Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-5 - Medicaid for Other Covered Groups › Section 5160:1-5-05 - Medicaid: refugee medical assistance (RMA)

Current through all regulations passed and filed through July 1, 2024
(A)
								This rule
			 describes a time-limited medical assistance program, funded through the office
			 of refugee resettlement (ORR), that provides a medical screening through
			 contracted refugee health screening providers and other medical services. There
			 is no resource limit for an individual described in this rule.
(B)
								Definitions.
(1)
									"Countable income," for the purpose of this rule, has
			 the same meaning as in rule 5160:1-3-03.2 of the Administrative
			 Code.
(2)
									"Current incurred medical expense" means a medical bill
			 or a portion of a medical bill that:
(a)
										Includes:
(i)
											A medically
			 necessary medical item or service provided to the individual or to the
			 individual's family member during the month for which the individual is seeking
			 to obtain RMA eligibility through the spenddown process;
(ii)
											An expense the
			 individual or family member is liable to pay, regardless of whether the
			 individual or family member has already paid it; and
(iii)
											A
			 transportation expense, as defined in paragraph (B)(14) of this rule, incurred
			 by the individual or family member during the month for which the individual is
			 seeking to obtain RMA eligibility through the spenddown
			 process.
(b)
										Does not include:
(i)
											An expense that
			 has already been used in the spenddown process as a basis for approving RMA
			 eligibility for any individual; or
(ii)
											An expense the
			 individual or family member has not yet incurred for a medical item or service
			 because it has not yet been provided.
(3)
									"Derivative T
			 visa" means either a T-2, T-3, T-4, or T-5 visa issued to certain family
			 members of victims of a severe form of trafficking who may be eligible for RMA
			 benefits whenthe visa holder meets refugee program eligibility
			 requirements.
(4)
									"Family member," for the purpose of this rule:
(a)
										For an individual
			 of any age, means:
(i)
											The individual's spouse or deceased spouse, unless a
			 court has eliminated the individual's duty of medical support to such
			 spouse;
(ii)
											The individual's natural or adopted child under the age
			 of eighteen, including a deceased child, unless a court has eliminated the
			 individual's duty of medical support to such child; and
(iii)
											The
			 individual's former spouse, including a deceased former spouse, provided the
			 individual has a duty of medical support to the former spouse.
(b)
										For an
			 individual under age eighteen, also includes:
(i)
											The individual's
			 natural or adoptive parent, unless a court has eliminated such parent's duty of
			 medical support to the individual;
(ii)
											The individual's
			 sibling (including half-sibling) under the age of eighteen, who lives with the
			 individual;
(iii)
											The individual's deceased parent, provided the
			 surviving parent who lives with the individual had a duty of medical support to
			 the deceased parent at the time of his or her death; and
(iv)
											The individual's
			 deceased sibling (including half-sibling) provided the deceased sibling lived
			 with the individual at the time of his or her death, and a parent who lives
			 with the individual had a duty of medical support to the deceased sibling at
			 the time of his or her death.
(c)
										Does not include
			 a step-parent, a step-child, or a step-sibling.
(5)
									"Income," for the
			 purpose of this rule, has the same meaning as defined in rule 5160:1-3-03.1 of
			 the Administrative Code.
(6)
									"Incurred" means that the individual or family member
			 has become liable to pay a medical bill as defined in paragraph (B)(8) of this
			 rule. An expense is incurred on the date liability for the expense
			 arises.
(7)
									"Individual," for the purpose of this rule, means an
			 applicant for or a recipient of RMA who is not a United States (U.S.) citizen
			 and meets one of the following definitions of immigration status under the
			 Immigration and Nationality Act (INA) (as in effect October 1, 2023), as
			 verified by documentation issued by the U.S. department of state, U.S.
			 department of homeland security, or U.S. department of justice:
(a)
										Paroled as a
			 refugee or asylee under section 212(d)(5) of the INA (as in effect October 1,
			 2023);
(b)
										Admitted to the U.S. as a refugee under section 207 of
			 the INA (as in effect October 1, 2023);
(c)
										Granted asylum
			 under section 208 of the INA (as in effect October 1, 2023);
(d)
										A Cuban or
			 Haitian entrant in accordance with requirements in 45 C.F.R. part 401 (as in
			 effect October 1, 2023);
(e)
										An Amerasian from Vietnam who is admitted to the U.S.
			 as an immigrant pursuant to section 584 of the Foreign Operations, Export
			 Financing, and Related Programs Appropriations Act of 1988 (as contained in
			 section
			 101(e) of Pub. L. No. 100-202 ) (as in effect
			 October 1, 2023), and amended by the 9th proviso under migration and refugee
			 assistance in title II of the Foreign Operations, Export Financing, and Related
			 Programs Appropriations Act, 1989 ( Pub. L. No. 100-461, as amended) (as in
			 effect October 1, 2023);
(f)
										A victim of a severe form of trafficking as identified
			 in
			 22 U.S.C.
			 7105(b) (1) (as in effect
			 October 1, 2023) and certain family members, as identified in the Trafficking
			 Victims Protection Reauthorization Act of 2003 (TVPRA) (
			 Pub.
			 L. No. 108-193 ) (as in effect October 1, 2023). A
			 victim of a severe form of trafficking is awarded a certification letter from
			 ORR and is potentially eligible for RMA as described in
			 28
			 C.F.R. 1100.33 (as in effect October 1,
			 2023). Certain family members are awarded "Derivative T" visas and are
			 potentially eligible for RMA; or
(g)
										Admitted as an
			 Afghan or Iraqi special immigrant under section 101(a)(27) of the INA (as in
			 effect October 1, 2023).
(8)
									"Medical bill"
			 means an invoice for a medically necessary medical item or service provided to
			 the individual or family member.
(9)
									"Medical
			 insurance premiums" means the amount paid for insurance coverage for medical
			 items or services such as health, dental, vision, long-term care, hospital,
			 prescriptions, etc.
(10)
									"Medically necessary" has the same meaning as in rule
			 5160-1-01
			 of the Administrative Code.
(a)
										Medical insurance premiums as defined in paragraph
			 (B)(9) of this rule are always considered medically necessary.
(b)
										The
			 administrative agency may generally accept that medical expenses and bills
			 submitted in the spenddown process are for items or services that were
			 medically necessary. In an unusual situation, the administrative agency may
			 question whether an item or service was medically necessary. In such a
			 situation, the administrative agency will need to determine whether the item or
			 service was medically necessary by following these steps:
(i)
											Contact the
			 individual and assist the individual with gathering relevant information from
			 the medical provider and other appropriate persons about the medical necessity
			 of the item or service.
(ii)
											When the medical provider of the item or service
			 indicates the item or service was not medically necessary, the administrative
			 agency shall not use the expense for that item or service in the spenddown
			 process.
(iii)
											When the medical provider of the item or service
			 indicates the item or service was medically necessary, the administrative
			 agency may use the expense for that item or service in the spenddown process in
			 accordance with the other provisions of this rule. When the administrative
			 agency questions the provider's statement regarding medical necessity, the
			 administrative agency must ask the prior authorization unit (PAU) of the Ohio
			 department of medicaid (ODM) to determine whether the item or service was
			 medically necessary.
(iv)
											When the PAU determines the item or service was
			 medically necessary, the administrative agency must use the expense for that
			 item or service in the spenddown process in accordance with the other
			 provisions of this rule. The PAU decision is for the sole purpose of
			 determining whether the item or service was medically necessary. The PAU
			 decision is not for the purpose of determining whether to prior authorize the
			 item or service under rule
			 5160-1-31
			 of the Administrative Code, nor for the purpose of determining whether the item
			 or service is payable by the medical assistance program.
(v)
											When the PAU
			 determines the item or service was not medically necessary, the administrative
			 agency shall not use the expense for that item or service in the spenddown
			 process.
(11)
									"RMA need
			 standard" means one hundred per cent of the federal poverty level (FPL) based
			 on family size.
(12)
									"Spenddown amount" means the dollar amount by which the
			 individual's countable income exceeds the applicable RMA need standard. The
			 individual must satisfy the spenddown amount in accordance with paragraph (F)
			 of this rule in order to become eligible for RMA for all or part of a given
			 calendar month.
(13)
									"Subject to the spenddown process" means the
			 individual:
(a)
										Has countable monthly income that exceeds the RMA need
			 standard; and
(b)
										Is otherwise eligible for RMA.
(14)
									"Transportation expense" means a reasonable expense incurred
			 by the individual or family member for transportation that is needed to obtain
			 a medically necessary item or service.
(a)
										Transportation
			 expenses include but are not limited to the following:
(i)
											Charges for
			 public transportation;
(ii)
											Expenses related to the transportation such as parking
			 fees and tolls;
(iii)
											The state mileage reimbursement rate as set by the Ohio
			 office of budget and management for the use of a private motor vehicle owned by
			 the individual or a family member, in effect on the date of
			 travel;
(iv)
											The actual expense incurred by the individual or family
			 member for transportation by a private motor vehicle not owned by the
			 individual or family member;
(v)
											Overnight lodging
			 expenses when overnight travel is needed to obtain the medical item or
			 service;
(vi)
											Actual expenses for meals, up to thirty dollars per
			 person per day, subject to the restrictions in paragraph (B)(14)(a)(vii) of
			 this rule, when overnight travel is required;
(vii)
											Attendant care
			 costs and/or the costs of a companion when a medical provider verifies that an
			 attendant and/or companion is required due to the age and/or physical or mental
			 condition of the individual or family member; and
(viii)
											Expenses
			 related to delivering a medical service or item to the individual or family
			 member.
(b)
										Transportation expenses do not include the
			 following:
(i)
											The cost of transportation provided to the individual or
			 family member through county-administered transportation assistance;
(ii)
											Any transportation expenses excluded from income as an
			 "impairment-related work expense" (IRWE) as described in
			 20 C.F.R.
			 404.1576 (as in effect October 1, 2023);
			 or
(iii)
											Any transportation expense excluded from earned income
			 as a "blind work expense" as defined in rule 5160:1-3-03.1 of the
			 Administrative Code.
(c)
										The
			 administrative agency may generally accept that transportation expenses
			 submitted in the spenddown process are for transportation that was needed to
			 obtain a medically necessary item or service and that the cost is reasonable.
			 When the administrative agency questions whether a transportation expense was
			 needed and/or reasonable, the administrative agency will need to determine
			 whether the expense was needed and/or reasonable by following these
			 steps:
(i)
											Contact the individual and assist the individual with
			 gathering relevant information from the medical provider and other appropriate
			 persons concerning all of the relevant circumstances including the
			 following:
(a)
												The age, physical and mental condition, and transportation
			 needs of the individual;
(b)
												The medical item or service for which the individual
			 needed the transportation;
(c)
												The suitability
			 of the transportation alternatives reasonably available to the individual;
(d)
												The reasonableness of the expense based on the
			 circumstances; and
(e)
												Any other relevant factors.
(ii)
											After
			 considering all of the listed factors, when the administrative agency
			 determines that the expense or a portion of the expense was not needed and/or
			 not reasonable, the administrative agency shall not use the expense in the
			 spenddown process.
(15)
									"Unpaid past
			 medical expense" (UPME) means a medical bill or a portion of a medical bill, as
			 defined in paragraph (B)(8) of this rule, that:
(a)
										Is still owed,
			 and is not subject to payment by a third party who is legally obligated to pay
			 the bill;
(b)
										Is not owed to a nursing facility (NF) or intermediate
			 care facility for individuals with intellectual disabilities (ICF-IID) for
			 services provided to a family member; and
(c)
										Has not been used
			 in a previous month to meet a spenddown amount.