5101:1-40-01 Covered families and children's (CFC) medicaid: assistance groups and definitions.

(A) CFC medicaid is a federal and state financed grant-in-aid program which is administered by ODJFS. CFC medicaid represents a collection of several federal mandatory and optional eligibility categories that cover families, children, and pregnant women who meet the eligibility criteria of the rules in Chapter 5101:1-40 of the Administrative Code.

(B) Federal regulations for the administration of the program are promulgated by the center for medicare and medicaid services (CMS) of the department of health and human services.

(C) When medicaid eligibility under any category is to be terminated or denied continued eligibility for medicaid under all other categories must be explored prior to taking the adverse action. This exploration must ensure that an assistance group or any individual in an assistance group is not denied or terminated from medicaid based on requirements of other programs (such as Ohio works first (OWF) foster care maintenance, food stamps, etc.)

(D) Eligibility for CFC medicaid is determined on an individual basis. Each individual included in the assistance group is to be determined eligible or ineligible according to CFC medicaid requirements. Eligibility factors in general are those eligibility requirements regarding income, resources, residence and citizenship, but not all factors apply nor do they necessarily apply in the same way to all of the various categories of CFC medicaid. The specifics to the various eligibility requirements are addressed in Chapters 5101:1-38, 5101:1-39, and 5101:1-40 of the Administrative Code. If an individual or assistance group does not meet all of the eligibility requirements for a given category of medicaid, then eligibility must be explored for all other categories. This may entail reviewing for other potential assistance groups which contain some, but not necessarily all, of the members of an ineligible assistance group. This means that an individual may have potential eligibility in more than one assistance group, and ineligibility in one of these assistance groups does not necessarily cause ineligibility in the others.

(E) Eligibility for CFC medicaid may exist for individuals/families when they are ineligible for OWF, foster care (IV-E), or adoption assistance solely because of their inability to satisfy an eligibility condition(s) or other requirement not prohibited or not required by title XIX (medicaid). For example, there are federal medicaid prohibitions against deeming of income from stepparents, sibling to sibling, or child to parent, this means that the OWF standard filing unit requirements may not be used as a basis for terminating any category of CFC medicaid.

(F) An individual/family must meet the income and resource eligibility (where applicable) requirements of rules 5101:1-40-20 to 5101:1-40-25 and 5101:1-40-14 to 5101:1-40-17 of the Administrative Code.

(G) Unless otherwise noted in the rules in this chapter of the Administrative Code, the requirements of rules in Chapter 5101:1-38 of the Administrative Code are applicable for verification, application processing, etc. to CFC medicaid applications and redeterminations.

(H) Applicants/recipients of CFC medicaid have the right to a state hearing as stated in division-level 5101:6 of the Administrative Code.

(I) Eligibility for CFC medicaid coverage begins on the first day of the month and ends on the last day. A change in circumstances during the month cannot adversely affect eligibility for the month during which the change occurred. A change in income which can not be reflected in eligibility for the month following the month of change due to prior notice or other administrative requirement shall be effective the first of the second month following the month of change.

(1) The exceptions to monthly coverage are birth and death, expedited medicaid and alien emergency medical assistance (AEMA). CFC medicaid coverage cannot precede a recipient’s date of birth or extend beyond a recipient’s date of death. Expedited medicaid coverage is limited to sixty days from the date all expedited medicaid criteria are met. AEMA coverage consists of only the period of time that services were provided for the emergency medical condition.

(J) The following definitions apply specifically to CFC medicaid:

(1) “Parental responsibility” means the natural or adoptive parent has certain financial responsibility for a child until the child becomes twenty-one if he is living with his parent(s) and was not previously emancipated. However, parents are not financially responsible for a pregnant daughter age eighteen or over who is living with them. If an individual under the age of twenty-one lives outside his parent(s) home, only contributions made by the parent(s) to the child are countable as income to the child.

(2) “Emancipated” means those individuals under age twenty-one who have married or have been (or are) members of the armed forces. Divorced individuals under age twenty-one are also considered to be emancipated. If an individual under age twenty-one has married and subsequently had that marriage annulled, the individual is not considered to be emancipated due to the annulled marriage. An individual under the age of twenty one can also be emancipated by court order.

(3) “Child” for purposes of CFC eligibility varies by the requirements of the specific category that is being explored. For example, for healthy families/LIF and transitional medicaid, “child” is defined as an individual who has not attained age eighteen or an individual who has not attained age nineteen and is a full-time student in a secondary school or in the equivalent level of vocational or technical training. However, an individual is eligible for healthy start as a “child” until age nineteen without regard to school enrollment or attendance.

(4) “Assistance group/family” means the parent(s), natural and adoptive, or in some cases a specified relative, and eligible children living in the home including the unborn child(ren) of a medically verified pregnant woman if provided for under the appropriate program rules. Those individuals included or excluded in the assistance group/family are further discussed in this paragraph.

(a) Individuals who are included in the assistance group for CFC benefits are determined by the category that is being explored, relationship, and financial responsibility. The principles for forming a CFC assistance group are based around whose income (and resources, where applicable) are used to calculate countable income and resources in order to determine eligibility. Because certain individuals have a legal responsibility for support (e.g. spouse to spouse, parent to child) some individuals may be included for assistance group size or for income purposes even though they are not eligible to be covered for benefits in the assistance group. An individual (child or parent) who is determined to be “Temporarily Absent”, as defined in this rule, remains a part of the assistance group/family as though they were physically living in the home. A childless married couple is also considered an assistance group/family.

(b) Individuals who can be, but are not required to be, excluded from the assistance group’s/family’s eligibility are emancipated individuals and individuals age eighteen to twenty-one who are not applying for CFC medicaid, and pregnant women age eighteen or over. Individuals who have income that causes the remaining members of the assistance group to be ineligible shall be excluded if they are individuals subject to medicaid prohibitions against income deeming as defined in paragraph (E) of this rule. Eligibility for the remaining family members shall be determined without consideration of the excluded individual’s need or income.

(c) An exception to inclusion is an assistance group also exists for families containing a child who is receiving SSI who would otherwise qualify for medicaid as a disabled individual under the provisions of Chapter 5101-1-39 of the Administrative Code. If the income or resources of the child’s parent(s) would cause this child to be ineligible for medicaid as a disabled individual or to have a spenddown, then the parent(s) have the option to have the child’s eligibility determined for healthy start. The parent(s) income shall be used in determining the child’s eligibility as well as the child’s own income except for exclusion of the SSI income. Because SSI individuals are prohibited from being part of a healthy families/LIF assistance group, if the remaining family members are receiving healthy families/LIF then the child will have his/her own healthy start assistance group.

(5) “Temporary Absence” means an individual (parent or child) who is otherwise considered part of the assistance group/family is considered to be temporarily absent if all of the following conditions are met:

(a) The location of the absent individual is known;

(b) There is a definite plan for the return of the absent individual to the home;

(d) There is no maximum period of time that an individual may be considered to be temporarily absent provided that the above conditions are met. An exception is in circumstances involving removal of a child(ren) by a public children services agency under the reunification plan. The child(ren) removed are considred temporarily absent as long as they meet the reunification requirements specified in the reunification plan. The individual medicaid eligibility is determined based upon current living arrangements of the child(ren). The remaining assistance group members eligibility is based upon the assistance group size that should include the individual who is temporarily absent.

(e) An individual who has been determined to be temporarily absent remains a part of the assistance group as though he/she were physically present in the household. They remain members of the assistance group throughout the period of temporary absence. An individual who is incarcerated is not considered temporarily absent.

(K) Steps in determining a CFC assistance group:

(1) The assistance group is determined by first deciding for which child(ren) assistance is requested. The child for whom assistance is requested must meet the age requirement for the category being explored.

(2) Add to the assistance group siblings living in the household who also meet the age requirement who are not specifically excluded. “Sibling” means any and all blood-related or adoptive brothers/sisters. Also, include those siblings who meet the temporary absence provision as set forth in this rule.

(3) Add to the assistance group for assistance group size for budgeting purposes the parent(s) living in the household who are not specifically excluded. A parent must not be added to the assistance group unless the child(ren) meets the age requirement for financial responsibility as referenced in paragraph (L)(1)(a) of this rule. “Parents” mean any and all natural and adoptive parents who live in the household and are not specifically excluded. When the child resides with a specified relative, who is in need and has no eligible biological or adoptive children, and has chosen to be part of a healthy families/LIF assistance group, add that individual to the assistance group. These specified relatives are not included in any other CFC assistance groups for benefits or assistance group size with the exception of transitional medicaid. Refer to paragraph (L)(4) of this rule.

(4) This group is considered to be the assistance group. If a person or persons are subject to be included in more than one assistance group within the same household, then the assistance groups containing that individual are first combined and eligibility for this group is determined as a whole. If the largest assistance group is not eligible for benefits, then eligibility for other assistance groups must be explored and determined. Eligibility for each member in that household must be evaluated for medicaid under any potential medicaid category.

(5) Assistance groups or individuals that are eligible for medicaid under more than one category at the same time shall be given the opportunity to make an informed choice as to the category for which they are approved. The goal is to enroll the assistance group for coverage under the category which provides the maximum level of coverage, e.g. healthy families/LIF confers potential eligibility for transitional medicaid if the family later loses healthy families due to earnings and it is, therefore, preferable to enroll a family for healthy families/LIF whenever possible.

(L) Certain additional considerations apply when eligibility is being explored for an assistance group that contains parents as well as children, e.g. healthy families/LIF and transitional medicaid assistance groups. The requirements of the specific eligibility categories are defined elsewhere in this chapter. The following are some principles that apply to certain types of assistance groups:

(1) Determination of the healthy families/LIF assistance group:

(a) An assistance group shall first be explored which includes the natural or adoptive parent(s) and their child(ren). A minor child is an individual who has not attained age eighteen or an individual who has not attained age nineteen and is a full-time student in a secondary school or in the equivalent level of vocational or technical training. The assistance group includes those individuals residing in the same household. An individual who is determined to be temporarily absent from the home as set forth in paragraph (J)(5) of this rule is considered to be residing in the household. Rule 5101:1-40-021(D)(1) of the Administrative Code states the healthy families/LIF assistance group must include a child as defined in this section. An exception to this requirement is in situations where the assistance group only contains the natural, adoptive parent or specified relative because the eligible child is not included due to receipt of SSI assistance.

(b) A minor parent residing with his/her parent(s) who are eligible for healthy families/LIF shall constitute one assistance group containing the parent(s), minor parent, siblings of the minor parent, and the minor parent’s child(ren) unless the income of the minor parent causes the minor’s parents and siblings of the minor parent to be ineligible.

(c) An individual, with no eligible children of his/her own, who resides with child(ren) who meet a degree of specified relationship as defined in paragraph (L)(1)(f) of this rule below may choose to be included in the assistance group with the child(ren) if a natural or adoptive parent of the child(ren) is not in the home. The specified relative’s income would be considered in determining the eligibility of the assistance group, if the specified relative is included. If the specified relative does not choose or is not eligible to be included in the group, then neither their income nor need are considered toward the financial eligibility of the children. When the specified relative has a spouse, the income of the spouse must be evaluated to determine the spouse’s ability to support the specified relative. If the specified relative’s spouse is in need, the spouse cannot be included in the assistance group. To determine whether the specified relative is eligible to be included in the assistance group with the minor child(ren), the allocation process as set forth in rule 5101:1-40-22 of the Administrative Code is applied. The income of the spouse of the specified relative is not countable toward the financial eligibility of the children.

(d) An individual who resides with his or her biological or adoptive children, and children who meet a degree of relationship, as defined in paragraph (L)(1)(f) of this rule shall be included in the assistance group with his or her children. CFC for the assistance group containing the other related children shall be determined separately and independently of the assistance group containing the individual and his or her biological or adoptive children. Income of the specified relative would not be considered in determining eligibility of the assistance group with the related children.

(e) A parent or specified relative in need, who is serving house arrest shall be included in the assistance group, provided that the individual’s confinement is in the household with the minor child(ren).

(f) Specified relative means the following individuals who are age eighteen or older:

(i) The following individuals related by blood or adoption:

(a) Grandparents, including grandparents with the prefix great, great-great, or great-great-great;

(b) Siblings;

(c) Aunts, uncles, nephews, and nieces, including such relatives with the prefix great, great-great, grand, or great-grand;

(d) First cousins and first cousins once removed.

(ii) Stepparents and stepsiblings;

(iii) Spouses and former spouses of individuals named in (f)(i) or (ii) of this paragraph.

(g) Income allotted pursuant to rule 5101:1-40-022 of the Administrative Code affects only individuals for whom the responsible individual has a financial responsibility. This affects eligibility of individual members of the assistance group. The eligibility of remaining members must still be explored.

(2) The following are individuals who would normally be included pursuant to paragraph (A) of this rule but who are excluded due to an ineligibility factor. Although these individuals are not covered by healthy families/LIF for benefits, their income is required to be included if they are a parent or spouse and they are included for purposes of determining assistance group size:

(a) The following are individuals who would normally be included pursuant to paragraph (A) of this rule but who are excluded due to an ineligibility factor. Although these individuals are not covered by healthy families/LIF for benefits, their income is required to be included if they are a parent or spouse and they are included for purposes of determining assistance group size:

(b) Individuals who fail to cooperate with an eligibility requirement such as a failure to cooperate with third party or medical support as defined in rule 5101:1-38-01.4 of the Administrative Code, provide information about a family member required to be included in an assistance group; or failure to comply with an initial eligibility requirement, such as enumeration.

(c) Adults who are ineligible due to a third failure to comply with a work activity as pursuant to rule 5101:1-40-07 of the Administrative Code.

(3) Individuals not eligible to be included in the healthy families/LIF assistance group:

(a) Parents or children receiving SSI. The income of a parent or child who is receiving SSI is not counted toward the healthy families/LIF assistance group containing the other parent and/or children. SSI recipients are also not counted in assistance group size for purposes of financial eligibility determination. A recipient of SSI who wishes to receive healthy families/LIF can choose to terminate their SSI benefits in order to be included in the healthy families/LIF assistance group. The healthy families/LIF eligibility effective date shall not precede the effective date of the SSI termination.

(b) Stepparents, unless there is a common child with the natural or adoptive parent included in the healthy families/LIF assistance group. Stepparents can also be included if the natural/adoptive parent(s) is not in the household and the stepparent is a caretaker in need pursuant to paragraph (L)(1)(c) of this rule.

(d) Parents or children for whom federal, state or local adoption assistance payments are being made, unless the inclusion of the individual, in whose behalf the payments are being made, allows the family to qualify for healthy families/LIF because the individual increases the assistance group size for financial eligibility budgeting purposes.

(4) Determination of the transitional medicaid assistance group:

Federal regulations require that an individual must be eligible to be included in the state’s section 1931 assistance group (healthy families/LIF) in order to be eligible for inclusion in the transitional medicaid assistance group. Therefore, the individuals who were included in the healthy families/LIF assistance group are the only members eligible to be included in the transitional medicaid assistance group with the following exceptions:

(a) An adult who was ineligible for healthy families/LIF because of a third work activity failure is included in the transitional medicaid assistance group pursuant to rule 5101:1-40-07 of the Administrative Code.

(b) Those individuals whose needs and income would be taken into account in determining healthy families/LIF eligibility of the assistance group if the family were applying in the current month. Under this definition, a child born after healthy families/LIF is terminated, or a child or parent who returns home after healthy families/LIF is terminated, is included in the assistance group for purposes of transitional medicaid.

HISTORY: Eff 6-1-84; 8-1-86 (Emer.); 10-3-86; 2-13-87 (Emer.); 4-25-87; 11-1-87; 1-1-88; 1-1-89 (Emer.); 2-6-89; 1-1-93; 10-31-97 (Emer.); 1-26-98; 11-1-99 (Emer.); 2-1-00; 6-1-02 (Emer); 8-30-02

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.011, 5111.01

Rule amplifies: RC 5111.01, 5107.02, 5111.011

Replaces: former 5101:1-40-01

R.C. 119.032 review dates: 3/15/2002 and 08/30/2007