5101:1-39-03.4 Medicaid: continued medicaid coverage for children who lost their eligibility for supplemental security income (SSI) due to a change in the disability determination.

(A) Section 4913 of the Balanced Budget Act (BBA) provides that any child who was receiving SSI and medicaid on August 22, 1996 whose SSI payments were terminated as a result of the change in the SSI disability criteria for children, continues to meet the limiting physical factor requirement of disability for medicaid.

(1) "Receiving SSI" means that, as of August 22, 1996, the child was in current SSI pay status, had received a favorable or partially favorable administrative decision awarding SSI, or had appealed a decision by SSA to deny his or her application for SSI or to terminate his or her SSI. Medicaid is protected pending the outcome of the appeal.

(2) Medicaid disability eligibility for the pending SSI category is protected pending the outcome of the appeal through the appeals council decision.

(3) Medicaid is not protected for those individuals whose applications for SSI were pending as of August 22, 1996 and they failed to file timely appeals of the SSI denial.

(B) Children not receiving SSI as of August 22, 1996 as defined in paragraph (A) of this rule or who filed for SSI on or after August 22, 1996 are not protected under section 4913 and are, therefore, covered by the new SSI definition of disability for children.

(C) Protected children are required to meet medicaid income and resource requirements in order to get or keep medicaid coverage.

(1) A protected child does not lose his protected status if he becomes eligible under another category of medicaid.

(2) All categories of medicaid must be explored for the child and the child given the choice of category if she or she is eligible under more than one category of medicaid.

(D) If the child is in receipt of medicaid for the disabled (MA-D), the child's disability must be reviewed for continued MA-D eligibility at the first reapplication after all SSI appeals have been exhausted, the child must continue to meet the pre August 22, 1996 criteria to remain in protected status. The child's disability must be reviewed if the child is not eligible for medicaid under any category other than MA-D. The county medical services (CMS) will determine if the child continues to meet the pre-August 22, 1996 criteria.

(E) As a child nears age eighteen, his or her disability must be redetermined by CMS using the adult definition of disability. The individual must also apply for SSI as part of the redetermination process.

(F) Children covered by section 4913 whose medicaid eligibility is uninterrupted should have their eligibility redetermined at their regularly scheduled time. Whenever a redetermination is scheduled, the medicaid non-disability eligibility criteria that is in effect at the time of the reapplication shall be used.

(G) In accordance with rule 5101:1-38-01.1 of the Administrative Code, eligibility for all other categories of medicaid must be determined prior to proposing terminating coverage under the child's current category of medicaid.

Eff 10-1-02
Rule promulgated under: RC 111.15
Rule authorized by: RC 5111.01 , 5111.011
Rule amplifies: RC 5111.01 , 5111.011
R.C. 119.032 review dates: 10/01/2007