5101:1-40-26 Medicaid: standards of need.

(A) This rule describes the need standards used to determine financial eligibility for medicaid coverage of families, pregnant women, and children.

(B) Definitions.

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

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

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

(C) There are six need standards which are used in computing eligibility for covered families and children medicaid. They are the one-hundred per cent need standard, the payment standard, the ninety per cent federal poverty level (FPL), the one hundred fifty per cent healthy start standard, the two hundred per cent healthy start standard and the transitional medicaid standard. All six standards are used at various times throughout the eligibility and budget calculations.

(D) When determining the appropriate AG size/household size for an AG containing a pregnant woman, the unborn child(ren) is counted as if the child(ren) had been born and was living in the household. The increased AG/household size is used only for expedited medicaid and healthy start financial determinations.

(E) Need standards.

(1) The one hundred per cent need standard is the amount determined necessary to meet the minimum requirements for food, clothing, housing, utilities, transportation and personal/incidental items. This standard is used as the basis for calculation of the low income families LIF payment standard.

The one hundred per cent need standard is used in calculations as an allowance for the needs of a non-recipient individual. An example is in the stepparent budget or minor caretaker budget where an allowance must be made for the individual’s needs which are not being included in the AG.

(2) The payment standard is a ratable reduction of the one hundred per cent standard. The payment standard is the figure used to calculate the actual cash payment and from which all countable income is deducted.

(3) The one hundred per cent healthy start standard is the basis for the calculation of the one hundred fifty per cent healthy start standard and the one hundred eighty-five per cent transitional medicaid standard.

(4) For pregnant women the AG’s countable income may not exceed one hundred fifty per cent of the federal poverty level for the appropriate AG. 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, 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, as described in rule 5101:1-40-08 of the Administrative Code.

(5) For children from birth through age eighteen, the AG’s countable income may not exceed one hundred fifty per cent of the federal poverty level for the appropriate AG size.

(6) For children from birth through age eighteen, the AG’s countable income may not exceed two hundred per cent of the federal poverty level for the appropriate AG size.

(7) For low income families, the AG’s countable income may not exceed the standards described in rule 5101:1-40-25 of the Administrative Code.

(8) The federal poverty level is the basis of income eligibility for transitional medicaid. The transitional medicaid standard is the standard used to determine eligibility for the second six month period of transitional medicaid coverage.

Effective: 03/01/2008

R.C. 119.032 review dates: 10/12/2007 and 03/01/2013

Promulgated Under: 111.15

Statutory Authority: 5111.01

Rule Amplifies: 5111.01, 5111.013, 5111.014, 5111.019

Prior Effective Dates: 1/1/89 (Emer.), 3/6/89, 5/1/89 (Emer.), 7/1/89 (Emer.) 7/8/89, 9/23/89, 4/2/90 (Emer.), 6/22/90, 10/1/90, 4/1/91 (Emer.), 6/30/92, 1/1/93 (Emer.), 3/18/93, 6/20/94, 10/31/97 (Emer.), 1/26/98, 11/19/99, 1/1/00, 7/1/00, 6/1/03 (Emer.), 9/20/03, 1/1/06