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, "qualified entity" has the same meaning as defined in rule 5160:1-1-01 of the Administrative Code.
(B) To become a QE, the eligible entity must:
(1) Have an active provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code;
(2) Read the presumptive eligibility training guide found on the ODM website, www.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 "acknowledgment of terms and conditions governing the presumptive eligibility determinations authority granted by the Ohio department of medicaid to a qualified entity" (rev. 8/2019), found on the ODM website, www.medicaid.ohio.gov.
(C) Once designated as a QE, the QE must:
(1) Remain in good standing as an Ohio medicaid provider;
(2) Follow rule 5160:1-2-13 of the Administrative Code and all other applicable federal and state laws when determining medicaid PE;
(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 who have responsibility to submit claims to the medicaid program for reimbursement of medicaid services are not individuals 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 who violate federal or state law. 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 federal or state law;
(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, at least eighty-five per cent have a completed application for full medicaid benefits 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 for all persons who had an application submitted for full medicaid benefits, at least eighty-five per cent result in an awarding of medicaid eligibility.
(D) 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, including, but not limited to the following circumstances:
(1) Revocation or cancellation of the QE's Ohio medicaid provider agreement;
(2) Requirements set forth in this rule are not met;
(3) Unauthorized use of MITS by the QE;
(4) Programmatic or systematic changes related to the medicaid eligibility or enrollment system; or
(5) The QE is unable to perform its functions.
(E) A QE may utilize reconsideration rights as stated in rule 5160-70-02 of the Administrative Code to challenge a decision of ODM to deny or terminate QE designation.
Supplemental Information