5101:1-40-08.2 Medicaid: coverage for children with income more than two hundred per cent of the federal poverty level (FPL).

(A) This rule describes medicaid eligibility requirements for children, from birth until the individual reaches age nineteen, with countable family income more than two hundred per cent and no more than three hundred per cent of the FPL, who have no creditable insurance, and who are not eligible under any other medicaid covered group.

(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 determined by adding all of a family's gross non-exempt unearned income and gross non-exempt earned income, then subtracting all appropriate disregards.

(3) "Creditable insurance" or "creditable coverage" means health insurance coverage as defined in 42 U.S.C. 300gg(a) to (c) (as in effect on July 1, 2009).

(a) This includes:

(i) A group health plan;

(ii) Health insurance coverage;

(iii) Medicare part A, in accordance with 42 U.S.C. 1395c to 42 U.S.C. 1395i-5 (as in effect on July 1, 2009) or part B, in accordance with 42 U.S.C. 1395j to 42 U.S.C. 1395w-4 (as in effect on July 1, 2009);

(iv) Coverage under medicaid, in accordance with Title XIX of the Social Security Act, other than coverage consisting solely of benefits under the pediatric vaccine program in accordance with 42 U.S.C. 1396s (as in effect on July 1, 2009);

(v) Armed forces health insurance in accordance with 10 U.S.C. Chapter 55 (as in effect on July 1, 2009);

(vi) A medical care program of the Indian health service or of a tribal organization;

(vii) A state health benefits risk pool;

(viii) A federal employee health plan offered in accordance with 5 U.S.C. Chapter 89 (as in effect July 1, 2009);

(ix) A public health plan;

(x) A peace corps volunteer health benefit plan in accordance with section 22 U.S.C. 2504 (as in effect on July 1, 2009).

(b) Creditable insurance does not include:

(i) Coverage only for accident, or disability income insurance;

(ii) Liability insurance, including general liability insurance and automobile liability insurance, or coverage issued as a supplement to liability insurance;

(iii) Workers' compensation or similar insurance;

(iv) Automobile medical payment insurance;

(v) Credit-only insurance;

(vi) Coverage for on-site medical clinics;

(vii) Other similar insurance coverage under which benefits for medical care are secondary or incidental to other insurance benefits;

(viii) Limited scope dental or vision benefits;

(ix) Benefits for long-term care, nursing home care, home health care, community-based care;

(x) Coverage only for a specified disease or illness;

(xi) Hospital indemnity or other fixed indemnity insurance, if purchased separately;

(xii) Medicare supplemental health insurance as defined in accordance with 42 U.S.C. 1395ss (as in effect on July 1, 2009), coverage supplemental to the coverage provided to military or former military personnel in accordance with 10 U.S.C. Chapter 55, and similar supplemental coverage provided under a group health plan.

(4) "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 pregnant woman.

(5) "Family premium" means premium for all eligible individuals receiving medical assistance in the same covered group.

(6) "Individual," for the purpose of this rule, means any child from birth until the individual reaches age nineteen.

(C) Eligibility criteria.

(1) The family's countable income shall be more than two hundred per cent and no more than three hundred per cent of the FPL for the appropriate family size.

(2) The family shall pay monthly premiums as calculated in paragraphs (D) and (E) of this rule.

(3) An individual is not eligible for this covered group if the individual has creditable insurance.

(4) An individual shall not be eligible under this group if the individual is eligible under any other medicaid covered group.

(5) There is no resource limit.

(6) An individual receiving medicaid under this covered group remains eligible through the end of the month he or she turns nineteen.

(7) Retroactive eligibility periods shall not extend earlier then the effective date of this rule.

(D) Premium calculation. A family with an individual eligible for this covered group shall pay a monthly family premium as follows:

(1) A family with one eligible individual shall pay a premium of forty dollars per month;

(2) A family with two eligible individuals shall pay eighty dollars per month; and

(3) A family with three or more eligible individuals shall pay one hundred twenty dollars per month.

(E) The premium obligation begins the month following the month eligibility is authorized, and is due and payable in full no later than the due date established by the administrative agency.

(1) Partial payments do not satisfy the eligibility criteria in paragraph (C) of this rule.

(2) Partial payments and payments in full received after the due date established by the administrative agency are applied to the most delinquent premium.

(3) A family failing to pay a premium in full for two consecutive months will be subject to termination in accordance with Chapter 5101:1-38 of the Administrative Code.

(4) A family may re-establish eligibility for this covered group if they were terminated due to non-payment of premiums by reapplying and:

(a) Meeting all criteria in paragraph (C) of this rule; and

(b) Paying all delinquent premiums for the months prior to termination.

(5) A family with an individual eligible for retroactive coverage is not required to pay a monthly premium for the months of retroactive coverage.

(F) Family responsibilities. The family shall:

(1) Provide verification in accordance with Chapter 5101:1-38 of the Administrative Code; and

(2) Inform the administrative agency of any health insurance coverage.

(G) Administrative agency responsibilities. The administrative agency shall:

(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 establish retroactive eligibility for this covered group for any month prior to the effective date of this rule;

(3) Not require an individual or family to complete a face-to-face interview;

(4) Redetermine eligibility every twelve months;

(5) Explore eligibility for other categories of medicaid as described in Chapters 5101:1-37 to 5101:1-42 of the Administrative Code before approving an individual for this covered group;

(6) Not terminate medicaid for an individual until a pre-termination review (PTR) of continuing medicaid or medical assistance eligibility is completed;

(7) Terminate medicaid for a family who failed to pay their family premium for two consecutive months or more; and

(8) Issue proper notice and hearing rights as outlined in division 5101:6 of the Administrative Code.

Effective: 07/01/2009
R.C. 119.032 review dates: 07/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.01 , 5101.47 , 5101.522
Rule Amplifies: 5111.01 , 5101.47 , 5101.52 to 5101.529