5160:1-2-03 Medicare buy-in.

(A) This rule sets forth:

(1) The eligibility criteria for benefits under the medicare part B buy-in agreement between the social security administration (SSA) and the Ohio department of job and family services (ODJFS), which allows ODJFS to pay medicare part B (supplemental medical insurance) premiums for certain medicaid-eligible individuals even if those individuals are not eligible for a medicare premium assistance program (MPAP) set out in rule 5101:1-39-01.1 of the Administrative Code; and

(2) The beginning date of payment of medicare part A (part A) or medicare part B (part B) benefits under this rule; and

(3) The date and effect of termination of benefits under the medicare buy-in or an MPAP; and

(4) The process of coordinating enrollment with ODJFS and the SSA.

(B) Definitions.

(1) "Medicare buy-in" means the program and process of paying part A or part B benefits on behalf of an eligible individual.

(2) "MPAP" means any or all of the medicare premium assistance programs defined in rule 5101:1-39-01.1 of the Administrative Code.

(3) "Part B buy-in" means the agreement under which ODJFS pays part B premiums on behalf of individuals even if those individuals are not eligible for benefits under rule 5101:1-39-01.1 or 5101:1-39-01.2 of the Administrative Code.

(4) "SSA" means the social security administration.

(C) Eligibility criteria. To be eligible for payment of the part B premium under the medicare buy-in agreement, an individual must meet all three of the following requirements:

(1) Be eligible for part B.

(2) Be eligible for a category of medicaid other than:

(a) Medicaid with a spenddown calculated under rule 5101:1-39-10 of the Administrative Code; or

(b) Breast and cervical cancer project medicaid as set forth in rule 5101:1-41-01 of the Adminstrative Code; or

(c) Expedited medicaid as set forth in rule 5101:1-40-60 of the Administrative Code.

(3) Be receiving at least one of the following:

(a) Medicare premium assistance under rule 5101:1-39-01.1 of the Administrative Code.

(b) One of the following kinds of cash assistance:

(i) Ohio works first (OWF); or

(ii) Supplemental security income (SSI); or

(iii) Residential state supplement.

(c) Four-month extended coverage as set forth in Chapter 5101:1-40 of the Administrative Code.

(d) Grandfathered medicaid as set forth in rule 5101:1-39-02 of the Administrative Code.

(e) Foster care maintenance payments or adoption assistance payments as set forth in rule 5101:1-40-03 of the Administrative Code.

(f) Medicaid as a result of section 1619(b) of the Social Security Act (as in effect on January 1, 2010) as set forth in rule 5101:1-39-02.3 of the Administrative Code.

(g) Deemed OWF as set forth in Chapter 5101:1-40 of the Administrative Code.

(h) Long-term care services in a Title XIX certified nursing facility (NF) or intermediate care facility for the mentally retarded (ICF-MR).

(i) Home and community-based (HCB) services, including the program of all inclusive care for the elderly (PACE), under a waiver described in division 5101:3 of the Administrative Code.

(D) Coordination of enrollment. If an individual is eligible for benefits under this rule or rule 5101:1-39-01.1 or 5101:1-39-01.2 of the Administrative Code, or would be eligible if the individual were enrolled in part A or part B, the county department of job and family services(CDJFS) shall coordinate the individual's receipt of benefits.

(1) If the individual:

(a) Is or has ever been in receipt of part A or part B benefits, the CDJFS shall approve MPAP or part B buy-in benefits for the individual in the electronic eligibility system.

(b) Has never received part A or part B benefits, the CDJFS shall:

(i) Inform the individual that the Ohio department of job and family services (ODJFS) can not pay medicare premiums until the individual has enrolled in part A or part B through the SSA; and

(ii) Advise the individual to apply for part A or part B benefits, and advise the individual that the CDJFS will assist upon request; and

(iii) Advise the individual to report the approval of part A or part B benefits to the CDJFS immediately, so payment of premiums can be approved; and

(iv) Approve MPAP or part B buy-in benefits for the individual in the electronic eligibility system upon being informed that the individual has been enrolled by the SSA in part A or part B.

(2) After three weeks, if the electronic submission was not successful, the CDJFS shall submit a completed JFS 07102 "Changes in Medicaid Health Coverage Date and Medicare Buy-In Eligibility" (rev. 11/2007) to the ODJFS buy-in unit.

(E) Coverage period.

(1) Start date.

(a) For MPAP benefits under rule 5101:1-39-01.1 of the Administrative Code or for QDWI under rule 5101:1-39-01.2 of the Administrative Code, the beginning date for payment of premiums is addressed in those rules. If an individual is eligible for MPAP benefits under rule 5101:1-39-01.1 of the Administrative Code and also eligible for part B buy-in under this rule, payment of part B premiums begins on the earlier of the coverage date under rule 5101:1-39-01.1 of the Administrative Code or the coverage date under this rule.

(b) For individuals eligible for payment of premiums under the part B buy-in agreement, eligibility begins:

(i) The first month an individual is eligible for both medicare and cash assistance as defined in paragraph (C)(3)(b) of this rule; or

(ii) The first day of the second month after the administrative agency made the determination the individual was eligible for medicaid, if the individual is not in receipt of cash assistance as defined in paragraph (C)(3)(b) of this rule.

(2) Termination date. Eligibility for payment of medicare premiums under this rule, rule 5101:1-39-01.1 of the Administrative Code, or rule 5101:1-39-01.2 of the Administrative Code ends on the earliest of the following dates:

(a) The last day of the month in which the individual dies; or

(b) The last day of the last month in which the individual is entitled to part B benefits; or

(c) The last day of the last month in which the individual meets the eligibility criteria for MPAP, QDWI, or medicare part B buy-in benefits, if notice was provided to the centers for medicare and medicaid (CMS) no later than the twenty-fifth day of the second month of ineligibility; or

(d) The last day of the second month before CMS received notice the individual was no longer eligible for MPAP, QDWI, or medicare part B buy-in benefits, if notice was not provided within the time limit in paragraph (E)(2)(c) of this rule.

(F) Retroactive termination. An individual's part B premium payment under buy-in can be terminated retroactively for as many as two months before the state's notice to CMS that the individual is no longer eligible.

(1) After CMS receives notice from ODJFS, CMS sends the individual a notice stating the individual is responsible for paying part B premiums beginning with the month following the last month of buy-in coverage. Because of administrative delays, an individual can already be in the third month after buy-in termination and owe three months of part B premiums before receiving notice that buy-in coverage has been terminated.

(2) The individual may request equitable relief from CMS under certain conditions specified by CMS in its notice.

Replaces:

5101:1-38-03

Effective: 01/01/2010
R.C. 119.032 review dates: 01/01/2015
Promulgated Under: 111.15
Statutory Authority: 5111.01
Rule Amplifies: 5111.01 , 5111.011
Prior Effective Dates: 8/15/1982, 10/1/2002