicaid application,

(b) CRIS-E history to determine if the applicant is currently enrolled in medicaid or has a pending medicaid application.

(2) ODJFS shall utilize the eligibility criteria set forth in rules 5101: 1-41-03 and 5101:1-41-04 of the Administrative Code.

(3) ODJFS will complete all determinations of eligibility within forty-five days of receipt of a complete application. A delay in the determination or redetermination shall not be a basis for granting eligibility nor shall pendency beyond forty-five days be the sole basis for denial.

(4) Determinations of eligibility shall include:

(a) BCCP medicaid eligibility,

(b) BCCP medicaid eligibility for a time limited period (if information on the BCCP medicaid application indicates possible eligibility in any other category of medicaid), or

(c) BCCP medicaid ineligibility.

(5) All decisions are to be documented.

(G) ODJFS is responsible for all redeterminations of BCCP medicaid eligibility.

(1) ODJFS will redetermine BCCP medicaid eligibility either:

(a) Prior to the completion of the lesser of:

(i) The individual's treatment period, or,

(ii) Twelve months continuous enrollment in BCCP medicaid.

(b) When ODJFS is notified of a change in the individual's circumstances (e.g., completion of treatment prior to the originally determined treatment period).

(2) ODJFS will provide written notice to the BCCP medicaid recipient:

(a) That information is required for the determination of continued BCCP medicaid eligibility, and

(b) To return required completed redetermination materials to the assigned ODH BCCP regional case manager.

(3) The BCCP medicaid recipient must submit the required completed redetermination materials to the designated ODH BCCP regional case manager.

(4) Submission of BCCP medicaid redetermination documents to ODJFS.

(a) If the BCCP medicaid recipient submits the completed BCCP medicaid redetermination documents to the designated ODH BCCP regional case manager and subsequently the treating health professional notifies the designated ODH BCCP case manager that the individual has been found to need continued treatment for either breast or cervical cancer, pre-cancerous conditions, or early stage cancer, the designated ODH BCCP regional case manager shall provide ODJFS completed BCCP medicaid redetermination materials to ODJFS within five business days of receipt of both the completed BCCP medicaid redetermination documents and notification from the treating health professional.

(b) BCCP medicaid redetermination documents include:

(i) JFS 07161 signed by the applicant or authorized representative, and

(ii) JFS 07160.

(c) If the BCCP medicaid recipient has not submitted the completed BCCP medicaid redetermination documents to the designated ODH BCCP regional case manager and the treating health professional notifies the designated ODH BCCP case manager that the individual has been found to need continued treatment for either breast or cervical cancer, pre-cancerous conditions, or early stage cancer, the designated ODH BCCP regional case manager shall notify the BCCP medicaid recipient in writing within five business days of receiving diagnostic notification, that the BCCP medicaid redetermination documents must be completed and submitted to the designated ODH BCCP regional case manager for continued BCCP medicaid eligibility to be determined.

(d) If the BCCP medicaid recipient submits the completed BCCP medicaid redetermination documents to the designated ODH BCCP regional case manager and if the treating health professional notifies the designated ODH BCCP case manager that the individual has been found to not need continued treatment for either breast or cervical cancer, pre-cancerous conditions, or early stage cancer, the designated ODH BCCP regional case manager will notify the individual in writing within five business days that the BCCP medicaid redetermination documents will not be submitted to ODJFS.

(5) Determinations of continued BCCP medicaid eligibility shall be based on:

(a) All required information as supplied by the recipient to the ODH BCCP regional case manager, and

(b) A review of CRIS-E history to determine if the recipient is currently receiving medicaid benefits or has a pending medicaid application.

(6) All decisions are to be documented.

(7) Determinations of continuing BCCP medicaid eligibility:

(a) Eligibility continued for the duration of a new certified treatment period which the treating health professional states is needed for continued treatment,

(b) Termination of eligibility based on the individual's failure to submit reapplication materials by required deadline,

(c) No longer meets the eligiblity criteria for continued eligibility and ineligible for any other category of medicaid, or

(d) Termination of BCCP medicaid, in accordance with rule 5101:1-38-01.1 of the Administrative Code.

(H) An individual may apply for a new period of BCCP medicaid eligibility after BCCP medicaid termination.

(1) A period of BCCP medicaid eligibility will commence each time an individual:

(a) Is screened for breast or cervical cancer under the CDC NBCCEDP,

(b) Is found, as a result of the CDC NBCCEDP screening, to need treatment of breast or cervical cancer, pre-cancerous condition, or early stage cancer,

(c) Submits a completed BCCP medicaid application in accordance with paragraphs (C) and (D) of this rule, and

(d) Is determined by ODJFS to meet all eligibility criteria for BCCP medicaid as described in rule 5101:1-41-03 of the Administrative Code.

(2) Individuals who have completed a treatment period, have had their BCCP medicaid eligibility terminated, and subsequently have been found to have new, recurrent, or metasticized breast or cervical cancer, pre-cancerous condition, or early stage cancer must meet the BCCP medicaid eligibility requirements defined in rule 5101:1-41-03 of the Administrative Code to be determined eligible for an additional period of BCCP medicaid coverage.

(3) Individuals who have not completed their treatment period, have had their BCCP medicaid eligibility terminated, and have been found to have new, recurrent, or metasticized breast or cervical cancer:

(a) Do not need to be recertified as eligible for the ODH BCCP to reestablish BCCP medicaid eligibility; and

(b) Must submit a new JFS 07161 to reestablish BCCP medicaid eligibility.

(I) Screening for potential eligibility for other categories of medicaid by ODJFS at application and redetermination.

(1) If information on the JFS 07161 indicates the applicant is not potentially eligible for any other category of medicaid, neither income nor asset information is not needed.

(2) If information on the JFS 07161 indicates the applicant is potentially eligible for any other category of medicaid, the applicant must provide income and/or asset information to screen for eligibility under any other category of medicaid.

(a) If income or asset information indicates the applicant does not appear eligible for any other category of medicaid, no additional income or asset information is needed.

(b) If income or asset information indicates the applicant appears eligible for any other category of medicaid, the applicant must be:

(i) Notified of potential eligibility; and

(ii) Given the opportunity to and instructions for submission of additional information required to make a determination of eligibility in other categories of medicaid.

(a) ODJFS will notify the applicant in writitng to complete and submit additional information required to the CDJFS in the applicant's county of residence,

(b) ODJFS will notify the applicant in writing to complete and submit additional information required to the CDJFS in the applicant's county of residence,

(i) If the CDJFS determines the applicant eligible for any other category of medicaid, ODJFS will terminate BCCP medicaid and transfer the case information to the CDJFS in accordance with paragraph (D) (8) of rule 5101:1-41-04 of the Administrative Code.

(ii) If the CDJFS determines the applicant ineligible for any other category of medicaid, the CDJFS will notify ODJFS and ODJFS will maintain the BCCP medicaid case.

Effective: 10/01/2006
R.C. 119.032 review dates: 07/14/2006 and 10/01/2011
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011
Rule Amplifies: 5111.011
Prior Effective Dates: 7/1/2002