Ohio Admin. Code 3701-43-21 - Providing assistance with medicaid spenddown payments
(A) As used in this
rule:
(1) "Eligible participant" means a
recipient who also meets the conditions for eligibility for medicaid spenddown
payment assistance as set forth in paragraphs (B) to (F) of this rule.
(2) "Cost-effective" means the
total cost to the department for uncovered services provided to an eligible
participant plus the cost for medicaid spenddown payments paid by the program
on behalf of the eligible participant plus the associated administrative costs
to the program is less than the total anticipated annual costs to the program
for authorized services provided to an eligible participant.
(3) "Assistance" means the payment of
medicaid spenddown liability by the program to a county job and family services
agency for the purpose of providing continued medicaid coverage or obtaining
medicaid coverage.
(4) "Uncovered
services" means authorized services provided to an eligible participant that
are not covered benefits of the eligible participant's medicaid health plan.
(5) "Total anticipated annual
costs" means the estimated costs to the program for authorized services if the
eligible participant had no health insurance coverage.
(6) "Primary source of payment" mean the
payment source with primary responsibility for payment.
(B) The director may authorize assistance for
a recipient who has a spenddown liability for medicaid and meets the following
conditions:
(1) Recipient has been approved
for medical assistance disability (MA-D) with a spenddown liability for
medicaid as defined in rule 5101:1-39-10 of the Administrative Code.
(2) The recipient is requiring a bone marrow
transplant and has insurance, but the recipient 's primary source of payment is
the program for a bone marrow transplant.
(3) The director determines that it is
cost-effective.
(C) The
director shall require that the following information be submitted by the
recipient or the recipient 's parent, guardian or other legal representative to
determine the recipient 's eligibility for assistance:
(1) A written approval letter from the
department of job and family services documenting the spenddown amount and the
effective date of the spenddown.
(2) Any other documentation as requested by
the director .
(D) The
director shall determine the recipient 's eligibility for assistance and provide
written documentation to the recipient and to the county department of job and
family services within thirty days of receipt of all required documentation.
Assistance with medicaid spenddown payments will not begin prior to the first
of the month in which all required documentation is received.
(E) The director shall establish an initial
period of eligibility for assistance not to exceed twelve months. The director
may establish a continued period of eligibility for assistance based upon a
determination of cost-effectiveness to the program .
(F) The recipient or eligible participant or
parent, guardian or other legal representative shall submit within thirty days
of the date of the change, documentation of any changes to income that result
in an increase in annual gross earnings, changes to the recipient 's health
insurance coverage, changes in medicaid status, changes in recipient 's medicaid
spenddown amount or documentation of any other changes that would affect the
recipient 's eligibility for assistance.
(G) The director may discontinue assistance
or change the terms of assistance if:
(1) The
eligible participant or the eligible participant's parent, guardian or other
legal representative fails to meet the requirements set forth in paragraphs (B)
to (F) of this rule.
(2) The
eligible participant or the eligible participant's parent, guardian or other
legal representative does not comply with the rules, the requirements or follow
through with the application process of the involved county department of job
and family services.
(H) The director shall provide the eligible
participant or the eligible participant's parent, guardian or other legal
representative written notification of the decision to discontinue or change
the terms of assistance. Any such discontinuation or change will become
effective no sooner than thirty calendar days from the date of the written
notice.
Notes
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021, 3701.022, 3701.023, 3701.024, 3701.025, 3701.026, 3701.027, 3701.028
Prior Effective Dates: 12/1/2001
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021, 3701.022, 3701.023, 3701.024, 3701.025, 3701.026, 3701.027, 3701.028
Prior Effective Dates: 12/1/2001
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