Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-59 - OhioRISE
Section 5160-59-02.1 - OhioRISE: first day eligibility and enrollment

Universal Citation: OH Admin Code 5160-59-02.1

Current through all regulations passed and filed through December 16, 2024

(A) Scope. This rule sets forth the provisions for eligibility and enrollment into Ohio resilience through integrated systems and excellence (OhioRISE) on the first day the program is effective. Individuals that do not meet the OhioRISE first day eligibility criteria described in paragraph (B) of this rule will have the opportunity to be enrolled in OhioRISE as set forth in rule 5160-59-02 of the Administrative Code.

(B) Eligibility. For individuals who meet criteria in paragraphs (B)(1) to (B)(4) of this rule, enrollment will be mandatory in the OhioRISE program on the first day the program is in effect:

(1) Be twenty years of age or younger;

(2) Be determined eligible for Ohio medicaid in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code;

(3) Not enrolled in a MyCare Ohio plan as described in Chapter 5160-58 of the Administrative Code on the first day the program is in effect; and

(4) Meet one or more of the following criteria:
(a) Within six months prior to the effective date of the OhioRISE program had an admission into an out of state psychiatric residential treatment facility (PRTF) as defined in 42 C.F.R. 441.150 (October 1, 2021) to 42 C.F.R. 441.184 (October 1, 2021), or had an inpatient admission to a hospital, as defined in Chapter 5160-2 of the Administrative Code, with a primary diagnosis of mental illness or substance use disorder; or

(b) Within three months prior to the effective date of the OhioRISE program:
(i) Received intensive home-based treatment (IHBT) as described in rule 5160-27-05 of the Administrative Code; or

(ii) Met the criteria described in either paragraph (A)(4) or (A)(5) in rule 5160-59-02 of the Administrative Code; or

(iii) Received the intensive behavioral support rate add-on at an intermediate care facility for individuals with intellectual disabilities as described in rule 5123-7-28 of the Administrative Code; or

(iv) Be seventeen years of age or younger and receive services in a developmental center as defined in section 5124.01 of the Revised Code; or

(c) Within two months prior to the effective date of the OhioRISE program:
(i) Received substance use disorder residential treatment services as described in rule 5122-29-09 of the Administrative Code; or

(ii) While in the custody of a Title IV-E agency as defined in rule 5101:2-1-01 of the Administrative Code, was placed in a children's residential center or was a parent in a residential parenting facility as described in rule 5101:2-9 of the Administrative Code.

(C) For individuals enrolled by meeting the criteria in paragraph (B) of this rule, the conditions for disenrollment from OhioRISE set forth in rule 5160-59-02 of the Administrative Code apply.

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