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

Chapter 5160:1-5 | Medicaid Special Covered Groups

 
 
 
Rule
Rule 5160:1-5-01 | Medicaid: the residential state supplement (RSS) program.
 

(A) RSS provides cash assistance to aged, blind, or disabled adults who are eligible for medical assistance and who have increased needs due to a medical condition which is not severe enough to require institutionalization. The RSS cash payment is used together with the individual's income to help prevent institutionalization and to deinstitutionalize those aged, blind, or disabled adults who have been placed in long-term care facilities and who can return to the community through an alternative living arrangement.

(B) Definitions.

(1) "Countable income," for the purpose of this rule, means income remaining after exclusions.

(2) "Income standard," for the purpose of this rule, means the aggregate of the allowable fee standard and the personal needs allowance as defined in rule 5122-36-05 of the Administrative Code.

(3) "Individual," for the purpose of this rule, means a person who is applying for or receiving RSS benefits.

(4) "Institutional placement," for the purpose of this rule, means placement in a public medical institution, a hospital which has a provider agreement with the Ohio department of medicaid, or a Title XIX certified long-term care facility (LTCF).

(5) "OhioMHAS" means the Ohio department of mental health and addiction services or the entity designated by OhioMHAS pursuant to division (A) of section 5119.41 of the Revised Code.

(6) "RSS living arrangement" means an arrangement listed in paragraph (E) of rule 5122-36-02 of the Administrative Code.

(7) "RSS" means the residential state supplement program described in section 5119.41 of the Revised Code.

(8) "RSS protected date," for the purpose of this rule, means the signature date on a completed "Residential State Supplement (RSS) Referral for Enrollment" (ODM 07120 rev. 11/2020) or an electronic equivalent, or a "Residential State Supplement (RSS) Program Application" (DMHAS-7046 rev. 01/18).

(9) "Temporary institutional placement," for the purpose of this rule, means placement, not to exceed ninety days, in a public medical institution, a hospital which has a provider agreement with the Ohio department of medicaid, or a Title XIX certified long-term care facility (LTCF).

(C) Eligibility criteria. To be eligible for the RSS program an individual must:

(1) Be determined eligible for medical assistance in accordance with Chapter 5160:1-3 of the Administrative Code; and

(2) Meet the financial requirements described in paragraph (E) of this rule; and

(3) Meet the resource requirements described in paragraph (F) of this rule; and

(4) Have at least a protective level of care as defined in rule 5160-3-06 of the Administrative Code; and

(5) Meet the non-financial requirements described in paragraph (I) of this rule; and

(6) Not require more than one hundred twenty days of skilled nursing care within a twelve month period.

(D) RSS registration and enrollment process. The RSS application process is initiated upon receipt of all of the following:

(1) An application for medical assistance, if the individual is not currently in receipt of medical assistance; and

(2) Non-financial verifications from OhioMHAS as described in paragraph (I) of this rule; and

(3) A completed ODM 07120 or electronic equivalent from OhioMHAS verifying that the individual has been selected for placement in the RSS program.

(a) If the individual submits a completed ODM 07120 either at the county department of job and family services (CDJFS) or by mail, a copy of the ODM 07120 will be forwarded to OhioMHAS to register the individual for the RSS program.

(b) If a completed ODM 07120 or electronic equivalent has been submitted to OhioMHAS, it shall be made available to the Ohio department of medicaid and the CDJFS for the determination of eligibility in accordance with paragraph (C) of this rule.

(c) The date the signed ODM 07120 or electronic equivalent is completed and submitted to OhioMHAS will be considered the date of application.

(E) Financial eligibility.

(1) The definitions of earned and unearned income in Chapter 5160:1-1 of the Administrative Code are applicable to the RSS program.

(2) When an individual and his or her spouse reside in the same RSS living arrangement and both have appropriate levels of care, the CDJFS shall determine their RSS financial and resource eligibility collectively, utilizing the appropriate couple income standard as defined in rule 5160:1-3-03.5 of the Administrative Code.

(3) When an individual and his or her spouse reside in the same RSS living arrangement and only one of them has an appropriate level of care, the CDJFS shall determine RSS financial and resource eligibility utilizing the appropriate individual income standard as defined in rule 5160:1-3-03.5 of the Administrative Code. The spouse who does not have the necessary level of care shall have eligibility for medical assistance determined as an individual, except that income cannot be deemed to or from the RSS eligible spouse.

(4) The treatment of income for RSS shall be the same as the treatment of income for medical assistance in accordance with rule 5160:1-3-03.1 of the Administrative Code, with the following exceptions:

(a) SSI income is countable income in the RSS program.

(b) When an individual has countable income equal to or in excess of the income standard identified in rule 5122-36-05 of the Administrative Code, the individual is ineligible for RSS.

(c) The RSS program has no deeming provision.

(5) When the RSS individual's countable income is less than the income standard, but the individual's RSS enrollment is not yet completed, the CDJFS shall pend the RSS application until the RSS enrollment determination is completed.

(6) If the RSS individual's countable income is less than the income standard, the individual is eligible for an RSS payment.

(F) Resource eligibility shall be determined in accordance with rule 5160:1-3-05.1 of the Administrative Code.

(G) Determination of RSS payment.

(1) The RSS payment to the individual shall be equal to the difference between the individual's income after all allowable deductions and disregards and the income standard.

(2) The approval date for the RSS payment cannot precede the date of placement in an appropriate RSS living arrangement or the date when all financial and non-financial eligibility requirements are met including appropriate level of care, whichever occurs last.

(3) When an individual leaves an RSS living arrangement after the monthly RSS payment has been made, and does not begin residence in another eligible RSS living arrangement, the individual shall be responsible for returning the RSS payment. The return amount shall be prorated from the date the individual leaves the RSS living arrangement.

(4) When an individual leaves an RSS living arrangement and moves to another RSS living arrangement and the monthly RSS payment has been made to the individual, a second monthly RSS payment will not be made for the new living arrangement.

(5) When an individual moves from a nursing facility or a personal residence into an RSS living arrangement on the first day of the month and is otherwise eligible for RSS, the individual is eligible for a full month's RSS payment.

(6) When an individual moves into an RSS living arrangement on a date other than the first day of the month and is otherwise eligible for RSS, the first month's payment is calculated according to the following formula:

(a) Determine the regular monthly RSS payment in accordance with paragraph (G)(1) of this rule.

(b) Divide the monthly RSS payment amount by the number of days in the month to arrive at the daily supplement amount. Round amounts up to the next whole cent.

(c) Multiply the daily supplement amount by the actual number of days of RSS placement in the month. The actual number of days of RSS placement in the month includes the day that the individual moves into the RSS living arrangement through the last day of the month. Round amounts up to the next whole cent.

(d) The resulting product is the prorated RSS payment.

(H) Temporary institutional placement.

(1) RSS benefits are intended to allow an individual to maintain and pay for the RSS living arrangement in which he or she intends to live when discharged from temporary institutional placement.

(2) Individuals in a temporary institutional placement are potentially eligible to receive full uninterrupted RSS benefits during the first ninety days of institutional placement.

(3) Individuals are eligible for continued RSS benefits provided the following criteria are met:

(a) The individual must be eligible for an RSS payment both the month prior to and the first month of temporary institutional placement; and

(b) The individual period of temporary institutional placement is not likely to exceed ninety consecutive days, beginning the day after the day of admission; and

(c) The individual must maintain residency in the RSS living arrangement during the temporary institutional placement.

(4) OhioMHAS shall submit written documentation to the CDJFS that the criteria listed in paragraph (H)(3) of this rule has been met by the earlier of:

(a) Ninety days after the date of admission to the temporary institutional placement; or

(b) The date of release from the temporary institutional placement.

(5) RSS payments and all of the individual's income are exempt from consideration as income in the long-term care post-eligibility treatment of income calculation for individuals temporarily entering an LTCF.

(a) This income exemption continues through the last day of the month in which the temporary period of institutional placement ends.

(b) Effective the month following the month in which the temporary period of institutional placement ends, when the RSS individual remains in an institutional placement, the CDJFS must stop the RSS payment.

(6) The CDJFS shall continue RSS payments to all individuals meeting the criteria outlined in paragraph (H)(3) of this rule.

(7) Any RSS payments made under paragraph (H) of this rule are not overpayments if the individual's actual stay exceeds the expected stay of not more than ninety days.

(8) Prior notice in accordance with division 5101:6 of the Administrative Code is required to stop RSS payments.

(I) OhioMHAS responsibilities. OhioMHAS shall:

(1) Determine the individual's non-financial eligibility for the RSS program, for the individual in accordance with rule 5122-36-02 of the Administrative Code.

(2) Determine whether the individual is residing in an appropriate living arrangement in accordance with rule 5122-36-02 of the Administrative Code.

(3) Document that the individual meets at least a protective level of care pursuant to rule 5122-36-02 of the Administrative Code.

(4) Participate in state hearings resulting from non-financial RSS eligibility criteria decisions.

(5) Provide non-financial verifications as described in paragraphs (H) and (I) of this rule to the CDJFS in order for the CDJFS to determine RSS financial eligibility for the individual.

(6) Inform the CDJFS of any change in the individual's or couple's RSS non-financial eligibility criteria or RSS placement.

(7) Maintain a census of all individuals who receive RSS payments and the RSS living arrangement in which each individual currently resides.

(8) Confirm that the individuals who receive RSS payments are residing in the RSS living arrangement on record.

(J) CDJFS responsibilities. The CDJFS shall:

(1) Inform OhioMHAS of the individual's eligibility for medical assistance and the amount of the calculated RSS payment.

(2) Verify that the individual is not receiving services through a home and community-based services (HCBS) waiver.

(3) Verify that the individual is not a participant in a program of all-inclusive care for the elderly (PACE).

(4) Verify that the individual is not enrolled in a medicare- or medicaid-certified hospice program.

(5) For an individual who is not already receiving medical assistance, determine eligibility for medical assistance and RSS financial eligibility upon receipt of the items described in paragraph (D) of this rule.

(a) The CDJFS shall determine retroactive eligibility for medical assistance in accordance with rule 5160:1-2-01 of the Administrative Code for coverage of non-RSS medical services.

(b) The CDJFS shall explore eligibility for the medicare premium assistance programs (MPAP) in accordance with rule 5160:1-3-02.1 of the Administrative Code.

(6) For an individual who is receiving medical assistance, upon receipt of the ODM 07120 or electronic equivalent, determine if the individual meets the RSS financial eligibility criteria. The CDJFS must notify OhioMHAS of the results of the RSS determination.

(7) Not delay the determination of eligibility for other assistance programs when RSS eligibility is still pending.

(8) Not treat the level of care determination for RSS eligibility as evidence that the limiting physical factor requirement for medical assistance eligibility, as defined in rule 5160:1-3-02 of the Administrative Code, has been met.

(9) When RSS income or resource eligibility is not met in accordance with Chapter 5160:1-3 of the Administrative Code, the CDJFS shall deny the RSS application. The denial notice shall be sent to the individual and authorized representative, or legal guardian, if one has been indicated on the application. A copy of the denial notice shall also be issued to OhioMHAS.

(10) Inform OhioMHAS of any change in the individual's or couple's medical assistance and/or RSS financial eligibility.

(11) Confirm in the case record that the individual has received a level of care determination for the RSS program that meets the criteria outlined in paragraph (C) of this rule, document that OhioMHAS has confirmed that the individual is residing in an appropriate RSS living arrangement, and document the approved RSS payment amount.

(K) Individual responsibilities.

(1) The individual shall cooperate with the CDJFS in order to determine financial eligibility for RSS.

(2) The individual shall cooperate with OhioMHAS in order to determine non-financial eligibility for RSS.

(3) The individual is responsible for reporting changes within ten days to the CDJFS in accordance with rule 5160:1-2-08 of the Administrative Code.

Supplemental Information

Authorized By: 5162.03, 5163.02
Amplifies: 5162.03, 5163.02, 5119.41
Five Year Review Date: 12/14/2025
Prior Effective Dates: 9/1/1984, 3/6/1989, 9/12/1991 (Emer.), 11/1/1993 (Emer.), 7/24/1994, 7/1/1995 (Emer.), 10/1/2002, 7/1/2011 (Emer.), 9/29/2011, 7/8/2020 (Emer.)
Rule 5160:1-5-02 | Medicaid: breast and cervical cancer project (BCCP).
 

(A) This rule describes the medicaid breast and cervical cancer project.

(B) The rules in Chapter 5160:1-5 of the Administrative Code set forth the eligibility requirements for participation in the breast and cervical cancer project. The Breast and Cervical Cancer Prevention and Treatment Act of 2000 (BCCPTA), in accordance with Pub. L. No. 106-354 and 42 U.S.C. 1396a(a)(10)(A)(ii) (as in effect on October 1, 2016), authorizes an optional category of medicaid to provide full medicaid benefits to certain individuals who need treatment for breast or cervical cancer, breast or cervical pre-cancerous conditions, and/or breast or cervical early stage cancer. The goals of the BCCPTA are as follows:

(1) To improve access to needed breast and cervical cancer treatment for uninsured individuals identified under the national breast and cervical cancer early detection program as needing such treatment;

(2) To facilitate the prompt enrollment in medicaid and immediate access to services for individuals who are in need of treatment for breast or cervical cancer;

(3) To ensure that needed treatment begins as early as possible; and

(4) To coordinate activities between medicaid and public health agencies, including but not limited to application procedures and case management.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 1/1/2023
Prior Effective Dates: 7/1/2002
Rule 5160:1-5-02.1 | Medicaid: breast and cervical cancer project (BCCP) definitions.
 

(A) This rule contains definitions generally used for BCCP.

(B) Definitions.

(1) "Breast and Cervical Cancer Project (BCCP) medicaid" means the category of medicaid for qualified individuals in need of treatment for breast or cervical cancer, including pre-cancerous conditions and early stage cancer. BCCP medicaid is administered by the Ohio department of medicaid (ODM) in coordination with the Ohio department of health (ODH).

(2) "Breast or cervical cancer diagnosis", for the purpose of BCCP medicaid, means that a treating health professional has made a general determination that breast or cervical cancer(s) or pre-cancerous condition(s) exists. For the purposes of BCCP medicaid, breast or cervical cancer diagnosis does not require the determination of the specific stage or grade of cancer or pre-cancerous conditions.

(a) "Breast or cervical cancer diagnosis" includes metastasized cancer known or presumed by a treating health professional as a complication of breast or cervical cancer.

(b) "Date of diagnosis" is the date of the screening or diagnostic service which the treating health professional utilized to determine the individual's breast or cervical cancer diagnosis.

(c) "Pre-cancerous" means a condition, which, if left untreated is known or presumed by a treating health professional to develop into cancer.

(3) "Centers for Disease Control and Prevention (CDC) Title XV grantee" means an entity receiving funds under a cooperative agreement with CDC to support activities related to the national breast and cervical cancer early detection program.

(4) "Individual", for the purpose of BCCP medicaid, means men or women in need of or receiving treatment for breast or cervical cancer, breast or cervical pre-cancerous conditions, and/or breast or cervical early stage cancer or eligible for BCCP medicaid.

(5) "The National Breast and Cervical Cancer Early Detection Program (NBCCEDP)" means the program of the CDC established under Title XV of the Public Health Service Act.

(6) "The Ohio Department of Health Breast and Cervical Cancer Project (ODH BCCP)" means NBCCEDP funded by the CDC and administered by the Ohio department of health (ODH).

(a) "ODH BCCP breast and cervical cancer screening provider" means an entity which has entered into a written agreement with the ODH BCCP to provide specified breast and cervical cancer screening and diagnostic services for ODH BCCP enrollees.

(b) "ODH BCCP designated local agency or subgrantee" means an entity which has received a grant from ODH to implement specified activities of the ODH BCCP.

(c) "ODH BCCP enrollee" means an individual determined by ODH BCCP, or its designated local agencies or subgrantees, to meet the eligibility requirements (e.g., age and income) for participation in the ODH BCCP.

(d) "ODH BCCP regional case manager" means an individual who determines an individual's eligibility for BCCP, enrolls individuals, schedules services with health care providers, and provides case management to individuals.

(7) "Screened for breast or cervical cancer under NBCCEDP" means that a breast or cervical cancer screening was provided, all or in part, by CDC Title XV funds.

(a) For the purposes of BCCP medicaid, breast or cervical cancer screening includes diagnostic test(s) following a breast or cervical cancer screen.

(b) For the purposes of BCCP medicaid, case management services provided by a CDC Title XV grantee are not considered breast or cervical cancer screening.

(8) "Treatment" means the provision of medical services to control, minimize, or eliminate cancer or pre-cancerous cells of the breast or cervix. "Treatment" includes the provision of hormonal therapies to prevent recurrence of cancer following breast cancer surgery, radiation, and/or chemotherapy. Monitoring services alone (e.g., Papanicolaou smears, pelvic examinations, clinical breast examinations, mammograms) for recurrence or new primary cancers are not considered treatment.

(a) "Needs treatment" means that according to a written certification by the individual's treating health professional, which is documented by the ODH BCCP, a breast or cervical cancer screening indicates that the individual is in need of treatment for breast or cervical cancer. Individuals who are determined to require only monitoring services (e.g., Papanicolaou smears, pelvic examinations, clinical breast examinations, mammograms) are not considered to need treatment.

(b) "No longer receives treatment for breast or cervical cancer" means:

(i) The individual's course of treatment of breast or cervical cancer is completed, or

(ii) The individual chooses to delay or decline available treatment options.

(c) "Treating health professional" means an individual licensed to provide breast or cervical cancer diagnosis and/or treatment services.

(d) "Treatment period" means the period of time, according to a written certification by the individuals treating health professional, needed for the completion of treatment of the individual's breast or cervical cancer or pre-cancerous condition. A treatment period lasting more than twelve months from initial eligibility requires both a review of continuing medicaid eligibility and verification of need for continued treatment.

(9) "Uninsured" means not having creditable coverage for health care services.

(a) For the purposes of determining eligibility under BCCP medicaid, the following are considered creditable coverage:

(i) Health insurance benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care) under any hospital or medical service policy or certificate, hospital or medical service plan contract;

(ii) Health maintenance organization contract offered by a health insurance issuer;

(iii) Medicare, parts A or B; and,

(iv) Medicaid.

(b) For the purposes of determining eligibility under BCCP medicaid, creditable coverage does not include:

(i) Limited scope coverage such as those which only cover dental, vision, or long term care;

(ii) Coverage for only a specified disease or illness;

(iii) Coverage which excludes treatment for breast or cervical cancer, including situations whereby a period of exclusion has been applied, such as for a pre-existing condition or the individual has exhausted the health insurance plan's covered benefits;

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 1/1/2023
Prior Effective Dates: 7/1/2002
Rule 5160:1-5-02.2 | Medicaid: breast and cervical cancer project (BCCP): eligibility requirements.
 

(A) This rule describes the eligibility criteria for BCCP medicaid.

(B) An individual shall meet all of the following criteria to be eligible for BCCP medicaid:

(1) Be screened for breast or cervical cancer under the national breast and cervical cancer early detection program (NBCCEDP).

(a) An individual is not required to obtain screening for both breast and cervical cancer as a condition of eligibility for participation in the NBCCEDCP.

(b) Individuals screened for breast or cervical cancer under the NBCCEDP in a state other than Ohio must be determined eligible for the Ohio department of health (ODH) BCCP and must utilize the ODH BCCP case management services and Ohio 's BCCP medicaid application process as outlined in rule 5160:1-5-02.4 of the Administrative Code.

(2) Be in need of treatment for breast or cervical cancer, precancerous conditions, or early stage cancer, as indicated by a treating health professional, based on the centers for disease control and prevention (CDC) NBCCEDP funded screening.

(3) Be uninsured as defined in rule 5160:1-5-02.1 of the Administrative Code.

(4) Must not meet the eligibility criteria of any other medicaid program described in Chapters 5160:1-3, 5160:1-4, 5160:1-5, and 5160:1-6 of the Administrative Code.

(5) Be under sixty-five years of age.

(6) Meet all other nonfinancial eligibility requirements applicable to medicaid applicants described in Chapters 5160:1-1 and 5160:1-2 of the Administrative Code.

(C) Effective date of BCCP medicaid. As defined in rule 5160:1-2-01 of the Administrative Code, the effective date is the first day of the month that the Ohio department of medicaid (ODM) receives an application for BCCP medicaid and the individual meets all eligibility requirements described in this rule.

(1) Retroactive eligibilty shall be explored as described in rule 5160:1-2-01 of the Administrative Code.

(2) The first month of BCCP medicaid coverage may be a partial month of coverage based on the date of diagnosis of breast or cervical cancer, pre-cancerous conditions, or early stage cancer. "Date of diagnosis" is defined in rule 5160:1-5-02.1 of the Administrative Code.

(D) BCCP medicaid shall be discontinued when the individual meets the eligibility criteria of any other category of medicaid. If the individual is determined eligible for any other category of medicaid, the last day of BCCP medicaid coverage will be the last day of the month prior to the month the new category of medicaid begins.

(E) The Ohio department of health (ODH) or its designated local agencies or subgrantees shall:

(1) Determine the individual eligible for the ODH BCCP.

(2) Screen for all other medicaid programs before determining the individual eligible for ODH BCCP.

(F) The Ohio department of medicaid (ODM) shall:

(1) Screen all BCCP medicaid applicants for potential eligibility in other medicaid programs as described in rule 5160:1-5-02.4 of the Administrative Code.

(2) Require BCCP medicaid applicants to provide information regarding income and/or resources to screen the applicant for potential eligibility for other medicaid programs.

(3) Not provide BCCP medicaid coverage, including retroactive coverage, for any period of time preceding the date of diagnosis of breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(G) Individuals not meeting citizenship or immigration status eligibility requirements may be eligible for coverage for an emergency medical condition as described in rule 5160:1-5-06 of the Administrative Code.

Supplemental Information

Authorized By: 5163.02, 5160.02
Amplifies: 5160.02 , 5163.02
Five Year Review Date: 1/1/2023
Prior Effective Dates: 3/23/2015
Rule 5160:1-5-02.4 | Medicaid: breast and cervical cancer project (BCCP): application and renewal process.
 

(A) This rule describes the application and renewal process for the breast and cervical cancer project (BCCP).

(B) The BCCP medicaid application and renewal process shall:

(1) Be coordinated between Ohio department of medicaid (ODM), Ohio department of health (ODH) BCCP, and ODH BCCP designated local agencies and/or subgrantees,

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

(3) Support the goals of the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (BCCPTA), identified in rule 5160:1-5-02 of the Administrative Code.

(C) ODH BCCP and its designated local agencies or subgrantee responsibilities. The ODH BCCP and its designated local agencies or subgrantee shall:

(1) Provide the ODM 07161 "Ohio Breast and Cervical Cancer Project (BCCP) Medicaid Application" (rev. 9/2017) to ODH BCCP enrollees screened for breast or cervical cancer under the centers for disease control and prevention's (CDC) national breast and cervical cancer early detection program (NBCCEDP) and referred for breast or cervical cancer diagnostic evaluation.

(2) Provide the ODM 07161 to ODH BCCP enrollees screened for breast or cervical cancer under the CDC NBCCEDP who are receiving treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(3) Notify in writing ODH BCCP enrollees described in paragraphs (C)(1) and (C)(2) of this rule to return the completed ODM 07161 to the designated ODH BCCP regional case manager.

(D) ODH BCCP regional case manager responsibilities.

(1) The application process. The ODH BCCP regional case manager shall:

(a) Provide to ODM the completed ODM 07161 and ODM 7160 "Healthcare Provider's Treatment Plan" (rev. 9/2017) within five business days of receipt of the diagnostic information when:

(i) The ODH BCCP enrollee has submited the ODM 07161; and

(ii) The ODH BCCP screening provider notifies the designated ODH BCCP regional case manager that, as a result of the NBCCEDP funded screening, a treating health professional has determined the ODH BCCP enrollee needs treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(b) Notify the ODH BCCP enrollee in writing within five business days of the receipt of the diagnostic information, that the ODM 07161 must be submitted to the designated ODH BCCP regional manager when:

(i) The enrollee has not submitted the ODM 07161; and

(ii) The ODH BCCP screening provider notifies the designated ODH BCCP regional case manager that, as a result of the NBCCEDP funded screening, a treating health professional has determined the ODH BCCP enrollee needs treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(c) Notify the ODH BCCP enrollee in writing within five business days that the ODM 07161 will not be submitted to ODM when:

(i) The ODH BCCP enrollee submits the ODM 07161; and

(ii) The diagnostic results indicate that the ODH BCCP enrollee does not need treatment for either breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(2) The renewal process. The ODH BCCP regional case manager shall:

(a) Provide to ODM the completed ODM 07160 within five business days of receipt of notification from the treating health professional when the individual has been found to need continued treatment for either breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(b) Notify the individual in writing within five business days that the ODM 07160 will not be submitted to ODM when the treating health professional notifies the designated ODH BCCP case manager the individual has been found to not need continued treatment for either breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(c) Notify ODM within five business days upon receipt of a medicaid renewal form from an individual.

(E) ODM responsibilies. ODM shall:

(1) Make available to ODH BCCP and its designated local agencies or subgrantees the ODM 07161 and ODM 07160.

(2) Be responsible for all determinations of BCCP medicaid eligibility, including retroactive eligibility.

(3) Use available sources of information in the eligibility determination including:

(a) Information contained in the ODM 07160 and ODM 07161; and

(b) Information in the case record to determine if the individual is currently enrolled in medicaid or has a pending medicaid application.

(4) Use the eligibility criteria set forth in rule 5160:1-5-02.2 of the Administrative Code.

(5) Complete all determinations of eligibility within forty-five days of receipt of a completed ODM 07161 or medicaid renewal form.

(a) A delay in the eligibility determination or renewal shall not be a basis for granting eligibility; or

(b) An application pending beyond forty-five days shall not be the sole basis for denial.

(6) Redetermine BCCP medicaid eligibility:

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

(i) The individual's treatment period; or

(ii) Twelve months continuous eligibility in BCCP medicaid.

(b) When ODM receives an ODM 07160 indicating a change in the individual's circumstances, including completion of treatment prior to the original determined treatment period.

(c) When the individual obtains other health insurance.

(d) When the individual turns sixty-five years of age.

(7) Provide written notice to the BCCP medicaid recipient:

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

(b) To return required completed renewal materials to the CDJFS.

(F) Individual responsibilities. The individual shall:

(1) Submit a completed ODM 07161 to the designated ODH BCCP regional case manager.

(2) Cooperate with ODM in the application and renewal process, as described in rule 5160:1-2-08 of the Administrative Code.

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

(1) A period of BCCP medicaid eligibility shall begin each time an individual:

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

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

(c) Submits a completed ODM 07161 in accordance with paragraph (F) of this rule, and

(d) Is determined by ODM to meet all eligibility criteria for BCCP medicaid as described in rule 5160:1-5-02.2 of the Administrative Code.

(2) Individuals who have completed a treatment period, have had their BCCP medicaid eligibility discontinued, and subsequently have been found to have new, recurrent, or metasticized breast or cervical cancer, pre-cancerous condition, or early stage cancer:

(a) Shall be recertified as eligible for the ODH BCCP to reestablish BCCP medicaid eligibility; and

(b) Shall submit a new ODM 07161 to reestablish BCCP medicaid eligibility.

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

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

(b) Shall submit a new ODM 07161 to reestablish BCCP medicaid eligibility.

(H) Screening for potential eligibility for other medicaid programs by ODM and/or the CDJFS at application and renewal.

(1) When information on the ODM 07161 or medicaid renewal form indicates the individual is not potentially eligible for any other medicaid program, income and asset information is not needed and ODM shall determine eligibility for BCCP medicaid.

(2) When information on the ODM 07161 or medicaid renewal form indicates the individual is potentially eligible for any other medicaid program, the individual shall provide income and asset information to screen for eligibility for other medicaid programs.

(a) When income or asset information indicates the individual does not appear eligible for any other medicaid program, no additional income or asset information is needed and ODM shall determine eligibility for BCCP medicaid.

(b) When income or asset information indicates the individual appears eligible for any other medicaid program, the individual shall be:

(i) Notified of potential eligibility;

(ii) Given instructions for submission of additional information required to make a determination of eligibility for other medicaid programs.

(iii) Notified by the CDJFS in writing to complete and submit additional information required to the CDJFS in the individual's county of residence.

(a) When the CDJFS determines the applicant eligible for any other category of medicaid, the CDJFS will discontinue BCCP medicaid in accordance with paragraph (D)(8) of rule 5160:1-5-02.2 of the Administrative Code and approve the category for which the individual is eligible.

(b) When the CDJFS determines the individual ineligible for any other medicaid program, the CDJFS will notify ODM and ODM will maintain the BCCP medicaid case.

Supplemental Information

Authorized By: 5163.02, 5160.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 1/1/2023
Prior Effective Dates: 10/1/2006
Rule 5160:1-5-03 | Medicaid: medicaid buy-in for workers with disabilities (MBIWD).
 

(A) This rule governs the eligibility requirements for the medical assistance programs authorized under sections 1902(a)(10)(A)(ii)(XV) and (XVI) of the Social Security Act (as in effect October 1, 2019). Medicaid buy-in for workers with disabilities (MBIWD) enables certain individuals to increase their income and resources without the risk of losing medical assistance coverage.

(B) Definitions.

(1) "Basic covered group" means the individuals meeting all criteria in paragraph (C)(1) of this rule.

(2) "Blind work expense (BWE)" has the same meaning as in rule 5160:1-3-03.2 of the Administrative Code.

(3) "Countable income," for the purpose of this rule, means income less exclusions.

(4) "Countable resources", for the purpose of this rule, means those resources remaining after all exclusions have been applied.

(5) "Family", for the purpose of this rule, means an individual, the individual's spouse, and dependent children living in the household of the individual. If an individual is younger than eighteen years of age, "family" also means the individual's parents.

(6) "Impairment-related work expense (IRWE)" as defined in 20 C.F.R. 404.1576 (as in effect October 1, 2019).

(7) "Income", for the purpose of this rule, means gross earned income and gross unearned income.

(8) "Individual", for the purpose of this rule, means the applicant for or recipient of MBIWD.

(9) "Individual with a medically improved disability" means an individual who is a recipient of MBIWD in the basic covered group but who no longer meets the disability criterion as defined in paragraph (C)(1)(b) of this rule.

(10) "Medicaid buy-in for workers with disabilities (MBIWD)" means the component of the medicaid program established under sections 5163.09 to 5163.098 of the Revised Code and includes the basic covered group and the medically improved covered group.

(11) "Medical and remedial expense (MRE)" means an incurred expense for care, services, or goods prescribed or provided by a licensed medical practitioner within the scope of practice as defined under state law. This expense is the responsibility of the individual, and cannot be reimbursed by any other source, such as medicaid, private insurance, or an employer.

(12) "Medical insurance premiums" means the amount paid for insurance coverage for medical items or services such as health, dental, vision, long-term care, hospital, prescriptions, etc.

(13) "Medically improved covered group" means the individuals meeting all criteria in paragraph (C)(2) of this rule.

(14) "Premium" means a periodic payment required under section 5163.094 of the Revised Code and described in paragraph (E) of this rule.

(15) "Resource eligibility limit for MBIWD" means countable resources limited to the amount specified under section 5163.092 of the Revised Code.

(16) "Social security disability insurance (SSDI)" means the program established under Title II of the Social Security Act (as in effect October 1, 2019).

(17) "Supplemental security income (SSI)" means the program established under Title XVI of the Social Security Act (as in effect October 1, 2019).

(18) "Work" or "working", for the purpose of this rule, means full- or part-time employment or self-employment from which state or federal income and payroll taxes are paid or withheld.

(C) Eligibility criteria.

(1) To be eligible for the MBIWD basic covered group an individual must:

(a) Meet the conditions of eligibility described in rule 5160:1-2-10 of the Administrative Code; and

(b) Meet the definition of disability used by the social security administration (SSA), except that employment, earnings, and substantial gainful activity must not be considered when determining whether the individual meets the disability criterion for MBIWD. An individual may be eligible for MBIWD regardless of whether the individual is receiving SSI or SSDI; and

(c) Be at least sixteen years of age but younger than sixty-five years of age; and

(d) Meet the financial eligibility requirements described in paragraph (D) of this rule; and

(e) Be working; and

(f) Pay the premium, as calculated in paragraph (E) of this rule, if applicable.

(2) To be eligible for the MBIWD medically improved covered group an individual must:

(a) Have participated in the MBIWD basic covered group as defined in paragraph (C)(1) of this rule the previous calendar month and continue to meet all eligibility criteria described in paragraph (C) of this rule except that the individual no longer meets the disability criterion defined in paragraph (C)(1)(b) of this rule; and

(b) Work at least forty hours per month earning at least state or federal minimum wage, whichever is lower.

(3) An individual participating in MBIWD with a medically improved disability, whose medical condition is determined to have regressed may be reevaluated for the MBIWD basic covered group in accordance with paragraph (C)(1) of this rule.

(4) When the individual is eligible for MBIWD under the basic or medically improved group and ceases to work, the individual may continue to participate in MBIWD when:

(a) The individual intends to return to work or look for a new job; and

(b) The individual continues to pay MBIWD premiums, if applicable; and

(c) The individual continues to meet all other eligibility requirements for MBIWD.

(D) Financial eligibility.

(1) For the purpose of determining whether an individual is income eligible for MBIWD, the administrative agency must compare the individual's countable income to two hundred fifty per cent of the federal poverty level (FPL) for one person. Only the individual's income is considered when determining eligibility for MBIWD.

(a) From the individual's income, apply exclusions in accordance with rule 5160:1-3-03.2 of the Administrative Code.

(b) If the amount determined in paragraph (D)(1)(a) of this rule is no more than two hundred fifty per cent of the FPL, the individual meets the income eligibility requirement for MBIWD.

(c) If the amount determined in paragraph (D)(1)(a) of this rule exceeds two hundred fifty per cent of the FPL:

(i) An additional annual amount up to twenty thousand dollars of earned income shall be excluded.

(ii) The twenty thousand dollar earned income exclusion may be applied wholly or in part in any month to reduce the individual's countable income below two hundred fifty per cent of the FPL. This exclusion begins the first month the individual would otherwise be eligible for MBIWD except for income and continues within a twelve-month period until the twenty thousand dollars is exhausted.

(2) For the purpose of determining whether an individual meets the resource eligibility requirement for MBIWD, an individual's countable resources must not exceed the resource eligibility limit for MBIWD as defined in paragraph (B) of this rule.

(a) Only the individual's resources are considered when determining resource eligibility for MBIWD. In the case of resources which are jointly owned, the administrative agency must consider the total amount of the resource available to the individual in accordance with rule 5160:1-3-05.1 of the Administrative Code.

(b) For the purpose of determining resource eligibility for MBIWD, resources are excluded in accordance with rule 5160:1-3-05.14 of the Administrative Code.

(c) Retirement funds are evaluated in accordance with rule 5160:1-3-03.10 of the Administrative Code.

(E) Premium calculation. An individual eligible for MBIWD whose individual income exceeds one hundred fifty per cent of the FPL for one person must pay a premium determined as follows (rounded down to the nearest dollar at each step):

(1) From the gross annual family income at the time of application and subsequent renewals for MBIWD, the administrative agency shall subtract one hundred fifty per cent of the FPL for the family size; and

(2) From the amount determined in paragraph (E)(1) of this rule, the administrative agency shall subtract the individual's IRWEs, BWEs, and/or MREs; and

(3) The amount determined in paragraph (E)(2) of this rule is the annual net family income; and

(a) When the annual net family income is less than or equal to four hundred fifty per cent of the FPL for the family size, multiply the individual's gross annual income by seven and one half per cent.

(b) When the annual net family income is greater than four hundred fifty per cent of the FPL for the family size, multiply the annual net family income by ten per cent.

(4) From the amount determined in paragraph (E)(3) of this rule, the administrative agency must subtract the amount of medical insurance premiums, including medicare premiums, paid by the family; and

(5) Divide the amount determined in paragraph (E)(4) of this rule by twelve and round down to the nearest whole dollar. This is the individual's monthly premium.

(F) The individual's monthly premium obligation begins the month following the month MBIWD coverage is authorized, and is due and payable in full no later than the due date established by the administrative agency.

(1) Partial payments do not satisfy the eligibility criterion in paragraph (C)(1)(f) of this rule.

(2) Partial payments and payments in full received after the due date established by the administrative agency are applied to the most delinquent premium.

(3) An individual who loses eligibility for MBIWD due to non-payment of premiums and reapplies for MBIWD must:

(a) Meet all criteria outlined in paragraph (C)(1) of this rule; and

(b) Pay all accumulated delinquent premiums that caused MBIWD discontinuance.

(4) Individuals who are eligible for retroactive coverage in accordance with rule 5160:1-2-01 of the Administrative Code are not required to pay a monthly premium for the months of retroactive coverage.

(G) Receipt of long-term care services, as defined in rule 5160:1-6-01.1 of the Administrative Code, is not a cause for discontinuance or denial of an individual's eligibility for MBIWD.

(H) Individuals eligible for MBIWD are not subject to a patient liability as described in rule 5160:1-6-07 or 5160:1-6-07.1 of the Administrative Code.

(I) Administrative agency responsibilities. The administrative agency shall:

(1) Process the application for MBIWD in accordance with rule 5160:1-2-01 of the Administrative Code.

(2) Determine eligibility for MBIWD as described in this rule.

(3) Calculate the premium for MBIWD as identified in paragraph (E) of this rule and recalculate this premium whenever the individual reports a decrease in income.

(4) Verify the individual's disability in accordance with paragraph (C)(1)(b) of this rule.

(5) Explore eligibility for qualified medicare beneficiary (QMB) and specified low income medicare beneficiary (SLMB) programs in accordance with rule 5160:1-3-02.1 of the Administrative Code. MBIWD individuals are not eligible for the qualified individual (QI-1) or qualified disabled and working individuals (QDWI) medicare premium assistance programs.

(J) Individual responsibilities. The individual shall:

(1) Provide the information necessary to establish eligibility, cooperate in the verification process, and report changes in accordance with rule 5160:1-2-08 of the Administrative Code.

(2) Pay premiums determined by the administrative agency in accordance with this rule.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02 , 5163.091, 5163.092, 5163.093, 5163.094, 5163.095, 5163.096, 5163.097, 5163.098
Five Year Review Date: 12/14/2025
Prior Effective Dates: 4/1/2008, 10/21/2016, 9/1/2017
Rule 5160:1-5-05 | Medicaid: refugee medical assistance (RMA).
 

(A) This rule describes a time-limited medical assistance program, funded through the office of refugee resettlement (ORR), that provides a medical screening through contracted refugee health screening providers and other medical services. There is no resource limit for an individual described in this rule.

(B) Definitions.

(1) "Countable income," for the purpose of this rule, has the same meaning as in rule 5160:1-3-03.2 of the Administrative Code.

(2) "Current incurred medical expense" means a medical bill or a portion of a medical bill that:

(a) Includes:

(i) A medically necessary medical item or service provided to the individual or to the individual's family member during the month for which the individual is seeking to obtain RMA eligibility through the spenddown process; and

(ii) An expense the individual or family member is liable to pay, regardless of whether the individual or family member has already paid it; and

(iii) A transportation expense, as defined in paragraph (B)(14) of this rule, incurred by the individual or family member during the month for which the individual is seeking to obtain RMA eligibility through the spenddown process.

(b) Does not include:

(i) An expense that has already been used in the spenddown process as a basis for approving RMA eligibility for any individual; or

(ii) An expense the individual or family member has not yet incurred for a medical item or service because it has not yet been provided.

(3) "Derivative T visa" means either a T-2, T-3, T-4, or T-5 visa issued to certain family members of victims of a severe form of trafficking who may be eligible for RMA benefits if the visa holder meets refugee program eligibility requirements.

(4) "Family member," for the purpose of this rule:

(a) For an individual of any age, means:

(i) The individual's spouse or deceased spouse, unless a court has eliminated the individual's duty of medical support to such spouse; or

(ii) The individual's natural or adopted child under the age of eighteen, including a deceased child, unless a court has eliminated the individual's duty of medical support to such child; or

(iii) The individual's former spouse, including a deceased former spouse, provided the individual has a duty of medical support to the former spouse.

(b) For an individual under age eighteen, also includes:

(i) The individual's natural or adoptive parent, unless a court has eliminated such parent's duty of medical support to the individual; or

(ii) The individual's sibling (including half-sibling) under the age of eighteen, who lives with the individual; or

(iii) The individual's deceased parent, provided the surviving parent who lives with the individual had a duty of medical support of the deceased parent at the time of his or her death; or

(iv) The individual's deceased sibling (including half-sibling) provided the deceased sibling lived with the individual at the time of his or her death, and a parent who lives with the individual had a duty of medical support to the deceased sibling at the time of his or her death.

(c) Does not include a step-parent, a step-child, or a step-sibling.

(5) "Income," for the purpose of this rule, is the same as defined in rule 5160:1-3-03.1 of the Administrative Code.

(6) "Incurred" means that the individual or family member has become liable to pay a medical bill as defined in paragraph (B)(8) of this rule. An expense is incurred on the date liability for the expense arises.

(7) "Individual," for the purpose of this rule, means an applicant for or a recipient of RMA who is not a United States (U.S.) citizen and meets one of the following definitions of immigration status under the Immigration and Nationality Act (INA) (as in effect October 1, 2020), as verified by documentation issued by the U.S. department of state, U.S. department of homeland security, or U.S. department of justice:

(a) Paroled as a refugee or asylee under section 212(d)(5) of the INA (as in effect October 1, 2020); or

(b) Admitted to the U.S. as a refugee under section 207 of the INA (as in effect October 1, 2020); or

(c) Granted asylum under section 208 of the INA (as in effect October 1, 2020); or

(d) A Cuban or Haitian entrant in accordance with requirements in 45 C.F.R. part 401 (as in effect October 1, 2020); or

(e) An Amerasian from Vietnam who is admitted to the U.S. as an immigrant pursuant to section 584 of the Foreign Operations, Export Financing, and Related Programs Appropriations Act of 1988 (as contained in section 101(e) of Pub. L. No. 100-202) (as in effect October 1, 2020), and amended by the 9th proviso under migration and refugee assistance in title II of the Foreign Operations, Export Financing, and Related Programs Appropriations Act, 1989 (Pub. L. No. 100-461, as amended) (as in effect October 1, 2020); or

(f) A victim of a severe form of trafficking as identified in 22 U.S.C. 7105(b)(1) (as in effect October 1, 2020) and certain family members, as identified in the Trafficking Victims Protection Reauthorization Act of 2003 (TVPRA) (Pub. L. No. 108-193) (as in effect October 1, 2020). A victim of a severe form of trafficking is awarded a certification letter from ORR and is potentially eligible for RMA as described in 28 C.F.R. 1100.33 (as in effect October 1, 2020). Certain family members are awarded "Derivative T" visas and are potentially eligible for RMA; or

(g) Admitted as an Afghan or Iraqi special immigrant under section 101(a)(27) of the INA (as in effect October 1, 2020).

(8) "Medical bill" means an invoice for a medically necessary medical item or service provided to the individual or family member.

(9) "Medical insurance premiums" means the amount paid for insurance coverage for medical items or services such as health, dental, vision, long-term care, hospital, prescriptions, etc.

(10) "Medically necessary" has the same meaning as in rule 5160-1-01 of the Administrative Code.

(a) Medical insurance premiums as defined in paragraph (B)(9) of this rule are always considered medically necessary.

(b) The administrative agency may generally accept that medical expenses and bills submitted in the spenddown process are for items or services that were medically necessary. In an unusual situation, the administrative agency may question whether an item or service was medically necessary. In such a situation, the administrative agency will need to determine whether the item or service was medically necessary by following these steps:

(i) Contact the individual and assist the individual with gathering relevant information from the medical provider and other appropriate persons about the medical necessity of the item or service.

(ii) If the medical provider of the item or service indicates the item or service was not medically necessary, the administrative agency shall not use the expense for that item or service in the spenddown process.

(iii) If the medical provider of the item or service indicates the item or service was medically necessary, the administrative agency may use the expense for that item or service in the spenddown process in accordance with the other provisions of this rule. If the administrative agency questions the provider's statement regarding medical necessity, the administrative agency must ask the prior authorization unit (PAU) of the Ohio department of medicaid (ODM) to determine whether the item or service was medically necessary.

(iv) If the PAU determines the item or service was medically necessary, the administrative agency must use the expense for that item or service in the spenddown process in accordance with the other provisions of this rule. The PAU decision is for the sole purpose of determining whether the item or service was medically necessary. The PAU decision is not for the purpose of determining whether to prior authorize the item or service under rule 5160-1-31 of the Administrative Code, nor for the purpose of determining whether the item or service is payable by the medical assistance program.

(v) If the PAU determines the item or service was not medically necessary, the administrative agency shall not use the expense for that item or service in the spenddown process.

(11) "RMA need standard" means one hundred per cent of the federal poverty level (FPL) based on family size.

(12) "Spenddown amount" means the dollar amount by which the individual's countable income exceeds the applicable RMA need standard. The individual must satisfy the spenddown amount in accordance with paragraph (F) of this rule in order to become eligible for RMA for all or part of a given calendar month.

(13) "Subject to the spenddown process" means the individual:

(a) Has countable monthly income that exceeds the RMA need standard; and

(b) Is otherwise eligible for RMA.

(14) "Transportation expense" means a reasonable expense incurred by the individual or family member for transportation that is needed to obtain a medically necessary item or service.

(a) Transportation expenses include but are not limited to the following:

(i) Charges for public transportation;

(ii) Expenses related to the transportation such as parking fees and tolls;

(iii) The state mileage reimbursement rate as set by the Ohio office of budget and management for the use of a private motor vehicle owned by the individual or a family member, in effect on the date of travel;

(iv) The actual expense incurred by the individual or family member for transportation by a private motor vehicle not owned by the individual or family member;

(v) Overnight lodging expenses if overnight travel is needed to obtain the medical item or service;

(vi) Actual expenses for meals, up to thirty dollars per person per day, subject to the restrictions in paragraph (B)(14)(a)(vii) of this rule, when overnight travel is required;

(vii) Attendant care costs and/or the costs of a companion if a medical provider verifies that an attendant and/or companion is required due to the age and/or physical or mental condition of the individual or family member; and

(viii) Expenses related to delivering a medical service or item to the individual or family member.

(b) Transportation expenses do not include the following:

(i) The cost of transportation provided to the individual or family member through county-administered transportation assistance; or

(ii) Any transportation expenses excluded from income as an "impairment-related work expense" (IRWE) as described in 20 C.F.R. 404.1576 (as in effect October 1, 2020); or

(iii) Any transportation expense excluded from earned income as a "blind work expense" as defined in rule 5160:1-3-03.1 of the Administrative Code.

(c) The administrative agency may generally accept that transportation expenses submitted in the spenddown process are for transportation that was needed to obtain a medically necessary item or service and that the cost is reasonable. If the administrative agency questions whether a transportation expense was needed and/or reasonable, the administrative agency will need to determine whether the expense was needed and/or reasonable by following these steps:

(i) Contact the individual and assist the individual with gathering relevant information from the medical provider and other appropriate persons concerning all of the relevant circumstances including the following:

(a) The age, physical and mental condition, and transportation needs of the individual; and

(b) The medical item or service for which the individual needed the transportation; and

(c) The suitability of the transportation alternatives reasonably available to the individual; and

(d) The reasonableness of the expense based on the circumstances; and

(e) Any other relevant factors.

(ii) After considering all of the listed factors, if the administrative agency determines that the expense or a portion of the expense was not needed and/or not reasonable, the administrative agency shall not use the expense in the spenddown process.

(15) "Unpaid past medical expense" (UPME) means a medical bill or a portion of a medical bill, as defined in paragraph (B)(8) of this rule, that:

(a) Is still owed, and is not subject to payment by a third party who is legally obligated to pay the bill; and

(b) Is not owed to a nursing facility (NF) or intermediate care facility for individuals with intellectual disabilities (ICF-IID) for services provided to a family member; and

(c) Has not been used in a previous month to meet a spenddown amount.

(C) Eligibility criteria.

(1) The individual shall be neither:

(a) Eligible for another category of medical assistance; nor

(b) A full-time student in an institution of higher education, except where such enrollment is approved by the state, or its designee, as part of an individual employability plan as described in rule 5101:1-2-40.5 of the Administrative Code.

(2) The individual meets the income requirements for RMA when:

(a) The individual's countable income is no more than the RMA need standard, or

(b) The individual whose countable income is more than the RMA need standard spends down countable income to the RMA need standard in accordance with the methods set forth in paragraph (E) of this rule.

(3) Continued eligibility of individuals who receive increased earnings from employment.

(a) Financial eligibility for RMA is based on the individual's income on the date of application.

(b) If an individual receiving RMA has increased earnings from employment, the earnings shall not affect the individual's continued eligibility for RMA.

(c) If an individual who qualified for another category of medical assistance becomes ineligible because of earnings from employment, the individual shall have his or her eligibility transferred to the RMA category without an RMA eligibility determination if he or she:

(i) Meets the non-financial eligibility criteria for RMA; and

(ii) Does not qualify for any other category of medical assistance; and

(iii) Has been residing in the U.S. less than the time-limited eligibility period for RMA as defined in paragraph (D) of this rule.

(d) An individual shall continue to receive RMA until he or she reaches the end of his or her eight month time-limited eligibility period, as described in 45 C.F.R. 400.104 (as in effect October 1, 2020).

(e) In cases where an individual is covered by employer-provided health insurance, any payment of RMA for that individual must be reduced by the amount of the third party payment.

(D) Eligibility period. An individual who meets the eligibility requirements of this rule may receive RMA for a time-limited period not to exceed eight continuous months from the individual's date of entry or from the date status is granted, as listed on the individual's U.S. citizenship and immigration services (USCIS) documentation.

(E) Calculation of spenddown amount. If the individual's countable monthly income, as determined in accordance with rule 5160:1-3-03.1 of the Administrative Code, exceeds the RMA need standard, the administrative agency must calculate the amount, if any, of the monthly spenddown as follows:

(1) Determine the total amount of all monthly medical insurance premiums of the individual and family members. Do not round down. Subtract that amount from the individual's countable monthly income and round down to the nearest whole dollar.

(a) If the result is less than or equal to the applicable RMA need standard, the individual is eligible for RMA for the entire calendar month without any monthly spenddown amount.

(b) If the result is greater than the applicable RMA need standard, continue to paragraph (E)(2) of this rule.

(2) Determine the total amount of the individual's and family members' UPMEs as determined in accordance with paragraph (G)(2) of this rule. Do not round down. Subtract that amount from the result calculated in paragraph (E)(1) of this rule and round down to the nearest whole dollar.

(a) If the result is less than or equal to the applicable RMA need standard, the individual is eligible for RMA for the entire calendar month without any monthly spenddown amount.

(b) If the result is greater than the applicable RMA need standard, the amount that is over the need standard is the individual's monthly spenddown amount. In order to become eligible for RMA for all or part of the calendar month, the individual must satisfy the monthly spenddown amount through one of the methods set forth in paragraph (F) of this rule.

(F) Ways of meeting spenddown. If the individual has a monthly spenddown amount calculated in accordance with paragraph (E) of this rule, the individual may satisfy, or meet, the spenddown through one or more of the following methods, and must do so each calendar month in order to be eligible for RMA:

(1) Recurring.

(a) The individual will not have a spenddown requirement for one or more calendar months if the individual is found eligible for RMA pursuant to paragraph (E)(1)(a) or (E)(2)(a) of this rule.

(b) If the individual's and/or family members' expenses described in paragraph (E) of this rule are not equal to or greater than the spenddown amount for a given calendar month, the individual may satisfy the spenddown amount by using one or more of the methods set forth in paragraphs (F)(2) to (F)(4) of this rule.

(2) Incurred. This method is frequently called "delayed spenddown."

(a) At the individual's option, the individual may satisfy spenddown for a calendar month by incurring a dollar amount of current medical expenses, as defined in paragraph (B)(6) of this rule, equal to or greater than the spenddown amount for the calendar month.

(b) An individual is eligible for RMA for a calendar month starting on the date the individual and/or family member(s) incurred the medical expenses that, combined with all other incurred medical expenses for the month, equal or exceed the individuals spenddown amount for the calendar month.

(3) Pay-in.

(a) At the individual's option, the individual may satisfy spenddown for the current calendar month by paying to the administrative agency the dollar amount of the spenddown amount for the current calendar month. If the individual does so, he or she is eligible for RMA for the entire calendar month.

(b) A third party may pay-in on behalf of the individual or a group of individuals subject to spenddown by making payments directly to the administrative agency from the third party's funds or other funds in the current calendar month in which eligibility is being sought. Such payments are not considered income, are not included in the individual's countable monthly income, and do not negatively affect the individual's RMA eligibility.

(c) Pay-in spenddown payments cannot be applied to retroactive months. Pay-in spenddown payments are restricted to payment for current or future calendar month(s) in which RMA eligibility through the spenddown process is being sought.

(4) Combination of methods.

(a) At the individual's option, he or she may meet the spenddown by using the incurred method described in paragraph (F)(2) of this rule for one or more calendar months, and the pay-in method described in paragraph (F)(3) of this rule for one or more other calendar months.

(b) At the individual's option, he or she may meet the spenddown by combining two methods in a single calendar month as follows:

(i) After the individual and/or family member has incurred an amount of current medical expenses for the calendar month that is less than the individual's spenddown amount for the calendar month, the administrative agency permits the individual to pay-in the difference between the current incurred medical expenses and the spenddown amount.

(ii) If the individual does so, he or she is eligible for RMA for the month starting on the date the individual or family member incurred the last current medical expense for the calendar month.

(5) Failure to satisfy spenddown for a calendar month. If the individual does not satisfy spenddown for a calendar month, the individual is not eligible for RMA for the calendar month. The individual may be eligible for a future calendar month in which the individual satisfies spenddown during the time-limited RMA period, not exceeding eight continuous months from the individual's date of entry or date status is granted.

(6) Documentation of a met spenddown liability must be submitted to the county department of job and family services (CDJFS) within three hundred sixty-five days of the date of service.

(G) Treatment of expenses.

(1) Treatment of current incurred medical expenses subject to payment by a third party:

(a) If written off by the provider: the expense is treated as a current incurred medical expense for the calendar month in which the item or service was provided.

(b) If paid, or subject to payment, by a third party that is not legally obligated to pay the expense for the individual or family member: the expense is treated as a current incurred medical expense for the calendar month in which the item or service was provided, even if it is paid by the third party later in the same or a subsequent month.

(c) If paid, or subject to payment, by a third party that is legally obligated to pay the expense or a portion of the expense for the individual or family member: the expense is not treated as a current incurred medical expense.

(d) If an agency or program provides a direct medical service based on out-of-pocket limits, or a "sliding" or "ability-to-pay" fee scale, only the amount the individual or family member is liable to pay for the service, including deductibles and co-pays, are treated as current incurred medical expenses.

(2) Treatment of UPMEs. For the purpose of calculating the spenddown amount, the amount of UPME to be subtracted is determined in accordance with this paragraph.

(a) A UPME is considered to have been incurred in the calendar month during which the provider supplied the item or service to the individual or family member.

(b) The individual is not required to pay or provide evidence of paying the UPME for RMA purposes.

(c) UPMEs that may be applied in the spenddown process are:

(i) Incurred during a calendar month in which the individual or family member receiving the item or service was not eligible for another category of medical assistance.

(ii) Incurred during a calendar month in which the individual did not satisfy the monthly spenddown amount, even with the application of the bill.

(iii) Incurred for a medical item or service not payable under any category of medical assistance, regardless of an individual's eligibility during the calendar month in which the medical expense occurred, because the item or service was:

(a) Not covered by medical assistance; or

(b) Supplied by a provider who was not participating in the medical assistance program; or

(c) Was supplied by a medical assistance provider who did not accept medical assistance for the UPME.

(d) The administrative agency shall assist the individual with choosing the amount of the UPME to apply, and the calendar month(s) for which to apply it. To assist the individual with making an informed decision, the administrative agency shall determine the minimum number of calendar months for which the UPME might be applied. To make this determination, the administrative agency shall:

(i) Determine the combined total of all the UPMEs of the individual and family members;

(ii) Divide the total UPME by the result calculated in paragraph (E)(1) of this rule;

(iii) The quotient is the minimum number of calendar months the UPME would allow the individual to meet the spenddown amount, assuming no changes in any factor that would affect the calculation of the spenddown amount.

(e) The amount of the UPME the administrative agency must subtract in the calculation of the spenddown amount in paragraph (E)(2) of this rule is either:

(i) The amount of the UPME the individual chooses to use; or

(ii) If the individual does not choose an amount to use, the difference between the result calculated in paragraph (E)(2) of this rule and the RMA need standard applicable to the individual.

(f) A UPME or portion of a UPME that the administrative agency applies toward the spenddown for a given calendar month cannot be used again in the spenddown process for a future calendar month.

(g) A UPME or portion of a UPME that the administrative agency does not apply toward the spenddown can be used to meet the spenddown for a future calendar month.

(3) Treatment of medical expenses used in the spenddown process. Any medical expenses of the individual or family member that are used in the spenddown process to approve the individual's RMA for a given calendar month remain the obligation of the individual or family member and are not payable by the RMA program.

(H) Spenddown during retroactive calendar months in which the individual incurred a medically necessary medical expense:

(1) The administrative agency must determine whether the individual is retroactively eligible, including eligibility through the spenddown process, in accordance with rule 5160:1-2-01 of the Administrative Code. RMA eligibility cannot begin prior to the individual's date of entry or date status was granted.

(2) If the individual is not retroactively eligible (even through the spenddown process), the individual may apply the medical expense as a UPME in the spenddown process for a calendar month in which the individual is otherwise eligible.

(3) If the individual is retroactively eligible (whether through the spenddown process or not):

(a) The individual may apply the UPME in the spenddown process for the retroactive calendar month only if the UPME is not payable for the individual under another category of medical assistance, as described in paragraph (G)(2)(c)(iii) of this rule; and

(b) The individual must apply the UPME to meet the spenddown for the retroactive calendar month(s) first, before using it to meet the spenddown for any subsequent calendar month.

(I) Administrative agency responsibilities.

(1) Accept an application, or electronic equivalent, for medical assistance as an application for RMA;

(2) In order to assist the individual with making informed decisions about the spenddown process, explain to and/or discuss with the individual the following:

(a) The various recurring and incurred spenddown medical expenses the individual may use in the spenddown process; and

(b) The methods for satisfying spenddown.

(3) Not require an individual to apply for or receive refugee cash assistance (RCA);

(4) Not require a face-to-face interview;

(5) Use actual countable individual income for the month of application. Do not average income prospectively in determining income eligibility for RMA;

(6) Determine eligibility for another category of medical assistance, as described in Chapter 5160:1-1, 5160:1-3, 5160:1-4 or 5160:1-5 of the Administrative Code, prior to determining eligibility for RMA;

(7) Call the trafficking verification line to confirm the validity of the certification letter or letter for children and to notify ORR of the benefits for which the individual has applied;

(8) Make eligible for RMA an individual who receives RCA and who meets the eligibility requirements of this rule;

(9) Obtain third-party liability information from an individual who has other health insurance;

(10) Explore retroactive eligibility for RMA, in accordance with rule 5160:1-2-01 of the Administrative Code. Retroactive eligibility cannot begin prior to the individual's date of entry or date status was granted.

(11) Issue the RMA card for the month within two business days after the individual submits verification showing that current incurred medical expenses for the month satisfy the spenddown amount for the calendar month.

(12) Implement and make available in writing reasonable policies and procedures for administering the pay-in spenddown method. The policies and procedures must:

(a) Permit and provide reasonable methods of accepting payments by third parties on behalf of individuals and groups of individuals subject to spenddown.

(b) Ensure that, at the individual's option, the individual will receive an RMA card for a month on or about the first day of the month by making his or her pay-in payment by a date chosen by the administrative agency near the end of the preceding month.

(i) If the administrative agency receives the individual's pay-in payment before the preceding month's cutoff date for benefit issuance, the administrative agency will authorize the issuance of the RMA card in the electronic eligibility system within two business days after the cutoff date; or

(ii) If the administrative agency receives the individual's pay-in payment on or after the preceding month's cutoff date for benefit issuance, the administrative agency will issue the RMA card within two business days after the administrative agency receives the individual's pay-in payment.

(c) Ensure that, at the individual's option, the individual may pay-in for a given calendar month at any time during the calendar month and that the administrative agency will issue the RMA card for the month within two business days after the administrative agency receives the individual's pay-in payment.

(d) Establish reasonable methods for accepting and accounting for pay-in payments, including but not limited to:

(i) Accepting cash payments; and

(ii) Defining conditions for accepting checks or money orders; and

(iii) Establishing provisions for refunding or crediting unused pay-in amounts.

(e) Establish provisions for refunding the individual's pay-in payment for a month in the event the individual:

(i) Becomes eligible for medical assistance for the month through means other than the spenddown process; or

(ii) Becomes ineligible for medical assistance for the month despite meeting the spenddown; or

(iii) Paid in more than the spenddown amount, whether due to the individual's error or to the administrative agency's error in calculating the spenddown amount.

(13) Document all pay-in spenddown payments in the electronic eligibility system and in the individual's case record, and issue a receipt to all individuals and third parties who make pay-in spenddown payments. The documentation and receipts must state:

(a) The date payment was received; and

(b) The name of the person or entity from whom the payment was received; and

(c) The name and identifying case information of the individual for whom the payment was made; and

(d) The calendar month of eligibility for which the pay-in payment will be used and the effective date of RMA for that month; and

(e) The amount of the payment and the form in which it was paid.

(14) Document in the electronic eligibility system and in the individual's case record:

(a) For each month's current incurred medical expenses and UPMEs submitted by or on behalf of the individual:

(i) The name of the provider of the medical item or service; and

(ii) The item or service provided; and

(iii) The date the item or service was provided; and

(iv) The name of the individual or family member to whom the item or service was provided; and

(v) The amount the individual or family member paid or is liable to pay for the item or service; and

(vi) For UPMEs, the calendar month(s) for which the UPME or a portion of the UPME was used in the calculation of the spenddown amount; and

(vii) The amount still owed for the item or service.

(b) For current incurred medical expenses that require a decision by the PAU, as described in paragraph (B)(10) of this rule:

(i) The provider's statement; and

(ii) The PAU decision; and

(iii) All other information related to the administrative agency's decision to use or not use a current incurred medical expense in the spenddown process.

(c) For transportation expenses the administrative agency has determined cannot be used in the spenddown process:

(i) A description of which specific transportation expense(s) were not used; and

(ii) A clear explanation of the administrative agency's determination.

(15) Issue proper notice and hearing rights as set forth in division 5101:6 of the Administrative Code.

(16) Not deny RMA for an individual who is applying for medical assistance and does not anticipate satisfying spenddown in the month of application or in one or more future calendar months. Instead, the administrative agency shall cause the electronic eligibility system to give the individual the type of eligibility that will only issue an RMA card to the individual for those calendar months for which the individual satisfies the spenddown amount.

(17) Not propose to discontinue RMA for an individual who does not satisfy spenddown for one or more calendar months. Instead, the administrative agency shall cause the electronic eligibility system to give the individual the type of eligibility that will only issue an RMA card to the individual for those calendar months for which the individual satisfies the spenddown amount.

(J) Individual responsibilities. The individual shall:

(1) Provide:

(a) USCIS documentation of non-citizen status; and

(b) The name of the resettlement agency, if any, that resettled the individual; and

(c) The information necessary to establish eligibility, cooperate with the verification process, and report changes in accordance with rule 5160:1-2-08 of the Administrative Code.

(2) Spend down to the RMA need standard if the countable income exceeds the RMA need standard.

(3) Cooperate with providing verification of any third-party liability or coverage of medical expenses as defined in rule 5160:1-2-10 of the Administrative Code.

(4) The individual must submit monthly to the administrative agency, by mail, facsimile, electronically or in person, verification of the current incurred medical expenses the individual wishes to apply against his or her spenddown amount for the calendar month.

(a) Verifications may include unpaid bills, statements, invoices, paid receipts, etc.

(b) For each expense, the individual must provide the name of the provider, the item or service provided, the date the item or service was provided, the name of the individual or family member to whom the item or service was provided, and the amount the individual or family member paid or is liable to pay for the item or service.

Last updated July 1, 2021 at 9:52 AM

Supplemental Information

Authorized By: 5160.02, 5162.02, 5163.02
Amplifies: 5160.02, 5162.02, 5163.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 11/22/1981, 2/9/1984 (Temp.), 7/1/1984, 12/27/1984, 7/1/1988, 1/1/1989 (Emer.), 4/1/1989, 11/1/1989, 1/1/1990 (Emer.), 1/1/1996, 7/1/1998
Rule 5160:1-5-06 | Medicaid: alien emergency medical assistance (AEMA).
 

(A) This rule describes eligibility criteria for coverage of treatment of an emergency medical condition for certain individuals who do not meet the medicaid citizenship or satisfactory immigration status requirements described in rule 5160:1-2-11 or 5160:1-2-12 of the Administrative Code.

(B) Definition. "Emergency medical condition", for the purposes of this rule, means a medical condition with a sudden onset:

(1) Manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

(a) Placing the patient's health in serious jeopardy;

(b) Serious impairment to bodily functions; or

(c) Serious dysfunction of any bodily organ or part;

(2) Including labor and delivery, but

(3) Not including either:

(a) Routine prenatal or postpartum care, or

(b) Care and services related to an organ transplant procedure.

(C) Eligibility criteria. The individual must:

(1) Have received treatment for an emergency medical condition.

(2) Submit an application for medical assistance for the dates of a particular emergency medical episode.

(3) Meet eligibility criteria for a category of medicaid, except that the individual:

(a) Does not meet the medicaid citizenship or non-citizen requirements set forth in rules 5160:1-2-11 and 5160:1-2-12 of the Administrative Code. The individual is not required to verify the individual's:

(i) Social security number, or

(ii) Citizenship or immigration status.

(b) Is not required to apply for social security administration (SSA) benefits. If the individual is otherwise eligible for a category of medicaid that requires a disability determination, the administrative agency shall submit a disability determination packet to the disability determination area (DDA) in accordance with rule 5160:1-3-02.9 of the Administrative Code.

(D) Eligibility span. Coverage for an individual who meets the criteria in paragraph (C) of this rule:

(1) Begins on the day on which the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part, and

(2) Ends on the day on which the absence of immediate medical attention could no longer reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. The emergency medical condition episode:

(a) Includes labor and delivery, but

(b) Does not include ongoing treatment.

(E) Administrative agency responsibilities. The administrative agency shall:

(1) Determine the eligibility span for routine labor and delivery without submitting medical documentation to the DDA for a determination, and enter it into the electronic eligibility system in accordance with the following policy:

(a) The eligibility span begins on the date of admission for labor, and ends at midnight of the day in which one of the following time periods falls:

(i) A maximum of two days (forty-eight hours) following a vaginal delivery; and

(ii) A maximum of four days (ninety-six hours) following a caesarian section delivery.

(b) The time period beginning on the date of admission for labor and ending on the date of delivery shall not exceed two days (forty-eight hours).

(2) Submit medical documentation to the DDA for a determination of the covered dates of service when:

(a) The time period beginning on the date of admission for labor and ending on the date of delivery is greater than two days (forty-eight hours); or

(b) The labor and delivery episode from admission through discharge exceeds the timeframes described in paragraph (E)(1)(a) of this rule.

(3) For emergency medical conditions other than routine labor and delivery as described in paragraph (E)(1) of this rule, enter the eligibility span determined by the DDA into the electronic eligibility system.

(4) Upon request, assist the individual in obtaining medical documentation to support the AEMA claim.

(F) Disability determination area (DDA) responsibilities. The DDA shall:

(1) Make all emergency medical condition determinations except for routine labor and delivery cases, as described in paragraph (E)(1) of this rule.

(2) Determine if the individual received treatment for an emergency medical condition.

(3) Determine the eligibility span for the emergency medical condition episode.

(4) Notify the administrative agency of the AEMA determination and the eligibility span via the electronic eligibility system.

Supplemental Information

Authorized By: 5162.031, 5163.02
Amplifies: 5163.02
Five Year Review Date: 8/1/2021
Prior Effective Dates: 1/1/2014
Rule 5160:1-5-07 | Medicaid: specialized recovery services (SRS) program.
 

(A) This rule sets forth the eligibility criteria for a state plan home and community-based services (HCBS) benefit authorized under section 1915(i) of the Social Security Act (as in effect on October 1, 2017). Section 1915(i) of the act allows states the flexibility to provide HCBS to individuals who require less than an institutional level of care (LOC) and who would, therefore, not be eligible for HCBS under the more restrictive criteria of section 1915(c) waivers. The specialized recovery services (SRS) program provides targeted services to the following individuals described in rule 5160-43-02 of the Administrative Code:

(1) Individuals with severe and persistent mental illness (SPMI); or

(2) Individuals who are active on the solid organ or soft tissue waiting list; or

(3) Individuals with certain diagnosed chronic conditions.

(B) Eligibility for the SRS program state plan HCBS benefit. An individual shall meet all of the following criteria to be eligible for the SRS program state plan HCBS benefit:

(1) Be at least twenty-one years of age.

(2) Have been determined to meet the definition of disability used by the social security administration (SSA) for purposes of supplemental security income (SSI) or social security disability insurance (SSDI) benefits.

(a) A disability determination is not required for individuals over the age of sixty-five years old who are active on the solid organ or soft tissue waiting list, or who have certain diagnosed chronic conditions.

(b) A disability determination is not required for individuals under age sixty-five years old who are enrolled in the medicare end-stage renal disease program.

(3) Meet the clinical diagnostic, needs assessment, and risk criteria described in rule 5160-43-02 of the Administrative Code.

(4) Reside in a home and community-based setting consistent with the qualities identified in 42 C.F.R. 441.710 (as in effect on October 1, 2017).

(5) Meet the financial and nonfinancial eligibility requirements of one of the following groups:

(a) Group one.

(i) Be in receipt of medical assistance, as described in Chapters 5160:1-1 to 5160:1-5 of the Administrative Code; and

(ii) Have countable income that does not exceed one hundred fifty per cent of the federal poverty level (FPL), as determined using the same rules used for determining the individual's medical assistance eligibility.

(b) Group two.

(i) Meet the conditions of eligibility outlined in rule 5160:1-2-10 of the Administrative Code; and

(ii) Not be otherwise eligible for medical assistance; and

(iii) For the purpose of determining whether an individual is income eligible for the SRS program, the administrative agency shall compare the individual's countable income to one hundred fifty per cent of the FPL, as determined in accordance with Chapter 5160:1-3 of the Administrative Code.

(a) If the individuals countable income exceeds one hundred fifty per cent of the FPL, apply additional disregards in the following order:

(i) Twenty dollar personal needs disregard; then

(ii) Disregard income in the amount of the difference between one hundred fifty per cent of the FPL for an individual and three hundred per cent of the current supplemental security income (SSI) federal benefit rate (FBR) for an individual.

(b) If the amount determined in paragraph (B)(5)(b)(iii) of this rule is no more than one hundred fifty per cent of the FPL, the individual meets the income eligibility requirement for the SRS program.

(iv) There is no resource limit for individuals described in paragraph (B)(5)(b) of this rule.

(C) There is no retroactive eligibility for the SRS program state plan HCBS benefit. Coverage under this rule cannot begin prior to the first day of the month in which all financial, nonfinancial, and programmatic criteria are met.

(D) An individual who is receiving the state plan HCBS benefit cannot be concurrently enrolled in another HCBS authority, such as a section 1915(c) waiver. Subject to the individual's choice, he or she will be enrolled in the HCBS authority best meeting the totality of his or her needs regardless of the order in which the individual applied for or became eligible for HCBS.

(E) Eligibility for this program shall be determined for applications for medical assistance filed on or after the effective date of this rule.

Supplemental Information

Authorized By: 5162.03, 5163.02
Amplifies: 5162.03, 5163.02
Five Year Review Date: 8/1/2021
Prior Effective Dates: 8/1/2016
Rule 5160:1-5-08 | Medicaid: state-funded medical assistance for non-citizen victims of trafficking.
 

(A) This rule describes the eligibility requirements for state-funded medical assistance for a non-citizen victim of a severe form of human trafficking. Eligibility for this program shall be determined for applications for medical assistance filed on or after the effective date of this rule.

(B) For purposes of this rule the following definitions apply unless otherwise stated.

(1) "Labor trafficking" means recruiting, harboring, transporting, or obtaining of a person for labor or services through the use of force, fraud, or intimidation for the purpose of involuntary servitude, debt bondage, or slavery.

(2) "Severe form of human trafficking" means sex trafficking or labor trafficking.

(3) "Sex trafficking" means recruiting, harboring, transporting, or obtaining of a person for the purpose of a commercial sex act where the commercial sex act is induced by force, fraud, or intimidation, or the person being induced to perform such act is under eighteen years of age.

(4) "T non-immigration status" is also known as the T Visa and provides immigration protection to victims of a severe form of human trafficking.

(C) Eligibility criteria.

(1) To be eligible for medical assistance, the non-citizen victim of a severe form of human trafficking must:

(a) Have applied for, or be in the process of preparing to file an application with the United States citizenship and immigration services (USCIS) for, "T" non-immigration status;

(b) Be an Ohio resident as described in rule 5160:1-2-10 of the Administrative Code; and

(c) Meet the financial requirements described in paragraph (D) of this rule.

(2) An individual under this program is not required to provide a social security number.

(D) Financial eligibility.

(1) To have eligibility under this program, the individual must have countable monthly income at or below one hundred per cent of the federal poverty level (FPL) as determined in accordance with rules 5160:1-3-03.1 and 5160:1-3-03.2 of the Administrative Code. Only the individual's income is compared to the income standard. The FPL is adjusted annually.

(2) The deeming provisions set forth in rules 5160:1-3-03.1 and 5160:1-3-03.3 of the Administrative Code do not apply to the eligibility determination for a non-citizen victim of a severe form of human trafficking.

(E) Resource eligibility. There is no resource limit for individuals described in this rule.

(F) Retroactive eligibility. Eligibility for retroactive coverage of medical assistance shall be determined in accordance with rule 5160:1-2-01 of the Administrative Code.

(G) County department of job and family services (CDJFS) responsibilities. The CDJFS shall:

(1) Verify the individual has applied for, or is preparing to apply for, "T" non-immigration status with the USCIS.

(a) The CDJFS must accept the following documentation when the individual claims to have already applied for a "T" non-immigration status:

(i) Form I-797, "Notice of Action", issued by the USCIS; or

(ii) Completed Form I-914, "Application for T Non-Immigration Status"; or

(iii) Completed Form I-914, Supplement B, "Declaration of Law Enforcement Officer for Victim of Trafficking in Persons"; or

(iv) Printouts of case status queries from the USCIS website; or

(v) Other correspondence from USCIS regarding applications, such as appointment notices.

(b) When the individual is preparing to file for "T" non-immigration status, the CDJFS shall:

(i) Verify with a sworn written statement that the individual is a victim of a severe form of human trafficking and at least one item of additional credible evidence, including but not limited to any of the following:

(a) Police, government agency, or court records or files; or

(b) News articles; or

(c) Documentation from a social services agency, domestic violence center, rape crisis center, or a legal, clinical, or medical professional, or other professional to whom the individual has reported the crime; or

(d) A written statement from any other individual with knowledge of the circumstances that provided the basis for the claim; or

(e) Physical evidence; or

(f) A written notice from the federal agency of receipt of the visa application.

(ii) Determine if the sworn statement is credible if the individual is unable to provide any of the additional evidence listed in this rule.

(2) Determine the individual does not qualify for another category of medical assistance.

(H) Individual responsibilities. The individual shall:

(1) Cooperate with the CDJFS to determine financial eligibility for medical assistance.

(2) Cooperate with the CDJFS to determine non-financial eligibility for medical assistance.

(3) Cooperate in providing verification of any third-party liability or coverage of medical expenses as defined in rule 5160:1-2-10 of the Administrative Code.

(4) 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 rule 5160:1-2-10 of the Administrative Code.

(5) Report changes within ten days to the CDJFS in accordance with rule 5160:1-2-08 of the Administrative Code. Changes include but are not limited to the following:

(a) Approval or denial of the application for "T" non-immigration status; and

(b) Immigration status; and

(c) Address; and

(d) Marital status; and

(e) Income; and

(f) Pregnancy status.

(6) File a formal application for "T" non-immigration status within one year of his or her date of application for medical assistance, unless it can be determined that during the year the individual:

(a) Experienced a health crisis; or

(b) Has been unable, after reasonable attempts, to obtain the necessary information from a third party; or

(c) Has other extenuating circumstances that prevented the individual from completing his or her application.

(I) There is not a limitation on the amount of time the individual can receive coverage under this medical assistance category, provided the individual continues to meet all relevant eligibility criteria.

Supplemental Information

Authorized By: 5160.02
Amplifies: 5160.02
Five Year Review Date: 4/1/2024
Prior Effective Dates: 7/8/2020 (Emer.)