Current through all regulations passed and filed through September 16, 2024
The Ohio department of medicaid (ODM)
authorizes qualified entities (QEs) to determine presumptive eligibility (PE)
based on self-attested information to grant immediate medicaid coverage to
certain individuals seeking medicaid covered services. This rule sets forth
eligibility requirements and responsibilities to maintain designation as a
QE.
(A)
For the purposes of this rule, "qualified entity" has the
same meaning as defined in rule
5160:1-1-01 of the
Administrative Code.
(B)
To become a QE, the eligible entity must:
(1)
Have an active
provider agreement in accordance with rule
5160-1-17.2 of the
Administrative Code;
(2)
Read the presumptive eligibility training guide found
on the ODM website,
www.medicaid.ohio.gov; and
(3)
Attest that it will meet the terms and conditions as a
QE by reading, signing, and sending ODM form 10252 "acknowledgment of terms and
conditions governing the presumptive eligibility determinations authority
granted by the Ohio department of medicaid to a qualified entity" (rev.
8/2019), found on the ODM website,
www.medicaid.ohio.gov.
(C)
Once designated
as a QE, the QE must:
(1)
Remain in good standing as an Ohio medicaid
provider;
(2)
Follow rule
5160:1-2-13 of the
Administrative Code and all other applicable federal and state laws when
determining medicaid PE;
(3)
Verify the individual is not already enrolled in
another category of medicaid;
(4)
Without
compensation, agree to perform all of the administrative functions associated
with PE including, but not limited to:
(a)
Provide to ODM a
list of names and titles of all employees given responsibility to determine PE
and request appropriate access to the PE portal;
(b)
Ensure that
employees given responsibility to determine PE have read the presumptive
eligibility training guide, understand the criteria for all medicaid
eligibility categories and have been trained on how to use the presumptive
eligibility portal;
(c)
Ensure those who have responsibility to submit claims
to the medicaid program for reimbursement of medicaid services are not
individuals responsible for determining presumptive eligibility;
and
(d)
Agree to retain all records related to presumptive
eligibility determinations in accordance with rule
5160-1-27 of the Administrative
Code and provide such records to ODM, its designee, or to any authorized state
or federal agency upon request.
(5)
Agree that it may
be held responsible for the willful conduct of its employees who violate
federal or state law. Any employee who knowingly files a claim containing
false, incomplete, or misleading essential information to create eligibility
for medicaid or receive payment from medicaid may be punishable under federal
or state law;
(6)
If the QE is a hospital, agree to provide thirty-six
hours' worth of medically necessary medications to any person enrolled
presumptively by the QE at time of determination;
(7)
If the QE is a
federally qualified health center (FQHC) and is able to do so, provide
thirty-six hours' worth of medically necessary medications to any person
enrolled presumptively by the QE at the time of determination if such needs are
determined during a medical visit;
(8)
Ensure that for
all persons enrolled presumptively by the QE, at least eighty-five per cent
have a completed application for full medicaid benefits submitted no later than
the last day of the month following the month in which the QE makes the PE
determination; and
(9)
Ensure that for all persons who had an application
submitted for full medicaid benefits, at least eighty-five per cent result in
an awarding of medicaid eligibility.
(D)
ODM may terminate
authority granted under this rule with or without written notice, for any
reason supported by evidence of acts or omissions adversely affecting the
medicaid program, including, but not limited to the following
circumstances:
(1)
Revocation or cancellation of the QE's Ohio medicaid
provider agreement;
(2)
Requirements set forth in this rule are not
met;
(3)
Unauthorized use of MITS by the QE;
(4)
Programmatic or
systematic changes related to the medicaid eligibility or enrollment system;
or
(5)
The QE is unable to perform its
functions.
(E)
A QE may utilize reconsideration rights as stated in
rule 5160-70-02 of the Administrative
Code to challenge a decision of ODM to deny or terminate QE
designation.
