5101:1-40-01.1 Covered families and children (CFC) medicaid: covered groups.

To be eligible for covered families and children (CFC) medicaid, a family/individual must be a member of a covered group and meet all applicable eligibility requirements of the rules in chapter 5101:1-40 of the Administrative Code. The three divisions of CFC medicaid covered groups are: families, children, and pregnant women. The financial circumstances of an assistance group and individual members of the assistance group have a major impact on the eligibility criteria applied in the eligibility determination for CFC medicaid. The fact that an assistance group is over income does not necessarily render all members of the group ineligible. The eligibility for each individual must be thoroughly reviewed for other potential assistance groups and/or categories other than the one for which the entire assistance group is not eligible.

(A) Families. This covered group includes families where the eligibility of all members of the family is determined based upon their collective circumstances. The following identifies the families covered by CFC medicaid:

(1) Financially eligible families (healthy families/LIF) with children. This group includes those individuals who are not eligible for OWF cash assistance due to an OWF requirement that is not applicable to medicaid (e.g. signing of a self-sufficiency contract) or prohibited by medicaid (e.g. deeming of sibling income or deeming of income from a child to a parent). This group also includes individuals or families that are OWF cash eligible but decline cash assistance.

(2) OWF recipients. All OWF cash recipients automatically are eligible for healthy families/LIF without a separate eligibility determination. This group includes OWF parents and relatives who are eligible for and receiving OWF only for themselves because the only eligible child(ren) are receiving SSI, or effective February 28, 1994, federal, state, or local foster care maintenance payments or federal, state, or local adoption assistance payments.

(3) Transitional medicaid. Those terminated from healthy families/LIF due to increased earnings from employment.

(4) Four month extended medicaid. Those terminated healthy families/LIF due to the receipt of or increase in spousal or child support.

(5) Healthy start recipients. This includes family situations where a pregnant woman is receiving assistance along with her child(ren) in accordance with rules: 5101:1-40-08 and 5101:1-40-081 of the Administrative Code.

(B) Children. Eligibility for children is often determined independently from the circumstances of their families. Though it is necessary to determine financial eligibility taking into consideration the income of a child’s parents, when the child lives with the parents or is temporarily absent under the provisions of rule 5101:1-40-01(J)(5) of the Administrative Code, the basic nonfinancial eligibility determiner is the child’s circumstances. The following identifies the areas of potential eligibility for children:

(1) Newborns. A child born to a woman eligible for and receiving medicaid under any category at the time of the child’s birth. This includes situations where eligibility was determined retroactively for the period of time which included the child#s date of birth.

(2) Foster care maintenance (FCM) and adoption assistance (AA) cases.

(3) Children in care.

(4) Individuals not eligible for OWF due to deeming of income requirements prohibited by the medicaid program, such as:

(a) Deeming of stepparent to stepchild(ren) income;

(b) Deeming of grandparent income to grandchild(ren);

(c) Deeming of sibling income to other full or half-siblings in household;

(d) Deeming of income from a child to a parent.

Deeming of income prohibitions include all types of income and are not restricted to SSI or other income earmarked by court order or law.

(5) Individuals under age twenty-one living with their parents who are not included because they do not meet an eligibility requirement to be included within an assistance group with their parents (e.g. a 20-year old individual) and individuals who have their own income that would adversely affect the eligibility of other individuals listed in section (B)(4) of this rule.

(6) Individuals under age twenty-one who are not living with a specified relative or who are living by themselves.

(7) Children who are eligible for healthy start whose eligibility is determined pursuant to rules 5101:1-40-08 and 5101:1-40-081 of the administrative code.

(C) Pregnant women. Pregnant women are a covered group for medicaid solely due to the fact the woman is pregnant. These women are determined eligible in accordance with the provisions of healthy start as specified in rules 5101:1-40-08 and 5101:1-40-081 of the Administrative Code. However, they may also be included in an assistance group that receives Medicaid under another category (e.g. healthy families/LIF), but if that assistance group becomes ineligible, the pregnant woman must continue to receive coverage under healthy start throughout her pregnancy and the sixty day postpartum period.

(D) The initial financial eligibility is determined based on the circumstances of the pregnant woman. If the pregnant woman is married and is living with her spouse, his income must be considered in the determination of her initial eligibility. If an unemancipated pregnant woman is under eighteen and living with her parent(s), the income of her parents must be considered in the determination of her initial eligibility. Financial eligibility for healthy start is determined based on the appropriate assistance group size according to the number of fetuses that have been medically verified. Financial eligibility for healthy families/LIF does not count the fetus toward the assistance group size, but does allow a $20 pregnancy allowance (ref. OAC 5101:1-40-26).

HISTORY: Eff 2-15-85 (Emer); 3-12-85 (Emer); 6-10-85 (Emer); 12-30-85; 8-1-86; 9-23-86; 10-3-86; 10-8-86; 1-1-88 (Emer); 6-20-88; 3-6-89; 3-28-89 (Emer); 1-1-90 (Emer); 4-1-90; 10-1-91; 3-1-94 (Emer); 4-18-94; 9-1-94; 9-1-95; 12-31-97 (Emer); 3-9-98; 10-1-98; 8-30-02

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.011, Section 61.07 Am. Sub.

Rule amplifies: RC 5111.01, 5107.02, 5111.011

Replaces: former 5101:1-40-01.1

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