Rule 5160:1-2-10 | Medicaid: conditions of eligibility and verifications.
(A) This rule describes eligibility criteria that apply to all medical assistance programs, how eligibility criteria will be verified by the administrative agency, and when an individual will be asked to provide manual verification. Eligibility conditions that are specific to a certain eligibility group are addressed in the eligibility rule for that group.
(B) To be determined eligible for medical assistance, an individual shall:
(1) Provide a social security number (SSN) in accordance with 42 C.F.R. 435.910 (as in effect October 1, 2020).
(a) The individual's self-declaration of SSN meets this condition unless contradictory information is provided to or maintained by the administrative agency.
(b) An individual is not required to provide an SSN when the individual:
(i) Is applying for or receiving alien emergency medical assistance (AEMA), as described in rule 5160:1-5-06 of the Administrative Code.
(ii) Refuses to obtain an SSN because of well-established religious objections. Well-established religious objections exist when the individual:
(a) Is a member of a recognized religious sect or division of the sect; and
(b) Adheres to the tenets or teachings of the sect or division of the sect and for that reason is conscientiously opposed to applying for or using a national identification number.
(c) If the individual has not been issued or cannot recall his or her SSN, the administrative agency shall assist the individual with obtaining or applying for the individual's SSN.
(2) Be a resident, as defined in 42 C.F.R. 435.403 (as in effect October 1, 2020) of the state of Ohio on the date of application or requested coverage begin date.
(a) The individual's self-declaration of residency meets this condition unless contradictory information is provided to or maintained by the administrative agency.
(b) An individual remains a resident despite a temporary absence from the state when the individual intends to return when the purpose of the absence has been accomplished, unless another state has determined the individual is a resident there for purposes of medicaid eligibility.
(c) The individual shall not be eligible for and receiving medical assistance in another state or U.S. territory. An individual who has recently become an Ohio resident is not ineligible for medical assistance merely due to processing delays in terminating medical assistance in the prior state of residence.
(i) When there are delays in discontinuing medical assistance in the prior state of residence and the individual is unable to provide all needed verifications, the administrative agency shall explore presumptive coverage, as described in rule 5160:1-2-13 of the Administrative Code.
(ii) When all verifications have been provided, the administrative agency shall explore eligibility for medical assistance in accordance with Chapter 5160:1-3, 5160:1-4, 5160:1-5, or 5160:1-6 of the Administrative Code, as applicable.
(3) Be a U.S. citizen or qualified alien.
(a) An individual is not required to declare or verify citizenship or non-citizen status when the individual is applying for benefits only on behalf of another person.
(b) An individual's declaration of U.S. citizenship shall be verified as described in rule 5160:1-2-11 of the Administrative Code.
(c) An individual's declaration of qualified non-citizen status shall be verified as described in rule 5160:1-2-12 of the Administrative Code.
(d) Verification of non-citizen status is not required when the individual is applying for AEMA, as described in rule 5160:1-5-06 of the Administrative Code.
(4) Take all necessary steps to obtain any annuities, pensions, retirement, and disability benefits for which the individual is eligible, unless the individual can show good cause for not doing so, in accordance with 42 C.F.R. 435.608 (as in effect October 1, 2020).
(a) "Good cause," for the purposes of paragraph (B)(4) of this rule, means that to obtain a benefit, the individual would incur any significant disadvantage or detriment, including but not limited to any significant cost or expense.
(b) Benefits the individual shall take steps to obtain include, but are not limited to: annuities, retirement, veterans' benefits, social security disability insurance (SSDI), railroad retirement, and unemployment compensation.
(c) When eligibility or ineligibility for other benefits cannot be verified electronically, an official letter from the paying entity or financial institution is sufficient to verify the benefit.
(5) In accordance with 42 C.F.R. 435.610 (as in effect October 1, 2020) and section 5160.38 of the Revised Code, the state of Ohio shall automatically be assigned any rights to medical support and payments for medical care from any third party for:
(a) The individual; and
(b) Any medicaid-eligible individual for whom the individual is legally able to make an assignment.
(6) 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 paragraph (B)(5) of this rule, in accordance with 42 C.F.R. 433.147 (as in effect October 1, 2020).
(a) As part of cooperation, the individual may be required to:
(i) Appear at a state or local office to provide information or evidence relevant to the case; and
(ii) Appear as a witness at a court or other proceeding; and
(iii) Provide information, or attest to lack of information, under penalty of perjury; and
(iv) Take any reasonable steps to assist with establishing paternity and securing medical support or payments.
(b) Cooperation is required unless the individual:
(i) Is not receiving medical assistance for himself or herself; or
(ii) Is a pregnant woman, including a woman who is in her postpartum period; or
(iii) Has been approved for a good cause waiver as determined by the local CSEA; or
(iv) Is receiving transitional medical assistance.
(7) Cooperate with the administrative agency in identifying and providing information to assist the state with pursuing any third party who may be liable to pay for care and services. To meet this condition, the individual shall provide the name of the insurance company, billing address, subscriber identification number, group number, name of policy holder, and a list of covered individuals. In addition, the individual shall cooperate with requests:
(a) From a third-party insurance company to provide additional information that is required to authorize coverage or obtain benefits through the third-party insurance company.
(b) From a medicaid provider, managed care plan, or a managed care plan's contracted provider to provide additional information that is required for the provider or plan to obtain payments from a third-party insurance company for medicaid covered services.
(c) From a third-party insurance company, medicaid provider, managed care plan, or a managed care plan's contracted provider to forward or return to the third-party insurance company, medicaid provider, managed care plan, or managed care plan's contracted provider any payments received from the third-party insurance company for medicaid covered services when:
(i) The provider has billed the third-party insurance company for medicaid covered services provided to the individual; and
(ii) The third-party insurance company has sent payment to the individual for medicaid covered services the individual received from the provider.
(8) Meet all eligibility requirements for an eligibility category set out in an approved state plan amendment, Chapter 5160:1-2, 5160:1-3, 5160:1-4, 5160:1-5, or 5160:1-6 of the Administrative Code, including:
(a) Income requirements for the eligibility category.
(i) When an individual's declared income exceeds the relevant federal poverty level (FPL) threshold, the individual's declared income will be accepted without further verification.
(ii) When an individual's declared income is reasonably compatible with data available through electronic data sources, the individual's declared income will be accepted without further verification. Income shall be considered reasonably compatible when:
(a) Both the declared income and the electronic data verification are above, at, or below the applicable income standard for the individual's family size for the eligibility category being determined; or
(b) The difference between the declared income and the electronic data verification is within an amount equal to the reasonable compatibility standard for income specified in the state's MAGI-based eligibility verification plan.
(iii) When the administrative agency is unable to verify income through electronic data sources, acceptable verification documentation includes, but is not limited to:
(a) Information maintained as a regular part of business by a government entity; or
(b) A current pay stub; or
(c) An award letter from a certifying agency; or
(d) IRS form 1099 or other tax documents; or
(e) An employer statement including hourly or salary wage, hours worked per pay period, length of pay period, and any tax withholdings; or
(f) The individual's statement, if he or she declares the income verification cannot be accessed or submitted.
(b) Resource and asset requirements for the eligibility category. When the administrative agency is unable to verify the value of an individual's resources through electronic data sources, acceptable verification documentation includes, but is not limited to:
(i) Information maintained as a regular part of business by a government entity; or
(ii) A financial institution statement; or
(iii) Legal documents; or
(iv) The individual's statement, if he or she declares the resource verification cannot be accessed or submitted.
Last updated November 22, 2024 at 12:31 PM
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