(A)A child eligible for Title IV-E adoption assistance (AA), is eligible for Title XIX medicaid coverage beginning with the effective date of the JFS 01453 "Adoption Assistance Agreement" (rev. 4/20101/2014) unless the child is solely at substantial risk as defined in rule 5101:2-49-03 of the Administrative Code.

(B)The public children services agency (PCSA) shall inform the adoptive parent(s) that he or she shall immediately notify the PCSA within fifteen calendar days after if he or she is moving to another county or state.

(C)The parentparent(s) shall cooperate with the PCSA to assure that a move out-of state complies with any applicable interstate requirements for placement. Failure to notify the PCSA may result in the interruption of Title XIX medical coverage.

(D)For anadopteda child with an AA agreement in effect who moves or resides out-of state, the following shall apply:

(1)Within seven business days after the PCSA is notified by the adoptive parent(s) that the AA eligible child is moving to or residing in another state, the PCSA shall transfer Title XIX medical coverage to the state of residence by:

(a)Completing and forwarding the following forms to the Ohio department of job and family services interstate compact on adoption and medical assistance (ICAMA) state administrator pursuant to rule 5101:2-44-05.2 of the Administrative Code:

(i)The original interstate compact on adoption and medical assistance (ICAMA) 6.01 "Notice of Medicaid Eligibility/Case Activation (rev.8/2004);" and 6.02 "Notice of Action7.02 "Notice to Families" (rev.7/2012) can be obtained at http://aaicama.org/cms/index.php/icama-forms."

(ii)A copy of the current signed and dated JFS 01453.

(b)Providing written notification to the adoptive parent(s) of Ohio's intent to terminate the Title XIX medical coverage. Notification shall, at a minimum, include all of the following:

(i)The effective termination date of Ohio's Title XIX medical coverage.

(ii)A completed JFS 04065 "Prior Notice of Right To A State Hearing" (rev 05/2001).

(iii)A statement that the child will continue to receive AA payments from Ohio or, if no payments are being made, a statement that the JFS 01453 remains in effect and Title XIX medical coverage will be provided by the state in which the child resides.

(c)Providing written notification of the date Ohio's Title XIX medical coverage will be terminated to the responsible Title XIX medical authority in the state in which the AA eligible child resides.

(d)Requesting to be notified in writing by the Title XIX medical authority in the receiving state of the effective date of the child's Title XIX medical coverage.

(e)Terminating the medical coverage in the statewide automated child welfare information system(SACWIS).

(2)Upon notification of any change that would effect the medicaid status, the PCSA shall, within seven working business days, complete and forward the ICAMA form 6.03 "Report of Change in Child/Family Status" (rev. 8/2004) that can be obtained at http://aaicama.org/cms/index.php/icama-forms to the ODJFS ICAMA state administrator.

(3)No less than annually, the PCSA shall provide the responsible Title XIX medical authority in the state where the child resides with written verification that the child meets the continuing eligibility requirements for medicaid. If the PCSA determines the child does not meet the continuing eligibility requirements, within twenty working business days the PCSA shall:

(a)Complete a medicaid pre-termination review (PTR) of continuing medicaid eligibility pursuant to rule 5101:1-38-01.1 5160:1-2-01.2 of the Administrative Code.

(b)Provide written notification of the date Title XIX medical coverage shall be terminated to the responsible Title XIX medical authority in the state in which the AA eligible child resides.

(E)For anadopteda child with an out-of-state AA agreement in effect who moves to or resides in Ohio, the following shall apply:

(1)The child is automatically eligible for Title XIX medical coverage provided by Ohio.

(2)The PCSA shall, within twenty working business days after being notified by another state take the following actions to transfer Title XIX medical coverage:

(a)Obtain the following information from the adoptive parent(s), the agency with Title IV-E case management responsibility, and/or the responsible Title XIX authority:

(i)The child's name, social security number, date of birth, and address.

(ii)The name of adoptive parent(s).

(iii)The address where the medical card should be sent.

(iv)Verification of eligibility for AA.

(v)A copy of the sending state's adoption assistance agreement.

(vi)The name, address and telephone number of a contact person in the state with Title IV-E case management responsibility.

(vii)The termination date of Title XIX medical coverage in the state with Title IV-E case management responsibility or the state where the child moved.

(viii)Any additional information regarding other health insurance coverage the child may have, including third-party liability.

(b)Enter into SACWIS the Ohio medicaid effective date and an "active" status on the ICPC/ICAMA screen for the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) AA that authorizes medical coverage.

(c)Provide written notification to the responsible Title XIX medical authority in the state from where the child moved of the effective date Ohio Title XIX medical coverage will begin.

(d)Complete the JFS 06612 "Health Insurance Information Sheet" (rev. 5/2001) if there is information that the child is covered by a private health insurance plan.

(3)The PCSA shall maintain a separate case record for each AA eligible child who resides in Ohio. The case record shall contain all of the information required in paragraph (D) of this rule for all adopted children with AA agreements in effect who move to or reside in Ohio.

Effective: