Rule Summary and Fiscal Analysis (Part A)
Department of Job and Family Services
Agency Name
Division of Public Assistance Michael Lynch
Division Contact
OFC- 4200 E. 5th Ave., 2nd fl. J6-02 P.O. Box 183204 Columbus OH 43218-3204
614-466-4605 614-752-8298
5101:1-5-20
Rule Number
AMENDMENT
TYPE of rule filing
Rule Title/Tag Line Disability financial assistance: the determination of a
disability.
RULE SUMMARY
1. Is the rule being filed for five year review (FYR)? Yes
2. Are you proposing this rule as a result of recent legislation? No
3. Statute prescribing the procedure in accordance with the agency is required to adopt the rule: 111.15
4. Statute(s) authorizing agency to adopt the rule: 5115.03
5. Statute(s) the rule, as filed, amplifies or implements: 5115.01, 5115.03
6. State the reason(s) for proposing (i.e., why are you filing,) this rule:
Five-year review.
7. If the rule is an AMENDMENT, then summarize the changes and the content of the proposed rule; If the rule type is RESCISSION, NEW or NO CHANGE, then summarize the content of the rule:
This rule describes the disability determination process for the disability financial assistance program.
Minor language changes were made for clarity; and the forms required in the disability determination process were updated to reflect new titles and form revision dates from the Ohio Department of Medicaid. No substantive changes were made.
8. If the rule incorporates a text or other material by reference and the agency claims the incorporation by reference is exempt from compliance with sections
121.71 to 121.74 of the Revised Code because the text or other material is generally available to persons who reasonably can be expected to be affected by the rule, provide an explanation of how the text or other material is generally available to those persons:
This rule incorporates one or more references to the Social Security Act. This question is not applicable to those references in this rule because such references are exempt from compliance with RC 121.71 to 121.74 pursuant to RC 121.76(B)(2).
This rule incorporates one or more references to another rule or rules of the Ohio Administrative Code. This question is not applicable to any incorporation by reference to another OAC rule because such reference is exempt from compliance with RC 121.71 to 121.74 pursuant to RC 121.76 (A)(3).
This rule incorporates one or more dated references to an ODM form or forms. Each cited ODM form is dated and is generally available to persons affected by this rule via the "Resources/Publication/Forms Central" link on the Ohio Department of Medicaid web site (http://medicaid.ohio.gov//) in accordance with RC 121.75(E).
This rule incorporates one or more dated references to the U.S. Code. This question is not applicable to any dated incorporation by reference to the U.S. Code because such reference is exempt from compliance with RC 121.71 to 121.74 in accordance with RC 121.75(A).
This rule incorporates one or more references to the Ohio Revised Code. This question is not applicable to any incorporation by reference to the Ohio Revised Code because such reference is exempt from compliance with RC 121.71 to 121.74 pursuant to RC 121.76(A)(1).
9. If the rule incorporates a text or other material by reference, and it was infeasible for the agency to file the text or other material electronically, provide an explanation of why filing the text or other material electronically was infeasible:
Not Applicable.
10. If the rule is being rescinded and incorporates a text or other material by reference, and it was infeasible for the agency to file the text or other material, provide an explanation of why filing the text or other material was infeasible:
Not Applicable.
11. If revising or refiling this rule, identify changes made from the previously filed version of this rule; if none, please state so. If applicable, indicate each specific paragraph of the rule that has been modified:
Not Applicable.
12. Five Year Review (FYR) Date: 9/17/2015
(If the rule is not exempt and you answered NO to question No. 1, provide the scheduled review date. If you answered YES to No. 1, the review date for this rule is the filing date.)
NOTE: If the rule is not exempt at the time of final filing, two dates are required: the current review date plus a date not to exceed 5 years from the effective date for Amended rules or a date not to exceed 5 years from the review date for No Change rules.
FISCAL ANALYSIS
13. Estimate the total amount by which this proposed rule would increase / decrease either revenues / expenditures for the agency during the current biennium (in dollars): Explain the net impact of the proposed changes to the budget of your agency/department.
This will have no impact on revenues or expenditures.
$0.00
No impact on current budget.
14. Identify the appropriation (by line item etc.) that authorizes each expenditure necessitated by the proposed rule:
Not Applicable.
15. Provide a summary of the estimated cost of compliance with the rule to all directly affected persons. When appropriate, please include the source for your information/estimated costs, e.g. industry, CFR, internal/agency:
No new costs.
16. Does this rule have a fiscal effect on school districts, counties, townships, or municipal corporations? No
17. Does this rule deal with environmental protection or contain a component dealing with environmental protection as defined in R. C. 121.39? No
S.B. 2 (129th General Assembly) Questions
18. Has this rule been filed with the Common Sense Initiative Office pursuant to
R.C. 121.82? No
19. Specific to this rule, answer the following:
A.) Does this rule require a license, permit, or any other prior authorization to engage in or operate a line of business? No
B.) Does this rule impose a criminal penalty, a civil penalty, or another sanction, or create a cause of action, for failure to comply with its terms? No
C.) Does this rule require specific expenditures or the report of information as a condition of compliance? No
CD?I???? DOW
JFS 03605
Date County
Secti n I:Recipient Inf ?mation
Re?ent ID I I SSN?
DOB
Sex
Last
Name Address Line 1Address Line 2
Fi?t Name Ml
Secti?n IV: Case Inf, rmati?nApplication Date
? County Case ID
7302 CommentsRequested Onset Date
L_
7302 Unavailable ?
Expedite Case
Previous Denial ? Last Denied Date 
Secti?n V: Disability Applicati?n Inf, rmation - New Applicati?n?
New Application
0 Death ., From I I To | |
Q AEMA ??"10?ru\From I I To | |
?Not Qualified For Other Medicaid Services
Ar.'•??./lAllntll ??'\'Ml ,U???? /A7??? c.fl0Ll.11_'10.1
S
ACTION: Original DATE:
09/17/2015 1:44 PMOHIO DEPARTMENTOF MEDICAID
MEDICATION DEPENDENCIES
SECTION I: IDENTIFYING INFORMATION TO BE COMPLETED BY WORKER
Assistance Group Number Recipient ID DOB Sex County Name
Client Last Name Client First Name MI County Address
Client Address Client Phone City ZIP
City ZIP SSN Caseworker/Case Mgr. Caseload ID County Phone
STATEMENT OF MEDICAL CONDITION: MUST be completed by treating physician
Please describe your patient's chronic medical condition(s):
SECTION II: TO BE COMPLETED BY PHYSICIAN
Please list all medications prescribed by you for this patient to control the above listed chronic medical conditions and the prescription history of each for the previous 6 months:
Medication Prescription History
Medication _ _ _ _ _ _ _ _ Prescription History
_
Medication
Prescription History
Medication
Prescription History
_
Medication
Prescription History _
Medication
Prescription History
Medication
Prescription History
Medication
Prescription History
Medication Prescription History
SECTION III: STATEMENT OF CERTIFICATION: To be completed by testing physician
A medication-dependent person is one who is undergoing treatment for a chronic medical condition which requires the continuous prescription of the medication listed above for long-term, indefinite period of time. The loss of access to the listed medications would result in a significant risk of a medical emergency and loss of employability for at least 9 months.
is my patient and my signature below certifies that based up on this definition of medication dependency:
(s) he is a medication dependent person.
(s) he is NOT a medication dependent person.
I hereby certify under penalty of law that the above information is a true and accurate description of my patient's medical condition at this time to the best of my knowledge. I understand that I will have my provider agreement with the Ohio Department of Human Services revoked and/or be reported to the State Medical Board and/or be prosecuted for perjury should I knowingly make false
or misleading statements or provide altered or false documentation that results in my patient being inappropriately determined to be eligible for the Disability Assistance program as a medication dependent person.
Physician's Signature Date of Last Exam
Physician's Name(Please print) Specialty
Address
City State ZIP Physician's Phone
ODM 03606 (7/2014)
Formerly JFS 03606
Document Information
- File Date:
- 2015-09-17
- Five Year Review:
- Yes
- CSI:
- Yes
- Rule File:
- 5101$1-5-20_OF_A_RU_20150917_1344.pdf
- RSFA File:
- 5101$1-5-20_OF_A_RS_20150917_1344.pdf
- Related Chapter/Rule NO.: (1)
- Ill. Adm. Code 5101:1-5-20. Disability financial assistance: the determination of a disability