5160:1-1-01 Medicaid: definitions.

 

 

 

5160:1-1-01                 Medicaid: definitions.

 

 

 

(A)This rule contains definitions generally used in determining medicaid eligibility.

 

(B)Definitions.

 

(1)"Abuse" means any action by an individual or entity that results in unnecessary costs to the medical assistance program.

 

(2)"Administrative agency" means the Ohio department of medicaid  (ODM) and/or an agent of ODM authorized to determine eligibility for a medical assistance program.

 

(3)"AEMA"  means  alien  emergency  medical  assistance  as  established  in  rule 5160:1-5-06 of the Administrative Code.

 

(4)"Assignment" means a medicaid-eligible individual has transferred his or her right to collect and retain third-party and/or medical support payments to ODM up to the amount of medical services paid under the medicaid program.

 

(5)"Authorized representative" means an individual, who is at least eighteen years old or a legal entity who stands in place of the individual. Actions or failures of an authorized representative have the same effect as if the individual did them. If an individual has designated an authorized representative, all references to "individual" in regard to an individual's responsibilities include the individual's authorized representative.

 

(6)"Caretaker relative" means a relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child's care (as may, but is not required to, be indicated by claiming the child as a tax dependent for federal income tax purposes), and who is one of the following:

 

(a) The  child's  father,  mother,  grandfather,  grandmother,  brother,  sister, stepfather, stepmother, stepbrother, or stepsister.

 

(b) The child's aunt, uncle, nephew, or niece, including such relatives with the prefix great, great-great, grand, or great-grand.

 

(c) The child's first cousin or first cousin once removed.

 

(d)The  spouse  of  such  parent  or  relative,  even  after  the  marriage  is terminated by death or divorce.

 

(7)"Case record" means electronic or paper documents and information used to determine or redetermine an individual's eligibility for medical assistance.

 

(8) "Certificate of creditable coverage" means a written certificate, issued by a

 

 

health plan or health insurance issuer, that states the period of time an individual was or has been covered by the health plan. A certificate of creditable coverage must contain information about the duration of coverage and an educational statement that describes the individual's health insurance portability rights under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

(9) "Community Spouse" means an individual who is not in a medical institution or nursing facility and has an institutionalized spouse. If both spouses request or receive services under a home and community-based services (HCBS) waiver program or program of all inclusive care for the elderly (PACE), neither spouse meets this definition.

(10) "Confined" means serving time for a criminal offense or involuntary placement in a public institution, including a prison, jail, detention facility, or other penal institution. The term "confined":

(a) Includes placement while awaiting trial, sentencing, or other involuntary detainment determination.

(b) Does not include placement in a public institution pending arrangements appropriate to an individual's needs.

(11) "Continuous period of institutionalization" means an admission to a medical institution, receipt of home and community-based waiver services, or receipt of services under the program of all inclusive care for the elderly (PACE), for a period of at least thirty consecutive days.

(12) "Conviction" or "convicted" means a judgment of conviction has been decided by a federal, state, or local court, regardless of whether an appeal from that judgment is pending.

(13) "Creditable insurance" or "creditable coverage" means health insurance coverage as defined in 42 U.S.C. 300gg-3(c) (as in effect on September 1, 2013).

(a) This includes:

(i) A group health plan.

(ii) Health insurance coverage.

(iii) Medicare part A, as set forth in 42 U.S.C. 1395c to 1395i-5. (as in effect on April 1, 2013) or part B, as set forth in 42 U.S.C. 1395j to 1395w-4 (as in effect on April 1, 2013).

(iv) Coverage under medicaid, as set forth in Title XIX of the Social

Security Act, other than coverage consisting solely of benefits under the pediatric vaccine program set forth in 42 U.S.C. 1396s (as in effect on April 1, 2013).

(v) Armed forces health insurance as set forth in 10 U.S.C. 1071 to 1110a (as in effect on April 1, 2013).

(vi) A medical care program of the Indian health service or of a tribal organization.

(vii) A state health benefits risk pool.

(viii) A federal employee health plan offered under 5 U.S.C. 8901 to 8992 (as in effect on April 1, 2013).

(ix) A public health plan.

(x) A peace corps volunteer health benefit plan under section 22 U.S.C.

2504 (as in effect on April 1, 2013).

(b) Creditable insurance does not include:

(i) Coverage only for accident, or disability income insurance.

(ii) Liability insurance, including general liability insurance and automobile liability insurance, or coverage issued as a supplement to liability insurance.

(iii) Workers' compensation or similar insurance.

(iv) Automobile medical payment insurance.

(v) Credit-only insurance.

(vi) Coverage for on-site medical clinics.

(vii) Other similar insurance coverage under which benefits for medical care are secondary or incidental to other insurance benefits.

(viii) Limited-scope dental or vision benefits.

(ix) Benefits for long-term care, nursing home care, home health care, or community-based care.

(x) Coverage only for a specified disease or illness.

(xi) Hospital indemnity or other fixed indemnity insurance, if purchased

separately.

(xii) Medicare supplemental health insurance as defined under 42 U.S.C. 1395ss (as in effect on April 1, 2013), coverage supplemental to the coverage provided to military or former military personnel under 10 U.S.C. Chapter 55 (as in effect on April 1, 2013), and similar supplemental coverage provided to coverage under a group health plan.

(14) "Denial" or "deny" means a determination by the administrative agency that an individual is not eligible for one or more categories of assistance applied for by the individual.

(15) "Dependent child" means a person younger than age eighteen living with a parent or caretaker relative.

(16) "Early and periodic screening, diagnostic and treatment" (EPSDT or Healthchek) means periodic screening services for individuals under twenty-one years of age.

(17) "Electronic equivalent" means an electronic version of an Ohio Department of Job Family Services (ODJFS) or ODM form or application which has not been modified in any way other than format prior to completion and submission of that form to the administrative agency. The administrative agency is not required to accept forms that are altered.

(18) "Electronic protected health information" (ePHI) means any protected health information (PHI) that is maintained or transmitted in electronic form, regardless of the format.

(19) "Electronic signature" has the same meaning as in section 1306.01 of the Revised Code.

(20) "Erroneous payment" means a medicaid reimbursement made for an individual who was ineligible at the time services were received, regardless of the presence of fraud or abuse.

(21) "Family  size"  means  the  number  of  persons  counted  as  members  of  an individual's medicaid household.

(22) "Federal adoption assistance" (AA) means the Title IV-E subsidy program as defined by the Adoption Assistance and Child Welfare Act of 1980.

(23) "Federal means-tested public benefit" means a benefit in which eligibility for the benefit or the amount of the benefit, or both, is determined on the basis of income or resources of the individual seeking the benefit. Medicaid, cash assistance, and food assistance are federal means-tested public benefits, but

certain other benefits listed in 8 U.S.C. 1613(c) (as in effect on September 1, 2009) are not considered means-tested.

(24) "Federal poverty level" (FPL) means a measure of income level determined annually by the office of management and budget as required by 42 U.S.C. 9902(2) (as in effect on April 1, 2013).

(25) "Foster care maintenance" (FCM) means Ohio's Title IV-E foster care maintenance program, as described in rule 5101:2-47-01 of the Administrative Code.

(26) "Good cause" means circumstances that reasonably prevent an individual from cooperating with the administrative agency in the eligibility determination process. Factors relevant to good cause include, but are not limited to, natural disasters, riots or civil unrest, death or serious illness of the individual or a member of his/her immediate family, or the physical, mental, educational, or linguistic limitations of the individual.

(27) "Home and community-based services" (HCB services or HCBS) means services furnished under the provision of 42 C.F.R. 441, subpart G (as in effect on June 1, 2015), that provide specific individuals an alternative to placement in a hospital, a nursing facility (NF), or an intermediate care facility for individuals with intellectual disabilities (IDD) as set forth in rule 5160-1-06 of the Administrative Code.

(a) HCB services are approved by the federal centers for medicare and medicaid services (CMS) for certain individuals and are not otherwise covered by medicaid. These services may be provided:

(i) Only in certain areas of the state, and

(ii) Only to certain individuals.

(b) To receive HCB services, an individual must:

(i) Be eligible for medicaid;

(ii) Apply separately for HCB services; and

(iii) Be found eligible to receive HCB services.

(28) "Home and community-based (HCB) services waiver operational agency" means ODM or its designee that performs administrative functions related to an HCB services waiver program in accordance with agency 5160 of the Administrative Code.

(29) "Household income" is the sum of the MAGI-based income of every person

included in an individual's medicaid household.

(30) "Immigrant" means a person who comes to the United States with plans to live here permanently. This term includes refugees, asylees, parolees, and other entrants regardless of whether residing in the United States legally.

(31) "Income" means any benefit in cash or in-kind, received by an individual during a calendar month.

(32) "Income and eligibility verification system" (IEVS) means the electronic system that shares income and asset information among the social security administration (SSA), internal revenue service (IRS), state wage information collection agency (SWICA), agencies administering the state unemployment compensation (UC) laws, and the administrative agency.

(33) "Individual" means a person applying for or receiving medical assistance.

(34) "Individually identifiable health information" means information that is  a subset of health information that includes demographic information collected from an individual and:

(a) Is created or received by a health care provider, health plan, employer or health care clearinghouse; and

(b) Relates to the past, present, or future physical condition or mental health condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual and either:

(i) Identifies the individual; or

(ii) There is a reasonable basis to believe the information can be used to identify the individual.

(35) "Initial processing" means taking applications for medical assistance, assisting applicants in completing the application, providing information and referrals, obtaining required documentation needed to complete processing of the application, and assuring completeness of the information contained on the application. Initial processing does not include evaluating the information on the application and supporting documentation, or making a determination of eligibility.

(36) "Institution for mental diseases" (IMD) means a hospital, nursing facility, or other institution of more than sixteen beds which primarily provides diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services.

(a) A facility is an IMD, whether or not it is licensed as such, if it is operated primarily for the care and treatment of individuals with mental diseases.

(b) An   institution   for   persons   with   cognitive   impairments   or   other developmental disabilities is not an IMD.

(37) "Institutionalized" describes an individual who receives long-term care (LTC) services in a medical institution, a long-term care facility, under a home and community-based services (HCBS) waiver program, or under program of all inclusive care for the elderly (PACE) for at least thirty consecutive days.

(38) "Institutionalized spouse" means an individual who receives long-term care services in a medical institution, a long-term care facility, under a home and community-based services (HCBS) waiver program, or under program of all inclusive care for the elderly (PACE) for at least thirty consecutive days.

(39) "Legal custodian" means a person who has legal custody, as defined in section 2151.011 of the Revised Code, and the right to have physical care and control of a minor child.

(40) "Legal guardian" means any guardian, as defined in section 2111.01 of the Revised Code, appointed by the probate court to have the care and management of a minor child.

(41) "Limited English proficiency" (LEP) means the inability of any person or group of persons to speak, read, write or understand the English language at a level that allows them to meaningfully communicate with the administrative agency.

(42) "Long term care facility" (LTCF) is a medicaid-certified nursing facility, skilled nursing facility, or intermediate care facility for individuals with intellectual disabilities (ICF-IDD) as defined in Chapter 5160-3 of the Administrative Code.

(43) "Long term care services" are medicaid-funded, institutional or community-based, medical, health, psycho-social, habilitative, rehabilitative, and/or personal care services, as defined in Chapter 5160-3 of the Administrative Code, that may be provided to medicaid-eligible individuals.

(44) "MAGI-based income" has the same meaning as in 42 C.F.R. 435.603 (as in effect on January 1, 2014).

(45) "MBIWD" means the medicaid buy-in for workers with disabilities category set forth in rule 5160:1-5-03 of the Administrative Code.

(46) "Medical assistance" includes all programs administered by the state medicaid

administrative agency

(47) "Medicaid eligibility fraud" means that an individual knowingly:

(a) Made or caused to be made a false or misleading statement; or

(b) Concealed an interest in property or failed to disclose certain transfers of property.

(48) "Medicaid household" means a group of individuals, defined in relationship to one specific medical assistance applicant or recipient, who impact the applicant or recipient's family size or household income.

(49) "Medical support" has the same meaning as in section 5160.35 of the Revised Code.

(50) "Medical verification of pregnancy" means a written statement signed by a licensed medical professional verifying pregnancy and includes the expected date of delivery and, if more than one, the expected number of fetuses.

(51) "Non-applicant" means an individual who is not seeking an eligibility determination for himself or herself but is included in an applicant's or beneficiary's medicaid household to determine eligibility for such applicant or beneficiary

(52) "Non-cooperation" or "failure to cooperate" means failure by an individual to present required verifications, or to explain why it is not possible to present the verifications, after being notified the verification was required for eligibility determination.

(53) "Outstationing" means the federal requirement that administrative agencies provide opportunities for low-income pregnant women and children to apply for medicaid at locations other than the local county department of job and family services.

(54) "OWF sanction" means that an adult member of an Ohio works first (OWF) assistance group, as a result of his or her own failure, has become ineligible for OWF payments for at least six months due to a third or subsequent failure or refusal, without good cause, to comply in full with a provision of a self-sufficiency contract related to a work activity.

(55) "Parent" means a natural or adoptive parent, or step-parent.

(56) "Postpartum period" means a span of at least sixty days, beginning on the date a woman's pregnancy ends and ending on the last day of the month in which the sixtieth day falls.

(57) "Pre-termination review" (PTR) is set forth in rule 5160:1-2-01 of the Administrative Code. This is done prior to any termination of medical assistance to determine whether an individual is eligible for any other category of medical assistance.

(58) "Private child placing agency" (PCPA) as defined in rule 5101:2-1-01 of the Administrative Code.

(59) "Protected health information" (PHI) means individually identifiable health information that is transmitted by electronic media, maintained in electronic media or transmitted or maintained in any other form or medium.

(60) "Public children services agency" (PCSA) as defined in rule 5101:2-1-01 of the Administrative Code.

(61) "Public institution" means an institution which is the responsibility of a governmental unit or over which a governmental unit exercises administrative control, as evidenced by final administrative control, including ownership and control of the physical facilities and grounds.

(62) "Qualified  entity"  means  the  source  of  eligibility  determinations  for  the presumptive eligibility program and is limited to the following:

(a) A county department of job and family services (CDJFS); or

(b) A hospital, the department of youth services (DYS), a federally qualified health center (FQHC) or a FQHC look-alike, that meet the requirements described in Chapter 5160-28 of the Administrative Code.

(63) "Refugee" means a person who flees his or her country due to persecution or a well-founded fear of persecution because of race, religion, nationality, political opinion, or membership in a social group.

(64) "Renew" or "renewal" means a review to determine whether the individual continues to meet all of the eligibility requirements of the medical assistance category. A renewal is performed annually or when information about possible changes to an individual's eligibility is received by the administrative agency.

(65) "Reporting" means notifying the administrative agency of any changes that may affect an individual's eligibility for medical assistance. Reporting changes and providing verifications is the responsibility of any individual, person, or entity who has a legal or financial responsibility for or who stands in the place of an individual, including:

(a) The individual;

(b) The individual's spouse, including a community spouse;

(c) The  individual's  parent,  legal  custodian,  legal  guardian,  or  caretaker relative; and

(d)The individual's authorized representative.

(66) "Residence" means the place the individual considers his or her established or principal home and to which, if absent, he or she intends to return.

(67) "Residential care facility" (RCF) means a home that provides accommodations described in section 3721.01 of the Revised Code.

(68) "Safeguarding" means security measures taken to ensure that the information of individuals applying for or receiving medical assistance is protected against unauthorized inspection, disclosure, or use. Safeguarding also refers to the restriction on the use of, or disclosure of, individual information including federal tax information and returns (FTI), any protected health information (PHI), or other confidential information used in the administration of the medicaid program.

(69) "Self-declaration" means a statement or statements made by an individual.

(70) "Spouse" means a person who is legally married to another under Ohio law.

(71) "State adoption assistance" means the state-only adoption subsidy program as described in rule 5101:2-44-03 of the Administrative Code.

(72) "Support Services" means non-medical services offered or provided by the administrative agency to assist the individual and may include arranging or providing transportation, making medical appointments, accompanying the individual to medical appointments, and making referrals to community and other social services to be coordinated with the individual's medicaid-contracting managed care plan (MCP), where applicable.

(73) "Suspend" or "suspended" means the temporary closing or terminating of eligibility.

(74) "Temporary absence" means that an individual who is otherwise considered part of the family is considered not to have changed residence.

(a) An individual is considered to be temporarily absent with no time limit when all of the following conditions are met:

(i) The location of the absent individual is known;

(ii) There is a definite plan for the return of the absent individual to the family's place of residence; and

(iii) The absent individual shared the place of residence with the family immediately prior to the absence, except for individuals described in paragraph (C)(1)(h) of rule 5160:1-4-02 of the Administrative Code.

(b) Child(ren) removed by the PCSA are considered temporarily absent as long as the reunification requirements specified in the reunification plan are met.

(c) Individuals who are confined are not temporarily absent.

(75) "Terminate" or "terminated" means a determination by the administrative agency that an individual is no longer eligible, or has failed to cooperate with verification of eligibility, for one or more categories of assistance currently being received by that individual, resulting in a written notice of the administrative agency's intention to cease coverage under that category and providing notice of hearing rights as required by 42 C.F.R. 435.919 (as in effect on June 1, 2015).

(76) "United States (U.S.)" and "state(s)" mean all fifty U.S. states, the District of Columbia, and the U.S. territories of American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, Swain's Island and the U.S. Virgin Islands.

(77) "United States citizen or national" means any individual who is:

(a) A citizen or national through birth or collective naturalization as set forth in 8 U.S.C. Chapter 12, Subchapter Ill, Part I (as in effect on April 1, 2013); or

(b) A naturalized citizen or national as set forth in 8 U.S.C. Chapter 12, Subchapter III, Part II (as in effect on April 1, 2013).

(78) "Verification" means a document, statement, or other confirmation of information provided by an individual or by a third party to confirm statements made by the individual about any requirement for eligibility for medical assistance. A verification document or written statement may be an original, photocopy, facsimile (fax), or electronic version of the original, unless otherwise stated.

Replaces:                                                              5160:1-1-01, 5160:1-1-50.1

Effective:                                                             01/01/2016

Five Year Review (FYR) Dates:                         01/01/2021

CERTIFIED ELECTRONICALLY

Certification

12/21/2015

Date

Promulgated Under:                           111.15

Statutory Authority:                           5162.031, 5163.02

Rule Amplifies:                                  5162.031, 5163.02

Prior Effective Dates:                         9/3/71, 9/3/77, 10/26/78, 5/1/79, 9/21/79, 2/21/80,

7/3/80, 7/1/82, 10/14/83 (Temp.), 12/22/83, 2/15/85

(Emer.), 3/12/85, 6/10/85, 8/1/86 (Emer.), 10/3/86, 7/1/87 (Emer.), 8/3/87, 10/1/02, 10/1/09, 7/17/11,

1/9/12, 10/1/13, 1/1/14