MEDICAID ELIGIBILITY MANUAL TRANSMITTAL LETTER NO. _______ To:

 MEDICAID ELIGIBILITY MANUAL TRANSMITTAL LETTER NO. _______
To:
All Medicaid Eligibility Manual Holders
From:
John B. McCarthy, Director
Subject:
Medicaid: application for home and community-based (HCB) services
Section 119.032 of the Revised Code requires the review of all state agency rules within a fiveyear period. The purpose of this review is to determine whether a rule:
1. Should continue without amendment, be amended or rescinded, taking into consideration
the purpose, scope and intent of the statute under which the rule was adopted;
2. Should give more flexibility at the local level or eliminate unnecessary paperwork; and
3. Duplicates, overlaps with or conflicts with other rules.
The information contained in this clearance transmittal is for informational purposes only and is
not intended to be part of the clearance review. Your review of and comments on the attached
material are appreciated.
Chapter 2 Application Processing
5160:1-2-01.6 Medicaid: application for home and community-based (HCB) services
This rule is rescinded and the language is found in current OAC rule 5160:1-2-03 as part of a
five-year rule review.
5160:1-2-03 Medicaid: application for home and community-based (HCB) services
This rule replaces current rule 5160:1-2-01.6, but does not make substantive changes.
Fiscal Impact
The revisions to the rules in this clearance do not impose any new requirements on county
agencies and the implementation of these rule changes should result in no fiscal impact on the
county agencies.
Page 2 of 2 Training Statement
The revisions to the rules in this clearance will not require training or technical assistance to be
provided to county staff by ODM. Clarification regarding these rules will be available to county
staff through the Medicaid Eligibility Technical Assistance staff, who can be reached via email
at MEDICAID_ELIGIBILITY_TA@medicaid.ohio.gov.
*** DRAFT - NOT YET FILED ***
TO BE RESCINDED
5160:1-2-01.6
Medicaid: application for home and community-based (HCB)
services.
(A) This rule sets forth the process for determining whether an individual is eligible for
medicaid payments for services under the HCB services waivers set out in division
5101:3 of the Administrative Code.
(B) Eligibility for HCB services. To receive HCB services, the individual shall:
(1) Be in receipt of medicaid, as described in Chapters 5101:1-37 to 5101:1-40 or
rule 5101:1-41-30 of the Administrative Code;
(2) Be in need of HCB services under a waiver described in division 5101:3 of the
Administrative Code; and
(3) Be enrolled in an HCB services waiver described in rule 5101:3-1-06 of the
Administrative Code.
(C) Determination of eligibility for HCB services. The county department of job and
family services (CDJFS) shall approve HCB services for an individual in receipt of
medicaid only upon:
(1) Approval by the HCB services waiver operational agency; and
(2) If services under the waiver are available only to a specific number of
individuals, notification that the individual may be enrolled in the waiver
from the Ohio department of job and family services (ODJFS), its designee,
or a waiver operating agency.
(D) Coverage period. The HCB services coverage period can have a different beginning
date or ending date from the medicaid eligibility period. However, HCB services
cannot begin before an individual's medicaid eligibility period or before an
individual's retroactive medicaid eligibility period as determined under rule
5101:1-38-01.2 of the Administrative Code; HCB services cannot extend beyond
the termination date of an individual's medicaid coverage; and HCB services cannot
be provided during any period of medicaid ineligibility.
(1) Medicaid coverage of HCB services begins on the latest of the following dates:
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5160:1-2-01.6
TO BE RESCINDED
2
(a) The process date for application for HCB services. The process date is:
(i) The date the CDJFS receives a signed application for HCB services
from an individual; or
(ii) The signature date, if the CDJFS receives a signed and dated HCB
services application from a waiver operational agency no more
than five working days after the date of signature; or
(iii) The date the CDJFS receives the signed application for HCB
services, if the application was received from a waiver operational
agency more than five working days after the date of signature.
(b) The date the individual meets all criteria for coverage of an HCB services
waiver described in rule 5101:3-1-06 of the Administrative Code.
(c) The date the individual is authorized, by the waiver operational agency, to
receive HCB services.
(2) Medicaid coverage of HCB services terminates when either:
(a) The CDJFS determines the individual no longer meets medicaid
conditions of eligibility as described in rule 5101:1-38-01.8 of the
Administrative Code or the criteria for coverage of HCB services; or
(b) The waiver operational agency notifies the CDJFS that it no longer
authorizes the individual to receive its HCB services.
(E) HCB services waiver operational agency responsibilities. HCB services waiver
operational agencies shall:
(1) Submit a JFS 02399 "Request for Medicaid Home and Community-Based
Services (HCBS)" (rev. 1/2006), signed by the individual, to the CDJFS
within five days of the signature date, if assisting an individual with an
application for HCB services.
(2) Determine, in accordance with this rule and division 5101:3 of the
Administrative Code, whether the individual requesting medicaid coverage of
HCB services meets the requirements of the applicable HCB services waiver
program.
5160:1-2-01.6
TO BE RESCINDED
3
(3) Provide written notification of determinations to individuals, including to whom
any patient liability must be paid, if applicable.
(4) Notify the CDJFS of determinations and subsequent changes regarding approval
of HCB services.
(F) Administrative agency responsibilities. The CDJFS shall:
(1) Determine an individual's eligibility for HCB services in accordance with this
rule and Chapters 5101:1-37, 5101:1-38, 5101:1-39, 5101:1-40, 5101:1-41,
and 5101:1-42 of the Administrative Code.
(a) If an individual who applies for HCB services is currently in receipt of
medicaid, the CDJFS shall process the individual's application for HCB
services.
(b) If an individual who applies for HCB services is not currently in receipt of
medicaid, the CDJFS shall begin the application process described in
rule 5101:1-38-01.2 of the Administrative Code.
(c) If the CDJFS determines that an individual who applies for HCB services
is not eligible for any category of medical assistance under Chapters
5101:1-37 to 5101:1-40 or rule 5101:1-41-30 of the Administrative
Code, the agency shall deny both medical assistance and HCB services
for that individual.
(2) Within five days of the receipt of a signed JFS 02399, notify the applicable
waiver agency via the electronic eligibility system of the receipt of the
application. If the waiver agency is not known or if multiple waiver agencies
are indicated on the application, the CDJFS shall submit the JFS 02399 to the
Ohio department of job and family services (ODJFS) bureau administering
HCB waiver services.
(3) Notify the applicable HCB services waiver operational agency of changes in the
individual's eligibility for medicaid coverage of HCB services.
5160:1-2-01.6
TO BE RESCINDED
4
Effective:
R.C. 119.032 review dates:
Certification
Date
Promulgated Under:
Statutory Authority:
Rule Amplifies:
Prior Effective Dates:
111.15
5111.01, 5111.011, 5111.871
5111.01, 5111.011, 5111.012, 5111.87, 5111.871,
5111.91
6/1/88 (Emer.), 8/1/88 (Emer.), 10/30/88, 1/1/90
(Emer.), 3/1/90 (Emer.), 3/30/90 (Emer.), 4/1/90,
6/29/90, 7/1/90, 10/1/90, 1/1/91 (Emer.), 4/1/91,
1/1/92 (Emer.), 3/20/92, 3/30/92, 5/1/92 (Emer.),
7/1/92, 8/14/92 (Emer.), 1/1/92, 5/1/93, 9/1/93, 7/1/94,
10/1/02, 10/1/04
*** DRAFT - NOT YET FILED ***
5160:1-2-03
Medicaid: application for home and community-based (HCB)
services.
(A) This rule sets forth the process for determining whether an individual is eligible for
medicaid payments for services under the HCB services waivers set out in Agency
5160 of the Administrative Code.
(B) Eligibility for HCB services. To receive HCB services, the individual shall:
(1) Be in receipt of medicaid, as described in Chapters 5160:1-1 to 5160:1-5 of the
Administrative Code;
(2) Be in need of HCB services under a waiver described in Agency 5160 of the
Administrative Code; and
(3) Be enrolled in an HCB services waiver described in rule 5160-1-06 of the
Administrative Code.
(C) Determination of eligibility for HCB services. The administrative agency shall
approve HCB services for an individual in receipt of medicaid only upon:
(1) Approval by the HCB services waiver operational agency, as defined in
5160:1-1-50.1 of the Administrative Code; and
(2) If services under the waiver are available only to a specific number of
individuals, notification that the individual may be enrolled in the waiver
from the Ohio department of medicaid (ODM), its designee, or a HCB
services waiver operational agency.
(D) Coverage period. The HCB services coverage period can have a different beginning
date or ending date from the medicaid eligibility period.
(1) HCB services cannot:
(a) Begin before an individual's medicaid eligibility period or before an
individual's retroactive medicaid eligibility period;
(b) Extend beyond the termination date of an individual's medicaid coverage;
and
(c) Be provided during any period of medicaid ineligibility.
(2) Medicaid coverage of HCB services begins on the latest of the following dates:
(a) The process date for application for HCB services. The process date is:
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5160:1-2-03
2
(i) The date the administrative agency receives a signed application for
HCB services from an individual; or
(ii) The signature date, if the administrative agency receives a signed
and dated HCB services application from a waiver operational
agency no more than five working days after the date of
signature; or
(iii) The date the administrative agency receives the signed application
for HCB services, if the application was received from a HCB
services waiver operational agency more than five working days
after the date of signature.
(b) The date the individual meets all criteria for coverage of an HCB services
waiver described in rule 5160-1-06 of the Administrative Code.
(c) The date the individual is authorized, by the HCB services waiver
operational agency, to receive HCB services.
(3) Medicaid coverage of HCB services terminates when either:
(a) The administrative agency determines the individual no longer meets
medicaid conditions of eligibility as described in rule 5160:1-1-58 of
the Administrative Code or the criteria for coverage of HCB services;
or
(b) The HCB services waiver operational agency notifies the administrative
agency that it no longer authorizes the individual to receive its HCB
services.
(E) HCB services waiver operational agency responsibilities. HCB services waiver
operational agencies shall:
(1) Submit a ODM 02399 "Request for Medicaid Home and Community-Based
Services (HCBS)" (rev. 7/2014), signed by the individual, to the
administrative agency within five days of the signature date, if assisting an
individual with an application for HCB services.
(2) Determine, in accordance with this rule and Agency 5160 of the Administrative
Code, whether the individual requesting medicaid coverage of HCB services
meets the requirements of the applicable HCB services waiver program.
(3) Provide written notification of determinations to individuals, including to whom
any patient liability must be paid, if applicable.
(4) Notify the administrative agency of determinations and subsequent changes
5160:1-2-03
3
regarding approval of HCB services.
(F) Administrative agency responsibilities. The administrative agency shall:
(1) Determine an individual's eligibility for HCB services in accordance with this
rule.
(a) If an individual who applies for HCB services is currently in receipt of
medicaid, the administrative agency shall process the individual's
application for HCB services.
(b) If an individual who applies for HCB services is not currently in receipt of
medicaid, the administrative agency shall begin the application process
described in rule 5160:1-1-51 of the Administrative Code.
(c) If the administrative agency determines that an individual who applies for
HCB services is not eligible for any category of medical assistance, the
administrative agency shall deny both medical assistance and HCB
services for that individual.
(2) Notify the applicable HCB services waiver operational agency, within five days
of the receipt of a signed ODM 02399, via the electronic eligibility system of
the receipt of the application. If the HCB services waiver operational agency
is not known or if multiple waiver agencies are indicated on the application,
the administrative agency shall submit the ODM 02399 to ODM.
(3) Notify the applicable HCB services waiver operational agency of changes in the
individual's eligibility for medicaid coverage of HCB services.
5160:1-2-03
Replaces:
4
5160:1-2-01.6
Effective:
R.C. 119.032 review dates:
Certification
Date
Promulgated Under:
Statutory Authority:
Rule Amplifies:
Prior Effective Dates:
111.15
5160.02, 5163.02, 5166.20, 5166.21
5160.02, 5163.02, 5166.21, 5162.35
6/1/88 (Emer.), 8/1/88 (Emer.), 10/30/88, 1/1/90
(Emer.), 3/1/90 (Emer.), 3/30/90 (Emer.), 4/1/90,
6/29/90, 7/1/90, 10/1/90, 1/1/91 (Emer.), 4/1/91,
1/1/92 (Emer.), 3/20/92, 3/30/92, 5/1/92 (Emer.),
7/1/92, 8/14/92 (Emer.), 1/1/92, 5/1/93, 9/1/93, 7/1/94,
10/1/02, 10/1/04, 10/1/09