Chapter 5160:1-4 Medicaid for Families and Children

5160:1-4-02 MAGI-based medicaid: coverage for children younger than age nineteen.

(A) This rule describes medicaid eligibility criteria for children from birth until the individual reaches age nineteen in accordance with 42 C.F.R. 435.118 (as in effect July 1, 2014) for applications for medical assistance filed on or after January 1, 2014.

(B) Definition. "Child", for the purpose of this rule, means an individual younger than age nineteen.

(C) Eligibility criteria for coverage because a newborn child was born to a medicaid-eligible woman (deemed newborn). In accordance with 42 C.F.R. 435.117 (as in effect July 1, 2014), a child is automatically eligible for medicaid as of the child's date of birth, and remains eligible until the child reaches the age of one, provided the birth mother has applied for, been determined eligible for, and is receiving medicaid on the date of the child's birth.

(1) Coverage under this paragraph also applies to newborns under the following circumstances:

(a) When labor and delivery services were furnished prior to the date of application and the birth mother's medicaid eligibility is based on retroactive coverage in accordance with 42 C.F.R. 435.915 (as in effect on July 1, 2014).

(b) While the birth mother is receiving alien emergency medical assistance (AEMA) in accordance with rule 5160:1-1-91 of the Administrative Code.

(c) While the birth mother is residing in a public institution and is:

(i) Restricted from payment of services as referenced in rule 5160:1-1-58.1 of the Administrative Code, and

(ii) Within twelve months from the date of her most recent medicaid application or redetermination.

(d) While the birth mother is in the custody of a public children services agency (PCSA) or private child placing agency (PCPA).

(e) While the birth mother is in receipt of adoption or foster care assistance under Title IV-E.

(f) While the birth mother is in receipt of state or federal adoption assistance.

(g) When the birth mother loses medicaid eligibility after the birth of the newborn.

(h) When the birth mother is no longer a member of the newborn's household at any time prior to the newborn reaching the age of one.

(2) For newborns described in this paragraph, the administrative agency must:

(a) Upon verbal or written notification of the newborn's birth from any individual or entity reporting the birth:

(i) Verify, in the electronic eligibility system, that the birth mother was eligible for and received medicaid on the date of the child's birth, and

(ii) Approve the child's eligibility for medicaid without delay and without consideration of household composition or income.

(b) Not require an application for the child or a redetermination prior to the month of the child's first birthday.

(c) Not require verification of U.S. citizenship or identity.

(d) Complete a redetermination when the child reaches the age of one.

(D) Eligibility criteria for coverage because an individual is in foster care, receives adoption assistance, or is in the custody of a PCSA or PCPA or Title IV-E agency.

(1) A child is eligible for medicaid under this rule, regardless of family size, income, or resources, when the child is in the custody of a PCSA, PCPA, or Title IV-E agency and in receipt of:

(a) Adoption or foster care assistance under Title IV-E of the Social Security Act as in effect July 1, 2014; or

(b) State or federal foster care assistance in accordance with section 1902(e)(14)(D)(i) of the Social Security Act (as in effect July 1, 2014); or

(c) State or federal adoption assistance.

(2) Child, individual, or authorized representative responsibilities. The child, the individual, or the authorized representative must:

(a) Sign and date the application;

(b) Meet the conditions of eligibility described in rule 5160:1-1-58 of the Administrative Code;

(c) Cooperate in establishing eligibility; and

(d) Report changes in accordance with rule 5160:1-1-55 of the Administrative Code.

(E) Eligibility criteria for coverage because an individual is a child under age nineteen.

(1) A child's family size and household income shall be calculated as described in rule 5160:1-1-61 of the Administrative Code.

(2) If the child is not covered by other creditable coverage, the child's household income must not exceed two hundred six per cent of the federal poverty level for the family size.

(3) If the child is covered by other creditable coverage, the child's household income for the family size must not exceed one hundred fifty-six per cent of the federal poverty level for the family size.

(4) A child receiving medical coverage under this paragraph remains eligible:

(a) Through the end of the month in which the child turns age nineteen, if the child remains otherwise eligible in accordance with rule 5160:1-1-58 of the Administrative Code; or

(b) Until the end of an inpatient stay during which inpatient services are being furnished, if the child is found eligible under this paragraph on or after his/her eighteenth birthday and turns age nineteen during the inpatient stay.

Replaces: 5160:1-1-63

Effective: 3/26/2015
Five Year Review (FYR) Dates: 03/26/2020
Promulgated Under: 111.15
Statutory Authority: 5161.02, 5161.12, 5160.02, 5163.02, 5163.40
Rule Amplifies: 5161.02, 5161.12, 5160.02, 5163.02, 5163.40
Prior Effective Dates: 10/1/13

5160:1-4-02.1 [Rescinded] Medicaid: coverage for families.

Effective: 3/26/2015
Five Year Review (FYR) Dates: 12/19/2014
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5162.03, 5163.02
Prior Effective Dates: 9/3/77, 10/26/78, 5/1/79, 9/21/79, 2/21/80, 1/1/83, 6/1/84, 10/1/84 (Emer.), 12/27/84, 1/1/85 (Emer.), 2/15/85 (Emer.), 3/12/85 (Emer.), 4/1/85, 6/10/85 (Emer.), 11/30/85, 1/3/86, 8/1/86 (Emer.), 8/1/86, 9/23/86, 10/3/86, 10/8/86, 2/13/87 (Emer.), 4/25/87, 10/1/87, 11/1/87, 1/1/88 (Emer.), 1/1/88, 6/20/88, 1/1/89 (Emer.), 2/6/89, 3/6/89, 3/28/89 (Emer.), 10/1/89, 12/16/89, 1/1/90 (Emer.), 4/1/90 (Emer.), 4/1/90, 6/20/90, 6/22/90, 10/1/91, 1/1/92, 1/1/93, 3/1/94 (Emer.), 4/18/94, 9/1/94, 9/1/95, 10/31/97 (Emer.), 12/31/97 (Emer.), 1/26/98, 3/9/98, 9/1/98, 10/1/98, 10/1/99, 11/1/99 (Emer.), 2/1/00, 7/1/00, 10/1/01, 6/1/02 (Emer.), 8/30/02, 1/1/05, 1/1/06, 1/1/08, 3/1/08, 7/17/11, 1/9/12

5160:1-4-02.2 [Rescinded] Medicaid: coverage for children.

Effective: 3/26/2015
Five Year Review (FYR) Dates: 12/19/2014
Promulgated Under: 111.15
Statutory Authority: 5161.02, 5161.12, 5160.02, 5163.02, 5163.40
Rule Amplifies: 5161.02, 5161.12, 5160.02, 5163.02, 5163.40
Prior Effective Dates: 9/3/77, 10/26/78, 5/1/79, 9/21/79, 2/21/80, 6/1/84, 10/1/84 (Emer.), 12/27/84, 1/1/85 (Emer.), 2/15/85 (Emer.), 3/12/85 (Emer.), 4/1/85, 6/10/85 (Emer.), 11/30/85, 1/3/86, 8/1/86 (Emer.), 8/1/86, 9/23/86, 10/3/86, 10/8/86, 2/13/87 (Emer.), 4/25/87, 11/1/87, 1/1/88 (Emer.), 1/1/88, 6/20/88, 1/1/89 (Emer.), 2/6/89, 3/6/89, 3/28/89 (Emer.), 5/1/89 (Emer.), 7/1/89 (Emer.), 7/8/89, 9/23/89, 10/1/89 (Emer.), 12/16/89, 1/1/90 (Emer.), 4/1/90, 4/2/90, 6/22/90, 10/1/90, 4/1/91 (Emer.), 10/1/91, 11/1/91 (Emer.), 1/1/92, 5/1/92, 6/30/92, 9/1/92, 1/1/93 (Emer.), 1/1/93, 3/18/93, 3/1/94 (Emer.), 4/18/94, 6/20/94, 9/1/94, 9/1/95, 10/31/97 (Emer.), 12/31/97 (Emer.), 1/1/98 (Emer.), 1/26/98, 3/9/98, 4/4/98, 10/1/98, 11/1/99 (Emer.), 11/1/99, 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, 9/20/03, 7/1/05, 1/1/06, 1/1/08, 7/17/11, 1/9/12

5160:1-4-02.3 [Rescinded] Medicaid: coverage for pregnant women.

Effective: 3/26/2015
Five Year Review (FYR) Dates: 12/19/2014
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5160.02, 5163.02, 5163.40
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, 7/17/11

5160:1-4-02.4 [Rescinded] Medicaid: coverage for individuals at least age nineteen and younger than age twenty-one.

Effective: 3/26/2015
Five Year Review (FYR) Dates: 12/19/2014
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5160.02, 5163.02
Prior Effective Dates: 2/1/95, 10/31/97 (Emer.), 1/26/98, 10/3/11

5160:1-4-03 MAGI-based medicaid: coverage for Ribicoff and former foster care adults.

(A) This rule describes medicaid eligibility criteria for applications for medical assistance filed on or after January 1, 2014, for individuals:

(1) Who are age nineteen or twenty, or

(2) Who aged out of foster care on their eighteenth birthday, are younger than age twenty-six, and are not eligible under rule 5160:1-4-02 of the Administrative Code.

(B) Eligibility criteria for coverage because an individual is age nineteen or twenty in accordance with 42 C.F.R. 435.222 (as in effect July 1, 2014).

(1) The individual must be age nineteen or twenty.

(2) The individual's family size and household income must be calculated as described in rule 5160:1-1-61 of the Administrative Code.

(3) The individual's household income must not exceed fourty-four per cent of the federal poverty level for the family size.

(C) Eligibility criteria for coverage because an individual aged out of foster care in accordance with section 1902(a)(10)(A)(i)(IX) of the Social Security Act (as in effect July 1, 2014).

(1) The individual must:

(a) Be at least eighteen years old and younger than twenty-six years old;

(b) Have been in foster care under the responsibility of the state on the individual's eighteenth birthday;

(c) Have been eligible for and enrolled in medicaid while in such foster care; and

(d) Cooperate in establishing eligibility, which includes signing and dating the application.

(2) Under this paragraph, there is no income test for coverage because an individual aged out of foster care.

Replaces: 5160:1-1- 63.1

Effective: 3/26/2015
Five Year Review (FYR) Dates: 03/26/2020
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5160.02, 5163.02
Prior Effective Dates: 10/1/13

5160:1-4-05 Medicaid: transitional medicaid.

(A) This rule describes transitional medical assistance (TMA), which is a covered group of individuals who lose eligibility due to earned income, as described in Section 1925 of the Social Security Act (as in effect on December 1, 2009).

(B) Eligibility criteria under this covered group.

(1) The individual must have received, or be deemed eligible for but not receiving, Ohio works first (OWF) or received low-income families (LIF) medicaid in the state of Ohio in at least three of the six months immediately preceding the month in which the individual becomes ineligible for medicaid.

(2) The family must have lost medicaid eligibility due to receipt of new earned income or increased earned income. Verification of income is not required and can be self-declared.

(3) Eligibility begins the month immediately following the last month the individual received medicaid. Any months of medicaid received in error, due to unreported earned income, are counted as months of transitional medical assistance.

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

(1) Verify in the electronic eligibility system the individual was receiving medicaid in previous months. Approve TMA if an individual meets the requirements in paragraph (B) of this rule;

(2) Deny or terminate TMA for an individual if the individual fraudulently received OWF during any of the last six months of the family's OWF eligibility;

(3) Not consider resources;

(4) Terminate or deny TMA when:

(a) There is no longer a dependent child in the family.

(b) The family becomes eligible for another medicaid covered group.

(D) Eligibility under this covered group is for twelve months. An individual who has eligibility terminated prior to the completion of the twelfth month of TMA may potentially re-establish TMA.

(1) Individuals who lose TMA eligibility and subsequently qualify for OWF or LIF medicaid may be eligible for a new period of TMA when eligibility criteria in paragraph (B) of this rule are met. There is no limit to the amount of times an individual re-establishes eligibility for TMA.

(2) Individuals who lose TMA eligibility and subsequently qualify for OWF or LIF medicaid may be eligible for the remainder of the original TMA period when only the eligibility criterion in paragraph (B)(2) of this rule is met.

Replaces: 5101:1-40-05

Effective: 01/01/2010
R.C. 119.032 review dates: 01/01/2015
Promulgated Under: 111.15
Statutory Authority: 5111.01, 5111.011
Rule Amplifies: 5111.01, 5111.011, 5111.019
Prior Effective Dates: 04/01/90 (Emer.), 06/22/90, 10/01/90, 01/01/93,
04/21/94, 10/31/97 (Emer.), 01/26/98, 06/01/02, 08/30/02, 08/04/03, 01/01/08

5160:1-4-20 [Rescinded] Medicaid: low-income families, children, and pregnant women budgeting.

Effective: 3/26/2015
Five Year Review (FYR) Dates: 12/19/2014
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5160.02, 5163.02
Prior Effective Dates: 8/1/1975, 7/1/76, 11/1/1976, 5/14/1977, 12/31/77, 10/26/78, 4/5/1979, 9/21/79, 2/3/80, 10/1/1981, 5/1/82, 12/1/1982, 12/10/82, 12/29/82, 1/13/83, 3/1/1984, 10/1/1984 (Emer.), 12/27/1984, 1/1/85 (Emer.), 4/1/85, 1/2/1986, 4/1/1986, 8/1/86 (Emer.), 10/3/86, 10/1/1987 (Emer.), 12/24/1987, 1/1/88 (Emer.), 3/28/88, 4/1/88 (Emer.), 6/30/88, 10/01/88 (Emer.), 12/20/88, 1/1/89 (Emer.), 3/6/89, 4/1/89, 4/5/89 (Emer.), 5/1/89 (Emer.), 6/18/89, 7/1/1989 (Emer.), 7/8/89, 9/23/89, 10/1/89 (Emer.), 12/16/89, 1/1/1990 (Emer.), 3/2/90, 3/22/90, 4/1/90, 4/2/90 (Emer.), 4/23/90, 6/22/90, 9/1/90 (Emer.), 10/1/90, 4/1/91 (Emer.), 5/1/91, 7/12/1991 (Emer.), 9/12/91, 9/22/1991, 6/30/92, 1/1/93 (Emer.), 3/18/93, 5/1/93, 3/01/94 (Emer.), 4/18/94, 6/20/94, 9/1/1994, 11/1/94, 3/1/95, 10/30/95, 10/31/1997 (Emer.), 1/26/98, 4/4/98, 10/1/99, 11/19/99, 1/1/00, 02/03/00, 7/1/00, 1/1/03, 6/01/02 (Emer.), 8/30/02, 6/1/03 (Emer.), 9/20/03, 1/1/05, 1/1/06, 1/1/08, 3/1/08, 1/9/12