Rule 3701-43-21 | Providing assistance with medicaid spenddown payments.
(A) As used in this rule:
(1) "Eligible participant" means a recipient who also meets the conditions for eligibility for medicaid spenddown payment assistance as set forth in paragraphs (B) to (F) of this rule.
(2) "Cost-effective" means the total cost to the department for uncovered services provided to an eligible participant plus the cost for medicaid spenddown payments paid by the program on behalf of the eligible participant plus the associated administrative costs to the program is less than the total anticipated annual costs to the program for authorized services provided to an eligible participant.
(3) "Assistance" means the payment of medicaid spenddown liability by the program to a county job and family services agency for the purpose of providing continued medicaid coverage or obtaining medicaid coverage.
(4) "Uncovered services" means authorized services provided to an eligible participant that are not covered benefits of the eligible participant's medicaid health plan.
(5) "Total anticipated annual costs" means the estimated costs to the program for authorized services if the eligible participant had no health insurance coverage.
(6) "Primary source of payment" mean the payment source with primary responsibility for payment.
(B) The director may authorize assistance for a recipient who has a spenddown liability for medicaid and meets the following conditions:
(1) Recipient has been approved for medical assistance disability (MA-D) with a spenddown liability for medicaid as defined in rule 5101:1-39-10 of the Administrative Code.
(2) The recipient is requiring a bone marrow transplant and has insurance, but the recipient's primary source of payment is the program for a bone marrow transplant.
(3) The director determines that it is cost-effective.
(C) The director shall require that the following information be submitted by the recipient or the recipient's parent, guardian or other legal representative to determine the recipient's eligibility for assistance:
(1) A written approval letter from the department of job and family services documenting the spenddown amount and the effective date of the spenddown.
(2) Any other documentation as requested by the director.
(D) The director shall determine the recipient's eligibility for assistance and provide written documentation to the recipient and to the county department of job and family services within thirty days of receipt of all required documentation. Assistance with medicaid spenddown payments will not begin prior to the first of the month in which all required documentation is received.
(E) The director shall establish an initial period of eligibility for assistance not to exceed twelve months. The director may establish a continued period of eligibility for assistance based upon a determination of cost-effectiveness to the program.
(F) The recipient or eligible participant or parent, guardian or other legal representative shall submit within thirty days of the date of the change, documentation of any changes to income that result in an increase in annual gross earnings, changes to the recipient's health insurance coverage, changes in medicaid status, changes in recipient's medicaid spenddown amount or documentation of any other changes that would affect the recipient's eligibility for assistance.
(G) The director may discontinue assistance or change the terms of assistance if:
(1) The eligible participant or the eligible participant's parent, guardian or other legal representative fails to meet the requirements set forth in paragraphs (B) to (F) of this rule.
(2) The eligible participant or the eligible participant's parent, guardian or other legal representative does not comply with the rules, the requirements or follow through with the application process of the involved county department of job and family services.
(H) The director shall provide the eligible participant or the eligible participant's parent, guardian or other legal representative written notification of the decision to discontinue or change the terms of assistance. Any such discontinuation or change will become effective no sooner than thirty calendar days from the date of the written notice.
Supplemental Information
Amplifies: –
Five Year Review Date: