Ohio Administrative Code

11.15 PDF: (A) Medicaid will not pay for services provided under the conditions set out in paragraph (C) of this rule, even when an individual has been found eligible for a medical assistance category and is enrolled in medicaid.(B) Definitions. For the purposes of this rule:(1) …

11.15 PDF: (A) This rule describes the requirements in section 1137 of the Social Security Act (as in effect October 1, 2020) and in section 42 C.F.R. 435.945 (as in effect October 1, 2020), requiring state agencies administering certain federally funded public assistance program…

11.15 PDF: (A) This rule describes the asset verification program outlined in section 1940 of the Social Security Act (as in effect October 1, 2023), requiring state agencies that administer medical assistance to implement a system by which the agency will obtain financial record…

11.15 PDF: (A) This rule describes section 1903(r)(3) of the Social Security Act (as in effect October 1, 2024) and paragraph (d) of 42 C.F.R 435.945 (as in effect October 1, 2024), that each medicaid state agency have an eligibility determination system which provides for data m…

11.15 PDF: (A) This rule describes the responsibilities of the administrative agency.(B) Calculation of time periods for eligibility determinations. All calculations of time periods used in the determination of eligibility, including an annual renewal or a redetermination as a re…

11.15 PDF: (A) This rule sets forth general income guidelines, calculations, and exclusions used in determining eligibility for medical assistance. Income guidelines, calculations, or exclusions that apply to a specific covered group will be addressed in the eligibility rules for…

11.15 PDF: (A) This rule sets forth the process for determining whether an individual is eligible for medical assistance payments for services under a home and community-based services (HCBS) waiver, as described in rules 5123-9-01, 5160-31-03, 5160-33-03, 5160-40-01, 5160-41-17,…

11.15 PDF: (A) This rule sets out requirements for the administrative agency with regard to identifying and referring consumer fraud and recouping medicaid payments from an individual.(B) Investigation of complaints. Upon notification of a complaint of medicaid fraud, abuse, or q…

11.15 PDF: (A) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law requiring the administrative agency to issue a notice of privacy practices.(B) The administrative agency shall:(1) Ensure appropriate safeguards are taken in accordance with ru…

11.15 PDF: (A) This rule describes the administrative agency's role in facilitating outreach services for low-income children and pregnant women through the process of outstationing workers at disproportionate share hospitals, federally qualified health centers, and other designa…

11.15 PDF: (A) This rule describes Ohio's medicaid estate recovery program and the undue hardship waiver request process.(B) Definitions.(1) "Estate" includes both of the following:(a) All real and personal property and other assets to be administered under Title XXI of the Revis…

11.15 PDF: (A) This rule describes the responsibilities of an individual, or someone acting on an individual's behalf, who is applying for or receiving medical assistance.(B) Individual responsibilities.(1) When applying for or receiving any medical assistance, an individual must…

11.15 PDF: (A) This rule describes eligibility criteria that apply to all medical assistance programs, how eligibility criteria will be verified by the administrative agency, and when an individual will be asked to provide manual verification. Eligibility conditions that are spec…

11.15 PDF: (A) This rule sets forth acceptable documentary evidence of U.S. citizenship and the circumstances under which an individual who declares U.S. citizenship, under penalty of perjury, may be given a reasonable opportunity to verify U.S. citizenship.(B) Definition."Nation…

11.15 PDF: (A) This rule sets forth: (1) Medical assistance eligibility criteria for an individual who is not a United States (U.S.) citizen or a national of the U.S.;(2) Acceptable documentary evidence of qualified non-citizen status; and(3) The circumstances under which an indi…

11.15 PDF: (A) This rule describes the requirement to deem income and resources from a sponsor to a non-citizen, exemptions from the sponsor deeming requirement, and the process for calculating the amount of income and resources to deem.(1) In accordance with 8 U.S.C. 1182 (as in…

11.15 PDF: (A) This rule describes the conditions under which an individual may receive time-limited medical assistance as a result of an initial, simplified determination of eligibility based on the individual's self-declared statements.(B) Eligibility criteria for presumptive c…

11.15 PDF: (A) This rule describes the twelve-month period of continuous eligibility for a child younger than age nineteen, and the conditions under which the child's coverage ends during the twelve-month period, as described in section 1902(e)(12) of the Social Security Act (as …

11.15 PDF: (A) This rule explains the requirements of healthchek, Ohio's early and periodic screening, diagnostic and treatment (EPSDT) benefit that is mandatory for an individual under twenty-one years of age who is enrolled in medicaid. (1) The healthchek benefit provides compr…

11.15 PDF: (A) The purpose of this rule is to outline the responsibilities of the administrative agency to inform a pregnant woman eligible for medical assistance about the benefits and importance of pregnancy related services (PRS), to make requested or needed referrals to suppo…

11.15 PDF: (A) The medicaid program provides coverage for individuals who meet the aged, blind, or disability status requirements as set forth in section 1902 of the Social Security Act (as in effect October 1, 2022). The provisions of Chapter 5160:1-3 of the Administrative Code …

11.15 PDF: (A) The medicaid program provides coverage for individuals who have been determined to meet the criteria for the limiting physical factors of age, blindness, or disability as set forth in section 1902 of the Social Security Act (as in effect on October 1, 2024). Age is…

11.15 PDF: (A) This rule sets forth the eligibility criteria and benefits for the medicare premium assistance programs (MPAP). The programs are: qualified medicare beneficiary (QMB), specified low-income medicare beneficiary (SLMB), qualified individual (QI-1), and qualified disa…

11.15 PDF: (A) This rule sets forth:(1) The eligibility criteria for benefits under the medicare part B (part B) buy-in agreement between the social security administration (SSA) and the Ohio department of medicaid (ODM), which allows ODM to pay part B (supplemental medical insur…

11.15 PDF: (A) This rule describes eligibility for medical assistance for aged, blind, or disabled individuals who receive SSI benefits authorized by the social security administration under Title XVI of the Social Security Act (as in effect October 1, 2023).(B) Eligibility crite…

11.15 PDF: (A) This rule describes eligibility for aged, blind, or disabled individuals who meet the income and resource requirements of the supplemental security income (SSI) program authorized by the social security administration (SSA) under Title XVI of the Social Security Ac…

11.15 PDF: (A) This rule describes the eligibility criteria for continued medical assistance coverage for an individual who is receving SSI benefits under section 1619 of the Social Security Act.(B) Section 1619 of the Social Security Act (as in effect October 1, 2022) comprises …

11.15 PDF: (A) Various grandfathering provisions and deemed eligibility requirements were enacted to assure that aged, blind, or disabled individuals previously eligible for cash assistance and medicaid under former programs of aid would not be disadvantaged by eligibility condit…

11.15 PDF: (A) This rule addresses the process of determining blindness or disability for non-citizen emergency medical assistance (NCEMA), medicaid buy-in for workers with disabilities (MBIWD), Ohio workability, retroactive coverage for a deceased individual, or the specialized …

11.15 PDF: (A) This rule describes how income, as defined in rule 5160:1-1-01 of the Administrative Code, is treated for the purpose of determining eligibility for medical assistance for an aged, blind, or disabled individual.(B) Treatment of income.(1) Eligibility for medical as…

11.15 PDF: (A) This rule describes how retirement funds are treated for the purpose of determining eligibility for medical assistance.(B) Definitions.(1) "Defined benefit retirement plan," also known as a "traditional pension plan," means an employer-sponsored retirement benefit …

11.15 PDF: (A) When determining eligibility for medical assistance for an individual who is aged, blind, or disabled, certain types of income, including income from certain sources, are not counted. This rule sets forth the types of income that are to be excluded, and the order i…

11.15 PDF: (A) This rule describes the process for calculating the amount of income to deem from an ineligible spouse or ineligible parent when determining eligibility for medical assistance for an eligible spouse or eligible child.(1) When an eligible spouse resides in the same …

11.15 PDF: (A) The purpose of this rule is to set forth the application of income standards used in eligibility determinations of medical assistance for aged, blind, or disabled individuals.(B) Definitions.(1) "Income standard" means the income limit above which an individual is …

11.15 PDF: (A) The purpose of this rule is to describe the calculation and treatment of rental income and expenses for medical assistance eligibility determinations.(B) Definitions.(1) "Net rental income" means gross rent less the ordinary and necessary expenses paid in the same …

11.15 PDF: (A) The purpose of this rule is to set forth the treatment of sick pay and sick leave for eligibility for medical assistance.(B) Definitions.(1) "Sick pay" means a payment made to or on behalf of an employee by an employer or a private third party for sickness or accid…

11.15 PDF: (A) This rule sets forth how in-kind support and maintenance is valued for the purpose of determining eligibility for medical assistance.(B) Definitions.(1) "Actual value" is the dollar amount that an individual paid for an item or service, or for his/her share of an i…

11.15 PDF: (A) This rule describes how resources are treated for purposes of determining eligibility for medical assistance.(B) Definitions.(1) "Countable resources" mean those resources remaining after all exclusions have been applied.(2) An "encumbrance" means a claim, lien, ch…

11.15 PDF: (A) This rule describes the treatment of household goods and personal effects for the purpose of determining eligibility for medical assistance.(B) Definitions.(1) "Encumbrance" is defined in rule 5160:1-3-05.1 of the Administrative Code.(2) "Household goods," for the …

11.15 PDF: (A) This rule describes the treatment of automobiles and other modes of transportation for purposes of determining eligibility for medical assistance.(B) Definition. "Automobile", for the purpose of this rule, means any vehicle used for transportation. It can include, …

11.15 PDF: (A) This rule describes how life insurance policies are treated for the purpose of determining medical assistance eligibility.(B) Definitions of terms contained within life insurance policies.(1) "Accelerated life insurance payments" means some or all of the proceeds f…

11.15 PDF: (A) This rule describes the treatment of an individual's home for purposes of determining eligibility for medical assistance.(B) Definitions.(1) "Home," for the purpose of this rule, means any property in which an individual has an ownership interest and which serves a…

11.15 PDF: (A) This rule describes excluded resources for the purpose of determining medical assistance eligibility for an individual who is aged, blind, or disabled.(B) Resource exclusions.(1) Resources excluded by federal laws other than the Social Security Act, in accordance w…

11.15 PDF: (A) This rule describes the application of the home replacement exclusion for the purpose of determining eligibility for medical assistance. When the home is being replaced due to loss or damage resulting from a disaster, refer to rule 5160:1-3-05.14 of the Administrat…

11.15 PDF: (A) This rule describes the treatment of life estates for the purposes of determining eligibility for medical assistance.(B) Definitions.(1) "Date of signature" is the date on which an individual with authority to transfer the physical property actually signed the life…

11.15 PDF: (A) This rule describes the treatment of stocks, mutual funds, and bonds for the purpose of determining eligibility for medical assistance.(B) Stocks held by an individual, including preferred stocks, warrants and rights, and stock option purchases.(1) Stock shares rep…

11.15 PDF: (A) This rule describes exclusions when real or personal property is essential to an individual's means of self-support.(B) Definition. (1) "Basic daily living needs", for the purpose of this rule, means any food, basic clothing, basic shelter, and any medical care tha…