Rule 5160:1-2-04. Medicaid: consumer fraud and recoupments

111.15 (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 questionable practices, the administrative agency must conduct a preliminary investigation in accordance with 42 C.F.R. 455.14 (as in effect October 1, 2023) to determine whether there is sufficient basis to warrant a full investigation. (1) When the preliminary investigation finds that a full investigation is warranted in accordance with 42 C.F.R. 455.15 (as in effect October 1, 2023): (a) And there is reason to believe that a beneficiary has defrauded the medicaid program as described in section 2913.401 of the Revised Code, then the administrative agency must refer the case to the county prosecutor. (b) And there is reason to believe that a beneficiary has abused the medicaid program, then the agency must conduct a full investigation of the abuse. (2) The investigation must continue until the investigation is resolved in accordance with 42 C.F.R. 455.16 (as in effect October 1, 2023). (C) The administrative agency cannot recover or recoup the cost of services from an individual, except under the following circumstances: (1) When a court judgment finds that medicaid benefits were improperly paid, under section 1917(a)(1)(A) of the Social Security Act (as in effect October 1, 2023) and 42 C.F.R

gation is resolved in accordance with 42 C.F.R. 455.16 (as in effect October 1, 2023). (C) The administrative agency cannot recover or recoup the cost of services from an individual, except under the following circumstances: (1) When a court judgment finds that medicaid benefits were improperly paid, under section 1917(a)(1)(A) of the Social Security Act (as in effect October 1, 2023) and 42 C.F.R. 433.36(g)(1) (as in effect October 1, 2023); (2) When an individual who is an inpatient in a medical institution, as defined in rule 5160:1-6-01.1 of the Administrative Code, who is receiving medicaid payment for long-term care services in accordance with Chapter 5160:1-6 of the Administrative Code, and who has been determined to not reasonably be expected to be discharged from the medical institution to return home; (a) No lien may be imposed under paragraph (C)(2) of this rule on such individual's home when the following individuals lawfully reside in the home: (i) The individual's spouse; or (ii) The individual's child who is under the age of twenty-one, or is blind or disabled in accordance with section 1614 of the Social Security Act (as in effect October 1, 2023); or (iii) The individual's sibling who has an equity interest in the home and who was residing in the individual's home for a period of at least one year before the date the individual was admitted into the medical institution. (b) A lien imposed under paragraph (C)(2) of this rule shall dissolve upon that individual's discharge from the medical institution and return home. (3) Estate recovery proceedings as described in rule 5160:1-2-07 of the Administrative Code. Last updated March 1, 2024 at 8:11 AM Supplemental Information Authorized By: 5162.03 , 5163.02 Amplifies: 2913.401 , 5162.03 , 5162.23 , 5163.02 3/1/2029