reglab/statecodes huggingface dataset:
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-80 - Rights and Procedures Applicable to Medical Assistance Recipients › Section 5160-80-07 - Recording of hearing

Current through all regulations passed and filed through July 1, 2024
(A)
								The hearing
			 examiner shall make an audio recording of the hearing. The recording shall be
			 started at the beginning of the hearing and shall continue until the hearing is
			 concluded. There shall be no testimony or other proceedings off the record. The
			 recording shall not be altered or edited in any manner or for any
			 reason.
(B)
								The recording of the hearing shall be a part of the
			 hearing record. The recording shall be maintained pursuant to the department's
			 record retention schedule.
(C)
								The appellant,
			 the appellant's attorney or authorized representative, or department's or
			 county department's legal representative may request a copy of the recording.
			 The department shall respond to such requests within twenty-one business days
			 whenever possible, and shall provide the copy free of any charge. Non-receipt
			 of a copy of a recording within the administrative appeal period shall not
			 result in an extension of the administrative appeal period.
(D)
								If, during the
			 administrative appeal process, it is found that the recording is lost or
			 unusable (for example, because it has been damaged or because material portions
			 of the recording are inaudible), the director shall remand the case to the
			 hearing examiner for a new hearing if any party takes material issue with the
			 recitation of the testimony set forth in the hearing decision.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-80 - Rights and Procedures Applicable to Medical Assistance Recipients › Section 5160-80-08 - Hearing decisions

Current through all regulations passed and filed through July 1, 2024
(A)
								The hearing
			 examiner is responsible for preparing and issuing the hearing decisions under
			 the authority of the department.
(B)
								Basis
(1)
									The hearing
			 examiner's findings of fact shall be based exclusively on the evidence
			 introduced at the hearing, and upon the submission of additional evidence after
			 the hearing and subject to examination and rebuttal by the parties as described
			 in rule
			 5160-80-06
			 of the Administrative Code.
(a)
										The hearing examiner may be guided, but shall not be
			 bound, by the Ohio Rules of Evidence in conducting hearings and in making
			 findings of fact. The hearing examiner shall consider all relevant evidence
			 offered at the hearing.
(b)
										Hearsay evidence may be considered by the hearing
			 examiner in arriving at the findings of fact. However, such evidence must be
			 critically evaluated, since it is not given under oath and cannot be
			 cross-examined to test the declarant's perception, memory, and veracity. Direct
			 evidence shall normally be given more weight than hearsay evidence when the two
			 are in conflict.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-80 - Rights and Procedures Applicable to Medical Assistance Recipients › Section 5160-80-09 - Administrative appeal of the hearing decision

Current through all regulations passed and filed through July 1, 2024
(A)
								An appellant who
			 disagrees with a hearing decision has the right to request an administrative
			 appeal from the director.
(B)
								Notice of the right to and the method of obtaining an
			 administrative appeal shall be included in all hearing denial notices, hearing
			 dismissal notices, and hearing decisions.
(C)
								Administrative
			 appeal requests
(1)
									A request for an administrative appeal must be in
			 writing and signed by the appellant or the appellant's authorized
			 representative or attorney.
(2)
									Written
			 documentation of the appointment of an authorization representative must
			 accompany the appeal request made on an appellant's behalf by the appellant's
			 authorized representative, unless the representative was the authorized
			 representative of record at the hearing stage, or the request is made by the
			 appellant's attorney.
(3)
									The request must be received by the depository agent
			 within fifteen calendar days from the date the hearing decision being appealed
			 was mailed.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-1 - General Medicaid Eligibility Policy › Section 5160:1-1-04 - Medicaid: income and eligibility verification system (IEVS)

Current through all regulations passed and filed through July 1, 2024
(A)
								This rule describes the requirements in section 1137 of
			 the Social Security Act (as in effect October 1, 2020) and in section
			 42 C.F.R.
			 435.945 (as in effect October 1, 2020),
			 requiring state agencies administering certain federally funded public
			 assistance programs to establish procedures for obtaining, using, and verifying
			 information relevant to determinations of eligibility. The Ohio department of
			 medicaid (ODM) shall obtain and share income and benefit information with the
			 following sources:
(1)
									The social security administration
			 (SSA).
(2)
									The internal revenue service (IRS).
(3)
									The state wage
			 information collection agency (SWICA).
(4)
									Agencies
			 administering unemployment compensation (UC) benefits.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-1 - General Medicaid Eligibility Policy › Section 5160:1-1-05 - Medicaid: asset verification system (AVS)

Current through all regulations passed and filed through July 1, 2024
(A) This rule describes the asset
			 verification program outlined in section 1940 of the Social Security Act (as in
			 effect  October 1,
			 2023),
			 requiring state agencies that administer medical assistance to implement a
			 system by which the agency will obtain financial records from financial
			 institutions with respect to an individual, his or her spouse, or any other
			 such person, as applicable, whose assets are required to be evaluated whenever
			 the administrative agency determines the record is needed in connection with a
			 determination of eligibility for, or the amount or extent of, medical
			 assistance on the basis of age, blindness, or disability, including a
			 determination regarding medical assistance for long-term care services. This
			 rule applies to a determination of eligibility for medical assistance for any
			 covered group subject to:
(1) A resource
			 limit; and/or
(2) Provisions
			 related to the transfer of assets.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-1 - General Medicaid Eligibility Policy › Section 5160:1-1-06 - Medicaid: public assistance reporting information system (PARIS)

Current through all regulations passed and filed through July 1, 2024
(A)
								This rule describes section 1903(r)(3) of the Social
			 Security Act (as in effect October 1, 2019) and paragraph (d) of
			 42 C.F.R
			 435.945 (as in effect October 1, 2019), that
			 each medicaid state agency have an eligibility determination system which
			 provides for data matching through the public assistance reporting information
			 system (PARIS).
(B)
								Definition. "PARIS" is a system for matching data with
			 select federal and state agencies for the purpose of determining medicaid or
			 other public assistance eligibility. PARIS provides information regarding
			 federal wages, veterans administration benefits, and duplicate benefits
			 received in two or more states.
(C)
								Administrative
			 agency responsibilities.
(1)
									Review and compare against the case record all
			 information received to determine whether it affects the individual's
			 eligibility.
(2)
									Verify the information received, in accordance with
			 42 C.F.R.
			 435.948 (as in effect October 1, 2019) and
			 42 C.F.R.
			 435.949 (as in effect October 1,
			 2019).
(3)
									Request additional verification from the individual, if
			 appropriate, to determine ongoing eligibility and initiate appropriate action
			 in accordance with
			 42
			 C.F.R. 435.952(c) (as in
			 effect October 1, 2019).
(4)
									Continue benefits while appropriate steps are being
			 taken to verify the matched data in accordance with
			 42
			 C.F.R. 435.952(d) (as in
			 effect October 1, 2019).
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-2 - Medicaid Application Procedures › Section 5160:1-2-01 - Medicaid: administrative agency responsibilities

Current through all regulations passed and filed through July 1, 2024
(A) This rule describes the responsibilities
			 of the administrative agency.
(B)
			 Calculation of time periods for eligibility determinations. All calculations of
			 time periods used in the determination of eligibility, including an annual
			 renewal or a redetermination as a result of a reported change, shall be
			 computed as follows:
(1) When counting the
			 number of days in a specified time period, the initial day is excluded from the
			 computation and the last day is included.
(2) When the last day of the time period
			 falls on a Saturday, Sunday, or legal holiday, the time period shall end on the
			 next business day.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-2 - Medicaid Application Procedures › Section 5160:1-2-02 - Medicaid: income guidelines, calculations, and exclusions

Current through all regulations passed and filed through July 1, 2024
(A) This rule sets forth general income
			 guidelines, calculations, and exclusions used in determining eligibility for
			 medical assistance. Income guidelines, calculations, or exclusions that apply
			 to a specific covered group will be addressed in the eligibility rules for that
			 group. Unless otherwise stated:
(1) If living
			 in the same household, income and resources of a spouse are considered
			 available to the other spouse, and income and resources of a parent are
			 considered available to children under age twenty-one.
(2) The income of a minor's parent, living in
			 the same home as the minor and the minor's dependent child, shall be counted as
			 income to the covered group.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-2 - Medicaid Application Procedures › Section 5160:1-2-03 - Medicaid: request for home and community-based services (HCBS) waiver

Current through all regulations passed and filed through July 1, 2024
(A) This rule sets
			 forth the process for determining whether an individual is eligible for medical
			 assistance payments for services under a home and community-based services
			 (HCBS) waiver, as described in rules
			 5123:2-9-01,
			 5160-31-03,
			 5160-33-03,
			 5160-40-01,
			 5160-41-17,
			 5160-42-01,
			 5160-46-02,
			 5160-58-02.2, and
			 5160-59-04 of the Administrative
			 Code.
(B) Eligibility for an HCBS
			 waiver. To receive services under an HCBS waiver, the individual shall:
(1) Be eligible for medical assistance, as
			 described in Chapters 5160:1-1 to 5160:1-6 of the Administrative Code;
			 and
(2) Be in need of HCBS under a
			 waiver described in agency 5123 or 5160 of the Administrative Code;
			 and
(3) Be enrolled in an HCBS
			 waiver described in agency 5123 or 5160 of the Administrative Code;
			 and
(4) Not be simultaneously
			 enrolled in another HCBS waiver, the residential state supplement (RSS) program
			 described in rule
			 5160:1-5-01 of the
			 Administrative Code, or the program of all-inclusive care for the elderly
			 (PACE).
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-2 - Medicaid Application Procedures › Section 5160:1-2-04 - Medicaid: consumer fraud and recoupments

Current through all regulations passed and filed through July 1, 2024
(A)
								This rule sets
			 out requirements for the administrative agency with regard to identifying and
			 referring consumer fraud and recouping medicaid payments from an
			 individual.
(B)
								Investigation of complaints. Upon notification of a
			 complaint of medicaid fraud, abuse, or questionable practices, the
			 administrative agency must conduct a preliminary investigation in accordance
			 with 42 C.F.R.
			 455.14 (as in effect October 1, 2023) to
			 determine whether there is sufficient basis to warrant a full
			 investigation.
(1)
									When the preliminary investigation finds that a full
			 investigation is warranted in accordance with
			 42 C.F.R.
			 455.15 (as in effect October 1, 2023):
(a)
										And there is
			 reason to believe that a beneficiary has defrauded the medicaid program as
			 described in section 2913.401 of the Revised Code,
			 then the administrative agency must refer the case to the county
			 prosecutor.
(b)
										And there is reason to believe that a beneficiary has
			 abused the medicaid program, then the agency must conduct a full investigation
			 of the abuse.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-2 - Medicaid Application Procedures › Section 5160:1-2-05 - Medicaid: notice of privacy practices

Current through all regulations passed and filed through July 1, 2024
(A) The Health Insurance Portability and
			 Accountability Act of 1996 (HIPAA) is a federal law requiring the
			 administrative agency to issue a notice of privacy practices.
(B) The administrative agency shall:
(1) Ensure appropriate safeguards are taken
			 in accordance with rule
			 5160-1-32 of the Administrative
			 Code.
(2) Issue
			 a notice of privacy practices to all individuals
			 eligible for medical assistance,
									 as
			 described in 45 C.F.R.
			 164.520 (as in effect October 1,
			 2023),
			 outlining all of the following descriptions of
			 uses,
									
			 disclosures, and procedures:
(a) A description
			 of the types of uses and disclosures of protected health information (PHI) the
			 administrative agency is permitted with examples for each of the following
			 purposes:
(i) Payment; and
(ii)
			 Treatment; and
(iii) Healthcare
			 operations.
(b) A
			 description of the uses and disclosures permitted without the individual's
			 written consent or authorization.
(c) A
			 statement that other uses and disclosures will be made only with the
			 individual's written authorization.
(d)
			 Complaint procedure.
(e)
			 Request for restriction procedure.
(f)
			 Request for amendment procedure.
(g)
			 Request for accounting procedure.
(h) A
			 name, or title, and telephone number of a person or
			 office to contact for further information.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-2 - Medicaid Application Procedures › Section 5160:1-2-06 - Medicaid: outstationing workers at disproportionate share hospitals and federally qualified health centers

Current through all regulations passed and filed through July 1, 2024
(A) This rule describes the administrative
			 agency's role in facilitating outreach services for low-income children and
			 pregnant women through the process of outstationing workers at disproportionate
			 share hospitals,
								 federally qualified health centers, and other designated locations where potentially eligible
			 children and pregnant women receive services.
(B)
								Definitions.
(1)
									"Administrative agency," for the purpose of this rule,
			 means the Ohio department of medicaid (ODM) and/or an agent of ODM authorized
			 to determine eligibility for a medical assistance program.
(2)
									"Individual," for
			 the purpose of this rule, means a person who is applying for medical assistance
			 benefits at a disproportionate share hospital, federally qualified health
			 center, or another designated outstation location.
(3)
									"Outstationing"
			 refers to the federal requirement that administrative agencies must provide
			 opportunities for low-income children and pregnant women to apply for medical
			 assistance at locations other than the local county department of job and
			 family services (CDJFS) office.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-2 - Medicaid Application Procedures › Section 5160:1-2-07 - Medicaid: estate recovery

Current through all regulations passed and filed through July 1, 2024
(A) This rule describes Ohio's medicaid
			 estate recovery program and the undue hardship waiver request
			 process.
(B) Definitions.
(1) "Estate" includes both of the following:
(a) All real and personal property and other
			 assets to be administered under Title XXI of the Revised Code and property that
			 would be administered under that title if not for section
			 2113.03 or
			 2113.031 of the Revised Code;
			 and
(b) Any other real and
			 personal property and other assets in which an individual had any legal title
			 or interest at the time of death (to the extent of the interest), including
			 assets conveyed to a survivor, heir, or assign of the individual through joint
			 tenancy, tenancy in common, survivorship, life estate, living trust, or other
			 arrangement.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-2 - Medicaid Application Procedures › Section 5160:1-2-10 - Medicaid: conditions of eligibility and verifications

Current through all regulations passed and filed through July 1, 2024
(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.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-2 - Medicaid Application Procedures › Section 5160:1-2-11 - Medicaid: United States (U.S.) citizenship documentation

Current through all regulations passed and filed through July 1, 2024
(A) This rule sets forth acceptable
			 documentary evidence of United States (U.S.) citizenship and the circumstances
			 under which an individual who declares U.S. citizenship, under penalty of
			 perjury, may be given a reasonable opportunity to verify U.S.
			 citizenship.
(B) Any individual
			 applying for medical assistance and declaring U.S. citizenship or nationality
			 shall verify citizenship in accordance with
			 42 C.F.R.
			 435.407 (as in effect October 1,
			 
								2022).
(1) After an individual's U.S. citizenship or
			 nationality is verified by the administrative agency, the administrative agency
			 shall not require the individual to re-verify citizenship.
(2) The following individuals are not
			 required to verify their U.S. citizenship:
(a)
			 An individual applying for medical assistance only for other
			 individuals.
(b) A child who
			 received medical assistance as a deemed newborn on or after July 1,
			 2006.
(c) An individual who is:
(i) Enrolled in medicare; or
(ii) Receiving supplemental security income
			 (SSI); or
(iii) Receiving social
			 security disability insurance (SSDI); or
(iv) Receiving adoption or foster care
			 assistance under Title IV-E of the Social Security Act (as in effect October 1,
			 
											2022);
			 or
(v) In foster care and receiving
			 child welfare services under Title IV-B of the Social Security Act (as in
			 effect October 1, 
											2022); or
(vi)
											Receiving federal kinship guardianship assistance
			 program (KGAP) payments under Title IV-E of the Social Security Act (as in
			 effect October 1, 2022).
(d) Other individuals on such other basis as
			 the secretary of the department of health and human services may specify, by
			 regulation, that satisfactory documentary evidence of citizenship or
			 nationality was previously presented.
(e) The administrative agency may rely,
			 without further documentation of citizenship or identity, on a verification of
			 citizenship made by a federal agency or another state agency, if such
			 verification was done on or after July 1, 2006.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-2 - Medicaid Application Procedures › Section 5160:1-2-12 - Medicaid: non-citizens

Current through all regulations passed and filed through July 1, 2024
(A) This rule sets forth:
(1)
									Medical assistance eligibility criteria for an individual
			 who is not a U.S. citizen or national; and
(2)
									Acceptable
			 documentary evidence of qualified non-citizen status; and
(3)
									The circumstances
			 under which an individual who declares qualified non-citizen status, under
			 penalty of perjury, may be given a reasonable opportunity to verify that
			 status.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-2 - Medicaid Application Procedures › Section 5160:1-2-13 - Medicaid: presumptive eligibility

Current through all regulations passed and filed through July 1, 2024
(A) This rule describes the conditions under
			 which an individual may receive time-limited medical assistance as a result of
			 an initial, simplified determination of eligibility based on the individual's
			 self-declared statements.
(B)
			 Eligibility criteria for presumptive coverage.
(1) Except as set forth in paragraph (B)(2)
			 of this rule, an individual is eligible for presumptive coverage
			 
									when the
			 individual:
(a) Is a resident of the state of
			 Ohio; and
(b) Is a U.S. citizen or
			 has an immigration status as defined in rule
			 5160:1-2-12 of the
			 Administrative Code that allows for medicaid eligibility; and
(c) Meets the non-financial eligibility
			 criteria for a group set out in rule
			 5160:1-4-02,
			 5160:1-4-03,
			 5160:1-4-04, or
			 5160:1-4-05 of the
			 Administrative Code, except that a simplified household composition will be
			 determined, comprised of the individual and, if living in the home:
(i) The individual's spouse; and
(ii) The individual's children under age
			 nineteen; and
(iii)
											
											When the
			 individual is under age nineteen:
(a) The
			 individual's parents; and
(b) The
			 individual's siblings under the age of nineteen.
(d) Has gross family income, for
			 the individual's family size, of no more than the eligibility limit set out for
			 the relevant eligibility group in rule
			 5160:1-4-02,
			 5160:1-4-03,
			 5160:1-4-04, or
			 5160:1-4-05 of the
			 Administrative Code.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-2 - Medicaid Application Procedures › Section 5160:1-2-14 - Medicaid: continuous eligibility for children younger than age nineteen

Current through all regulations passed and filed through July 1, 2024
(A) This rule
			 describes the twelve-month period of continuous eligibility for a child younger
			 than age nineteen, and the conditions under which the child's coverage ends
			 during the twelve-month period, as described in section 1902(e)(12) of the
			 Social Security Act (as in effect October 1, 2023).
(B) Eligibility criteria. A child remains
			 eligible for coverage despite changes in the child's circumstances for a period
			 of twelve months 
								when the child was found to be eligible for a category
			 of medical assistance other than:
(1)
			 Presumptive eligibility as described in rule
			 5160:1-2-13 of the
			 Administrative Code;
(2)
									Non-citizen emergency medical assistance as described
			 in rule  5160:1-5-06 of the
			 Administrative Code; or
(3) Refugee
			 medical assistance as described in rule
			 5160:1-5-05 of the
			 Administrative Code.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-2 - Medicaid Application Procedures › Section 5160:1-2-15 - Medicaid: healthchek (early and periodic screening, diagnostic and treatment services)

Current through all regulations passed and filed through July 1, 2024
(A)
								The purpose of
			 this rule is to explain the requirements of healthchek, Ohio's early and
			 periodic screening, diagnostic and treatment (EPSDT) benefit that all medicaid
			 eligible individuals under twenty-one years of age are entitled to receive. A
			 separate healthchek application is not required. Each county department of job
			 and family services (CDJFS) is required to have a healthchek
			 coordinator.
(B)
								Definitions. For the purposes of this rule, the
			 following terms have the following meanings:
(1)
									"Healthchek" is
			 Ohio's early and periodic screening, diagnostic and treatment benefit for all
			 medicaid eligible individuals under twenty-one years of age.
(2)
									"Healthchek
			 coordinator" is the CDJFS employee who is responsible for the implementation of
			 healthchek services.
(3)
									"Healthchek services" are periodic screening services
			 (including a comprehensive medical exam, vision, dental, and hearing
			 screenings) and such other necessary health care, diagnostic services,
			 treatment, and other measures described in
			 42
			 U.S.C. section 1396d(a) (as
			 in effect 03-06-2016) to correct or ameliorate defects and physical and mental
			 illnesses and conditions discovered by the screening services, whether or not
			 such services are covered under the state plan. Healthchek services are
			 identical to "EPSDT services" as defined at
			 42
			 U.S.C. section 1396d(r) (as
			 in effect 03/06/2016).
(4)
									"Healthchek Services Implementation Plan" (HSIP), ODM
			 03517, (rev.07/2016) means the document submitted
			 by a CDJFS describing how it delivers healthchek services to individuals in its
			 county and who in the agency is responsible for ensuring the delivery of
			 healthchek services.
(5)
									"Individual" means, for purposes of this rule, a person
			 under age twenty-one eligible for medicaid.
(6)
									"Medically
			 necessary," otherwise known as "medical necessity," as used in this chapter is
			 the same as defined in paragraph (A) of rule
			 5160-1-01
			 of the Administrative Code.
(7)
									"Prior
			 authorization" for a member of a medicaid managed care plan (MCP) is the
			 process outlined in rule 5160-26-03.1 of the Administrative Code. For all other
			 individuals, prior authorization is the process outlined in rule
			 5160-1-31
			 of the Administrative Code.
(8)
									"Support
			 services" are non-medical services offered or provided by the administrative
			 agency to assist the individual and may include arranging or providing
			 transportation, making medical appointments, accompanying the individual to
			 medical appointments, and making referrals to community and other social
			 services. Support services shall be coordinated with the individual's
			 medicaid-contracting MCP, where applicable.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-2 - Medicaid Application Procedures › Section 5160:1-2-16 - Medicaid: pregnancy related services (PRS)

Current through all regulations passed and filed through July 1, 2024
(A)
								 The purpose of
			 this rule is to outline the responsibilities of the administrative agency to
			 inform medicaid-eligible pregnant women about the benefits and importance of
			 pregnancy related services (PRS), to make requested or needed referrals to
			 support services, and to provide non-medical services promoting healthy birth
			 outcomes in accordance with
			 42 C.F.R.
			 440.210 (as in effect January 1,
			 2014).
(B)
								 Definitions.
(1)
									 "Individual" for
			 the purpose of this rule, means a medicaid-eligible individual who is pregnant,
			 as verified by either self-declaration or medical verification, including the
			 sixty days post-partum period.
(2)
									 ODM 03515
			 "Pregnancy Related Services Implementation Plan" (PRSIP) (rev.
									1/2015) means the document submitted by an
			 administrative agency describing how it delivers PRS to pregnant women in its
			 county and which entity is responsible for ensuring the delivery of
			 PRS.
(3)
									 "PRS coordinator" means the administrative agency
			 employee who is responsible for the implementation of PRS.
(4)
									 "Support
			 services" are non-medical services offered or provided by the administrative
			 agency to assist the individual and may include arranging or providing
			 transportation, making medical appointments, accompanying the individual to
			 medical appointments, and making referrals to community and other social
			 services. Support services will be coordinated with the individual's
			 medicaid-contracting managed care plan (MCP), where applicable.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-3 - Medicaid for the Aged, Blind, or Disabled (ABD) › Section 5160:1-3-01 - Medicaid: coverage for the aged, blind, or disabled

Current through all regulations passed and filed through July 1, 2024
(A) The medicaid program provides coverage
			 for individuals who meet the aged, blind, or disability status
			 requirements as set forth in section 1902 of the
			 Social Security Act (as in effect 
								October 1, 2022). The provisions of
			 Chapter 5160:1-3 of the Administrative Code establish eligibility criteria,
			 standards, and procedures that apply to individuals enrolling in an aged,
			 blind, or 
								disabled
			 categorical coverage group.
(B) The
			 rules of this chapter are organized as follows:
(1) Rules under principal rule
			 5160:1-3-02 of the
			 Administrative Code set forth base eligibility requirements of the aged, blind,
			 or disabled eligibility covered groups.
(2) Rules under principal rule
			 
									5160:1-3-03.1 of the Administrative
			 Code set forth income eligibility requirements.
(3) Rules under principal rule
			 
									5160:1-3-05.1 of the Administrative
			 Code set forth resource eligibility requirements.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-3 - Medicaid for the Aged, Blind, or Disabled (ABD) › Section 5160:1-3-02 - Medicaid: criteria for age, blindness, or disability

Current through all regulations passed and filed through July 1, 2024
(A)
								The medicaid program provides coverage for individuals
			 who have been determined to meet the criteria for the limiting physical factors
			 of age, blindness, or disability as set forth in section 1902 of the Social
			 Security Act (as in effect on October 1, 2016). Age is determined by county
			 departments of job and family services (CDJFS). Blindness and disability are
			 determined by either the social security administration (SSA) or the Ohio
			 department of medicaid (ODM) in accordance with rule 5160:1-3-02.9 of the
			 Administrative Code. The criteria are as follows:
(1)
									Age: A person who
			 is age sixty-five years or older meets the age requirement for medicaid.
			 Verification of age is required.
(2)
									Blindness: A
			 person is considered to be blind if he or she has central visual acuity of
			 20/200 or less in the better eye with correcting glasses, or a limited visual
			 field of twenty degrees or less in the better eye.
(3)
									Disability.
			 Disability is defined differently for adults and children. An individual is
			 disabled if the individual is:
(a)
										An adult who is unable to do any substantial gainful
			 activity by reason of any medically determinable physical or mental impairment
			 or combination of impairments which can be expected to result in death or which
			 has lasted or can be expected to last for a continuous period of not less than
			 twelve months.
(b)
										A child under the age of eighteen who has a medically
			 determinable physical or mental impairment or combination of impairments that
			 causes marked and severe functional limitations, and that can be expected to
			 cause death or that has lasted or can be expected to last for a continuous
			 period of not less than twelve months. No individual under the age of eighteen
			 who engages in substantial gainful activity may be considered
			 disabled.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-3 - Medicaid for the Aged, Blind, or Disabled (ABD) › Section 5160:1-3-02.1 - Medicare premium assistance programs (MPAP)

Current through all regulations passed and filed through July 1, 2024
(A) This rule sets forth the eligibility
			 criteria and benefits for the medicare premium assistance programs (MPAP). The
			 programs are: qualified medicare beneficiary (QMB), specified low-income
			 medicare beneficiary (SLMB), qualified individual
			 (QI-1), and qualified disabled and working individual
			 (QDWI).
(B) Definitions.
(1) "Eligible," for the purpose of this rule,
			 means an individual meets all the requirements to enroll in MPAP.
(2) "Enrolled," for the purpose of this rule,
			 means an individual is in receipt of benefits under a medicare health
			 plan.
(3) "Entitled," for the purpose of this rule, means an individual
			 has coverage under medicare through the social security administration
			 (SSA).
(4) "Family," for the
			 purposes of MPAP, means the following persons living in the same household as
			 the individual for whom medicare premium assistance is sought or received:
(a) The individual; and
(b)
										When the individual
			 is a minor, the biological parents, adoptive parents, step-parents, legal
			 guardians, or legal custodians of the individual; and
(c) The spouse of the individual and of any
			 persons described in paragraph (B)(4)(b) of this rule; and
(d) The minor biological, adopted, or
			 stepchild(ren) of the individual and of any persons described in paragraphs
			 (B)(4)(b) and (B)(4)(c) of this rule.
(5) "Family of the size involved" means
			 "family" as defined in paragraph (B)(4) of this rule.
(6) "MPAP" means any or all of the medicare
			 premium assistance programs: QMB, SLMB, QI-1, and QDWI.
(7) "MPAP resource limit" means the maximum
			 amount of countable resources allowed under section 1905(p)(1) of the Social
			 Security Act (as in effect October 1, 2023), as
			 adjusted annually according to the change in the consumer price index for urban
			 areas (CPI-U).
(8) "Qualified," for
			 the purpose of this rule, means an individual is eligible to receive benefits
			 under a medicare health plan, whether or not the individual has applied for
			 those benefits.
(9) "QDWI" means
			 the qualified disabled and working individual
			 program established by section 1905(s) of the Social Security Act (as in effect
			 October 1, 2023). This program is sometimes referred to as the
			 qualified working disabled individuals (QWDI) program.
(10) "QI-1" means the qualified individual
			 group, described in section 1902(a)(10)(E)(iv) of the Social Security Act (as
			 in effect October 1, 2023).
(11) "QMB" means the qualified medicare
			 beneficiary group described in section 1905(p)(1) of the Social Security Act
			 (as in effect October 1, 2023).
(12) "SLMB" means the specified low-income
			 medicare beneficiary group described in section 1902(a)(10)(E)(iii) of the
			 Social Security Act (as in effect October 1, 2023).
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-3 - Medicaid for the Aged, Blind, or Disabled (ABD) › Section 5160:1-3-02.2 - Medicare buy-in

Current through all regulations passed and filed through July 1, 2024
(A) This rule sets forth:
(1) The eligibility criteria for benefits
			 under the medicare part B (part B) buyin
			 agreement between the social security administration (SSA) and the Ohio
			 department of medicaid (ODM), which allows ODM to pay
			  part B (supplemental medical
			 insurance) premiums for certain  individuals even
			 
									when those
			 individuals are not eligible for a medicare premium assistance program (MPAP)
			 set forth
			 in rule
			 5160:1-3-02.1 of the
			 Administrative Code; and
(2) The
			 beginning date of payment of  part
			 B  benefits under this rule;
			 and
(3) The date and effect of
			 termination of benefits under  part
			 B buy-in.
(4) The process of
			 coordinating enrollment with ODM and the SSA.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-3 - Medicaid for the Aged, Blind, or Disabled (ABD) › Section 5160:1-3-02.3 - Medicaid: coverage for individuals receiving supplemental security income (SSI) benefits

Current through all regulations passed and filed through July 1, 2024
(A) This rule describes eligibility for
			 medical assistance for aged, blind, or disabled
			 individuals who receive SSI benefits authorized by the social security
			 administration under Title XVI of the Social Security Act (as in effect
			  October 1, 2023).
(B) Eligibility
			 criteria. To be eligible for coverage under this group an individual must be
			 receiving SSI benefits based on the social security administration's
			 determination of eligibility for SSI payments. In addition, certain
			 requirements specific to medical assistance must be met in order for an
			 individual to be eligible under this group. Failure to comply with the
			 following requirements will prevent an individual from being determined
			 eligible under this provision:
(1) Consistent
			 with rule
			 5160:1-2-10 of the
			 Administrative Code:
(a) An individual must
			 assign to the state of Ohio any rights to medical support and payments for
			 medical care from any third party; and
(b) An individual must cooperate with the
			 child support enforcement agency (CSEA) in establishing the paternity of any
			 child eligible for medical assistance and in obtaining medical support and
			 payments for medical care from any third party, in accordance with
			 42 C.F.R.
			 433.147 (as in effect
			  October 1, 2023);
			 and
(c) An individual must
			 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.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-3 - Medicaid for the Aged, Blind, or Disabled (ABD) › Section 5160:1-3-02.4 - Medicaid: coverage for the categorically needy

Current through all regulations passed and filed through July 1, 2024
(A) This rule describes eligibility for aged,
			 blind, or disabled individuals who meet the
			 income and resource requirements of the supplemental security income (SSI)
			 program authorized by the social security administration (SSA) under Title XVI
			 of the Social Security Act (as in effect 
								October 1, 2022) but
			 who do not receive cash benefits under the
			 program. Eligibility for this program shall be determined for applications for
			 medical assistance filed on or after the August 1,
			 2016 effective date of this rule.
(B) Eligibility criteria. To be eligible
			 under this group, an individual must meet all of the following critiera:
(1) Be aged, blind, or disabled; and
(2)
			 Determinations of blindness and disability must be in accordance with SSA
			 policy; and
(3) Have countable income, as determined
			 under Chapter 5160:1-3 of the Administrative Code, which does not exceed the
			 income standard described in rule
			 5160:1-3-03.5 of the Administrative Code;
			 and
(4) Have countable resources, as determined
			 under Chapter 5160:1-3 of the Administrative Code, which do not exceed the
			 resource limit described in rule
			 5160:1-3-05.1 of the Administrative Code;
			 and
(5) Not be receiving cash benefits from the
			 SSI program; and
(6) Meet the
			 conditions of eligibility outlined in rule
			 5160:1-2-10 of the
			 Administrative Code.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-3 - Medicaid for the Aged, Blind, or Disabled (ABD) › Section 5160:1-3-02.5 - Medicaid: supplemental security income (SSI) recipients qualifying under section 1619 of the Social Security Act for continued medical assistance coverage

Current through all regulations passed and filed through July 1, 2024
(A) This rule describes the eligibility
			 criteria for continued medical assistance coverage
			 for an individual who is receving SSI
			 benefits under section 1619 of the Social Security Act.
(B)
			 Section 1619 of the Social Security Act (as in effect
			 
								October 1, 2022) comprises two basic provisions:
(1) Section 1619(a) extends special SSI cash
			 to individuals whose earnings preclude eligibility for regular SSI cash
			 benefits. Individuals in 1619(a) status may still receive an SSI cash benefit
			 in addition to the individual's earned income.
(2) Section 1619(b) extends medicaid coverage
			 to individuals whose earnings, although high enough to preclude eligibility for
			 regular SSI cash benefits or special SSI cash benefits under section 1619(a),
			 may not be enough for medical care.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-3 - Medicaid for the Aged, Blind, or Disabled (ABD) › Section 5160:1-3-02.9 - Medicaid: disability determination process

Current through all regulations passed and filed through July 1, 2024
(A) This rule addresses the process of
			 determining blindness or disability for non-citizen
			 emergency medical assistance (NCEMA), medicaid buy-in for workers with
			 disabilities (MBIWD), retroactive coverage for a deceased individual, or the
			 specialized recovery services (SRS) program.
(B) Definitions.
(1) "Administrative agency," for the purpose
			 of this rule, means the county department of job and family services
			 (CDJFS).
(2) "Current medical
			 information" means medical records that originated within eighteen months of
			 the date of initial application.
(3) "Deferred" means the delay in the
			 determination for a disability packet due to incomplete or
			 
									an
			 insufficient amount of current medical information for the disability
			 determination area (DDA) to approve, deny, or
			 continue the blindness or disability claim.
(4) "Disability begin date" means the date
			 the individual is otherwise eligible for medical assistance and meets the
			 limiting physical factor.
(5)
			 "Disability determination" is the process by which the DDA determines whether
			 the individual meets the social security administration's
			 (SSA's) definition of "blind" or "disabled" for
			 medical assistance eligibility. The DDA determines blindness and disability in
			 accordance with SSA policy.
(6)
			 "Disability packet" consists of all required forms specified in paragraph (C)
			 of this rule and all available current medical information to support the
			 individual's blindness or disability claim. The disability packet is submitted
			 by the administrative agency to the DDA for a disability
			 determination.
(7) "Disability
			 review date" means the date, determined by the DDA, that the individual's
			 current blindness or disability approval will expire.
(8) "Limiting physical factor" is a
			 non-financial eligibility criterion consisting of a physical or mental
			 characteristic or impairment, or a combination of physical or mental
			 characteristics or impairments, that may limit the individual's ability to
			 work. An individual meets the limiting physical factor by meeting the criteria
			 of age, blindness, or disability as set forth in
			 rule 5160:1-3-02 of the
			 Administrative Code.
(9) "SSA
			 disability" means a determination of blindness or disability, as set forth in
			 section 1902 of the Social Security Act (as in effect
			  October 1, 2023), by the
			 SSA.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-3 - Medicaid for the Aged, Blind, or Disabled (ABD) › Section 5160:1-3-03.1 - Medicaid: income

Current through all regulations passed and filed through July 1, 2024
(A) This rule describes how income, as
			 defined in rule
			 5160:1-1-01 of the
			 Administrative Code, is treated for the purpose of determining eligibility for
			 medical assistance for an aged, blind, or
			 disabled individual.
(B) Treatment of income.
(1) Eligibility for medical assistance is
			 dependent in part upon the amount of monthly income available to or received by
			 the individual.
(a) Gross income, prior to any
			 deductions or exclusions, that can be reliably anticipated is considered
			 available when calculating countable income for a month. Thus,
			 when an individual is receiving a pension or is regularly employed or
			 self-employed, the expected amount of income is counted.
(i) Wages are counted as earned income in the
			 calendar month in which they are received, even when all of the
			 work which produced the wages was performed in a prior month.
(ii) When the time of receipt of the income
			 is at the individual's discretion, the
			 individual shall promptly request such
			 wages.
(iii) When the payment of
			 wages is deferred at the individual's request, the administrative agency shall
			 determine when the wages would normally have been paid and allocate them as
			 income for the month in which the wages would have normally been paid. The
			 administrative agency shall assume the wages were payable in equal segments
			 throughout the applicable period and determine eligibility accordingly. When
			 the payment of wages is deferred due to circumstances beyond the control of the
			 individual, the administrative agency shall consider
			 the wages as income when the income is actually received.
Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-3 - Medicaid for the Aged, Blind, or Disabled (ABD) › Section 5160:1-3-03.2 - Medicaid: income exclusions

Current through all regulations passed and filed through July 1, 2024
(A)
								When determining
			 eligibility for medical assistance for the aged, blind, or disabled, certain
			 types of income, including income from certain sources, are not counted. This
			 rule sets forth the types of income that are to be excluded, and the order in
			 which they are excluded from the individual's income.
(B)
								Definitions.
(1)
									"Blind work expense" (BWE) means the portion of the
			 individual's earned income used to meet any expenses reasonably attributable to
			 the earning of the income if the individual is blind; and
(a)
										Is under age
			 sixty-five; or
(b)
										Is age sixty-five or older and received SSI payments
			 due to blindness for the month before attaining age sixty-five.