5101:1-40-05 Medicaid: transitional medicaid.

(A) Transitional medicaid is a category of continuing medicaid available to certain assistance groups that lose healthy families/low income families (LIF) eligibility.

(B) Definitions.

(1) “Transitional medicaid assistance group” includes:

(a) The healthy families/LIF assistance group at the time of loss of healthy families/LIF eligibility,

(b) Individuals who would be included in the healthy families/LIF assistance group if the assistance group applied in the month of loss of healthy families/LIF eligibility,

(d) Specified relative because the natural parent is not in the home (pursuant to paragraph (L)(1)(f) of rule 5101:1-40-01 of the Administrative Code),

(e) Individual(s) not receiving healthy families/LIF medicaid because of a third tier work activity sanction (pursuant to rule 5101:1-40-07 of the Administrative Code),

(f) Individual(s) not receiving healthy families/LIF benefits because of failure to cooperate in establishing paternity and/or obtaining or pursuing medical support (pursuant to rule 5101:1-38-02.2 of the Administrative Code), and

(g) Parents or specified relatives of children for whom federal, state, or local foster care maintenance payments are made, who are otherwise eligible for healthy families/LIF.

(2) “Administrative agency” means the county department of job and family services (CDJFS), Ohio department of job and family services (ODJFS), or other entity that determines eligibility for a medical assistance program.

(3) “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,” pursuant to paragraph (J)(3) of rule 5101:1-40-01 of the Administrative Code.

(4) “Countable income” means the amount of income compared to the appropriate payment or need standard to determine if an individual is eligible for medicaid. Countable income is determined by adding all of a family’s nonexempt unearned income to nonexempt earned income after subtracting all appropriate disregards.

(5) “Family” has the same meaning as in rule 5101:1-40-01 of the Administrative Code.

(6) “Income” has the same meaning as in rule 5101:1-40-20 of the Administrative Code.

(7) “Individual” means an applicant for or recipient of a medical assistance program.

(8) “Quarter” is defined as three months of transitional medicaid coverage.

(a) “First quarter” is defined as the first, second, and third months of transitional medicaid coverage;

(b) “Second quarter” is defined as the fourth, fifth, and sixth months of transitional medicaid coverage;

(d) “Fourth quarter” is defined as the tenth, eleventh, and twelfth months of transitional medicaid coverage.

(1) Eligibility criteria.

(a) The assistance group must have been eligible for and received healthy families/LIF in the state of Ohio in at least three of the six months immediately preceding the month in which the assistance group became ineligible for healthy families/LIF. Receipt of medicaid benefits under another state’s program does not count toward meeting this requirement.

(b) The transitional medicaid assistance group must have lost healthy families/LIF eligibility due to earned income which caused countable income to exceed ninety per cent of the federal poverty level.

(d) The transitional medicaid assistance group must include either:

(i) A child, or

(ii) Parent(s) or specified relative whose child(ren) receives medicaid benefits in a separate assistance group due to receipt of adoption assistance, foster care maintenance, or SSI.

(e) Individuals must not have a conviction(s) of medicaid fraud by a court of competent jurisdiction within the six month period prior to becoming ineligible for healthy families/LIF.

(2) Eligibility period.

If the administrative agency determines the healthy families/LIF assistance group is eligible for transitional medicaid, a notice advising the assistance group of their reporting responsibilities, will be issued. The notice must advise the assistance group that healthy families/LIF will stop on the date indicated on the notice. The notice will also state “Your Medicaid health card will stop on _________.” The date entered in this space will be the last day of the twelfth month of potential medicaid coverage. When the last day of the twelfth month is indicated on the notice, the following statement is included: “see information enclosed.”

(a) Eligibility for the first six month period of transitional medicaid is for six months, provided the eligibility criteria in paragraph (C)(1) of this rule are met.

(b) Eligibility for the first six month period of transitional medicaid begins the month immediately following the last month of healthy families/LIF eligibility. If healthy families/LIF continues beyond the last month of healthy families/LIF eligibility, the months of coverage beyond eligibility are counted as months of the transitional medicaid period of eligibility.

(3) Quarterly income reports

(a) The administrative agency must send a quarterly report form to the transitional medicaid assistance group no later than the third Friday of the third and sixth months of traditional medicaid coverage.

(i) These reports are for, respectively, the first and second quarters of transitional medicaid coverage.

(ii) The quarterly report form will notify the transitional medicaid assistance group of the requirement to report the assistance group’s gross earned income and costs of child care for each of the three preceding months.

(b) The transitional medicaid assistance group must complete the quarterly report form(s) and return it to the administrative agency by the fifth day of the month following the end of the quarterly reporting period, which would be, respectively, the fourth and seventh months of the transitional medicaid coverage period.

(c) The administrative agency must determine eligibility for continued transitional medicaid coverage upon the timely receipt of a quarterly report.

(i) Upon the timely receipt of the first quarterly report, the administrative agency must determine eligibility based upon the eligibility criteria delineated in paragraph (C)(1) of this rule.

(4) Termination of transitional medicaid.

(a) Eligibility for transitional medicaid ends if:

(i) The assistance group no longer meets the eligibility criteria delineated in paragraph (C)(1)(d) of this rule;

(ii) The transitional medicaid assistance group regains eligibility for healthy families/LIF;

(iii) The transitional medicaid assistance group fails, without good cause, to return a required first quarterly report in accordance with this rule, the transitional medicaid assistance group will lose eligibility for transitional medicaid for the second six month period of eligibility;

(b) The administrative agency shall not terminate medicaid for any assistance group or members(s) of an assistance group until a pre-termination review (PTR) of continuing medicaid eligibility has been completed in accordance with rule 5101:1-38-01.1 of the Administrative Code.

(D) The second six month period of transitional medicaid.

(1) Eligibility criteria.

(a) The assistance group must have received transitional medicaid continuously for the entire first six-month period.

(b) The assistance group must meet the eligibility criteria of paragraph (C)(1) of this rule.

(c) The assistance group must meet the quarterly income reporting requirements as defined in paragraphs (C)(3)(b), (C)(3)(c), (D)(3)(b), and (D)(3)(c) of this rule.

(d) The assistance group’s average gross monthly earned income (less child care costs as is necessary for employment of the parent or specified relative) must not exceed the transitional medicaid standard, as set forth in rule 5101:1-40-26 of the Administrative Code.

(i) When a change in the transitional medicaid assistance group composition is reported during the three month period covered by the quarterly report, the average assistance group size (rounded up) is used for the period covered by the quarterly report.

(2) Eligibility period.

(a) An assistance group’s potential eligibility for the second six month period of transitional medicaid begins the month immediately following the completion of the first six months of transitional medicaid. If healthy families/LIF continued beyond the last month of healthy families/LIF eligibility, the months of coverage beyond eligibility are counted as months of the transitional medicaid period of eligibility.

(3) Quarterly income reports.

(a) The administrative agency must send a quarterly report form to the transitional medicaid assistance group no later than the third Friday of the ninth month of transitional medicaid coverage.

(i) This report is for the third quarter of transitional medicaid coverage.

(b) The transitional medicaid assistance group must complete the quarterly report form and return it to the administrative agency by the fifth day of the month following the end of the quarterly reporting period, which would be the tenth month of the transitional medicaid coverage period.

(c) The administrative agency must determine eligibility for continued transitional medicaid coverage upon the timely receipt of a quarterly report.

(i) Upon timely receipt of the second and third quarterly reports, the administrative agency must determine eligibility based on the eligibility criteria delineated in paragraph (D)(1) of this rule.

(ii) If the parent’s or specified relative’s child care costs bring the transitional medicaid assistance group’s gross monthly earned income to within the transitional medicaid standard as defined in rule 5101:1-40-26 of the Administrative Code, the child care costs must be verified.

(4) Termination of transitional medicaid.

(a) Eligibility for transitional medicaid ends if:

(i) The transitional medicaid assistance group no longer meets the eligibility criteria delineated in paragraphs (C)(1) and (D)(1) of this rule;

(ii) The transitional medicaid assistance group regains eligibility for healthy families/LIF;

(iii) The transitional medicaid assistance group fails to return a required quarterly report in accordance with this rule;

(iv) The parent or specified relative in the transitional medicaid assistance group reports no earnings in one of the three months of the second or third quarterly reporting period (unless the lack of earnings is due to involuntary loss of employment, illness, or the administrative agency establishes that there was other good cause); or

(v) The transitional medicaid assistance group’s gross monthly earned income, less child care costs, exceeds the transitional medicaid standard as defined in rule 5101:1-40-26 of the Administrative Code.

(b) The administrative agency shall not terminate medicaid for a members(s) of an assistance group until a pre-termination review (PTR) of continuing medicaid eligibility has been completed in accordance with rule 5101:1-38-01.1 of the Administrative Code.

(E) Transitional medicaid assistance groups that have coverage terminated prior to the completion of the twelfth month of transitional medicaid may potentially reestablish transitional medicaid coverage.

(1) Assistance groups which lose transitional medicaid eligibility in accordance with paragraph (C)(4)(a)(ii) or paragraph (D)(4)(a)(ii) of this rule will be eligible for a new period of transitional medicaid upon meeting all requirements in paragraph (C)(1) of this rule.

(2) Assistance groups which lose transitional medicaid eligibility in accordance with paragraph (C)(4)(a)(ii) or paragraph (D)(4)(a)(ii) of this rule will be eligible for the remaining span of transitional medicaid upon meeting eligibility requirements in paragraphs (C)(1)(b) to (C)(1)(e) of this rule.

Effective: 01/01/2008

R.C. 119.032 review dates: 10/12/2007 and 01/01/2013

Promulgated Under: 111.15

Statutory Authority: 5111.01

Rule Amplifies: 5111.01, 5111.019

Prior Effective Dates: 4/1/90 (Emer.), 6/22/90, 10/1/90, 1/1/93, 4/21/94, 10/31/97 (Emer.), 1/26/98, 6/1/02, 8/30/02, 8/4/03