Chapter 5160:1-4 Medicaid for the MAGI Covered Groups

5160:1-4-01 MAGI-based medicaid: income and household income.

(A) This rule describes how an individual's or household's income is calculated under 42 C.F.R. 435.603 (as in effect on September 1, 2013) when determining an individual's eligibility for applications for medical assistance. This rule does not apply to determinations for the following categories of eligibility:

(1) For which an individual must be at least age sixty-five; or

(2) For which an individual must be found to be blind or disabled; or

(3) Which cover only an individual's medicare premium or cost-sharing.

(B) Definition. "Person," for the purpose of this rule, means someone in the family or household of an individual applying for or receiving medical assistance.

(C) Determining household composition and family size.

(1) For each individual, the administrative agency must follow the requirements and definitions set out to determine household composition and family size. For the tax year in which the eligibility determination is being made:

(a) If an individual expects to file a tax return and does not expect to be claimed as a tax dependent, the household composition is determined under 42 C.F.R. 435.603(f)(1) (as in effect on September 1, 2013).

(b) If an individual expects to be claimed as a tax dependent, the household composition is determined under 42 C.F.R. 435.603(f)(2) (as in effect on September 1, 2013) unless the individual meets one of the exceptions set out in the subparagraphs of that section.

(c) Household composition is determined under 42 C.F.R. 435.603(f)(3) (as in effect on September 1, 2013) if the individual:

(i) Does not expect to file taxes or to be claimed as a tax dependent, or if it is unclear whether the individual will be claimed as a tax dependent; or

(ii) Meets one of the exceptions set out in a subparagraph of 42 C.F.R. 435.603(f)(2) (as in effect on September 1, 2013).

(2) When determining the family size of a household containing at least one pregnant woman, each pregnant woman is counted as herself plus:

(a) One; or

(b) The number of verified fetuses, if a doctor or nurse has provided a statement verifying a woman's pregnancy, including the expected date of confinement and the number of unborn fetuses.

(3) When determining the household of a married couple who live together, each spouse will always be considered a part of the other spouse's household, regardless of tax filing status and regardless of whether either spouse is claimed as a tax dependent.

(4) When determining the household, if a parent, whether a natural parent, step-parent or adopted parent and a child, whether a natural child, step-child, or adopted child, live together, the parent will always be considered a part of the child's household, regardless of tax filing status and regardless of whether the child is claimed as a tax dependent.

(D) Determining household income.

(1) The administrative agency must follow the requirements and definitions set forth in 42 C.F.R. 435.603 (as in effect on September 1, 2013) to determine the MAGI-based income, as set forth in 42 C.F.R. 435.603(e) (as in effect on September 1, 2013) of:

(a) The individual, and

(b) Each person in the individual's household.

(2) The individual's household income is the sum of the individual's MAGI-based income plus the MAGI-based income of each person in the individual's household, excluding only income from an individual who is:

(a) Included in the household of his or her natural, adopted or step parent; or

(b) A tax dependent who meets the definition of a qualifying child or qualifying relative under 26 U.S.C. 152 (as in effect on September 1, 2013); and

(c) Not expected to be required to file a tax return under section 6012(a)(1) of the Internal Revenue Code (as in effect on September 1, 2013) for the taxable year in which eligibility for medical assistance is being determined, whether or not the individual files a tax return.

(3) Before comparing an individual's household income to the highest income standard under which the individual may be determined eligible using MAGI-based methodologies, deduct a dollar amount equal to five per cent of the federal poverty level (FPL) for the individual's family size.

Effective: 8/1/2016
Five Year Review (FYR) Dates: 04/15/2016 and 08/01/2021
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02
Prior Effective Dates: 10/1/13, 1/1/16

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.

(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 5160:1-5-06 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 5160:1-1-03 of the Administrative Code, and

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

(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 renewal prior to the month of the child's first birthday.

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

(d) Complete a renewal 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 5160:1-2-10 of the Administrative Code;

(c) Cooperate in establishing eligibility; and

(d) Report changes in accordance with rule 5160:1-2-08 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 5160:1-4-01 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 5160:1-2-10 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.

Effective: 1/1/2016
Five Year Review (FYR) Dates: 03/26/2020
Promulgated Under: 111.15
Statutory Authority: 5161.02, 5161.12, 5160.02, 5162.03, 5163.02, 5163.40
Rule Amplifies: 5161.02, 5161.12, 5160.02, 5162.03, 5163.02, 5163.40
Prior Effective Dates: 10/1/13, 3/26/15

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 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 5160:1-4-01 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.

Effective: 1/1/2016
Five Year Review (FYR) Dates: 03/26/2020
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5162.03, 5163.02
Rule Amplifies: 5160.02, 5162.03, 5163.02
Prior Effective Dates: 10/1/13, 3/26/15

5160:1-4-04 MAGI-based medicaid: coverage for pregnant women.

(A) This rule describes eligibilty for pregnant women as described in 42 C.F.R. 435.116 (as in effect on April 1, 2013) for applications for medical assistance.

(B) Eligibility criteria for coverage because a woman is pregnant.

(1) The individual must be female and pregnant. Unless the administrative agency has information contradicting an individual's statement, the individual's statement is sufficient verification of her pregnancy.

(2) The woman's household income must not exceed two hundred per cent of the federal poverty level for the family size.

(C) Eligibility span for pregnant women.

(1) Once established, eligibility for a pregnant woman continues throughout her pregnancy and postpartum period.

(2) A woman is eligible for postpartum coverage if she was 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 who is determined eligible for retroactive coverage of the labor and delivery services as described in rule 5160:1-2-01 of the Administrative Code.

(D) Administrative agency responsibilities. The administrative agency must:

(1) Calculate a pregnant woman's family size and household income as described in rule 5160:1-4-01 of the Administrative Code.

(2) Inform a pregnant woman who has indicated that she is carrying more than one fetus that she may have to provide verification of pregnancy if the increase in family size makes her income-eligible for medicaid.

(3) Not terminate eligibility for a pregnant woman during her pregnancy or postpartum period unless the woman dies, moves out of state, or requests that coverage be terminated.

(E) Individual responsibilities. The individual must provide medical verification of pregnancy, only if necessary for income eligibility by increasing the family size.

Replaces: 5160:1-1-64

Effective: 1/1/2016
Five Year Review (FYR) Dates: 01/01/2021
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02, 5163.40
Prior Effective Dates: 10/1/13

5160:1-4-05 MAGI-based medicaid: coverage for a parent or caretaker relative residing with a child.

(A) This rule describes eligibilty for parents and caretaker relatives residing with children as described in 42 C.F.R. 435.110 (as in effect on July 1, 2015).

(B) Eligibility criteria for coverage because an individual is a parent or caretaker relative residing with a child.

(1) The individual must be residing with a dependent child under the age of eighteen. An individual is considered to be residing with the child even if the child is temporarily absent with the intent to return home.

(2) The individual must be the child's parent or caretaker relative, or a spouse residing with the child's parent or caretaker relative.

(3) An individual must not be subject to an OWF sanction, unless the individual has agreed to comply with the work activity. The sanctioned individual shall regain medicaid eligibility beginning on the first day of the month in which the individual agrees to comply with the work activity.

(4) The individual's household income must not exceed ninety per cent of the federal poverty level for the family size.

(C) Transitional medical assistance (TMA) or extended medical assistance (EMA).

(1) To be eligible for TMA or EMA an individual must have:

(a) Been eligible for and enrolled in medicaid:

(i) For at least three of the six months immediately preceding the loss of eligibility; and

(ii) As a parent or caretaker relative eligible under paragraph (B) of this rule.

(b) Become ineligible for medicaid under this rule as a result of:

(i) Earned income, to be eligible for the first six-month period of TMA. Verification of increased income is not required and can be self-declared.

(ii) Increased collection of spousal support, to be eligible for EMA. Verification of increased income is not required and can be self-declared.

(2) Duration of eligibility.

(a) A parent or caretaker relative is eligible for:

(i) Four months of EMA beginning the month immediately following the last month the individual had income below the threshold for coverage as a parent or caretaker relative. Any months of medicaid received in error due to unreported income are counted as months of EMA.

(ii) Up to two six-month periods of TMA.

(a) The first six-month period of TMA beginning the month immediately following the last month the individual had income below the threshold for coverage as a parent or caretaker relative. Any months of medicaid received in error due to unreported income are counted as months of TMA.

(b) The second six-month period of TMA beginning the month immediately following the completion of the first six-month period when the parent or caretaker relative:

(i) Received continuous TMA for the entire first six-month period; and

(ii) Met the quarterly request for financial information requirements for the first six-month period described in paragraph (D) of this rule; and

(iii) Has average gross monthly income minus employment-related child care expenses (if applicable) that does not exceed one hundred eighty-five per cent of the federal poverty level for the family size.

(3) Resuming interrupted spans of eligibility.

(a) Individuals whose span of TMA was interrupted because the individual became eligible for coveage under paragraph (B) of this rule is eligible for a new span of TMA if the individual subsequently loses eligbility under paragraph (B) of this rule due to increase in earned income and meets the critieria in paragraph (C)(1)(a) of this rule.

(b) Individuals whose span of TMA was interrupted because the individual became eligible for coverage under paragraph (B) of this rule is eligible for any remaining months of the original TMA span if the individual subsequently loses eligiblity under paragraph (B) of this rule due to an increase in earned income.

(4) Repeated spans of eligibility. There is no limit to the number of times an individual may receive coverage under TMA or EMA, provided the individual meets all of the relevant criteria for the coverage each time.

(D) Quarterly request for financial information for TMA. The parent or caretaker relative must report quarterly income and child care expenses (if applicable) to the administrative agency by the fifth business day of the fourth, seventh, and tenth months of TMA coverage.

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

(1) Calculate a parent's or caretaker relative's family size and household income as described in rule 5160:1-4-01 of the Administrative Code for parent or caretaker relative eligibility.

(2) Send a quarterly request for financial information to the parent or caretaker relative no later than the third week of the third, sixth, and ninth month of TMA coverage.

(3) Update the electronic eligibility system with information reported from the quarterly request for financial information.

(4) Determine eligibility for the second six-month period of TMA.

(5) Consider an individual's eligibility for TMA or EMA as part of the renewal and pre-termination review processes described in rule 5160:1-2-01 of the Administrative Code.

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

(b) Deny or terminate TMA or EMA when:

(i) There is no longer a dependent child under the age of eighteen residing with the parent or caretaker relative, or

(ii) The parent or caretaker relative:

(a) Becomes eligible for another medicaid covered group, or

(b) No longer has earned income for TMA, or

(c) No longer collects spousal support for EMA, or

(d) Fails to report quarterly income and child care expenses (if applicable) for TMA, or

(e) Is over income for the second six-month period of TMA, or

(f) Receives four months of EMA, or

(g) Receives twelve months of TMA.

Replaces: 5160:1-1-65, 5160:1-4-05

Effective: 1/1/2016
Five Year Review (FYR) Dates: 01/01/2021
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02
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, 1/1/10, 10/1/13

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