LAW
Writer®
Ohio Laws and Rules
(A) This rule describes two medicaid covered groups:
(1) Pregnant women; and
(2) Low income children with income no more than two hundred per cent of the federal poverty level (FPL), including children with no creditable insurance, from birth until the individual reaches age nineteen, who are not eligible under any other category of medicaid.
(B) Definitions.
(1) “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.
(2) “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.
(3) “Creditable insurance” means health insurance coverage as defined in 42 U.S.C. 300gg (a) to (c) as in effect on January 1, 2008.
(a) This includes, but is not limited to, coverage under a group health plan, either group or individual health insurance, the federal employee health benefit program, and a public health plan.
(b) Creditable insurance does not include coverage consisting solely of expected benefits, including but not limited to coverage only for accidents, disability income insurance, liability insurance, supplemental policies to liability insurance, worker’s compensation insurance, automobile medical payment insurance, credit-only insurance, coverage for on-site medical clinics, or limited-scope dental, vision, or long-term care insurance.
(4) “Family” has the same meaning as in rule 5101:1-40-01 of the Administrative Code.
(5) “Income” has the same meaning as in rule 5101:1-40-20 of the Administrative Code.
(6) “Individual”, for the purpose of this rule, means a child younger than age nineteen or a pregnant woman.
(7) “Medical verification of pregnancy” means a written statement signed by a doctor or nurse verifying pregnancy and the expected date of delivery or confinement as well as the number of fetuses.
(8) “Postpartum coverage” means a span of medicaid eligibility that begins on the last day of a pregnancy (if the woman was eligible for and receiving medicaid on that date) and ends on the last day of the month in which the sixtieth day (after the last day of the woman’s pregnancy) falls.
(C) Eligibility criteria.
(1) Countable income must be no more than two hundred per cent of the FPL for the appropriate family size.
(2) There is no resource limit.
(3) Eligibility for low income children.
(a) There are two standards for children with income no more than two hundred per cent:
(i) A child whose family’s countable income is no more than one hundred fifty per cent of the FPL remains eligible for medicaid even if the child is covered by creditable insurance;
(ii) A child whose family’s countable income is more than one hundred fifty per cent but no more than two hundred per cent of the FPL is only eligible for medicaid if the child is not covered by creditable insurance as per paragraph (B)(3) of this rule.
(b) Children already in receipt of medicaid under this program at age eighteen, will remain eligible through the end of the month in which he or she turns nineteen.
(4) Eligibility for pregnant women.
(a) Determination of income at initial eligibility during pregnancy:
(i) If a pregnant woman is married and living with her spouse, his income must be considered.
(ii) If a pregnant woman is younger than eighteen, unemancipated, and living with her parents, the income of her parents must be considered.
(b) Income eligibility for pregnant women:
(i) A pregnant woman with countable income of no more than one hundred fifty per cent of the FPL for her family size is financially eligible for medicaid.
(ii) If a pregnant woman has countable income of more than one hundred fifty per cent but no more than two hundred per cent of the FPL for her family size:
(a) Income is disregarded in the amount of the difference between two hundred per cent and one hundred fifty per cent of the FPL for her family size; and
(b) She is financially eligible for medicaid.
(c) Eligibility for a pregnant woman, once established, continues throughout pregnancy and the postpartum period without redetermination and regardless of changes in her family income.
(i) An individual may have retroactive eligibility for up to three prior months during which she was pregnant.
(ii) To be eligible for postpartum coverage, an individual must be receiving medicaid on the date her pregnancy ends.
(d) Family size. When determining an individual’s eligibility for medicaid as a pregnant woman, the family size includes the unborn child or children.
(i) If the number of fetuses is not on the medical verification of pregnancy, eligibility shall be determined using an assumption there is one fetus.
(ii) A pregnant woman found ineligible due to excess income must be informed that the number of fetuses may affect eligibility and be given an opportunity to verify the number of fetuses.
(D) Individual responsibilities. The individual must:
(1) Cooperate in establishing eligibility and provide verification in accordance with Chapter 5101:1-38 of the Administrative Code;
(2) Provide medical verification of pregnancy, if applying for medicaid as a pregnant woman; and
(3) Inform the administrative agency of any available health insurance coverage according to rule 5101:1-38-02.2 of the Administrative Code.
(E) Administrative agency responsibilities. The administrative agency must:
(1) Determine medicaid eligibility in accordance with the eligibility rules contained in Chapters 5101:1-37 to 5101:1-42 of the Administrative Code;
(2) Not require an individual to complete a face-to-face interview;
(3) Perform a redetermination of the eligibility of low income children every twelve months;
(4) Explore eligibility for other categories of medicaid under low income families or medicaid for the aged, blind, and disabled, as described in Chapters 5101:1-37 to 5101:1-42 of the Administrative Code, before approving coverage as a pregnant woman or child under two hundred per cent of the FPL;
(5) Not terminate medicaid for a member of an assistance group until a pre-termination review (PTR) of continuing medicaid or medical assistance eligibility has been completed in accordance with rule 5101:1-38-01.1 of the Administrative Code; and
(6) Issue proper notice and hearing rights as outlined in division 5101:6 of the Administrative Code.
Replaces: 5101:1-40-08
Effective: 01/01/2008
R.C. 119.032 review dates: 01/01/2013
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.012, 5111.013
Rule Amplifies: 5111.01, 5111.012, 5111.013, 5111.014
Prior Effective Dates: 10/1/89 (Emer.), 12/16/89, 10/1/90, 4/4/98, 11/19/99 (Emer.), 1/1/98 (Emer.), 1/1/00, 7/1/00, 9/20/03