AGO 2006-019.

• Case Date: May 05, 2006
• Court: Ohio

Ohio Attorney General Opinions 2006. AGO 2006-019. May 5, 2006OPINION NO. 2006-019The Honorable Sherri Bevan Walsh Summit County Prosecuting Attorney 53 University Avenue, 7th Floor Akron, Ohio 44308-1680 SYLLABUS: 2006-019 1.

An alcohol, drug addiction and mental health services board (ADAMH board) established pursuant to R.C. Chapter 340, or a provider with which the ADAMH board contracts, may only access Medicaid funding when authorized by statute and rule, including R.C. 5111.023, R.C. 5111.025, 14 Ohio Admin. Code Chapter 5101:3-27, and 14 Ohio Admin. Code Chapter 5101:3-30. Neither an ADAMH board nor a provider with which the board contracts may access Medicaid funding for services provided to an individual who is not eligible for Medicaid. The determination as to whether a particular individual meets all Medicaid eligibility requirements is made, in the first instance, by the county department of job and family services, except with regard to the Ohio breast and cervical cancer project, where eligibility is determined by the Ohio Department of Health or its designated local agencies or subgrantees.

2.

The provisions of division (G) of rule 5101:1-39-04 of the Ohio Administrative Code (12 Ohio Admin. Code 5101:1-39-04) stating that "[a] person is not considered to be an inmate of a public facility until he has resided therein for a full calendar month" are not applicable to inmates of penal institutions governed by division (H) of rule 5101:1-39-04. Rather, pursuant to division (H) of rule 5101:1-39-04, a person is considered an inmate of a penal institution "if he is incarcerated under process of the penal system" (whether the offense is a misdemeanor, a felony, or a delinquent act), and is totally excluded from Medicaid coverage (whether during the period before trial or other disposition of the charges or after conviction), regardless of whether the person resides in the penal institution for a full calendar month.

Opinions Section 30 E. Broad St., 15th Floor Columbus, OH 43215-3400 Telephone: (614) 752-6417 Facsimile: (614) 466-0013 www.ag.state.oh.us The Honorable Sherri Bevan Walsh Summit County Prosecuting Attorney 53 University Avenue, 7th Floor Akron, Ohio 44308-1680 Dear Prosecutor Walsh: We have received your request for a formal opinion concerning the billing of Medicaid for services provided to clients who are incarcerated. You have described the matter at issue as follows:

Our local Alcohol, Drug Addiction and Mental Health Services Board (ADM Board) contracts with Community Support Services (CSS) to provide mental health services. At times, the client is in counseling and then becomes incarcerated at the County Jail. An issue has arisen as to whether ADM/CSS can bill Medicaid for reimbursement for services provided to the inmate while in the jail. It is our reading of the law that a client does not become an inmate for Medicaid purposes until the person has resided in the jail for 30 days. (OAC §5101:1-39-04) Thus, we believe that ADM/CSS can bill for services provided during the first 30 days of incarceration. However, considering the severity of the consequences of reading the law incorrectly,(fn1) our client has requested that we ask your office to issue an opinion on this issue. (Footnote added.)

Although your question asks about the ability of the ADAMH board or provider to bill Medicaid, we note that your basic concern is not about the billing but about the receipt of payment for services rendered. In essence, your question asks if an ADAMH board, or provider with which the ADAMH board contracts, may access Medicaid funding for services provided to individuals who reside in penal institutions. For the reasons discussed below, we conclude that an alcohol, drug addiction and mental health services board (ADAMH board) established pursuant to R.C. Chapter 340, or a provider with which the ADAMH board contracts, may only access Medicaid funding when authorized by statute and rule, including R.C. 5111.023, R.C. 5111.025, 14 Ohio Admin. Code Chapter 5101:3-27, and 14 Ohio Admin. Code Chapter 5101:3-30. Neither an ADAMH board nor a provider with which the board contracts may access Medicaid funding for services provided to an individual who is not eligible for Medicaid. The determination as to whether a particular individual meets all Medicaid eligibility requirements is made, in the first instance, by the county department of job and family services, except with regard to the Ohio breast and cervical cancer project, where eligibility is determined by the Ohio Department of Health or its designated local agencies or subgrantees. We conclude, further, that the provisions of division (G) of rule 5101:1-39-04 of the Ohio Administrative Code (12 Ohio Admin. Code 5101:1-39-04) stating that "[a] person is not considered to be an inmate of a public facility until he has resided therein for a full calendar month" are not applicable to inmates of penal institutions governed by division (H) of rule 5101:1-39-04. Rather, pursuant to division (H) of rule 5101:1-39-04, a person is considered an inmate of a penal institution "if he is incarcerated under process of the penal system" (whether the offense is a misdemeanor, a felony, or a delinquent act), and is totally excluded from Medicaid coverage (whether during the period before trial or other disposition of the charges or after conviction), regardless of whether the person resides in the penal institution for a full calendar month. Ohio's Medicaid program The Medicaid program, established under Title XIX of the Federal Social Security Act, is a health care coverage plan that provides medical assistance to qualifying individuals through the use of federal and state funds. Federal law establishes basic requirements, and each participating state adopts its own plan, containing a package of services defined by the state in compliance with the federal requirements. See 42 U.S.C.A. §§ 1396-1396d (West 2003 & Supp. 2005); R.C. 5111.01; R.C. 5111.021. The Ohio Department of Job and Family Services (ODJFS) is designated as the single state agency with authority to supervise the administration of the Medicaid program in Ohio. R.C. 5111.01; 12 Ohio Admin. Code 5101:1-37-01. ODJFS has authority to adopt rules implementing the Medicaid program, and its rules are binding upon other agencies that administer components of the Medicaid program. "No agency may establish, by rule or otherwise, a policy governing medicaid that is inconsistent with a medicaid policy established, in rule or otherwise, by the director of job and family services." R.C. 5111.01; see also R.C. 5111.02. ODJFS is authorized to "provide medical assistance under the medicaid program as long as federal funds are provided for such assistance," to various persons and families meeting statutory criteria. R.C. 5111.01(A). If funds are appropriated by the General Assembly, ODJFS may provide medical assistance to groups whose coverage under Medicaid is optional. R.C. 5111.01(B). Ohio's Medicaid program covers low-income individuals who are sixty-five or older, blind, have a disability, are pregnant, or are children under age twenty-one, and also covers members of families with dependent children. 12 Ohio Admin. Code 5101:1-37-01(A). To receive Medicaid assistance, an individual must be a member of a covered group and must meet all other eligibility requirements. See R.C. 5111.01; 12 Ohio Admin. Code 5101:1-37-01(B)-(C). Eligibility requirements for individuals who are aged, blind, or have a disability are set forth in Chapter 5101:1-39 of the Ohio Administrative Code, and eligibility requirements for covered families and children are set forth in Chapter 5101:1-40 of the Ohio Administrative Code. 12 Ohio Admin. Code 5101:1-37-01(B). The responsibility for determining whether eligibility exists in a particular case is given, in the first instance, to the county department of job and family services (CDJFS), except with regard to the Ohio breast and...