Rule 5160-1-17.12 | Qualified entity requirements and responsibilities for determining presumptive eligibility.
The Ohio department of medicaid (ODM) authorizes qualified entities (QEs) to determine presumptive eligibility (PE) based on self-attested information to grant immediate medicaid coverage to certain individuals seeking medicaid covered services. This rule sets forth eligibility requirements and responsibilities to maintain designation as a QE.
(A) For the purposes of this rule, the following definitions apply:
(1) "Qualified Entity" has the same meaning as defined in rule 5160:1-1-01 of the Administrative Code.
(2) "Unauthorized Use" means any access or activity that exceeds granted access or is performed without ODM approval, including misuse, credential sharing, or using the system for personal gain.
(B) To become a QE, the eligible entity must:
(1) Be an eligible provider as defined in rule 5160-1-17 of the Administrative Code;
(2) Read the presumptive eligibility training guide found on the ODM website, medicaid.ohio.gov; and
(3) Attest that it will meet the terms and conditions as a QE by reading, signing, and sending ODM form 10252 "Acknowledgement of Terms and Conditions Governing the Presumptive Eligibility Determinations Authority Granted by the Ohio Department of Medicaid to a Qualified Entity," found on the ODM website, medicaid.ohio.gov.
(C) Once designated as a QE, the QE must:
(1) Remain in good standing as an Ohio medicaid provider;
(2) Determine presumptive eligibility in accordance with rule 5160:1-2-13 of the Administrative Code and all other applicable federal and state laws;
(3) Verify the individual is not already enrolled in another category of medicaid;
(4) Without compensation, agree to perform all of the administrative functions associated with PE including, but not limited to:
(a) Provide to ODM a list of names and titles of all employees given responsibility to determine PE and request appropriate access to the PE portal;
(b) Ensure that employees given responsibility to determine PE have read the presumptive eligibility training guide, understand the criteria for all medicaid eligibility categories and have been trained on how to use the presumptive eligibility portal;
(c) Ensure those employees who have responsibility to submit claims to the medicaid program for reimbursement of medicaid services are not also employees responsible for determining presumptive eligibility; and
(d) Agree to retain all records related to presumptive eligibility determinations in accordance with rule 5160-1-27 of the Administrative Code and provide such records to ODM, its designee, or to any authorized state or federal agency upon request.
(5) Agree that it may be held responsible for the willful conduct of its employees. Any employee who knowingly files a claim containing false, incomplete, or misleading essential information to create eligibility for medicaid or receive payment from medicaid may be punishable under section 2913.40 or 2913.401 of the Revised Code;
(6) If the QE is a hospital, agree to provide thirty-six hours worth of medically necessary medications to any person enrolled presumptively by the QE at time of determination;
(7) If the QE is a federally qualified health center (FQHC) and is able to do so, provide thirty-six hours worth of medically necessary medications to any person enrolled presumptively by the QE at the time of determination if such needs are determined during a medical visit;
(8) Ensure that for all persons enrolled presumptively by the QE, a completed application for full medicaid benefits is submitted no later than the last day of the month following the month in which the QE makes the PE determination; and
(9) Ensure that at least 92.5 per cent of individuals determined presumptively eligible are subsequently awarded full medicaid eligibility.
(D) Monitoring.
(1) ODM will monitor performance standards in paragraphs (C)(8) and (C)(9) of this rule monthly for all PE determinations. A comprehensive PE training will be mandatory for all employees designated to make PE determinations for each period during which the QE fails to meet these performance standards, in accordance with section 5163.103 of the Revised Code.
(2) ODM will request a corrective action plan (CAP) from each QE for each period wherein performance standards set forth in this rule are not met in accordance with section 5163.103 of the Revised Code. Improvement will be monitored and reviewed annually to determine whether revocation of the QE designation in these instances is appropriate.
(3) A QE on an approved CAP will be monitored until successful completion of the CAP or revocation of the QE designation. Any QE exhibiting repeated instances of noncompliance with performance standards outlined in this rule or remaining on a CAP for more than one year may have its QE designation revoked.
(E) Revocation. ODM may terminate authority granted under this rule with or without written notice, for any reason supported by evidence of acts or omissions adversely affecting the medicaid program. An entity reapplying for QE designation after a revocation will need to follow the process outlined in paragraph (B) of this rule. QE designation revocation will occur in the following circumstances:
(1) Administrative revocation. ODM may revoke QE designation for the following reasons without subjecting the QE to a QE designation exclusion period:
(a) Suspension or termination of the QE's Ohio medicaid provider agreement;
(b) Unauthorized use of the PE portal by the QE;
(c) State or federal programmatic or systematic changes related to the medicaid eligibility or enrollment system;
(d) The QE does not perform at least fifty PE determinations in a twelve month period.
(2) Noncompliant revocation. ODM may revoke QE designation for failure to comply with performance standards outlined in paragraph (C)(8) or (C)(9) of this rule. Revocation resulting from noncompliance will subject the QE to the following periods of exclusion from QE designation:
(a) First revocation: one year exclusion from QE designation;
(b) Second revocation: three year exclusion from QE designation; and
(c) Third revocation: five year exclusion from QE designation.
Last updated October 1, 2026 at 10:11 AM
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