(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
if
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)
If
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.
(2)
Limitations. An individual is ineligible for a subsequent presumptive coverage
period for twelve months beginning on the date of a presumptive coverage
determination, except that a woman may receive presumptive coverage based on
pregnancy once during each pregnancy.
(C) Duration and scope of presumptive
coverage.
(1) Presumptive coverage begins on
the date an individual is determined to be presumptively eligible. No
retroactive coverage may be provided as a result of a presumptive eligibility
determination.
(2) Presumptive
coverage ends on the earlier of (and includes):
(a) The date the administrative agency
determines the individual is eligible or ineligible for ongoing medical
assistance pursuant to rule
5160:1-2-01 of the
Administrative Code; or
(b)
If
When an
application for ongoing medical assistance for the individual has not been
filed, the last day of the month following the month in which the individual
was determined to be presumptively eligible.
(3) Services for individuals found
presumptively eligible on the basis of pregnancy are restricted to ambulatory
prenatal care.
(D) State
agency responsibilities. The Ohio department of medicaid (ODM) is responsible
for training and monitoring each qualified entity (QE) in accordance with rule
5160-1-17.12 of the
Administrative Code.
(E) QE
responsibilities.
(1)
If
When the
QE is
ODM or a county department of job and
family services (CDJFS) office:
(a) No later
than twenty-four hours after receipt of a signed and dated full application for
medical assistance on behalf of an individual, the CDJFS must determine, based
on the individual's self-declared information, whether the individual is
eligible for presumptive coverage under this rule.
(b)
If
When an individual is eligible for presumptive
coverage,
ODM or the CDJFS must:
(i) Approve presumptive coverage for the
individual; and
(ii) Provide a
notice issued from the electronic eligibility system to inform the individual:
(a) That presumptive coverage was approved;
and
(b) That failure to cooperate
with the eligibility determination process set forth in rule
5160:1-2-01 of the
Administrative Code will result in a denial of medical assistance, which will
trigger the discontinuance of presumptive coverage.
(c)
If
When an individual is not eligible for
presumptive coverage,
ODM or the CDJFS must
inform the individual that eligibility for medical assistance will be
determined within forty-five days.
(d) Whether or not an individual is eligible
for presumptive coverage,
ODM or the CDJFS
must determine whether the individual is eligible for ongoing medical
assistance pursuant to rule
5160:1-2-01 of the
Administrative Code.
(2)
If
When the QE is a hospital, the Ohio department of
rehabilitation and correction (DRC), the Ohio department of youth services
(DYS), a federally qualified health center (FQHC), an FQHC look-alike, a local
health department, a special supplemental nutrition program for women, infants,
and children (WIC) clinic, or other entity as designated by the director as
defined in rule
5160:1-1-01 of the
Administrative Code:
(a) Upon request,
determine whether the individual is presumptively eligible under this rule.
Such determination shall not be delegated to a third party, but shall be
completed by the QE.
(b) Accept
self-declaration of the presumptive eligibility criteria unless contradictory
information is provided to or maintained by the QE.
(c)
If
When the individual is presumptively eligible:
(i) Approve presumptive coverage for the
individual using the electronic eligibility system designated by ODM;
and
(ii) Provide a notice issued
from the electronic eligibility system to the individual at the time of
determination which indicates that presumptive coverage was approved and which
includes:
(a) The presumptive eligibility
determination date; and
(b) The
basis for presumptive eligibility; and
(c) The individual's name, date of birth, and
address; and
(d) The individual's
medicaid information technology system
(MITS) billing number; and
(e) A reminder that the individual must apply
for ongoing medical assistance no later than the last day of the month
following the month of approval.
(iii) Upon request, assist the individual
with completing an application for ongoing medical assistance.
(d)
If
When the
individual is not presumptively eligible, inform the individual that there may
be other categories of medical assistance available and that he or she should
apply for a full determination of eligibility for medical assistance.
(3) If the QE is a hospital, in
addition to the eligibility criteria identified in paragraph (B)(1) of this
rule, the hospital may also make presumptive eligibility determinations for the
group set out in rule
5160:1-6-03.1 of the
Administrative Code.
(F) Denial of presumptive coverage is not
grounds for a state hearing under division 5101:6 of the Administrative
Code.
Notes
Ohio Admin. Code
5160:1-2-13
Effective:
9/1/2023
Five Year Review (FYR) Dates:
6/8/2023 and
09/01/2028
Promulgated
Under: 111.15
Statutory Authority: 5163.02
Rule
Amplifies: 5163.01, 5163.02, 5163.10, 5163.101
Prior Effective
Dates: 03/31/2014, 04/25/2015, 01/01/2017, 07/08/2020 (Emer.),
01/07/2021