Current through all regulations passed and filed through September 16, 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.
(2)
The investigation must continue until the investigation
is resolved in accordance with
42 C.F.R.
455.16 (as in effect October 1,
2023).
(C)
The administrative agency cannot recover or recoup the
cost of services from an individual, except under the following
circumstances:
(1)
When a court judgment finds that medicaid benefits were
improperly paid, under section 1917(a)(1)(A) of the Social Security Act (as in
effect October 1, 2023) and 42 C.F.R.
433.36(g)(1) (as in effect
October 1, 2023);
(2)
When an individual who is an inpatient in a medical
institution, as defined in rule
5160:1-6-01.1 of the
Administrative Code, who is receiving medicaid payment for long-term care
services in accordance with Chapter
5160:1-6 of the Administrative
Code, and who has been determined to not reasonably be expected to be
discharged from the medical institution to return home;
(a)
No lien may be
imposed under paragraph (C)(2) of this rule on such individual's home when the
following individuals lawfully reside in the home:
(i)
The individual's
spouse; or
(ii)
The individual's child who is under the age of
twenty-one, or is blind or disabled in accordance with section 1614 of the
Social Security Act (as in effect October 1, 2023); or
(iii)
The
individual's sibling who has an equity interest in the home and who was
residing in the individual's home for a period of at least one year before the
date the individual was admitted into the medical institution.
(b)
A lien
imposed under paragraph (C)(2) of this rule shall dissolve upon that
individual's discharge from the medical institution and return
home.
(3)
Estate recovery proceedings as described in rule
5160:1-2-07 of the
Administrative Code.
