5101:1-40-02.3 Medicaid: coverage for pregnant women.

(A) This rule describes the pregnant women covered group in accordance with section 1902(a)(10)(A) of the Social Security Act (as in effect June 1, 2010). There is no resource limit for pregnant women described in this rule.

(B) Definitions.

(1) "Medical verification of pregnancy" means a written statement signed by a doctor or nurse verifying pregnancy and includes the expected date of confinement.

(2) "Expected day of confinement" means expected date of delivery.

(3) "Parents," for the purpose of this rule, means natural or adoptive parents, step-parents, or legal guardians.

(C) Eligibility criteria for the pregnant women covered group.

(1) The individual shall be pregnant.

(2) Income.

(a) The net countable family income shall be no more than two hundred per cent of the federal poverty level.

(b) If a pregnant woman is married and living with her spouse, his income shall be counted.

(c) If a pregnant woman is younger than eighteen, unmarried, and living with her parents, the income of her parents shall be counted.

(3) An individual may have retroactive eligibility as a member of this covered group for up to three months prior to the month of application, in accordance with rule 5101:1-38-01.2 of the Administrative Code, during which she met all the eligibility criteria in paragraph (C) of this rule.

(4) To be eligible for postpartum coverage, an individual shall be eligible for medicaid on the date her pregnancy ends. This includes a birth mother whose labor and delivery services were furnished prior to the date of application and the services are eligible for coverage by medicaid in accordance with 42 C.F.R. 435.117 (as in effect September 1, 2009), and based on retroactive eligibility in accordance with rule 5101:1-38-01.2 of the Administrative Code.

(5) Family size.

(a) When determining an individual's eligibility for medicaid as a pregnant woman, the family size includes the unborn child or children.

(b) If the number of fetuses is not provided on the medical verification of pregnancy, eligibility shall be determined using the assumption that there is one fetus. If the woman is found ineligible due to excess income, she shall be given the opportunity to obtain medical verification confirming the number of fetuses.

(c) If a pregnant woman is younger than eighteen, unmarried, and living with her parents, her parents and her parents' minor children count toward family size.

(D) Individual responsibilities. The individual shall provide medical verification of pregnancy.

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

(1) Verify the individual's pregnancy by obtaining from the individual her medical verification of pregnancy.

(2) Not deny eligibility because the individual has existing creditable insurance.

(3) Not terminate eligibility for a pregnant woman. Once established, eligibility shall continue throughout pregnancy and postpartum coverage period, regardless of changes in her net countable family income.

Replaces: 5101:1-40-01, 5101:1-40-08, 5101:1-40-26

Effective: 07/17/2011
R.C. 119.032 review dates: 07/01/2016
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011
Rule Amplifies: 5111.01 , 5111.011 , 5111.013 , 5111.014
Prior Effective Dates: 6/1/84, 8/1/86 (Emer.), 10/3/86, 2/13/87 (Emer.), 4/25/87, 11/1/87, 1/1/88, 1/1/89 (Emer.), 2/6/89, 3/6/89, 5/1/89 (Emer.), 7/1/89 (Emer.), 7/8/89, 9/23/89, 10/1/89 (Emer.), 12/16/89, 4/2/90 (Emer.), 6/22/90, 10/1/90, 4/1/91 (Emer.), 6/20/92, 1/1/93 (Emer.), 1/1/93, 3/18/93, 6/20/94, 10/31/97 (Emer.), 1/1/98 (Emer.), 1/26/98, 4/4/98, 11/1/99 (Emer.), 11/19/99 (Emer.), 11/19/99, 1/1/00, 2/1/00, 7/1/00, 6/1/02 (Emer.), 8/30/02, 6/1/03 (Emer.), 9/20/03, 1/1/06, 1/1/08