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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5160:1 Medicaid General Principles |
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Chapter5160:1-5. Medicaid for Other Covered Groups |
5160:1-5-02.4. Medicaid: breast and cervical cancer project (BCCP): application and renewal process
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(A) This rule describes the application and renewal process for the breast and cervical cancer project (BCCP).
(B) The BCCP medicaid application and renewal process shall:
(1) Be coordinated between Ohio department of medicaid (ODM), Ohio department of health (ODH) BCCP, and ODH BCCP designated local agencies and/or subgrantees,
(2) Be coordinated with ODH BCCP case management services, and
(3) Support the goals of the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (BCCPTA), identified in rule 5160:1-5-02 of the Administrative Code.
(C) ODH BCCP and its designated local agencies or subgrantee responsibilities. The ODH BCCP and its designated local agencies or subgrantee shall:
(1) Provide the ODM 07161 "Ohio Breast and Cervical Cancer Project (BCCP) Medicaid Application" (rev. 9/2017) to ODH BCCP enrollees screened for breast or cervical cancer under the centers for disease control and prevention's (CDC) national breast and cervical cancer early detection program (NBCCEDP) and referred for breast or cervical cancer diagnostic evaluation.
(2) Provide the ODM 07161 to ODH BCCP enrollees screened for breast or cervical cancer under the CDC NBCCEDP who are receiving treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer.
(3) Notify in writing ODH BCCP enrollees described in paragraphs (C)(1) and (C)(2) of this rule to return the completed ODM 07161 to the designated ODH BCCP regional case manager.
(D) ODH BCCP regional case manager responsibilities.
(1) The application process. The ODH BCCP regional case manager shall:
(a) Provide to ODM the completed ODM 07161 and ODM 7160 "Healthcare Provider's Treatment Plan" (rev. 9/2017) within five business days of receipt of the diagnostic information when:
(i) The ODH BCCP enrollee has submited the ODM 07161; and
(ii) The ODH BCCP screening provider notifies the designated ODH BCCP regional case manager that, as a result of the NBCCEDP funded screening, a treating health professional has determined the ODH BCCP enrollee needs treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer.
(b) Notify the ODH BCCP enrollee in writing within five business days of the receipt of the diagnostic information, that the ODM 07161 must be submitted to the designated ODH BCCP regional manager when:
(i) The enrollee has not submitted the ODM 07161; and
(ii) The ODH BCCP screening provider notifies the designated ODH BCCP regional case manager that, as a result of the NBCCEDP funded screening, a treating health professional has determined the ODH BCCP enrollee needs treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer.
(c) Notify the ODH BCCP enrollee in writing within five business days that the ODM 07161 will not be submitted to ODM when:
(i) The ODH BCCP enrollee submits the ODM 07161; and
(ii) The diagnostic results indicate that the ODH BCCP enrollee does not need treatment for either breast or cervical cancer, pre-cancerous conditions, or early stage cancer.
(2) The renewal process. The ODH BCCP regional case manager shall:
(a) Provide to ODM the completed ODM 07160 within five business days of receipt of notification from the treating health professional when the individual has been found to need continued treatment for either breast or cervical cancer, pre-cancerous conditions, or early stage cancer.
(b) Notify the individual in writing within five business days that the ODM 07160 will not be submitted to ODM when the treating health professional notifies the designated ODH BCCP case manager the individual has been found to not need continued treatment for either breast or cervical cancer, pre-cancerous conditions, or early stage cancer.
(c) Notify ODM within five business days upon receipt of a medicaid renewal form from an individual.
(E) ODM responsibilies. ODM shall:
(1) Make available to ODH BCCP and its designated local agencies or subgrantees the ODM 07161 and ODM 07160.
(2) Be responsible for all determinations of BCCP medicaid eligibility, including retroactive eligibility.
(3) Use available sources of information in the eligibility determination including:
(a) Information contained in the ODM 07160 and ODM 07161; and
(b) Information in the case record to determine if the individual is currently enrolled in medicaid or has a pending medicaid application.
(4) Use the eligibility criteria set forth in rule 5160:1-5- 02.2 of the Administrative Code.
(5) Complete all determinations of eligibility within forty-five days of receipt of a completed ODM 07161 or medicaid renewal form.
(a) A delay in the eligibility determination or renewal shall not be a basis for granting eligibility; or
(b) An application pending beyond forty-five days shall not be the sole basis for denial.
(6) Redetermine BCCP medicaid eligibility :
(a) Prior to the completion of the lesser of:
(i) The individual's treatment period; or
(ii) Twelve months continuous eligibility in BCCP medicaid.
(b) When ODM receives an ODM 07160 indicating a change in the individual's circumstances, including completion of treatment prior to the original determined treatment period.
(c) When the individual obtains other health insurance.
(d) When the individual turns sixty-five years of age.
(7) Provide written notice to the BCCP medicaid recipient:
(a) That information is required for the determination of BCCP medicaid eligibility, and
(b) To return required completed renewal materials to the CDJFS.
(F) Individual responsibilities. The individual shall:
(1) Submit a completed ODM 07161 to the designated ODH BCCP regional case manager.
(2) Cooperate with ODM in the application and renewal process, as described in rule 5160:1-2-08 of the Administrative Code.
(G) An individual may apply for a new period of BCCP medicaid eligibility after BCCP medicaid discontinuance.
(1) A period of BCCP medicaid eligibility shall begin each time an individual:
(a) Is screened for breast or cervical cancer under the CDC NBCCEDP, and
(b) Is found, as a result of the CDC NBCCEDP screening, to need treatment of breast or cervical cancer, pre-cancerous condition, or early stage cancer, and
(c) Submits a completed ODM 07161 in accordance with paragraph (F) of this rule, and
(d) Is determined by ODM to meet all eligibility criteria for BCCP medicaid as described in rule 5160:1-5-02.2 of the Administrative Code.
(2) Individuals who have completed a treatment period, have had their BCCP medicaid eligibility discontinued, and subsequently have been found to have new, recurrent, or metasticized breast or cervical cancer, pre-cancerous condition, or early stage cancer:
(a) Shall be recertified as eligible for the ODH BCCP to reestablish BCCP medicaid eligibility; and
(b) Shall submit a new ODM 07161 to reestablish BCCP medicaid eligibility.
(3) Individuals who have not completed their treatment period, have had their BCCP medicaid eligibility discontinued, and have been found to have new, recurrent, or metasticized breast or cervical cancer:
(a) Do not need to be recertified as eligible for the ODH BCCP to reestablish BCCP medicaid eligibility; and
(b) Shall submit a new ODM 07161 to reestablish BCCP medicaid eligibility.
(H) Screening for potential eligibility for other medicaid programs by ODM and/or the CDJFS at application and renewal.
(1) When information on the ODM 07161 or medicaid renewal form indicates the individual is not potentially eligible for any other medicaid program, income and asset information is not needed and ODM shall determine eligibility for BCCP medicaid.
(2) When information on the ODM 07161 or medicaid renewal form indicates the individual is potentially eligible for any other medicaid program, the individual shall provide income and asset information to screen for eligibility for other medicaid programs.
(a) When income or asset information indicates the individual does not appear eligible for any other medicaid program, no additional income or asset information is needed and ODM shall determine eligibility for BCCP medicaid.
(b) When income or asset information indicates the individual appears eligible for any other medicaid program, the individual shall be:
(i) Notified of potential eligibility;
(ii) Given instructions for submission of additional information required to make a determination of eligibility for other medicaid programs.
(iii) Notified by the CDJFS in writing to complete and submit additional information required to the CDJFS in the individual's county of residence.
(a) When the CDJFS determines the applicant eligible for any other category of medicaid, the CDJFS will discontinue BCCP medicaid in accordance with paragraph (D)(8) of rule 5160:1-5- 02.2 of the Administrative Code and approve the category for which the individual is eligible.
(b) When the CDJFS determines the individual ineligible for any other medicaid program, the CDJFS will notify ODM and ODM will maintain the BCCP medicaid case.