Ohio Revised Code Search

...r of job and family services, regarding medical assistance programs. The auditor of state and attorney general shall do both of the following regarding the records: (1) Provide safeguards that restrict access to the records to purposes directly connected with an audit or investigation, prosecution, or criminal or civil proceeding conducted in connection with the administration of the programs; (2) Comply, and...

...The auditor of state is responsible for the costs the auditor incurs in carrying out the auditor's duties under sections 5160.21 and 5160.22 of the Revised Code.

...ining an individual's eligibility for a medical assistance program, at least all of the following information about the individual shall be verified: (1) Identity; (2) Citizenship and alien eligibility; (3) Social security number; (4) State residency status; (5) Disability status; (6) Gross nonexempt income; (7) Household status ; (8) Medical expenses; (9) Enrollment status in other state-administer...

...ances that may affect eligibility for a medical assistance program; (b) Take appropriate action. ( 2) Division (A)(1) of this section applies only to the extent information described in division (A) of section 5160.29 of the Revised Code is available to the department or entity. (B) If the department of medicaid or an entity with which the department has entered into an agreement under section 5160.30 of the R...

...ocess of determining or redetermining a medical assistance recipient's eligibility, the case shall be referred for investigation to the county prosecutor of the county in which the medical assistance recipient resides, referred for an administrative disqualification hearing, or both.

...lated to individuals' eligibility for a medical assistance program beyond the information specified in division (A) of section 5160.29 of the Revised Code; (B) Contracting with one or more independent vendors to provide such additional information for such purpose.

...m related administrative activities for medical assistance programs. (B) The department may enter into agreements with one or more agencies of the federal government, the state, other states, and local governments of this or other states to accept applications, determine eligibility, redetermine eligibility, and perform related administrative activities on behalf of the department with respect to medical assi...

...(A) A medical assistance recipient may appeal a decision regarding the recipient's eligibility for a medical assistance program or services available to the recipient under a medical assistance program. (B) Regarding appeals authorized by this section, the department of medicaid shall do one or more of the following: (1) Administer an appeals process similar to the appeals process established under section 51...

...ction: (1) "Chronic condition" means a medical condition that has persisted after reasonable efforts have been made to relieve or cure its cause and has continued, either continuously or episodically, for longer than six continuous months. (2) "Clinical peer" means a health care provider in the same, or in a similar, specialty that typically manages the medical condition, procedure, or treatment under review. (3) ...

...on 5160.43 of the Revised Code. (B) "Medical support" means support specified as support for the purpose of medical care by order of a court or administrative agency. (C)(1) Subject to division (C)(2) of this section, and except as provided in division (C)(3) of this section, "third party" means all of the following: (a) A person authorized to engage in the business of sickness and accident insurance under T...

...(A) A medical assistance recipient's enrollment in a medical assistance program gives an automatic right of recovery to the department of medicaid and a county department of job and family services against the liability of a third party for the cost of medical assistance paid on behalf of the recipient. When an action or claim is brought against a third party by a medical assistance recipient, any payment, settlement...

...partment of job and family services, a medical assistance recipient and the recipient's attorney, if any, shall cooperate with each medical provider of the recipient. Cooperation with a medical provider shall consist of disclosing to the provider all information the recipient and attorney, if any, possess that would assist the provider in determining each third party that is responsible for the payment or proc...

...e application for, or enrollment in, a medical assistance program constitutes an automatic assignment of rights specified in division (B) of this section to the department of medicaid. This assignment includes the rights of the medical assistance recipient and also the rights of any other member of the assistance group for whom the recipient can legally make an assignment. (B) Pursuant to this section, a medi...

...lishing third party liability regarding medical assistance programs. (B) In furtherance of the requirement in division (A) of this section and to allow the department to determine any period that the individual or the individual's spouse or dependent may have been covered by the third party and the nature of the coverage, a third party shall provide, as the department so chooses, information or access to info...

...ment regarding a claim for payment of a medical item or service that was submitted to the third party not later than six years after the date of the provision of such medical item or service; (3) Respond to the department's request for payment of a claim described in division (B)(2) of this section not later than sixty business days after receipt of written proof of the claim, either by paying the claim or issuing...

...evised Code on a claim for payment of a medical item or service provided to a medical assistance recipient is final on the date that is two years after the payment was made to the department of medicaid or the applicable medicaid managed care organization. After a claim is final, the claim is subject to adjustment only if an action for recovery of an overpayment was commenced under division (B) of this section before...

...vidual is eligible for or enrolled in a medical assistance program when either of the following applies: (A) The individual seeks to obtain a policy or enroll in a plan or program operated or administered by the third party; (B) The individual, or a person or governmental entity on the individual's behalf, seeks payment for a medical item or service provided to the individual.

...(A) If a third party violates section 5160.39, 5160.40, or 5160.41 of the Revised Code, a governmental entity that is responsible for issuing a license, certificate of authority, registration, or approval that authorizes the third party to do business in this state may impose a fine against the third party or deny, revoke, or terminate the third party's license, certificate, registration, or approval to do busi...

...orts to obtain support or payments, or medical assistance payments, and when cooperation may be waived. (B) The department shall adopt rules under section 5160.02 of the Revised Code to do all of the following: (1) For purposes of the definition of "information" in division (A) of section 5160.35 of the Revised Code, any data other than the data specified in that division that should be included in the defi...

...use or disclose information regarding a medical assistance recipient for any purpose not directly connected with the administration of a medical assistance program. (C) Both of the following shall be considered to be purposes directly connected with the administration of a medical assistance program: (1) Treatment, payment, or other operations or activities authorized by 42 C.F.R. Chapter IV; (2) Any administ...

...ment, enrollment, or eligibility for a medical assistance program cannot be conditioned on signing the authorization unless the authorization is necessary for determining eligibility for the program. (B) An authorization for the release of information regarding a medical assistance recipient to the recipient's attorney under division (D)(3) of section 5160.45 of the Revised Code may include a provision specifi...

...nt may disclose information regarding a medical assistance recipient to the extent necessary to participate as an active member in the public assistance reporting information system or other multistate cooperative.

...etermine whether an individual who is a medical assistance recipient may be eligible for federal military-related health care benefits. If the department determines that the individual may be eligible for federal military-related health care benefits, it shall notify the individual of the potential eligibility and encourage the individual to contact the veterans service commission in the county in which the individua...

...participating in the administration of medical assistance programs. The rules shall be adopted in accordance with Chapter 119. of the Revised Code. The rules may define who is an "authorized representative" for purposes of sections 5160.45 and 5160.46 of the Revised Code. The rules shall specify conditions and procedures for the release of information, which may include both of the following: (1) Permitting a...

...sses, or other information relating to medical assistance recipients is held by any agency other than the department of medicaid or a county department of job and family services, that other agency shall adopt rules consistent with sections 5160.45 to 5160.481 of the Revised Code to prevent the publication or disclosure of names, lists, or other information concerning those recipients.