(A) This rule describes the twelve-month period of continuous eligibility for a child younger than age nineteen, and the conditions under which the child's coverage ends during the twelve-month period, as described in section 1902(e)(12) of the Social Security Act (as in effect on April 1, 2010).
(B) Eligibility criteria. A child remains eligible for coverage despite changes in the child's circumstances for a period of twelve months if the child was found to be eligible for a category of medical assistance other than:
(1) Presumptive eligibility as described in Chapter 5101:1-38 of the Administrative Code; or
(2) Alien emergency medical assistance as described in rule 5101:1-41-20 of the Administrative Code; or
(3) Children's buy-in as described in rule 5101:1-42-30 of the Administrative Code; or
(4) Refugee medical assistance as described in rule 5101:1-42-90 of the Administrative Code.
(1) A child's twelve-month period of continuous eligibility begins:
(a) On the date that medical assistance began as a result of an initial determination or annual redetermination pursuant to rule 5101:1-38-01.2 of the Administrative Code,
(b) Without regard to any months of retroactive eligibility.
(2) The child's coverage shall be terminated during the continuous eligibility period only:
(a) Upon oral or written request of the child (if the child is at least eighteen years old) or the child's representative; or
(b) When the child:
(i) No longer resides in the state of Ohio; or
(ii) Dies; or
(iii) Has not paid the premium amounts required for the child's category of medical assistance, as set forth in the rule describing that category of assistance; or
(iv) Reaches age nineteen.
(D) Spenddown, patient liability, or premium.
(1) A spenddown, patient liability, or premium calculated for a child pursuant to Chapters 5101:1-39 to 5101:1-42 of the Administrative Code shall not increase during the child's continuous coverage period. Any decrease in a child's spenddown, patient liability, or premium results in a new maximum amount, which will not increase for the remainder of the child's continuous coverage period.
(2) If a child is eligible for medical assistance only through the spenddown process set forth in Chapter 5101:1-39 of the Administrative Code, the child will not receive medical assistance in any month until the child's spenddown has been satisfied for that month.
(E) Regardless of a child's status under this rule, payment for services shall not be made if payment is prohibited under rule 5101:1-37-20 of the Administrative Code.
R.C. 119.032 review dates: 07/01/2015
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011
Rule Amplifies: 5111.01, 5111.011
Prior Effective Dates: 4/1/2010 (Emer.), 7/1/2010