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)
Universal Citation: OH Admin Code 5160:1-5-05
Current through all regulations passed and filed through September 16, 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.
(C) Eligibility criteria.
(1)
The individual
shall be neither:
(a)
Eligible for another category of medical assistance;
nor
(b)
A full-time student in an institution of higher
education, except where such enrollment is approved by the state, or its
designee, as part of an individual employability plan as described in rule
5101:1-2-40.5 of the Administrative Code.
(2)
The individual
meets the income requirements for RMA when:
(a)
The individual's
countable income is no more than the RMA need standard, or
(b)
The individual
whose countable income is more than the RMA need standard spends down countable
income to the RMA need standard in accordance with the methods set forth in
paragraph (E) of this rule.
(3)
Continued
eligibility of individuals who receive increased earnings from
employment.
(a)
Financial eligibility for RMA is based on the individual's
income on the date of application.
(b)
When an
individual receiving RMA has increased earnings from employment, the earnings
shall not affect the individual's continued eligibility for
RMA.
(c)
When an individual who qualified for another category
of medical assistance becomes ineligible because of earnings from employment,
the individual shall have his or her eligibility transferred to the RMA
category without an RMA eligibility determination when the individual:
(i)
Meets the
non-financial eligibility criteria for RMA; and
(ii)
Does not qualify
for any other category of medical assistance; and
(iii)
Has been
residing in the U.S. less than the time-limited eligibility period for RMA as
defined in paragraph (D) of this rule.
(d)
An individual
shall continue to receive RMA until he or she reaches the end of the twelve
month time-limited eligibility period, as described in
45
C.F.R. 400.104 (as in effect October 1,
2023).
(e)
In cases where an individual is covered by
employer-sponsored health insurance, any payment of RMA for that individual
must be reduced by the amount of the third party payment.
(D) Eligibility period. An individual who meets the eligibility requirements of this rule may receive RMA for a time-limited period not to exceed twelve continuous months from the individual's date of entry or from the date status is granted, as listed on the individual's U.S. citizenship and immigration services (USCIS) documentation.
(E) Calculation of spenddown amount. When the individual's countable monthly income, as determined in accordance with rule 5160:1-3-03.1 of the Administrative Code, exceeds the RMA need standard, the administrative agency must calculate the amount, if any, of the monthly spenddown as follows:
(1)
Determine the total amount of all monthly medical
insurance premiums of the individual and family members. Do not round down.
Subtract that amount from the individual's countable monthly income and round
down to the nearest whole dollar.
(a)
When the result is less than or equal to the applicable
RMA need standard, the individual is eligible for RMA for the entire calendar
month without any monthly spenddown amount.
(b)
When the result
is greater than the applicable RMA need standard, continue to paragraph (E)(2)
of this rule.
(2)
Determine the total amount of the individual's and
family members' UPMEs as determined in accordance with paragraph (G)(2) of this
rule. Do not round down. Subtract that amount from the result calculated in
paragraph (E)(1) of this rule and round down to the nearest whole dollar.
(a)
When the result
is less than or equal to the applicable RMA need standard, the individual is
eligible for RMA for the entire calendar month without any monthly spenddown
amount.
(b)
When the result is greater than the applicable RMA need
standard, the amount that is over the need standard is the individual's monthly
spenddown amount. In order to become eligible for RMA for all or part of the
calendar month, the individual must satisfy the monthly spenddown amount
through one of the methods set forth in paragraph (F) of this
rule.
(F) Ways of meeting spenddown. When the individual has a monthly spenddown amount calculated in accordance with paragraph (E) of this rule, the individual may satisfy, or meet, the spenddown through one or more of the following methods, and must do so each calendar month in order to be eligible for RMA:
(1)
Recurring.
(a)
The individual
will not have a spenddown requirement for one or more calendar months when the
individual is found eligible for RMA pursuant to paragraph (E)(1)(a) or
(E)(2)(a) of this rule.
(b)
When the individual's and/or family members' expenses
described in paragraph (E) of this rule are not equal to or greater than the
spenddown amount for a given calendar month, the individual may satisfy the
spenddown amount by using one or more of the methods set forth in paragraphs
(F) (2) to (F)(4) of this rule.
(2)
Incurred. This
method is frequently called "delayed spenddown."
(a)
At the
individual's option, the individual may satisfy spenddown for a calendar month
by incurring a dollar amount of current medical expenses, as defined in
paragraph (B)(6) of this rule, equal to or greater than the spenddown amount
for the calendar month.
(b)
An individual is eligible for RMA for a calendar month
starting on the date the individual and/or family member(s) incurred the
medical expenses that, combined with all other incurred medical expenses for
the month, equal or exceed the individual's spenddown amount for the calendar
month.
(3)
Pay-in.
(a)
At the individual's option, the individual may satisfy
spenddown for the current calendar month by paying to the administrative agency
the dollar amount of the spenddown amount for the current calendar month. When
the dollar amount of the spenddown is satisfied, the individual is eligible for
RMA for the entire calendar month.
(b)
A third party may
pay-in on behalf of the individual or a group of individuals subject to
spenddown by making payments directly to the administrative agency from the
third party's funds or other funds in the current calendar month in which
eligibility is being sought. Such payments are not considered income, are not
included in the individual's countable monthly income, and do not negatively
affect the individual's RMA eligibility.
(c)
Pay-in spenddown
payments cannot be applied to retroactive months. Pay-in spenddown payments are
restricted to payment for current or future calendar month(s) in which RMA
eligibility through the spenddown process is being sought.
(4)
Combination of methods.
(a)
At the
individual's option, the individual may meet the spenddown by using the
incurred method described in paragraph (F)(2) of this rule for one or more
calendar months, and the pay-in method described in paragraph (F)(3) of this
rule for one or more other calendar months.
(b)
At the
individual's option, the individual may meet the spenddown by combining two
methods in a single calendar month as follows:
(i)
After the
individual and/or family member has incurred an amount of current medical
expenses for the calendar month that is less than the individual's spenddown
amount for the calendar month, the administrative agency permits the individual
to pay-in the difference between the current incurred medical expenses and the
spenddown amount.
(ii)
When the individual does so, the individual is eligible
for RMA for the month starting on the date the individual or family member
incurred the last current medical expense for the calendar
month.
(5)
Failure to
satisfy spenddown for a calendar month. If the individual does not satisfy
spenddown for a calendar month, the individual is not eligible for RMA for the
calendar month. The individual may be eligible for a future calendar month in
which the individual satisfies spenddown during the time-limited RMA period,
not exceeding twelve continuous months from the individual's date of entry or
date status is granted.
(6)
Documentation of a met spenddown liability must be
submitted to the county department of job and family services (CDJFS) within
three hundred sixty-five days of the date of service.
(G) Treatment of expenses.
(1)
Treatment of
current incurred medical expenses subject to payment by a third party:
(a)
When written off
by the provider: the expense is treated as a current incurred medical expense
for the calendar month in which the item or service was
provided.
(b)
When paid, or subject to payment, by a third party that
is not legally obligated to pay the expense for the individual or family
member: the expense is treated as a current incurred medical expense for the
calendar month in which the item or service was provided, even when it is paid
by the third party later in the same or a subsequent month.
(c)
When paid, or
subject to payment, by a third party that is legally obligated to pay the
expense or a portion of the expense for the individual or family member: the
expense is not treated as a current incurred medical expense.
(d)
When an agency or
program provides a direct medical service based on out-ofpocket limits, or a
"sliding" or "ability-to-pay" fee scale, only the amount the individual or
family member is liable to pay for the service, including deductibles and
co-pays, are treated as current incurred medical expenses.
(2)
Treatment of UPMEs. For the purpose of calculating the
spenddown amount, the amount of UPME to be subtracted is determined in
accordance with this paragraph.
(a)
A UPME is considered to have been incurred in the
calendar month during which the provider supplied the item or service to the
individual or family member.
(b)
The individual is
not required to pay or provide evidence of paying the UPME for RMA
purposes.
(c)
UPMEs that may be applied in the spenddown process
are:
(i)
Incurred during a calendar month in which the individual or
family member receiving the item or service was not eligible for another
category of medical assistance.
(ii)
Incurred during
a calendar month in which the individual did not satisfy the monthly spenddown
amount, even with the application of the bill.
(iii)
Incurred for a
medical item or service not payable under any category of medical assistance,
regardless of an individual's eligibility during the calendar month in which
the medical expense occurred, because the item or service was:
(a)
Not covered by
medical assistance;
(b)
Supplied by a provider who was not participating in the
medical assistance program; or
(c)
Was supplied by a
medical assistance provider who did not accept medical assistance for the
UPME.
(d)
The administrative agency shall assist the individual
with choosing the amount of the UPME to apply, and the calendar month(s) for
which to apply it. To assist the individual with making an informed decision,
the administrative agency shall determine the minimum number of calendar months
for which the UPME might be applied. To make this determination, the
administrative agency shall:
(i)
Determine the combined total of all the UPMEs of the
individual and family members;
(ii)
Divide the total
UPME by the result calculated in paragraph (E)(1) of this rule;
(iii)
The quotient is
the minimum number of calendar months the UPME would allow the individual to
meet the spenddown amount, assuming no changes in any factor that would affect
the calculation of the spenddown amount.
(e)
The amount of the UPME the
administrative agency must subtract in the calculation of the spenddown amount
in paragraph (E)(2) of this rule is either:
(i)
The amount of the
UPME the individual chooses to use; or
(ii)
When the
individual does not choose an amount to use, the difference between the result
calculated in paragraph (E)(2) of this rule and the RMA need standard
applicable to the individual.
(f)
A UPME or portion
of a UPME that the administrative agency applies toward the spenddown for a
given calendar month cannot be used again in the spenddown process for a future
calendar month.
(g)
A UPME or portion of a UPME that the administrative
agency does not apply toward the spenddown can be used to meet the spenddown
for a future calendar month.
(3)
Treatment of
medical expenses used in the spenddown process. Any medical expenses of the
individual or family member that are used in the spenddown process to approve
the individual's RMA for a given calendar month remain the obligation of the
individual or family member and are not payable by the RMA
program.
(H) Spenddown during retroactive calendar months in which the individual incurred a medically necessary medical expense:
(1)
The
administrative agency must determine whether the individual is retroactively
eligible, including eligibility through the spenddown process, in accordance
with rule
5160:1-2-01
of the Administrative Code. RMA eligibility cannot begin prior to the
individual's date of entry or date status was granted.
(2)
When the
individual is not retroactively eligible (even through the spenddown process),
the individual may apply the medical expense as a UPME in the spenddown process
for a calendar month in which the individual is otherwise
eligible.
(3)
When the individual is retroactively eligible (whether
through the spenddown process or not):
(a)
The individual
may apply the UPME in the spenddown process for the retroactive calendar month
only when the UPME is not payable for the individual under another category of
medical assistance, as described in paragraph (G)(2)(c)(iii) of this rule;
and
(b)
The individual must apply the UPME to meet the
spenddown for the retroactive calendar month(s) first, before using it to meet
the spenddown for any subsequent calendar month.
(I) Administrative agency responsibilities.
(1)
Accept an
application, or electronic equivalent, for medical assistance as an application
for RMA.
(2)
In order to assist the individual with making informed
decisions about the spenddown process, explain to and/or discuss with the
individual the following:
(a)
The various recurring and incurred spenddown medical
expenses the individual may use in the spenddown process; and
(b)
The methods for
satisfying spenddown.
(3)
Not require an
individual to apply for or receive refugee cash assistance
(RCA).
(4)
Not require a face-to-face interview.
(5)
Use actual
countable individual income for the month of application. Do not average income
prospectively when determining income eligibility for RMA.
(6)
Determine
eligibility for another category of medical assistance, as described in Chapter
5160:1-1, 5160:1-3, 5160:1-4 or 5160:1-5 of the Administrative Code, prior to
determining eligibility for RMA.
(7)
Call the
trafficking verification line to confirm the validity of the certification
letter or letter for children and to notify ORR of the benefits for which the
individual has applied.
(8)
Make eligible for RMA an individual who receives RCA
and who meets the eligibility requirements of this rule.
(9)
Obtain
third-party liability information from an individual who has other health
insurance.
(10)
Explore retroactive eligibility for RMA, in accordance
with rule
5160:1-2-01
of the Administrative Code. Retroactive eligibility cannot begin prior to the
individual's date of entry or date status was granted.
(11)
Issue the RMA
card for the month within two business days after the individual submits
verification showing that current incurred medical expenses for the month
satisfy the spenddown amount for the calendar month.
(12)
Implement and
make available in writing reasonable policies and procedures for administering
the pay-in spenddown method. The policies and procedures must:
(a)
Permit and
provide reasonable methods of accepting payments by third parties on behalf of
individuals and groups of individuals subject to spenddown.
(b)
Ensure that, at
the individual's option, the individual will receive an RMA card for a month on
or about the first day of the month by making his or her pay-in payment by a
date chosen by the administrative agency near the end of the preceding
month.
(i)
When
the administrative agency receives the individual's pay-in payment before the
preceding month's cutoff date for benefit issuance, the administrative agency
will authorize the issuance of the RMA card in the electronic eligibility
system within two business days after the cutoff date; or
(ii)
When the
administrative agency receives the individual's pay-in payment on or after the
preceding month's cutoff date for benefit issuance, the administrative agency
will issue the RMA card within two business days after the administrative
agency receives the individual's pay-in payment.
(c)
Ensure that, at
the individual's option, the individual may pay-in for a given calendar month
at any time during the calendar month and that the administrative agency will
issue the RMA card for the month within two business days after the
administrative agency receives the individual's pay-in payment.
(d)
Establish
reasonable methods for accepting and accounting for pay-in payments, including
but not limited to:
(i)
Accepting cash payments;
(ii)
Defining
conditions for accepting checks or money orders; and
(iii)
Establishing
provisions for refunding or crediting unused pay-in amounts.
(e)
Establish provisions for refunding the individual's pay-in payment for a month
in the event the individual:
(i)
Becomes eligible for medical assistance for the month
through means other than the spenddown process;
(ii)
Becomes
ineligible for medical assistance for the month despite meeting the spenddown;
or
(iii)
Paid in more than the spenddown amount, whether due to
the individual's error or to the administrative agency's error in calculating
the spenddown amount.
(13)
Document all
pay-in spenddown payments in the electronic eligibility system and in the
individual's case record, and issue a receipt to all individuals and third
parties who make pay-in spenddown payments. The documentation and receipts must
state:
(a)
The
date payment was received;
(b)
The name of the
person or entity from whom the payment was received;
(c)
The name and
identifying case information of the individual for whom the payment was made;
(d)
The calendar month of eligibility for which the pay-in
payment will be used and the effective date of RMA for that month;
and
(e)
The amount of the payment and the form in which it was
paid.
(14)
Document in the electronic eligibility system and in
the individual's case record:
(a)
For each month's current incurred medical expenses and
UPMEs submitted by or on behalf of the individual:
(i)
The name of the
provider of the medical item or service;
(ii)
The item or
service provided;
(iii)
The date the item or service was provided;
(iv)
The name of the individual or family member to whom the item
or service was provided;
(v)
The amount the individual or family member paid or is
liable to pay for the item or service;
(vi)
For UPMEs, the
calendar month(s) for which the UPME or a portion of the UPME was used in the
calculation of the spenddown amount; and
(vii)
The amount
still owed for the item or service.
(b)
For current
incurred medical expenses that require a decision by the PAU, as described in
paragraph (B)(10) of this rule:
(i)
The provider's statement;
(ii)
The PAU
decision; and
(iii)
All other information related to the administrative
agency's decision to use or not use a current incurred medical expense in the
spenddown process.
(c)
For
transportation expenses the administrative agency has determined cannot be used
in the spenddown process:
(i)
A description of which specific transportation
expense(s) were not used; and
(ii)
A clear
explanation of the administrative agency's determination.
(15)
Issue proper notice and hearing rights as set forth in
division 5101:6 of the Administrative Code.
(16)
Not deny RMA for
an individual who is applying for medical assistance and does not anticipate
satisfying spenddown in the month of application or in one or more future
calendar months. Instead, the administrative agency shall cause the electronic
eligibility system to give the individual the type of eligibility that will
only issue an RMA card to the individual for those calendar months for which
the individual satisfies the spenddown amount.
(17)
Not propose to
discontinue RMA for an individual who does not satisfy spenddown for one or
more calendar months. Instead, the administrative agency shall cause the
electronic eligibility system to give the individual the type of eligibility
that will only issue an RMA card to the individual for those calendar months
for which the individual satisfies the spenddown amount.
(J) Individual responsibilities. The individual shall:
(1)
Provide:
(a)
USCIS
documentation of non-citizen status;
(b)
The name of the
resettlement agency, if any, that resettled the individual; and
(c)
The information
necessary to establish eligibility, cooperate with the verification process,
and report changes in accordance with rule
5160:1-2-08
of the Administrative Code.
(2)
Spend down to the
RMA need standard when the countable income exceeds the RMA need
standard.
(3)
Cooperate with providing verification of any
third-party liability or coverage of medical expenses as defined in rule
5160:1-2-10
of the Administrative Code.
(4)
The individual
must submit monthly to the administrative agency, by mail, facsimile,
electronically or in person, verification of the current incurred medical
expenses the individual wishes to apply against his or her spenddown amount for
the calendar month.
(a)
Verifications may include unpaid bills, statements,
invoices, paid receipts, etc.
(b)
For each expense,
the individual must provide the name of the provider, the item or service
provided, the date the item or service was provided, the name of the individual
or family member to whom the item or service was provided, and the amount the
individual or family member paid or is liable to pay for the item or
service.
Replaces: 5160:1-5-05
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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