(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;
(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 when 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;
(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; and
(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;
(ii) The
individual's sibling (including half-sibling) under the age of eighteen,
who lives with the individual;
(iii) The
individual's deceased parent, provided the surviving parent who lives with
the individual had a duty of medical support to the deceased parent at the time
of his or her death; and
(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, has the same meaning 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, 2023), 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, 2023);
(b) Admitted to the U.S. as a refugee under section 207 of the
INA (as in effect October 1, 2023);
(c) Granted asylum under section 208 of the INA (as in effect
October 1, 2023);
(d) A Cuban or Haitian entrant in accordance with requirements in
45 C.F.R. part 401 (as in effect October 1, 2023);
(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, 2023), 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, 2023);
(f) A victim of a severe form of trafficking as identified in 22
U.S.C. 7105(b)(1) (as in effect October 1, 2023) 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, 2023). 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, 2023). 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, 2023).
(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) When 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) When 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. When 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) When 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) When 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 when 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 when 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;
(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, 2023);
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. When 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;
(b) The medical item or
service for which the individual needed the transportation;
(c) The suitability of
the transportation alternatives reasonably available to the
individual;
(d) The reasonableness of
the expense based on the circumstances; and
(e) Any other relevant
factors.
(ii) After considering
all of the listed factors, when 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;
(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) When an individual receiving RMA has increased earnings from
employment, the earnings shall not affect the individual's continued
eligibility for RMA.
(c) When 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 when the individual:
(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 the twelve month time-limited eligibility period, as
described in 45 C.F.R. 400.104 (as in effect October 1, 2023).
(e) In cases where an individual is covered by employer-sponsored
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 twelve 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. When 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) When 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) When 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) When 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) When 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. When 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 when the individual is found eligible for RMA pursuant
to paragraph (E)(1)(a) or (E)(2)(a) of this rule.
(b) When 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 individual's 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. When
the dollar amount of the spenddown is satisfied, the individual 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, the individual 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, the individual 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) When the individual
does so, the individual 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 twelve 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) When 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) When 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 when it is paid by the
third party later in the same or a subsequent month.
(c) When 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) When 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;
(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) When 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) When 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) When 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 when 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 when 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) When 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) When 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;
(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;
(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;
(b) The name of the person or entity from whom the payment was
received;
(c) The name and identifying case information of the individual
for whom the payment was made;
(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;
(ii) The item or service
provided;
(iii) The date the item
or service was provided;
(iv) The name of the
individual or family member to whom the item or service was
provided;
(v) The amount the
individual or family member paid or is liable to pay for the item or
service;
(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;
(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;
(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 when 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.
