Rule 5160:1-5-05 | Medicaid: refugee medical assistance (RMA).
(A) This rule describes a time-limited medical assistance program, funded through the office of refugee resettlement (ORR), that provides a medical screening through contracted refugee health screening providers and other medical services. There is no resource limit for an individual described in this rule.
(B) Definitions.
(1) "Countable income," for the purpose of this rule, has the same meaning as in rule 5160:1-3-03.2 of the Administrative Code.
(2) "Current incurred medical expense" means a medical bill or a portion of a medical bill that:
(a) Includes:
(i) A medically necessary medical item or service provided to the individual or to the individual's family member during the month for which the individual is seeking to obtain RMA eligibility through the spenddown process;
(ii) An expense the individual or family member is liable to pay, regardless of whether the individual or family member has already paid it; and
(iii) A transportation expense, as defined in paragraph (B)(14) of this rule, incurred by the individual or family member during the month for which the individual is seeking to obtain RMA eligibility through the spenddown process.
(b) Does not include:
(i) An expense that has already been used in the spenddown process as a basis for approving RMA eligibility for any individual; or
(ii) An expense the individual or family member has not yet incurred for a medical item or service because it has not yet been provided.
(3) "Derivative T visa" means either a T-2, T-3, T-4, or T-5 visa issued to certain family members of victims of a severe form of trafficking who may be eligible for RMA benefits when the visa holder meets refugee program eligibility requirements.
(4) "Family member," for the purpose of this rule:
(a) For an individual of any age, means:
(i) The individual's spouse or deceased spouse, unless a court has eliminated the individual's duty of medical support to such spouse;
(ii) The individual's natural or adopted child under the age of eighteen, including a deceased child, unless a court has eliminated the individual's duty of medical support to such child; and
(iii) The individual's former spouse, including a deceased former spouse, provided the individual has a duty of medical support to the former spouse.
(b) For an individual under age eighteen, also includes:
(i) The individual's natural or adoptive parent, unless a court has eliminated such parent's duty of medical support to the individual;
(ii) The individual's sibling (including half-sibling) under the age of eighteen, who lives with the individual;
(iii) The individual's deceased parent, provided the surviving parent who lives with the individual had a duty of medical support to the deceased parent at the time of his or her death; and
(iv) The individual's deceased sibling (including half-sibling) provided the deceased sibling lived with the individual at the time of his or her death, and a parent who lives with the individual had a duty of medical support to the deceased sibling at the time of his or her death.
(c) Does not include a step-parent, a step-child, or a step-sibling.
(5) "Income," for the purpose of this rule, has the same meaning as defined in rule 5160:1-3-03.1 of the Administrative Code.
(6) "Incurred" means that the individual or family member has become liable to pay a medical bill as defined in paragraph (B)(8) of this rule. An expense is incurred on the date liability for the expense arises.
(7) "Individual," for the purpose of this rule, means an applicant for or a recipient of RMA who is not a United States (U.S.) citizen and meets one of the following definitions of immigration status under the Immigration and Nationality Act (INA) (as in effect October 1, 2023), as verified by documentation issued by the U.S. department of state, U.S. department of homeland security, or U.S. department of justice:
(a) Paroled as a refugee or asylee under section 212(d)(5) of the INA (as in effect October 1, 2023);
(b) Admitted to the U.S. as a refugee under section 207 of the INA (as in effect October 1, 2023);
(c) Granted asylum under section 208 of the INA (as in effect October 1, 2023);
(d) A Cuban or Haitian entrant in accordance with requirements in 45 C.F.R. part 401 (as in effect October 1, 2023);
(e) An Amerasian from Vietnam who is admitted to the U.S. as an immigrant pursuant to section 584 of the Foreign Operations, Export Financing, and Related Programs Appropriations Act of 1988 (as contained in section 101(e) of Pub. L. No. 100-202) (as in effect October 1, 2023), and amended by the 9th proviso under migration and refugee assistance in title II of the Foreign Operations, Export Financing, and Related Programs Appropriations Act, 1989 (Pub. L. No. 100-461, as amended) (as in effect October 1, 2023);
(f) A victim of a severe form of trafficking as identified in 22 U.S.C. 7105(b)(1) (as in effect October 1, 2023) and certain family members, as identified in the Trafficking Victims Protection Reauthorization Act of 2003 (TVPRA) (Pub. L. No. 108-193) (as in effect October 1, 2023). A victim of a severe form of trafficking is awarded a certification letter from ORR and is potentially eligible for RMA as described in 28 C.F.R. 1100.33 (as in effect October 1, 2023). Certain family members are awarded "Derivative T" visas and are potentially eligible for RMA; or
(g) Admitted as an Afghan or Iraqi special immigrant under section 101(a)(27) of the INA (as in effect October 1, 2023).
(8) "Medical bill" means an invoice for a medically necessary medical item or service provided to the individual or family member.
(9) "Medical insurance premiums" means the amount paid for insurance coverage for medical items or services such as health, dental, vision, long-term care, hospital, prescriptions, etc.
(10) "Medically necessary" has the same meaning as in rule 5160-1-01 of the Administrative Code.
(a) Medical insurance premiums as defined in paragraph (B)(9) of this rule are always considered medically necessary.
(b) The administrative agency may generally accept that medical expenses and bills submitted in the spenddown process are for items or services that were medically necessary. In an unusual situation, the administrative agency may question whether an item or service was medically necessary. In such a situation, the administrative agency will need to determine whether the item or service was medically necessary by following these steps:
(i) Contact the individual and assist the individual with gathering relevant information from the medical provider and other appropriate persons about the medical necessity of the item or service.
(ii) When the medical provider of the item or service indicates the item or service was not medically necessary, the administrative agency shall not use the expense for that item or service in the spenddown process.
(iii) When the medical provider of the item or service indicates the item or service was medically necessary, the administrative agency may use the expense for that item or service in the spenddown process in accordance with the other provisions of this rule. When the administrative agency questions the provider's statement regarding medical necessity, the administrative agency must ask the prior authorization unit (PAU) of the Ohio department of medicaid (ODM) to determine whether the item or service was medically necessary.
(iv) When the PAU determines the item or service was medically necessary, the administrative agency must use the expense for that item or service in the spenddown process in accordance with the other provisions of this rule. The PAU decision is for the sole purpose of determining whether the item or service was medically necessary. The PAU decision is not for the purpose of determining whether to prior authorize the item or service under rule 5160-1-31 of the Administrative Code, nor for the purpose of determining whether the item or service is payable by the medical assistance program.
(v) When the PAU determines the item or service was not medically necessary, the administrative agency shall not use the expense for that item or service in the spenddown process.
(11) "RMA need standard" means one hundred per cent of the federal poverty level (FPL) based on family size.
(12) "Spenddown amount" means the dollar amount by which the individual's countable income exceeds the applicable RMA need standard. The individual must satisfy the spenddown amount in accordance with paragraph (F) of this rule in order to become eligible for RMA for all or part of a given calendar month.
(13) "Subject to the spenddown process" means the individual:
(a) Has countable monthly income that exceeds the RMA need standard; and
(b) Is otherwise eligible for RMA.
(14) "Transportation expense" means a reasonable expense incurred by the individual or family member for transportation that is needed to obtain a medically necessary item or service.
(a) Transportation expenses include but are not limited to the following:
(i) Charges for public transportation;
(ii) Expenses related to the transportation such as parking fees and tolls;
(iii) The state mileage reimbursement rate as set by the Ohio office of budget and management for the use of a private motor vehicle owned by the individual or a family member, in effect on the date of travel;
(iv) The actual expense incurred by the individual or family member for transportation by a private motor vehicle not owned by the individual or family member;
(v) Overnight lodging expenses when overnight travel is needed to obtain the medical item or service;
(vi) Actual expenses for meals, up to thirty dollars per person per day, subject to the restrictions in paragraph (B)(14)(a)(vii) of this rule, when overnight travel is required;
(vii) Attendant care costs and/or the costs of a companion when a medical provider verifies that an attendant and/or companion is required due to the age and/or physical or mental condition of the individual or family member; and
(viii) Expenses related to delivering a medical service or item to the individual or family member.
(b) Transportation expenses do not include the following:
(i) The cost of transportation provided to the individual or family member through county-administered transportation assistance;
(ii) Any transportation expenses excluded from income as an "impairment-related work expense" (IRWE) as described in 20 C.F.R. 404.1576 (as in effect October 1, 2023); or
(iii) Any transportation expense excluded from earned income as a "blind work expense" as defined in rule 5160:1-3-03.1 of the Administrative Code.
(c) The administrative agency may generally accept that transportation expenses submitted in the spenddown process are for transportation that was needed to obtain a medically necessary item or service and that the cost is reasonable. When the administrative agency questions whether a transportation expense was needed and/or reasonable, the administrative agency will need to determine whether the expense was needed and/or reasonable by following these steps:
(i) Contact the individual and assist the individual with gathering relevant information from the medical provider and other appropriate persons concerning all of the relevant circumstances including the following:
(a) The age, physical and mental condition, and transportation needs of the individual;
(b) The medical item or service for which the individual needed the transportation;
(c) The suitability of the transportation alternatives reasonably available to the individual;
(d) The reasonableness of the expense based on the circumstances; and
(e) Any other relevant factors.
(ii) After considering all of the listed factors, when the administrative agency determines that the expense or a portion of the expense was not needed and/or not reasonable, the administrative agency shall not use the expense in the spenddown process.
(15) "Unpaid past medical expense" (UPME) means a medical bill or a portion of a medical bill, as defined in paragraph (B)(8) of this rule, that:
(a) Is still owed, and is not subject to payment by a third party who is legally obligated to pay the bill;
(b) Is not owed to a nursing facility (NF) or intermediate care facility for individuals with intellectual disabilities (ICF-IID) for services provided to a family member; and
(c) Has not been used in a previous month to meet a spenddown amount.
(C) Eligibility criteria.
(1) The individual shall be neither:
(a) Eligible for another category of medical assistance; nor
(b) A full-time student in an institution of higher education, except where such enrollment is approved by the state, or its designee, as part of an individual employability plan as described in rule 5101:1-2-40.5 of the Administrative Code.
(2) The individual meets the income requirements for RMA when:
(a) The individual's countable income is no more than the RMA need standard, or
(b) The individual whose countable income is more than the RMA need standard spends down countable income to the RMA need standard in accordance with the methods set forth in paragraph (E) of this rule.
(3) Continued eligibility of individuals who receive increased earnings from employment.
(a) Financial eligibility for RMA is based on the individual's income on the date of application.
(b) When an individual receiving RMA has increased earnings from employment, the earnings shall not affect the individual's continued eligibility for RMA.
(c) When an individual who qualified for another category of medical assistance becomes ineligible because of earnings from employment, the individual shall have his or her eligibility transferred to the RMA category without an RMA eligibility determination when the individual:
(i) Meets the non-financial eligibility criteria for RMA; and
(ii) Does not qualify for any other category of medical assistance; and
(iii) Has been residing in the U.S. less than the time-limited eligibility period for RMA as defined in paragraph (D) of this rule.
(d) An individual shall continue to receive RMA until he or she reaches the end of the twelve month time-limited eligibility period, as described in 45 C.F.R. 400.104 (as in effect October 1, 2023).
(e) In cases where an individual is covered by employer-sponsored health insurance, any payment of RMA for that individual must be reduced by the amount of the third party payment.
(D) Eligibility period. An individual who meets the eligibility requirements of this rule may receive RMA for a time-limited period not to exceed twelve continuous months from the individual's date of entry or from the date status is granted, as listed on the individual's U.S. citizenship and immigration services (USCIS) documentation.
(E) Calculation of spenddown amount. When the individual's countable monthly income, as determined in accordance with rule 5160:1-3-03.1 of the Administrative Code, exceeds the RMA need standard, the administrative agency must calculate the amount, if any, of the monthly spenddown as follows:
(1) Determine the total amount of all monthly medical insurance premiums of the individual and family members. Do not round down. Subtract that amount from the individual's countable monthly income and round down to the nearest whole dollar.
(a) When the result is less than or equal to the applicable RMA need standard, the individual is eligible for RMA for the entire calendar month without any monthly spenddown amount.
(b) When the result is greater than the applicable RMA need standard, continue to paragraph (E)(2) of this rule.
(2) Determine the total amount of the individual's and family members' UPMEs as determined in accordance with paragraph (G)(2) of this rule. Do not round down. Subtract that amount from the result calculated in paragraph (E)(1) of this rule and round down to the nearest whole dollar.
(a) When the result is less than or equal to the applicable RMA need standard, the individual is eligible for RMA for the entire calendar month without any monthly spenddown amount.
(b) When the result is greater than the applicable RMA need standard, the amount that is over the need standard is the individual's monthly spenddown amount. In order to become eligible for RMA for all or part of the calendar month, the individual must satisfy the monthly spenddown amount through one of the methods set forth in paragraph (F) of this rule.
(F) Ways of meeting spenddown. When the individual has a monthly spenddown amount calculated in accordance with paragraph (E) of this rule, the individual may satisfy, or meet, the spenddown through one or more of the following methods, and must do so each calendar month in order to be eligible for RMA:
(1) Recurring.
(a) The individual will not have a spenddown requirement for one or more calendar months when the individual is found eligible for RMA pursuant to paragraph (E)(1)(a) or (E)(2)(a) of this rule.
(b) When the individual's and/or family members' expenses described in paragraph (E) of this rule are not equal to or greater than the spenddown amount for a given calendar month, the individual may satisfy the spenddown amount by using one or more of the methods set forth in paragraphs (F)(2) to (F)(4) of this rule.
(2) Incurred. This method is frequently called "delayed spenddown."
(a) At the individual's option, the individual may satisfy spenddown for a calendar month by incurring a dollar amount of current medical expenses, as defined in paragraph (B)(6) of this rule, equal to or greater than the spenddown amount for the calendar month.
(b) An individual is eligible for RMA for a calendar month starting on the date the individual and/or family member(s) incurred the medical expenses that, combined with all other incurred medical expenses for the month, equal or exceed the individual's spenddown amount for the calendar month.
(3) Pay-in.
(a) At the individual's option, the individual may satisfy spenddown for the current calendar month by paying to the administrative agency the dollar amount of the spenddown amount for the current calendar month. When the dollar amount of the spenddown is satisfied, the individual is eligible for RMA for the entire calendar month.
(b) A third party may pay-in on behalf of the individual or a group of individuals subject to spenddown by making payments directly to the administrative agency from the third party's funds or other funds in the current calendar month in which eligibility is being sought. Such payments are not considered income, are not included in the individual's countable monthly income, and do not negatively affect the individual's RMA eligibility.
(c) Pay-in spenddown payments cannot be applied to retroactive months. Pay-in spenddown payments are restricted to payment for current or future calendar month(s) in which RMA eligibility through the spenddown process is being sought.
(4) Combination of methods.
(a) At the individual's option, the individual may meet the spenddown by using the incurred method described in paragraph (F)(2) of this rule for one or more calendar months, and the pay-in method described in paragraph (F)(3) of this rule for one or more other calendar months.
(b) At the individual's option, the individual may meet the spenddown by combining two methods in a single calendar month as follows:
(i) After the individual and/or family member has incurred an amount of current medical expenses for the calendar month that is less than the individual's spenddown amount for the calendar month, the administrative agency permits the individual to pay-in the difference between the current incurred medical expenses and the spenddown amount.
(ii) When the individual does so, the individual is eligible for RMA for the month starting on the date the individual or family member incurred the last current medical expense for the calendar month.
(5) Failure to satisfy spenddown for a calendar month. If the individual does not satisfy spenddown for a calendar month, the individual is not eligible for RMA for the calendar month. The individual may be eligible for a future calendar month in which the individual satisfies spenddown during the time-limited RMA period, not exceeding twelve continuous months from the individual's date of entry or date status is granted.
(6) Documentation of a met spenddown liability must be submitted to the county department of job and family services (CDJFS) within three hundred sixty-five days of the date of service.
(G) Treatment of expenses.
(1) Treatment of current incurred medical expenses subject to payment by a third party:
(a) When written off by the provider: the expense is treated as a current incurred medical expense for the calendar month in which the item or service was provided.
(b) When paid, or subject to payment, by a third party that is not legally obligated to pay the expense for the individual or family member: the expense is treated as a current incurred medical expense for the calendar month in which the item or service was provided, even when it is paid by the third party later in the same or a subsequent month.
(c) When paid, or subject to payment, by a third party that is legally obligated to pay the expense or a portion of the expense for the individual or family member: the expense is not treated as a current incurred medical expense.
(d) When an agency or program provides a direct medical service based on out-of-pocket limits, or a "sliding" or "ability-to-pay" fee scale, only the amount the individual or family member is liable to pay for the service, including deductibles and co-pays, are treated as current incurred medical expenses.
(2) Treatment of UPMEs. For the purpose of calculating the spenddown amount, the amount of UPME to be subtracted is determined in accordance with this paragraph.
(a) A UPME is considered to have been incurred in the calendar month during which the provider supplied the item or service to the individual or family member.
(b) The individual is not required to pay or provide evidence of paying the UPME for RMA purposes.
(c) UPMEs that may be applied in the spenddown process are:
(i) Incurred during a calendar month in which the individual or family member receiving the item or service was not eligible for another category of medical assistance.
(ii) Incurred during a calendar month in which the individual did not satisfy the monthly spenddown amount, even with the application of the bill.
(iii) Incurred for a medical item or service not payable under any category of medical assistance, regardless of an individual's eligibility during the calendar month in which the medical expense occurred, because the item or service was:
(a) Not covered by medical assistance;
(b) Supplied by a provider who was not participating in the medical assistance program; or
(c) Was supplied by a medical assistance provider who did not accept medical assistance for the UPME.
(d) The administrative agency shall assist the individual with choosing the amount of the UPME to apply, and the calendar month(s) for which to apply it. To assist the individual with making an informed decision, the administrative agency shall determine the minimum number of calendar months for which the UPME might be applied. To make this determination, the administrative agency shall:
(i) Determine the combined total of all the UPMEs of the individual and family members;
(ii) Divide the total UPME by the result calculated in paragraph (E)(1) of this rule;
(iii) The quotient is the minimum number of calendar months the UPME would allow the individual to meet the spenddown amount, assuming no changes in any factor that would affect the calculation of the spenddown amount.
(e) The amount of the UPME the administrative agency must subtract in the calculation of the spenddown amount in paragraph (E)(2) of this rule is either:
(i) The amount of the UPME the individual chooses to use; or
(ii) When the individual does not choose an amount to use, the difference between the result calculated in paragraph (E)(2) of this rule and the RMA need standard applicable to the individual.
(f) A UPME or portion of a UPME that the administrative agency applies toward the spenddown for a given calendar month cannot be used again in the spenddown process for a future calendar month.
(g) A UPME or portion of a UPME that the administrative agency does not apply toward the spenddown can be used to meet the spenddown for a future calendar month.
(3) Treatment of medical expenses used in the spenddown process. Any medical expenses of the individual or family member that are used in the spenddown process to approve the individual's RMA for a given calendar month remain the obligation of the individual or family member and are not payable by the RMA program.
(H) Spenddown during retroactive calendar months in which the individual incurred a medically necessary medical expense:
(1) The administrative agency must determine whether the individual is retroactively eligible, including eligibility through the spenddown process, in accordance with rule 5160:1-2-01 of the Administrative Code. RMA eligibility cannot begin prior to the individual's date of entry or date status was granted.
(2) When the individual is not retroactively eligible (even through the spenddown process), the individual may apply the medical expense as a UPME in the spenddown process for a calendar month in which the individual is otherwise eligible.
(3) When the individual is retroactively eligible (whether through the spenddown process or not):
(a) The individual may apply the UPME in the spenddown process for the retroactive calendar month only when the UPME is not payable for the individual under another category of medical assistance, as described in paragraph (G)(2)(c)(iii) of this rule; and
(b) The individual must apply the UPME to meet the spenddown for the retroactive calendar month(s) first, before using it to meet the spenddown for any subsequent calendar month.
(I) Administrative agency responsibilities.
(1) Accept an application, or electronic equivalent, for medical assistance as an application for RMA.
(2) In order to assist the individual with making informed decisions about the spenddown process, explain to and/or discuss with the individual the following:
(a) The various recurring and incurred spenddown medical expenses the individual may use in the spenddown process; and
(b) The methods for satisfying spenddown.
(3) Not require an individual to apply for or receive refugee cash assistance (RCA).
(4) Not require a face-to-face interview.
(5) Use actual countable individual income for the month of application. Do not average income prospectively when determining income eligibility for RMA.
(6) Determine eligibility for another category of medical assistance, as described in Chapter 5160:1-1, 5160:1-3, 5160:1-4 or 5160:1-5 of the Administrative Code, prior to determining eligibility for RMA.
(7) Call the trafficking verification line to confirm the validity of the certification letter or letter for children and to notify ORR of the benefits for which the individual has applied.
(8) Make eligible for RMA an individual who receives RCA and who meets the eligibility requirements of this rule.
(9) Obtain third-party liability information from an individual who has other health insurance.
(10) Explore retroactive eligibility for RMA, in accordance with rule 5160:1-2-01 of the Administrative Code. Retroactive eligibility cannot begin prior to the individual's date of entry or date status was granted.
(11) Issue the RMA card for the month within two business days after the individual submits verification showing that current incurred medical expenses for the month satisfy the spenddown amount for the calendar month.
(12) Implement and make available in writing reasonable policies and procedures for administering the pay-in spenddown method. The policies and procedures must:
(a) Permit and provide reasonable methods of accepting payments by third parties on behalf of individuals and groups of individuals subject to spenddown.
(b) Ensure that, at the individual's option, the individual will receive an RMA card for a month on or about the first day of the month by making his or her pay-in payment by a date chosen by the administrative agency near the end of the preceding month.
(i) When the administrative agency receives the individual's pay-in payment before the preceding month's cutoff date for benefit issuance, the administrative agency will authorize the issuance of the RMA card in the electronic eligibility system within two business days after the cutoff date; or
(ii) When the administrative agency receives the individual's pay-in payment on or after the preceding month's cutoff date for benefit issuance, the administrative agency will issue the RMA card within two business days after the administrative agency receives the individual's pay-in payment.
(c) Ensure that, at the individual's option, the individual may pay-in for a given calendar month at any time during the calendar month and that the administrative agency will issue the RMA card for the month within two business days after the administrative agency receives the individual's pay-in payment.
(d) Establish reasonable methods for accepting and accounting for pay-in payments, including but not limited to:
(i) Accepting cash payments;
(ii) Defining conditions for accepting checks or money orders; and
(iii) Establishing provisions for refunding or crediting unused pay-in amounts.
(e) Establish provisions for refunding the individual's pay-in payment for a month in the event the individual:
(i) Becomes eligible for medical assistance for the month through means other than the spenddown process;
(ii) Becomes ineligible for medical assistance for the month despite meeting the spenddown; or
(iii) Paid in more than the spenddown amount, whether due to the individual's error or to the administrative agency's error in calculating the spenddown amount.
(13) Document all pay-in spenddown payments in the electronic eligibility system and in the individual's case record, and issue a receipt to all individuals and third parties who make pay-in spenddown payments. The documentation and receipts must state:
(a) The date payment was received;
(b) The name of the person or entity from whom the payment was received;
(c) The name and identifying case information of the individual for whom the payment was made;
(d) The calendar month of eligibility for which the pay-in payment will be used and the effective date of RMA for that month; and
(e) The amount of the payment and the form in which it was paid.
(14) Document in the electronic eligibility system and in the individual's case record:
(a) For each month's current incurred medical expenses and UPMEs submitted by or on behalf of the individual:
(i) The name of the provider of the medical item or service;
(ii) The item or service provided;
(iii) The date the item or service was provided;
(iv) The name of the individual or family member to whom the item or service was provided;
(v) The amount the individual or family member paid or is liable to pay for the item or service;
(vi) For UPMEs, the calendar month(s) for which the UPME or a portion of the UPME was used in the calculation of the spenddown amount; and
(vii) The amount still owed for the item or service.
(b) For current incurred medical expenses that require a decision by the PAU, as described in paragraph (B)(10) of this rule:
(i) The provider's statement;
(ii) The PAU decision; and
(iii) All other information related to the administrative agency's decision to use or not use a current incurred medical expense in the spenddown process.
(c) For transportation expenses the administrative agency has determined cannot be used in the spenddown process:
(i) A description of which specific transportation expense(s) were not used; and
(ii) A clear explanation of the administrative agency's determination.
(15) Issue proper notice and hearing rights as set forth in division 5101:6 of the Administrative Code.
(16) Not deny RMA for an individual who is applying for medical assistance and does not anticipate satisfying spenddown in the month of application or in one or more future calendar months. Instead, the administrative agency shall cause the electronic eligibility system to give the individual the type of eligibility that will only issue an RMA card to the individual for those calendar months for which the individual satisfies the spenddown amount.
(17) Not propose to discontinue RMA for an individual who does not satisfy spenddown for one or more calendar months. Instead, the administrative agency shall cause the electronic eligibility system to give the individual the type of eligibility that will only issue an RMA card to the individual for those calendar months for which the individual satisfies the spenddown amount.
(J) Individual responsibilities. The individual shall:
(1) Provide:
(a) USCIS documentation of non-citizen status;
(b) The name of the resettlement agency, if any, that resettled the individual; and
(c) The information necessary to establish eligibility, cooperate with the verification process, and report changes in accordance with rule 5160:1-2-08 of the Administrative Code.
(2) Spend down to the RMA need standard when the countable income exceeds the RMA need standard.
(3) Cooperate with providing verification of any third-party liability or coverage of medical expenses as defined in rule 5160:1-2-10 of the Administrative Code.
(4) The individual must submit monthly to the administrative agency, by mail, facsimile, electronically, or in person, verification of the current incurred medical expenses the individual wishes to apply against his or her spenddown amount for the calendar month.
(a) Verifications may include unpaid bills, statements, invoices, paid receipts, etc.
(b) For each expense, the individual must provide the name of the provider, the item or service provided, the date the item or service was provided, the name of the individual or family member to whom the item or service was provided, and the amount the individual or family member paid or is liable to pay for the item or service.
Last updated February 1, 2024 at 9:05 AM
Supplemental Information
Amplifies: 5160.02, 5162.02, 5163.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 7/1/1976, 12/31/1977, 11/22/1981, 10/21/1982, 11/1/1982, 2/9/1984 (Temp.), 5/1/1984, 7/1/1984, 7/2/1984, 10/1/1984 (Emer.), 12/27/1984, 1/1/1985 (Emer.), 4/1/1985, 8/1/1986 (Emer.), 10/3/1986, 7/1/1988, 1/1/1989 (Emer.), 4/1/1989, 11/1/1989, 1/1/1990 (Emer.), 4/1/1990, 10/1/1991 (Emer.), 12/20/1991, 4/1/1992, 12/21/1992, 10/1/1993 (Emer.), 9/1/1994, 10/1/1995, 1/1/1996, 5/1/1997, 7/1/1998, 7/1/2000, 10/8/2000, 10/1/2002, 5/7/2009, 3/23/2015, 7/1/2021