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This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Chapter 5160:1-2 | Medicaid Application Procedures

 
 
 
Rule
Rule 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 an annual renewal or a redetermination as a result of a reported change, 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 business 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, when received by the administrative agency or the electronic eligibility system during the administrative agency's business hours.

(2) On the next business day, when received by the administrative agency or the electronic eligibility system after the administrative agency's business hours 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 shall:

(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 and application assistance is available through the portal.

(b) The beginning date of benefits depends on the date the signed application is received by the administrative agency.

(c) The verification requirements and deadlines.

(d) Individuals shall cooperate with eligibility determinations, renewals, redeterminations, 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.

(f) The Ohio attorney general (AGO) shall seek recovery or adjustment on behalf of the administrative agency from the estate of the following individuals, as set forth in rule 5160:1-2-07 of the Administrative Code:

(i) A permanently institutionalized individual of any age; or

(ii) An individual fifty-five years of age or older who is not permanently institutionalized.

(3) Fulfill a request for an application within one 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. When the application is provided in person or via U.S. mail, the administrative agency shall enclose a preaddressed, postage-paid envelope for return of the application.

(b) The application shall 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 receipt of a request for assistance or receipt of an application, the administrative agency shall:

(1) Make program information available and accessible to an individual upon request, consistent with 42 C.F.R. 435.905 (as in effect October 1, 2019):

(a) Provide language services at no cost to an individual with limited English proficiency, including oral interpretation and written translations; and

(b) Provide auxiliary aids and services at no cost to an individual living with a disability in accordance with the Americans with Disabilities Act of 1990 (ADA) (Pub. L. No. 101-336) and section 504 of the Rehabilitation Act of 1973 (Pub. L. No. 93-112).

(2) Distribute voter information and registration materials as required by 42 C.F.R. 431.307 (as in effect October 1, 2019).

(3) Coordinate with the special supplemental nutrition program for women, infants and children (WIC) as required by 42 C.F.R. 431.635 (as in effect October 1, 2019) to ensure written notice of the availability of the WIC program is provided to an individual determined eligible for medical assistance, including an individual who is presumptively eligible and is also a potential WIC recipient.

(a) The administrative agency shall advise a 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.

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

(c) The following individuals are potential WIC recipients:

(i) A woman who is:

(a) Pregnant; or

(b) Within a six-month period after giving birth; or

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

(ii) A child younger than five years old.

(F) Assistance.

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

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

(b) The administrative agency shall not reveal confidential information, as described in rule 5160-1-32 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 shall provide accurate information, to the best of his or her knowledge, regardless of whether the person is an authorized representative.

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

(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 when 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 authorized representative's authority.

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

(a) At the individual's request, an eligibility worker shall 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 shall not alter any answers given by the individual.

(b) When an eligibility worker assists with or helps complete an application, the worker shall sign the application form and include the worker's title as a person who assisted with completing the application.

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

(4) Upon request, the administrative agency shall 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 shall:

(a) Explore whether another person is available to assist the individual with obtaining verifications or accessing the individual's means of self-support. For an individual who resides in a nursing facility (NF), explore whether the person who signed the NF admission contract is able to assist the individual.

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

(ii) When verifications are provided, or when means of self-support are able to be accessed by the individual or on the individual's behalf by another person, the administrative agency shall consider the verified criteria or means of self-support in the eligibility determination process.

(b) When no person with the ability to access the individual's means of self-support 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 shall also:

(a) Note in the individual's case record that verifications or means of self-support are not available and shall 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 cannot be accessed because of the individual's 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. When such access has not been obtained prior to the individual's annual renewal, determine continuing eligibility using the most reliable information available.

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

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

(2) Accept and register the application within one business day of the time the signed application is received. Only an application signed under penalty of perjury in accordance with 42 C.F.R. 435.907 (as in effect October 1, 2019) is considered valid.

(a) Acceptable signatures for an application include:

(i) An original handwritten signature; and

(ii) An "electronic signature" or "e-signature," that includes electronic sounds, symbols, or processes attached to or logically associated with records and executed or adopted by individuals with the intent to sign a record. An electronic signature satisfies legal requirements in accordance with section 1306.06 of the Revised Code and includes:

(a) An audio or "telephonically recorded" signature obtained in accordance with procedures approved by the Ohio department of job and family services (ODJFS) that is retrievable and complies with federal record retention requirements in accordance with 7 C.F.R. 272.1(f) (as in effect October 1, 2019); and

(b) A signature submitted electronically as part of the online medical assistance application process; and

(c) A handwritten signature transmitted via any other electronic transmission, such as through email or facsimile; and

(d) A rubber stamp that replaces a signature for an individual who has an inability to sign in accordance with the Rehabilitation Act of 1973 (Pub. L. No. 93-112); and

(e) When the signatory cannot sign with a name, an "X" is a valid signature; and

(f) An electronically signed application received from the federally facilitated marketplace (FFM); and

(g) An electronically signed application received from the social security administration (SSA) for the low-income subsidy (LIS) program.

(b) An individual who applies for health coverage through the FFM will be assessed for medicaid eligibility with the signature provided to the FFM.

(3) When an application is received from a local WIC clinic, maternal, child and family health (MCFH) clinic, or the children with medical handicaps program (CMH) office within five business days of the signature date, the application shall be registered using the signature date. If the application is not received within five business days of the signature date, the application shall be registered using the date the application was received by the administrative agency.

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

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

(6) As required by section 329.051 of the Revised Code, the administrative agency shall:

(a) Give or send a notice meeting the requirements of section 3503.10 of the Revised Code or the JFS 07217 "Voter Registration Notice of Rights and Declination" (rev. 8/2009); and

(b) Give or send the "Voter Registration Information and Update Form" (undated) as prescribed by the secretary of state.

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

(1) Follow the safeguarding guidelines set forth in rule 5160-1-32 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 eligibility 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) When the administrative agency is unable to verify eligibility criteria through electronic sources, the administrative agency shall contact the applicant to collect information needed to process the application. If the individual declares the verifications cannot be accessed or submitted, the individual's statement shall be accepted. If the administrative agency is unable to make contact with the applicant, a written (electronic or on paper) request for the necessary information or verification documents shall be sent.

(a) The written request shall:

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

(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 regarding how an individual can request assistance from the administrative agency with gathering the requested documents.

(b) When 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 no more than twenty calendar days following the date of the application.

(i) The follow-up request for information or verification documents:

(a) Shall be sent electronically, via postal mail, or personally delivered to the individual. When sent via postal mail or personally delivered, the administrative agency shall enclose a preaddressed, postage paid envelope for return of the verification(s); and

(b) Shall 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) Shall 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 the application.

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

(c) The administrative agency shall deny the individual's application when 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. When this happens:

(i) An individual may reapply at any time.

(ii) An individual shall 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 that lists each 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) When information is verified through a telephone contact, record the following details:

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

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

(c) The date of the contact; and

(d) An accurate summary of the information provided.

(I) Determination, redetermination, and renewal of eligibility. The administrative agency shall:

(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 the income and eligibility verification system (IEVS) to assist with the determination of eligibility, as required by section 1137 of the Social Security Act (as in effect October 1, 2019).

(3) Require a signature for all renewals of medical assistance where eligibility was not passively renewed using the electronic eligibility system.

(4) Using the electronic eligibility system, the administrative agency shall:

(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 shall not approve medical assistance to an individual merely because of an agency error or delay in determining eligibility. All eligibility factors shall be met.

(ii) The administrative agency shall 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 shall:

(i) Record, in physical or electronic case records, any information, action, decision, or delay in the application, eligibility determination, or discontinuance 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 a medical assistance category set forth in Chapter 5160:1-2, 5160:1-3, 5160:1-4, 5160:1-5, or 5160:1-6 of the Administrative Code. When an individual who attests to U.S. citizenship or qualified non-citizen status meets all conditions of eligibility for a medical assistance category except for verification of the individual's citizenship or qualified non-citizen status, the administrative agency shall 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 Administrative 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 with 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 medical assistance category set forth in Chapter 5160:1-2, 5160:1-3, 5160:1-4, 5160:1-5, or 5160:1-6 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 5160:1-1-03 of the Administrative Code.

(f) Discontinue medical assistance for an individual who:

(i) Requests that assistance be discontinued; or

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

(J) Reinstatement of medical assistance for individuals whose termination of medical assistance was effective prior to March 18, 2020.

(1) When an individual cooperates with the renewal process, the administrative agency shall:

(a) Reinstate medical assistance, discontinued for failure to cooperate with the renewal process or verification of a reported change, within ninety calendar days of the discontinuance date without requiring a new application in accordance with 42 C.F.R. 435.916(a)(3)(C)(iii) (as in effect October 1, 2019).

(b) Accept the renewal form and/or verifications that caused the discontinuance of medical assistance.

(c) Reinstate medical assistance if all eligibility criteria are met.

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

(2) Individuals discontinued due to returned mail indicating whereabouts unknown.

(a) When the individual's whereabouts become known within the eligibility period, the administrative agency shall reinstate any discontinued medical assistance in accordance with 42 C.F.R. 431.231(d) (as in effect October 1, 2019).

(b) When the individual's whereabouts become known after the effective discontinuance date, a new application for medical assistance is required.

(3) When a hearing request is filed timely by an individual as outlined in division 5101:6 of the Administrative Code, the administrative agency shall reinstate medical assistance benefits at the same benefit level until a hearing decision is rendered in accordance with 42 C.F.R. 431.230 (as in effect October 1, 2019).

(K) Reinstatement of medical assistance for individuals whose termination of medical assistance was effective on or after March 18, 2020. In accordance with section 6008 of the Families First Coronavirus Response Act (FFCRA) (Pub. L. No. 116-127), the administrative agency shall reinstate medical assistance for any individual whose discontinuance of coverage was effective on or after March 18, 2020, except when the discontinuance was due to death, state residence, or the individual's voluntary request.

(L) Timely determinations and renewals. The administrative agency shall make a timely determination of an individual's eligibility for medical assistance under this chapter of the Administrative Code. The administrative agency shall 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 ongoing eligibility for medical assistance; or

(2) Forty-five 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 shall 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.

(M) 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 shall 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) Reports he or she received medical services of a type covered by medical assistance within the three months prior to the application month; and

(ii) Requests retroactive eligibility be determined; and

(iii) 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. Actual income received in each retroactive month shall be used to determine eligibility for that month.

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

(a) Transitional medical assistance 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 discontinues on the last day of a calendar month, except that coverage discontinues on the date an individual:

(a) Becomes a resident of another state; or

(b) Dies; or

(c) Requests that coverage be discontinued.

(N) Duration of eligibility span. The administrative agency shall:

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

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

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

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

(2) Schedule an individual's renewal of eligibility for medical assistance twelve months after the most recent eligibility determination.

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

(O) Third party liability (TPL). For individuals found eligible for or in receipt of medical assistance, the administrative agency shall 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 shall 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 shall be made for each possible health insurance policy.

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

(2) At renewal, or upon any reported change, the administrative agency shall compare the individual's current information to the information on the most recent ODM 06612 "Health Insurance Information Sheet" (rev. 9/2016) or ODM 06613 "Accident/Injury Insurance Information" (rev. 12/2016). When any information has changed, the administrative agency shall 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 shall contact the individual to obtain information regarding potential TPL.

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

(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) when 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 county department of job and family services (CDJFS) receiving report of a move shall determine whether the move is a change of residence or a temporary absence from the home. When 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. When the individual does not have an address in the new county, use the address of the administrative agency in the new county.

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

(c) Record requirements for intercounty transfers within the state.

(i) The CDJFS in the individual's original county of residence shall take the following actions for the identified type of case record:

(a) Electronic records. When the individual moves to another county within the state, the electronic document management system shall be updated with the most recent eligibility determination documentation no later than the end of the business day following the date the CDJFS becomes aware of the address change.

(b) Online records. Prior to the online record being transferred, the CDJFS in the individual's original county of residence shall ensure the electronic eligibility system is updated no later than the end of the business day following the date the CDJFS becomes aware of the address change.

(c) Hard copy records. Hard copy records used in the most recent eligibility determination shall be converted into digital format in the electronic document management system no later than the end of the business day following the date the CDJFS becomes aware of the address change. The remaining hard copy records shall be transferred no later than five calendar days following the date the CDJFS becomes aware of the address change. The CDJFS in the individual's original county of residence shall notify the CDJFS in the individual's county of new residence when a hard copy record is being transferred.

(ii) The case record to be transferred shall contain the following documents:

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

(b) Other pertinent documents, such as citizenship, qualified non-citizen status, income, and resource verifications.

(d) The CDJFS in the individual's 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) Verify potential changes in income, expenses, employment, or household composition resulting from the change in residence when the CDJFS that received the reported change did not complete the verification prior to the intercounty transfer.

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

(e) When 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 that established the claim remains responsible for any necessary action on the claim.

(ii) When no claim has been established and the CDJFS in each county agrees the CDJFS in 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.

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

(1) Shall distribute the internal revenue service (IRS) form 1095-B "Health Coverage" to individuals in January of each calendar year and upon an individual's request in accordance with the Patient Protection and Affordable Care Act (ACA) (Pub. L. No. 111-148).

(2) Shall distribute voter information and registration materials to individuals in accordance with 42 C.F.R. 431.307 (as in effect on October 1, 2019).

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

(R) The administrative agency shall provide timely and adequate written notice of any decision affecting an individual's eligibility, including an approval, denial, discontinuance, or suspension of eligibility, or a denial or change in benefits, consistent with 42 C.F.R. 435.917 (as in effect October 1, 2019) and division 5101:6 of the Administrative Code.

Supplemental Information

Authorized By: 5162.03, 5163.02
Amplifies: 3501.01, 3503.10, 5162.03, 5163.02, 329.051, 2913.401
Five Year Review Date: 12/14/2025
Prior Effective Dates: 10/1/2013, 1/1/2017
Rule 5160:1-2-02 | Medicaid: income guidelines, calculations, and exclusions.
 

(A) This rule sets forth general income guidelines, calculations, and exclusions used in determining eligibility for medical assistance. Income guidelines, calculations, or exclusions that apply to a specific covered group will be addressed in the eligibility rules for that group. Unless otherwise stated:

(1) If living in the same household, 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 income of a minor's parent, living in the same home as the minor and the minor's dependent child, shall be counted as income to the covered group.

(B) Gross monthly income shall be calculated as follows:

(1) The amount of gross monthly non-excluded income shall first be established. Disregards and deductions, as defined in rule 5160:1-1-01 of the Administrative Code, shall then be subtracted when applicable.

(2) In calculating gross income, both earned and unearned, the monthly amounts shall be rounded down to the nearest whole dollar by dropping the cents.

(3) To correctly calculate gross income that is not received on a monthly basis, use the following conversion factors. All cents in gross weekly, bi-weekly, or semi-monthly shall be dropped before and after multiplying.

(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.

(4) Hourly rates that contain cents are not rounded when determining a weekly, bi-weekly, or semi-monthly amount.

(C) The administrative agency shall exclude the following income:

(1) Grants, scholarships, fellowships, or gifts used to pay for educational expenses such as tuition, fees, or other necessary expenses that are required to attend an educational institution.

(2) Home produce, including farm and garden produce, grown by the individual or family, and utilized for household consumption, in accordance with 20 C.F.R. 416.1124 (as in effect October 1, 2016).

(3) Income tax refunds.

(4) Residential state supplement (RSS) payments.

(5) Federal, state, and local foster care payments received under title IV-E, for a child currently living in the household.

(6) Federal, state, and local adoption assistance payments received under title IV-E.

(7) The value of foods donated by the U.S. department of agriculture commodity supplemental food program.

(8) 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.

(9) Payments to volunteers participating in the retired senior volunteer program (RSVP), foster grandparent program, senior companion program, service corps of retired executives (SCORE), active corps of executives (ACE), volunteers in service to america (VISTA), or any other programs under 42 U.S.C 5044 (as in effect October 1, 2016).

(10) The value of supplemental food assistance received under the Child Nutrition Act of 1966 described in 42 U.S.C. 1771 (as in effect October 1, 2016) and the special food service program for children under the national school lunch act described in 42 U.S.C. 1751 (as in effect October 1, 2016).

(11) Payments made to Native Americans as listed in section IV of 20 C.F.R 416 Subpart K Appendix (as in effect on October 1, 2016).

(12) Benefits paid to eligible households under the Low-Income Home Energy Assistance Act of 1981, in accordance with 42 U.S.C. 8624 (as in effect October 1, 2016).

(13) Payments received on or after January 1, 1989, as a result of the Agent Orange Compensation Exclusion Act (Pub. L. 101-201).

(14) 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, in accordance with 50 U.S.C. 4215 (as in effect October 1, 2016).

(15) Restitution payments for Aleutian and Pribilof Island Restitution Act in accordance with 50 U.S.C. 4236 (as in effect October 1, 2016).

(16) Payments under the Radiation Exposure Compensation Act, 42 U.S.C. 2210 (as in effect October 1, 2016).

(17) Earned income tax credit payments in the form of a refund of federal income tax.

(18) Payments made from any fund established pursuant to a class settlement in the case of Susan Walker v. Bayer Corporation, 96-C-5024 (N.D. Ill).

(19) Payments to victims of Nazi persecution.

(20) Principal of a bona-fide loan.

(21) Any federal major disaster and emergency assistance described in 42 U.S.C. 5170 (as in effect on October 1, 2016), including comparable disaster assistance provided by states, local governments and disaster assistance organizations.

(22) Nutrition program benefits provided for the elderly under Title VII of the Older Americans Act of 1965, as amended.

(23) Federal housing assistance provided by the office of housing and urban development (HUD) or the U.S. department of agriculture's rural housing service (RHS), formally known as the farmers home administration (FHA).

(24) Retroactive payments paid to the individual as the result of a state hearing.

(25) 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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 11/1/2022
Prior Effective Dates: 8/1/1975, 7/1/1976, 11/1/1976, 3/1/1979, 12/1/1979, 9/7/1981, 10/1/1981, 12/10/1982, 12/29/1982, 6/1/1984, 12/24/1987, 4/1/1988 (Emer.), 1/1/1989 (Emer.), 9/23/1989, 10/1/1989 (Emer.), 11/1/1989 (Emer.), 1/21/1990, 3/2/1990, 3/22/1990, 9/1/1990 (Emer.), 5/1/1991, 6/17/1991, 7/12/1991 (Emer.), 6/30/1992, 10/1/1992 (Emer.), 3/18/1993, 6/20/1994, 9/1/1994, 3/1/1995, 10/30/1995, 10/31/1997 (Emer.), 1/26/1998, 10/1/1999, 11/19/1999, 1/1/2000, 8/6/2000, 6/1/2002 (Emer.), 8/30/2002, 6/1/2003 (Emer.), 9/20/2003, 1/1/2006
Rule 5160:1-2-03 | Medicaid: request for home and community-based services (HCBS) waiver.
 

(A) This rule sets forth the process for determining whether an individual is eligible for medical assistance payments for services under a home and community-based services (HCBS) waiver, as described in rules 5123:2-9-01, 5160-31-03, 5160-33-03, 5160-40-01, 5160-41-17, 5160-42-01, 5160-46-02, and 5160-58-02.2 of the Administrative Code.

(B) Eligibility for an HCBS waiver. To receive services under an HCBS waiver, the individual shall:

(1) Be eligible for medical assistance, as described in Chapters 5160:1-1 to 5160:1-6 of the Administrative Code; and

(2) Be in need of HCBS under a waiver described in agency 5123 or 5160 of the Administrative Code; and

(3) Be enrolled in an HCBS waiver described in agency 5123 or 5160 of the Administrative Code; and

(4) Not be simultaneously enrolled in another HCBS waiver, the residential state supplement (RSS) program described in rule 5160:1-5-01 of the Administrative Code, or the program of all-inclusive care for the elderly (PACE).

(C) Request for an HCBS waiver.

(1) An individual may request an HCBS waiver by:

(a) Indicating the request on an application for medical assistance; or

(b) Submitting an ODM 02399 "Request for Medicaid Home and Community-Based Services (HCBS) Waiver" (rev. 8/2018) to the administrative agency; or

(c) Indicating the request verbally or in writing to the administrative agency; or

(d) Indicating the request verbally or in writing to an Ohio department of medicaid (ODM) approved long-term services and supports agency.

(2) The effective date of an HCBS waiver request is determined in accordance with rule 5160:1-2-01 of the Administrative Code.

(D) Processing a request for an HCBS waiver.

(1) Upon receipt of an HCBS waiver request when the individual is currently in receipt of medical assistance, the administrative agency shall:

(a) Submit the request within two business days using the Ohio department of medicaid (ODM) approved submission process; and

(b) Document the following in the electronic eligibility system case record:

(i) The date the administrative agency received the request for HCBS; and

(ii) The date the administrative agency submitted the request using the ODM approved submission process.

(2) Upon receipt of an HCBS waiver request when the individual is not currently in receipt of medical assistance, the administrative agency shall:

(a) Begin the application process for medical assistance, as described in rule 5160:1-2-01 of the Administrative Code; and

(b) Submit the request within two business days using the ODM approved submission process; and

(c) Document the following in the electronic eligibility system case record:

(i) The date the administrative agency received the request for HCBS; and

(ii) The date the administrative agency submitted the request using the ODM approved submission process.

(E) Determination of eligibility for an HCBS waiver. The administrative agency is to approve an HCBS waiver for an individual eligible for medical assistance only upon:

(1) Approval by the HCBS waiver operational agency; and

(2) Notification that the individual may be enrolled in the waiver from ODM, its designee, or an HCBS waiver operational agency, when services under the waiver are available only to a specific number of individuals.

(F) Coverage period. The HCBS waiver coverage period can have a different beginning date or ending date from the medical assistance eligibility period.

(1) HCBS cannot:

(a) Begin before an individual's medical assistance eligibility period or before an individual's retroactive medical assistance eligibility period.

(b) Extend beyond the discontinuance date of an individual's medical assistance coverage.

(c) Be provided during any period of medical assistance ineligibility.

(2) Medical assistance coverage of HCBS begins on the latest of the following dates:

(a) The date the administrative agency receives a request for an HCBS waiver from an individual; or

(b) The date the individual meets all criteria for coverage of an HCBS waiver described in agency 5123 or 5160 of the Administrative Code; or

(c) The date the individual is authorized by the HCBS waiver operational agency to receive services under an HCBS waiver.

(G) HCBS waiver operational agency responsibilities.

(1) Determine, in accordance with this rule and agencies 5123 and 5160 of the Administrative Code, whether the individual requesting an HCBS waiver meets the requirements of the applicable HCBS waiver program.

(2) Provide written notification to the individual of the HCBS programmatic determination.

(3) Notify the administrative agency of determinations and subsequent changes regarding approval of HCBS.

(H) Administrative agency responsibilities.

(1) Determine an individual's eligibility for an HCBS waiver in accordance with this rule. When the administrative agency determines that an individual who requests an HCBS waiver is not eligible for any category of medical assistance, the administrative agency is to deny both the medical assistance application and HCBS waiver request for that individual.

(2) Notify the applicable HCBS waiver operational agency of changes in the individual's eligibility for medical assistance coverage of services under an HCBS waiver.

Supplemental Information

Authorized By: 5160.02, 5163.02, 5166.20, 5166.21
Amplifies: 5160.02, 5163.02, 5166.21, 5162.35
Five Year Review Date: 12/14/2025
Prior Effective Dates: 6/1/1988 (Emer.), 1/1/1990 (Emer.), 6/29/1990, 3/20/1992, 5/1/1993, 3/23/2015, 7/8/2020 (Emer.)
Rule 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.

Supplemental Information

Authorized By: 5162.03, 5163.02
Amplifies: 2913.401, 5162.03, 5162.23, 5163.02
Five Year Review Date: 8/1/2021
Prior Effective Dates: 10/1/2013
Rule 5160:1-2-05 | Medicaid: notice of privacy practices.
 

(A) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law requiring the administrative agency to issue a notice of privacy practices.

(B) The administrative agency shall:

(1) Ensure appropriate safeguards are taken in accordance with rule 5160-1-32 of the Administrative Code.

(2) Issue all individuals eligible through the medical assistance programs a notice of privacy practices, as described in 45 C.F.R. 164.520 (as in effect October 1, 2016), outlining the following descriptions of uses and disclosures, and procedures:

(a) A description of the types of uses and disclosures of protected health information (PHI) the administrative agency is permitted with examples for each of the following purposes:

(i) Payment;

(ii) Treatment; and

(iii) Healthcare operations.

(b) A description of the uses and disclosures permitted without the individual's written consent or authorization;

(c) A statement that other uses and disclosures will be made only with the individual's written authorization;

(d) Complaint procedure;

(e) Request for restriction procedure;

(f) Request for amendment procedure;

(g) Request for accounting procedure; and

(h) A name, or title, and telephone number of a person to contact for further information.

Supplemental Information

Authorized By: 5162.031, 5163.02
Amplifies: 5162.031, 5163.02
Five Year Review Date: 1/1/2022
Prior Effective Dates: 11/1/2009
Rule 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.

Supplemental Information

Authorized By: 5162.031, 5163.02
Amplifies: 5163.02, 5163.10, 5163.101
Five Year Review Date: 8/1/2021
Prior Effective Dates: 7/1/2000, 1/1/2014
Rule 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" as 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" as defined in section 5162.21 of the Revised Code.

(5) "Person responsible for the estate" as defined in section 2117.061 of the Revised Code.

(6) "Qualified long- term care partnership (QLTCP)" as defined in rule 5160:1-6-02.2 of the Administrative Code.

(7) "Time of death" as 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 including managed care capitation payments; 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 including managed care capitation payments (other than benefits paid on or after January 1, 2010, under the medicare premium assistance programs set forth in rule 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) When 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 shall 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 shall be presented by the AGO.

(a) The claim shall include all information required by Chapter 2117. of the Revised Code and shall be served on the person responsible for the estate or, when 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 shall include the following:

(i) The definition of undue hardship as stated in paragraph (H) of this rule;

(ii) The process for requesting an undue hardship as set forth in paragraph (I) of this rule; and

(iii) The date by which the request for an undue hardship waiver is to be received by ODM.

(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) When 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 5160:1-6-02.2 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 5160:1-6-06 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 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 shall 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) When the waiver request was not approved in full, or when the approval was time-limited, the applicant may, within thirty calendar days, request 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, shall 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 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.

Supplemental Information

Authorized By: 5162.21
Amplifies: 5162.21, 5162.211, 5162.23, 5164.86
Five Year Review Date: 1/1/2023
Prior Effective Dates: 7/1/2000, 9/1/2007, 1/15/2015
Rule 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) Income, including any:

(a) Change in hourly wage or salary;

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

(c) Loss of employment.

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

(iv) 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.

Supplemental Information

Authorized By: 5162.03, 5163.02
Amplifies: 5162.03, 5163.02, 5160.37
Five Year Review Date: 12/14/2025
Prior Effective Dates: 7/8/2020 (Emer.)
Rule 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 shall:

(1) Provide a social security number (SSN) in accordance with 42 C.F.R. 435.910 (as in effect October 1, 2020).

(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 an SSN when 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 an 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 his or her SSN, the administrative agency shall assist the individual with obtaining or applying for the individual's SSN.

(2) Be a resident, as defined in 42 C.F.R. 435.403 (as in effect October 1, 2020) 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 when the individual intends to return when the purpose of the absence has been accomplished, unless another state has determined the individual is a resident there for purposes of medicaid eligibility.

(c) The individual shall 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.

(i) When there are delays in discontinuing medical assistance in the prior state of residence and the individual is unable to provide all needed verifications, the administrative agency shall explore presumptive coverage, as described in rule 5160:1-2-13 of the Administrative Code.

(ii) When all verifications have been provided, the administrative agency shall explore eligibility for medical assistance in accordance with Chapter 5160:1-3, 5160:1-4, 5160:1-5, or 5160:1-6 of the Administrative Code, as applicable.

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

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

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

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

(d) Verification of non-citizen 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 C.F.R. 435.608 (as in effect October 1, 2020).

(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 the individual shall take steps to obtain include, but are not limited to: annuities, retirement, veterans benefits, social security disability insurance (SSDI), railroad retirement, and unemployment compensation.

(c) When 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 C.F.R. 435.610 (as in effect October 1, 2020) and section 5160.38 of the Revised Code, the state of Ohio shall automatically be assigned 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 and in obtaining medical support and payments as described in paragraph (B)(5) of this rule, in accordance with 42 C.F.R. 433.147 (as in effect October 1, 2020).

(a) As part of cooperation, the individual may be required to:

(i) Appear at a state or local office to provide information or evidence relevant to the case; and

(ii) Appear as a witness at a court or other proceeding; and

(iii) Provide information, or attest to lack of information, under penalty of perjury; and

(iv) Take any reasonable steps to assist with establishing paternity and securing medical support or payments.

(b) Cooperation is required unless the individual:

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

(ii) Is a pregnant woman, including a woman who is in her postpartum period; or

(iii) Has been approved for a good cause waiver as determined by the local CSEA; or

(iv) Is receiving transitional medical assistance.

(7) Cooperate with the administrative agency in identifying and providing information to assist the state with pursuing any third party who may be liable to pay for care and services. To meet this condition, the individual shall 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 shall 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, Chapter 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) When 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) When an individual's declared income is reasonably compatible with data available through electronic data sources, the individual's declared income will be accepted without further verification. Income shall be considered reasonably compatible when:

(a) Both the declared income and the electronic data verification are above, at, or below the applicable income standard for the individual's family size for the eligibility category being determined; or

(b) The difference between the declared income and the electronic data verification is within an amount equal to the reasonable compatibility standard for income specified in the state's MAGI-based eligibility verification plan.

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

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

(b) A current pay stub; or

(c) An award letter from a certifying agency; or

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

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

(f) The individual's statement, if he or she declares the income verification cannot be accessed or submitted.

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

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

(ii) A financial institution statement; or

(iii) Legal documents; or

(iv) The individual's statement, if he or she declares the resource verification cannot be accessed or submitted.

Last updated May 1, 2021 at 8:59 AM

Supplemental Information

Authorized By: 5162.03, 5163.02, 5164.02, 5160.02
Amplifies: 5162.03, 5163.02, 5164.02, 5160.38, 5160.02
Five Year Review Date: 5/1/2026
Prior Effective Dates: 1/1/2017
Rule 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 October 1, 2019).

(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 medical assistance as a deemed newborn on or after July 1, 2006.

(c) An individual who is:

(i) Enrolled in medicare; or

(ii) Receiving supplemental security income (SSI); or

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

(iv) Receiving adoption or foster care assistance under Title IV-E of the Social Security Act (as in effect October 1, 2019); or

(v) In foster care and receiving child welfare services under Title IV-B of the Social Security Act (as in effect October 1, 2019).

(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 (SSN) 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; or

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

(c) A certificate of Indian blood; or

(d) A 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) In the case of an individual declaring citizenship who does not have an SSN at the time of declaration, the county department of job and family services (CDJFS) may assist the individual with obtaining an SSN and attempt to verify the individual's citizenship in accordance with paragraph (B) of this rule.

(E) 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 (E)(1) of this rule and one identity document from paragraph (E)(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 citizenship 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). 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; and

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

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

(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 (Pub. L. No. 82-414) 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 childs 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 (E)(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 paragraph.

(a) A driver's license or similar document issued for the purpose of identification by a state, if the license or document 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 a federal, state, or local government agency or entity, provided the card 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; or

(ii) A military dependent's identification card; or

(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 (E)(2)(a) to (E)(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.

(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.

(F) Reasonable opportunity period.

(1) 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 (E) of this rule, the administrative agency is to give the individual a reasonable opportunity to present satisfactory documentation of U.S. citizenship.

(2) 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 and extends up to ninety days from the date the notice of reasonable opportunity is received by the individual.

(i) The date on which the notice is received is considered to be five days after the date on the notice, unless the individual shows that he or she did not receive the notice within the five-day period.

(ii) The reasonable opportunity period may end before the ninetieth day if the agency verifies the individual's U.S. citizenship status.

(iii) Medical assistance coverage for an individual on a reasonable opportunity period is effective the first day of the calendar month in which the Ohio department of medicaid (ODM) receives the application as defined in rule 5160:1-2-01 of the Administrative Code.

(b) May be extended. The administrative agency is to provide an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain necessary documentation or if the administrative agency is unable to complete the verification process within the ninety-day reasonable opportunity period.

(c) Is granted with each application needing verification of U.S. citizenship, provided the individual satisfies all other conditions of eligibility outlined in rule 5160:1-2-10 of the Administrative Code. If an individual who was previously provided a reasonable opportunity period was discontinued after ninety days for failing to provide verification, he or she is to be granted another ninety-day reasonable opportunity period with each subsequent new application.

(d) Ends on:

(i) The date the administrative agency verifies the individual's U.S. citizenship; or

(ii) The last date of the month in which the ninetieth day falls as described in paragraph (F)(2)(a) of this rule; or

(iii) An administrative agency approved extension date beyond the ninety-day reasonable opportunity period when:

(a) The administrative agency has determined the individual is making a good faith effort to resolve any inconsistencies or obtain necessary documentation; or

(b) The administrative agency is unable to complete the verification process within the ninety-day reasonable opportunity period.

Supplemental Information

Authorized By: 111.15
Amplifies: 5162.03, 5163.02, 5164.02
Five Year Review Date: 12/14/2025
Prior Effective Dates: 7/8/2020 (Emer.)
Rule 5160:1-2-12 | Medicaid: non-citizens.
 

(A) This rule sets forth:

(1) Medical assistance eligibility criteria for an individual who is not a U.S. citizen or national; and

(2) Acceptable documentary evidence of qualified non-citizen status; and

(3) 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 a person 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 October 1, 2019).

(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 eligibility for medical assistance upon an individual nor does it serve as an exemption to the five-year bar described in paragraph (C)(3) of this rule.

(7) "Lawful permanent resident" (LPR) means a person who is legally authorized to live permanently within 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; or

(b) An asylee who has been granted asylum under section 208 of the Immigration and Nationality Act (INA) (as in effect October 1, 2019); or

(c) A refugee admitted to the United States under section 207 of the INA (as in effect October 1, 2019); or

(d) A parolee allowed into the United States under section 212(d)(5) of the INA (as in effect October 1, 2019) for a period of at least one year; or

(e) A person whose deportation is being withheld under section 243(h) of the INA (as in effect prior to April 1, 1997) or whose removal has been withheld under section 241(b)(3) of the INA (as in effect October 1, 2019); or

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

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

(h) An Amerasian immigrant as defined in Section 584 of the Foreign Operations, Export Financing, and Related Programs Appropriations Act of 1988 (Pub. L. No. 100-202); or

(i) A non-citizen or non-citizen's child who has been battered or subjected to extreme cruelty in the United States under Section 501 of Pub. L. No. 104-208, under certain circumstances as defined in 8 U.S.C. 1641(c) (as in effect October 1, 2019); or

(j) An Afghan or Iraqi non-citizen granted special immigrant visa status under Section 8120 of the December 19, 2009 Defense Appropriations Bill (Pub. L. No. 111-118) and section 101(a)(27) of the INA (as in effect October 1, 2019).

(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 October 1, 2019), and is published annually in the Federal Register.

(11) "Veteran" means a person who served in the active United States military, naval, or air service, who fulfilled the minimum active duty service requirements and was released with a discharge characterized as honorable and not on account of alienage, including veterans who die while serving in active duty in the armed forces of the United States as defined in 38 U.S.C. 1101 (as in effect October 1, 2019). A veteran also includes individuals with certain military service before July 1, 1946 in the military forces (including certain organized guerilla forces) of the government of the Commonwealth of the Philippines and certain service in the Philippine scouts as described in 38 U.S.C. 107 (as in effect October 1, 2019).

(12) "Victim of trafficking" refers to:

(a) A victim 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 October 1, 2019).

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

(i) The ORR makes the certification determination and issues a letter of certification for an adult victim of trafficking.

(ii) A victim of trafficking who is younger than eighteen years of age does not need to be certified in order to receive benefits. Instead, the ORR issues a notarized letter similar to an adult certification letter, 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 medical assistance, 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; or

(ii) Asylee; or

(iii) A person whose deportation is being withheld under section 243(h) of the INA (as in effect October 1, 2019); or

(iv) Cuban or Haitian entrant; or

(v) Amerasian immigrant; or

(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 October 1, 2019) or can be credited with such quarters.

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

(a) All qualifying quarters worked by the LPR; and

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

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

(d) A parent or spouse whose quarters are credited to the LPR 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 LPR 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 October 1, 2019).

(f) A spouse or unmarried dependent child of a veteran or active duty service member as described in paragraph (C)(3)(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 with at least fifty per cent American Indian blood, covered by the provisions of 289 of the INA (8 U.S.C. 1359) (as in effect October 1, 2019).

(i) A member of an Indian tribe, as defined in 25 U.S.C. 450b(e) (as in effect October 1, 2019) and the Indian Self-Determination and Education Assistance Act of 1975 (Pub. L. No. 93-638).

(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 non-citizenship 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 a victim of trafficking:

(i) The original certification letter or notarized letter from the ORR for a child is to be used in place of immigration documentation from USCIS. Retain a copy in the case file. A victim of trafficking is 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 may not have documentation of original immigration status, and should instead present the following documentation, available from the ORR:

(i) I-220B (order of supervision), which must include the person'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 October 1, 2019) 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 certified copy of the veteran's discharge paper, United States department of defense form DD-214 (undated).

(G) 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 (F)(2) of this rule, the administrative agency:

(1) Is to provide a reasonable opportunity period in accordance with paragraph (H) of this rule; and

(2) Is not to delay, deny, reduce, or discontinue benefits for an individual who is determined by the agency to be otherwise eligible for medical assistance during such reasonable opportunity period, in accordance with 42 C.F.R. 435.911(c) (as in effect October 1, 2019).

(3) Is to promptly provide the individual with information obtained from the electronic data source described in paragraph (F) of this rule so that he or she can attempt to resolve any inconsistencies with regard to immigration status.

(H) The reasonable opportunity period:

(1) Begins on and extends up to ninety days from the date the notice of reasonable opportunity is received by the individual.

(a) The date on which the notice is received is considered to be five days after the date on the notice, unless the individual shows that he or she did not receive the notice within the five-day period.

(b) The reasonable opportunity period may end before the ninetieth day if the agency verifies the individual's satisfactory immigration status.

(c) Medical assistance coverage for an individual on a reasonable opportunity period is effective the first day of the calendar month in which the Ohio department of medicaid (ODM) receives the application as defined in rule 5160:1-2-01 of the Administrative Code.

(2) May be extended. The administrative agency is to provide an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain necessary documentation or if the administrative agency is unable to complete the verification process within the ninety-day reasonable opportunity period.

(3) Is granted with each application needing verification of satisfactory immigration status, provided the individual satisfies all other conditions of eligibility outlined in rule 5160:1-2-10 of the Administrative Code. If an individual who was previously provided a reasonable opportunity period was discontinued after ninety days for failing to provide verification, he or she is to be granted another ninety-day reasonable opportunity period with each subsequent new application.

(4) Ends on:

(a) The date the administrative agency verifies the individual's satisfactory immigration status; or

(b) The last day of the month in which the ninetieth day falls as described in paragraph (H)(1) of this rule; or

(c) An administrative agency approved extension date beyond the ninety-day reasonable opportunity period when:

(i) The administrative agency has determined the individual is making a good faith effort to resolve any inconsistencies or obtain necessary documentation; or

(ii) The administrative agency is unable to complete the verification process within the ninety-day reasonable opportunity period.

(5) Retroactive coverage.

(a) There is no provision for retroactive coverage for individuals on a reasonable opportunity period.

(b) If an individual provides evidence of satisfactory immigration status during his or her ninety-day reasonable opportunity period, he or she may have eligibility explored for retroactive medical assistance in accordance with rule 5160:1-2-01 of the Administrative Code.

Supplemental Information

Authorized By: 5162.03, 5163.02
Amplifies: 5162.03, 5163.02
Five Year Review Date: 12/14/2025
Rule 5160:1-2-13 | Medicaid: presumptive eligibility.
 

(A) This rule describes the conditions under which an individual may receive time-limited medical assistance as a result of an initial, simplified determination of eligibility based on the individual's self-declared statements.

(B) Eligibility criteria for presumptive coverage.

(1) Except as set forth in paragraph (B)(2) of this rule, an individual is eligible for presumptive coverage if the individual:

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

(b) Is a U.S. citizen or has an immigration status as defined in rule 5160:1-2-12 of the Administrative Code that allows for medicaid eligibility; and

(c) Meets the non-financial eligibility criteria for a group set out in rule 5160:1-4-02, 5160:1-4-03, 5160:1-4-04, or 5160:1-4-05 of the Administrative Code, except that a simplified household composition will be determined, comprised of the individual and, if living in the home:

(i) The individual's spouse; and

(ii) The individual's children under age nineteen; and

(iii) If the individual is under age nineteen:

(a) The individual's parents; and

(b) The individual's siblings under the age of nineteen.

(d) Has gross family income, for the individual's family size, of no more than the eligibility limit set out for the relevant eligibility group in rule 5160:1-4-02, 5160:1-4-03, 5160:1-4-04, or 5160:1-4-05 of the Administrative Code.

(2) Limitations. An individual is ineligible for a subsequent presumptive coverage period for twelve months beginning on the date of a presumptive coverage determination, except that a woman may receive presumptive coverage based on pregnancy once during each pregnancy.

(C) Duration and scope of presumptive coverage.

(1) Presumptive coverage begins on the date an individual is determined to be 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 administrative agency determines the individual is eligible or ineligible for ongoing medical assistance pursuant to rule 5160:1-2-01 of the Administrative Code; or

(b) If an application for ongoing medical assistance for the individual has not been filed, the last day of the month following the month in which the individual was determined to be presumptively eligible.

(3) Services for individuals found presumptively eligible on the basis of pregnancy are restricted to ambulatory prenatal care.

(D) State agency responsibilities. The Ohio department of medicaid (ODM) is responsible for training and monitoring each qualified entity (QE) in accordance with rule 5160-1-17.12 of the Administrative Code.

(E) QE responsibilities.

(1) If the QE is ODM or a county department of job and family services (CDJFS) office:

(a) No later than twenty-four hours after receipt of a signed and dated full application for medical assistance on behalf of an individual, the CDJFS must determine, based on the individual's self-declared information, whether the individual is eligible for presumptive coverage under this rule.

(b) If an individual is eligible for presumptive coverage, ODM or the CDJFS must:

(i) Approve presumptive coverage for the individual; and

(ii) Provide a notice issued from the electronic eligibility system to inform the individual:

(a) That presumptive coverage was approved; and

(b) That failure to cooperate with the eligibility determination process set forth in rule 5160:1-2-01 of the Administrative Code will result in a denial of medical assistance, which will trigger the discontinuance of presumptive coverage.

(c) If an individual is not eligible for presumptive coverage, ODM or the CDJFS must inform the individual that eligibility for medical assistance will be determined within forty-five days.

(d) Whether or not an individual is eligible for presumptive coverage, ODM or the CDJFS must determine whether the individual is eligible for ongoing medical assistance pursuant to rule 5160:1-2-01 of the Administrative Code.

(2) If the QE is a hospital, the Ohio department of rehabilitation and correction (DRC), the Ohio department of youth services (DYS), a federally qualified health center (FQHC), an FQHC look-alike, a local health department, a special supplemental nutrition program for women, infants, and children (WIC) clinic, or other entity as designated by the director as defined in rule 5160:1-1-01 of the Administrative Code:

(a) Upon request, determine whether the individual is presumptively eligible under this rule. Such determination shall not be delegated to a third party, but shall be completed by the QE.

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

(c) If the individual is presumptively eligible:

(i) Approve presumptive coverage for the individual using the electronic eligibility system designated by ODM; and

(ii) Provide a notice issued from the electronic eligibility system to the individual at the time of determination which indicates that presumptive coverage was approved and which includes:

(a) The presumptive eligibility determination date; and

(b) The basis for presumptive eligibility; and

(c) The individual's name, date of birth, and address; and

(d) The individual's medicaid information technology system (MITS) billing number; and

(e) A reminder that the individual must apply for ongoing medical assistance no later than the last day of the month following the month of approval.

(iii) Upon request, assist the individual with completing an application for ongoing medical assistance.

(d) If the individual is not presumptively eligible, inform the individual that there may be other categories of medical assistance available and that he or she should apply for a full determination of eligibility for medical assistance.

(3) If the QE is a hospital, in addition to the eligibility criteria identified in paragraph (B)(1) of this rule, the hospital may also make presumptive eligibility determinations for the group set out in rule 5160:1-6-03.1 of the Administrative Code.

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

Supplemental Information

Authorized By: 5163.02
Amplifies: 5163.01, 5163.02, 5163.101
Five Year Review Date: 1/7/2026
Prior Effective Dates: 3/31/2014, 7/8/2020 (Emer.)
Rule 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 October 1, 2019).

(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.

(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.

Supplemental Information

Authorized By: 5162.031, 5163.02
Amplifies: 5163.02 , 5163.03
Five Year Review Date: 12/14/2025
Prior Effective Dates: 7/8/2020 (Emer.)
Rule 5160:1-2-15 | Medicaid: 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) benefit that all medicaid eligible individuals under twenty-one years of age are entitled to receive. A separate healthchek application is not required. Each county department of job and family services (CDJFS) is required to have a healthchek coordinator.

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

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

(2) "Healthchek coordinator" is the CDJFS employee who is responsible for the implementation of healthchek services.

(3) "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) (as in effect 03-06-2016) 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) (as in effect 03/06/2016).

(4) "Healthchek Services Implementation Plan" (HSIP), ODM 03517, (rev. 07/2016) means the document submitted by a CDJFS describing how it delivers healthchek services to individuals in its county and who in the agency is responsible for ensuring the delivery of healthchek services.

(5) "Individual" means, for purposes of this rule, a person under age twenty-one eligible for medicaid.

(6) "Medically necessary," otherwise known as "medical necessity," as used in this chapter is the same as defined in paragraph (A) of rule 5160-1-01 of the Administrative Code.

(7) "Prior authorization" for a member of a medicaid managed care plan (MCP) is the process outlined in rule 5160-26-03.1 of the Administrative Code. For all other individuals, prior authorization is the process outlined in rule 5160-1-31 of the Administrative Code.

(8) "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 shall be coordinated with the individual's medicaid-contracting MCP, where applicable.

(C) The individual (or the individual's parent, guardian or legal custodian, as applicable) may:

(1) Complete and sign the ODM 03528, "Healthchek and Pregnancy Related Services Information Sheet" (rev. 7/2016) to verify receipt and understanding of information about healthchek;

(2) Complete, sign, and return the ODM 03528 to identify service needs;

(3) Request and attend scheduled appointments for healthchek services.

(D) CDJFS responsibilities. Each CDJFS shall:

(1) Inform. Each CDJFS shall use a combination of written and oral methods (including telephone calls, office visits, or home visits) to inform individuals (or such individuals 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 in this rule.

(a) Written informing.

(i) Each CDJFS shall ensure that each individual (or such individual's parent, guardian or legal custodian, as applicable) in its county receives the ODM 03528 within sixty days after the individual is determined eligible for medicaid and at least once each year thereafter.

(ii) Each CDJFS shall document that each individual (or such individual's parent, guardian or legal custodian, as applicable) in its county has received the ODM 03528.

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

(iv) Upon completion of the ODM 03528, the individual (or such individual's parent, guardian or legal custodian, as applicable) will be asked to sign the ODM 03528 to acknowledge receipt of healthchek information and to verify understanding of the healthchek services available. If the individual (or such individual'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.

(v) Each CDJFS shall enter data regarding individuals into the electronic information system, as directed by ODM. Such information shall include information from the completed ODM 03528, record of contacts with individuals and any requests and referrals made or services provided.

(vi) Each entity that distributes or accepts applications for medicaid shall prominently display a notice that complies with the methods of providing information about healthcheck as established by section 5164.26 of the Revised Code.

(vii) ODM may develop additional written materials containing information about healthchek. Each CDJFS shall distribute such written materials, as directed by ODM. Any written materials developed by a CDJFS to inform individuals about healthchek shall be submitted to ODM for review and approval.

(b) Oral informing. Each CDJFS shall ensure that each individual (or such individual's 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 using clear and non-technical language about the following:

(i) The benefits of preventive health care, including:

(a) Increased well-being;

(b) Reduced risk to the individuals health;

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

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

(ii) The services covered by healthchek.

(iii) Where and how to obtain healthchek services.

(iv) That services covered by healthchek are without cost to individuals.

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

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

(vii) The prior authorization process, including that:

(a) The process, whether fee-for-service or managed care, must be started by the individual's medicaid provider;

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

(c) 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; and

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

(viii) The CDJFS must explain necessary transportation and scheduling assistance is available to individuals under twenty-one years of age, upon request, in accordance with Chapter 5160-15 of the Administrative Code, and the following:

(a) Transportation will be provided to any medicaid reimbursable service;

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

(c) Verification requirements, if any; and

(d) For an individual who is a member of an MCP, transportation is also available through the individual's MCP.

(c) Each CDJFS shall use appropriate methods to inform individuals who are blind, deaf, or who cannot read or understand the English language (or such individuals' parents, guardians, or legal custodians, as applicable) about healthchek. Information provided to individuals who are blind, deaf, or who cannot read or understand the English language shall meet the requirements of paragraphs (C)(1) and (C)(2) of this rule.

(d) Informing pregnant women. An ODM 03528 shall be used to document the informing of pregnant women about healthchek services as outlined in rule 5160:1-02-16 of the Administrative Code. The ODM 03528 shall be used to document informing again upon the birth of the infant.

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

(i) Identify newborns and the infant's parent, guardian, legal custodian, as applicable;

(ii) Ensure that any infant born to a medicaid eligible woman is added to the medicaid case, in accordance with rule 5160:1-4-02.2 of the Administrative Code;

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

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

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

(2) Provide support services.

(a) The CDJFS shall refer the individual (or the individuals parent, guardian, or legal custodian, as applicable) to entities listed on the ODM 03528 and/or other community supportive services as requested. The CDJFS will ensure:

(i) 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.

(ii) Coordination between the individual and the entity where the referral is made.

(iii) Coordination between the individual and the individual's MCP by forwarding a copy of the ODM 03528 to the individual's MCP, if applicable.

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

(v) Assistance is provided with scheduling medical appointments as requested by the individual or the individual's parent, guardian or legal custodian, as applicable.

(vi) Requests for support services available in the individual's county of residence received by the individuals MCP and forwarded to the CDJFS are acted upon and the requested service(s) provided.

(b) The CDJFS shall provide individuals with necessary assistance in obtaining transportation to medicaid reimbursable services as requested by the individual or the individual's parent, guardian or legal custodian, as applicable.

(c) Each individual in a household who requests or is in need of non-medicaid covered medical services as indicated on the ODM 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.

(d) Elevated blood lead level services for assisting families of individuals 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:

(i) Referral of the individual to the Ohio department of health (ODH) for an environmental assessment.

(ii) Verification of the individuals medicaid eligibility at the time the environmental assessment is conducted and the ODH agent is informed of such eligibility. Verification shall only be provided upon receipt of proper verification of the identity of the ODH agent who is requesting the information.

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

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

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

(c) 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.

(iv) 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.

(v) 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.

(3) CDJFS healthchek services implementation plan (HSIP) ODM 03517 (rev. 07/2016). Each CDJFS is required to have a healthchek services implementation plan on file with ODM. The plan shall be signed by the agency director or his designee.

(a) 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 individual. The case file shall contain the following information, when appropriate:

(i) Copy of the ODM 03528;

(ii) Copies of all correspondence received and sent;

(iii) Documentation of attempted and successful contacts with the individual (or such individual's parent, guardian or legal custodian, as applicable);

(iv) Documentation of the MCP in which individuals are enrolled, if applicable;

(v) Documentation of contacts with or forms provided by the medical provider;

(vi) Information received from other counties when an individual's case is an inter-county transfer;

(vii) Documentation of support services requested and/or provided and referrals made on an individual's behalf, and the CDJFS' efforts to fulfill the referrals and/or requests. At a minimum the documentation shall contain:

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

(b) A copy of all documentation of services requested by an individual (or such individual's parent, guardian or legal custodian, as applicable) and provided or facilitated by the CDJFS;

(c) Records of transportation requested and provided; and

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

(b) 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 ODM. 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.

(c) The CDJFS shall submit a new or amended HSIP to ODM, including but not limited to, when there has been a change of agency address, director, Healthchek coordinator or where the responsibility for healthchek is organizationally located within the agency. The HSIP shall be submitted to ODM within ten business days of the change.

(4) Release of information. The CDJFS shall, if necessary, obtain a HIPAA-compliant signed authorization for release of information, form ODM 03397 "Authorization for the Release or Use of Protected Health Information (PHI)" (rev. 02/2016), if and when the CDJFS needs additional medical information from the individual or the individual's provider.

(5) 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 individuals. The CDJFS may make use of a variety of methods including personal visits, telephone calls, and letters to recruit providers.

(6) Training. Each CDJFS' healthchek coordinator, or such coordinator's designee(s), shall attend available healthchek training offered by ODM. For video conference or other training delivered electronically, verification of attendance shall consist of documenting the countys presence during roll call and submission of an evaluation form to the appropriate state monitored e-mail box within three days of the training. Verification of attendance at an on site training shall be documented by the healthchek coordinator, or such coordinators designee, signing the attendance log.

Supplemental Information

Authorized By: 5162.03
Amplifies: 5162.03, 5164.26
Five Year Review Date: 9/12/2021
Prior Effective Dates: 4/1/1986 (Emer.), 7/1/1988 (Emer.), 6/1/1997, 4/1/2001, 10/1/2009
Rule 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.

Supplemental Information

Authorized By: 5160.02
Amplifies: 5160.02, 5164.26
Five Year Review Date: 1/15/2020
Prior Effective Dates: 10/1/1998, 10/15/2005