(A) This rule describes the twelve-month period of continuous eligibility for a child younger than age nineteen, and the conditions under which the child's coverage ends during the twelve-month period, as described in section 1902(e)(12) of the Social Security Act (as in effect on January 1, 2016 ).
(B) Eligibility criteria. A child remains eligible for coverage despite changes in the child's circumstances for a period of twelve months if the child was found to be eligible for a category of medical assistance other than:
(1) Presumptive eligibility as described in Chapter 5160:1-1 or Chapter 5160:1-2 of the Administrative Code;
(3) Refugee medical assistance as described in rule 5160:1-5-05 of the Administrative Code.
(1) A child's twelve-month period of continuous eligibility begins:
(a) On the date that medical assistance began as a result of an initial determination or annual renewal in accordance with rule 5160:1-2-01 or rule 5160:1-2-01.2 of the Administrative Code,
(b) Without regard to any months of retroactive eligibility.
(2) The child's coverage shall be terminated during the continuous eligibility period only:
(a) Upon oral or written request of the child (if the child is at least eighteen years old) or the child's representative; or
(b) When the child:
(i) No longer resides in the state of Ohio; or
(ii) Dies; or
(iii) Has not paid the premium amounts required for coverage, if the child is covered under the medicaid buy-in for workers with disabilities category described in rule 5160:1-5-03 of the Administrative Code; or
(iv) Reaches age nineteen.
(D) Patient liability, or premium. A patient liability or premium calculated for a child in accordance with Chapters 5160:1-3 to 5160:1-6 of the Administrative Code shall not increase during the child's continuous coverage period. Any decrease in a child's patient liability or premium results in a new maximum amount, which will not increase for the remainder of the child's continuous coverage period.
(E) Regardless of a child's status under this rule, payment for services shall not be made if payment is prohibited under rule 5160:1-1-05 of the Administrative Code.
Replaces: 5160:1-1- 63.2
Five Year Review (FYR) Dates: 08/01/2021
Promulgated Under: 111.15
Statutory Authority: 5162.031, 5163.02
Rule Amplifies: 5163.02 , 5163.03
Prior Effective Dates: 4/1/10 (Emer.), 7/1/10, 10/15/10, 1/1/14