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
Universal Citation: OH Admin Code 5160:1-2-10
Current through all regulations passed and filed through September 16, 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.
(2) Be a resident, as defined in
42 C.F.R. 435.403
(as in effect October 1, 2020) of the state of Ohio on the date of
application or requested coverage begin date.
(a) The individual's self-declaration of
residency meets this condition unless contradictory information is provided to
or maintained by the administrative agency.
(b) An individual remains a resident despite
a temporary absence from the state when the individual intends to return when
the purpose of the absence has been accomplished, unless another state has
determined the individual is a
resident there for purposes of medicaid eligibility.
(c) The individual shall not be eligible for
and receiving medical assistance in another state or U.S. territory. An
individual who has recently become an Ohio resident is not ineligible for
medical assistance merely due to processing delays in terminating medical
assistance in the prior state of residence.
(i)
When there are
delays in discontinuing medical assistance in the prior state of residence and
the individual is unable to provide all needed verifications, the
administrative agency shall explore presumptive coverage, as described in rule
5160:1-2-13
of the Administrative Code.
(ii)
When all
verifications have been provided, the administrative agency shall explore
eligibility for medical assistance in accordance with Chapter 5160:1-3,
5160:1-4, 5160:1-5, or 5160:1-6 of the Administrative Code, as
applicable.
(3) Be a U.S. citizen or qualified alien.
(a) An individual is not required to declare
or verify citizenship or non-citizen status when the individual is applying for
benefits only on behalf of another person.
(b) An individual's declaration of U.S.
citizenship shall be verified as described in rule
5160:1-2-11
of the Administrative Code.
(c) An
individual's declaration of qualified non-citizen status shall be verified as
described in rule
5160:1-2-12
of the Administrative Code.
(d)
Verification of non-citizen status is not required when the individual
is applying for AEMA, as described in rule
5160:1-5-06
of the Administrative Code.
(4) Take all necessary steps to obtain any
annuities, pensions, retirement, and disability benefits for which the
individual is eligible, unless the individual can show good cause for not doing
so, in accordance with 42 C.F.R.435.608 (as in effect October 1,
2020).
(a) "Good cause," for the
purposes of paragraph (B)(4) of this rule, means that to obtain a benefit, the
individual would incur any significant disadvantage or detriment, including but
not limited to any significant cost or expense.
(b) Benefits the individual shall take steps to obtain
include, but are not limited to: annuities, retirement, veterans' benefits, social
security disability insurance (SSDI), railroad retirement, and
unemployment compensation.
(c) When
eligibility or ineligibility for other benefits cannot be verified
electronically, an official letter from the paying entity or financial
institution is sufficient to verify the benefit.
(5) In accordance with 42
C.F.R.435.610 (as in effect October 1,
2020) and section
5160.38
of the Revised Code, the
state of Ohio shall automatically be assigned any
rights to medical support and payments for medical care from any third party
for:
(a) The individual; and
(b) Any medicaid-eligible individual for whom
the individual is legally able to make an assignment.
(6) Cooperate with the child support
enforcement agency (CSEA) in establishing the paternity of any
medicaid-eligible child and in obtaining medical
support and payments as described in paragraph (B)(5) of this rule, in
accordance with
42
C.F.R. 433.147 (as in effect
October 1, 2020).
(a) As part of cooperation, the individual
may be required to:
(i) Appear at a state or
local office to provide information or evidence relevant to the case;
and
(ii) Appear as a witness at a court or other
proceeding; and
(iii) Provide information, or attest to lack
of information, under penalty of perjury; and
(iv) Take any reasonable steps to assist
with
establishing paternity and securing medical support or payments.
(b) Cooperation is required unless
the individual:
(i) Is not receiving medical
assistance for himself or herself; or
(ii) Is a pregnant woman, including
a woman who is in her postpartum period; or
(iii) Has been approved for a good cause
waiver as determined by the local CSEA; or
(iv) Is receiving transitional medical
assistance.
(7) 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. To
meet this condition, the individual shall provide the name of the insurance
company, billing address, subscriber identification number, group number, name
of policy holder, and a list of covered individuals. In addition, the
individual shall cooperate with requests:
(a)
From a third-party insurance company to provide additional information that is
required to authorize coverage or obtain benefits through the
third-party insurance company.
(b) From a medicaid provider, managed care
plan, or a managed care plan's contracted provider to provide additional
information that is required for the provider or plan to obtain payments from a
third-party insurance company for medicaid covered services.
(c) From a third-party insurance company,
medicaid provider, managed care plan, or a managed care plan's contracted
provider to forward or return to the third-party insurance company, medicaid
provider, managed care plan, or managed care plan's contracted provider any
payments received from the third-party insurance company for medicaid covered
services when:
(i) The provider has billed the
third-party insurance company for medicaid covered services provided to the
individual;
and
(ii) The third-party insurance
company has sent payment to the individual for medicaid covered services the
individual received from the provider.
(8) Meet all eligibility requirements for an
eligibility category set out in an approved state plan amendment, Chapter
5160:1-2, 5160:1-3, 5160:1-4, 5160:1-5, or 5160:1-6 of the Administrative Code,
including:
(a) Income requirements for the
eligibility category.
(i) When an individual's
declared income exceeds the relevant federal poverty level (FPL) threshold, the
individual's declared income will be accepted without further
verification.
(ii) When an
individual's declared income is reasonably compatible with data available
through electronic data
sources, the individual's declared income will be
accepted without further verification. Income shall be
considered reasonably compatible when:
(a)
Both the declared
income and the electronic data verification are above, at, or below the
applicable income standard for the individual's family size for the eligibility
category being determined; or
(b)
The difference
between the declared income and the electronic data verification is within an
amount equal to the reasonable compatibility standard for income specified in
the state's MAGI-based eligibility verification plan.
(iii) When the administrative
agency is unable to verify income through electronic data sources,
acceptable verification documentation includes, but is not limited to:
(a) Information maintained as a regular part
of business by a government entity; or
(b) A current pay stub;
or
(c) An award letter from a certifying agency;
or
(d) IRS form 1099 or other tax documents;
or
(e)
An
employer statement including hourly or salary wage,
hours worked per pay period, length of pay period, and any tax withholdings; or
(f)
The individual's
statement, if he or she declares the income verification cannot be accessed or
submitted.
(b) Resource and asset requirements for the
eligibility category. When the administrative agency is unable to verify the
value of an individual's resources through electronic data sources,
acceptable verification documentation includes, but is not limited to:
(i) Information maintained as a regular part
of business by a government entity; or
(ii) A financial institution statement;
or
(iii) Legal documents; or
(iv)
The individual's
statement, if he or she declares the resource verification cannot be accessed
or submitted.
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