(A) This rule governs the eligibility requirements for the medical assistance programs authorized under sections 1902(a)(10)(A)(ii)(XV) and (XVI) of the Social Security Act (as in effect on May 1, 2016 ). Medicaid buy-in for workers with disabilities (MBIWD) enables certain individuals to increase their income and resources without the risk of losing medical assistance coverage.
(1) "Basic covered group" means the individuals meeting all criteria in paragraph (C)(1) of this rule.
(2) "Blind work expense (BWE)" has the same meaning as in rule 5160:1-3- 03.2 of the Administrative Code.
(3) "Countable income," for the purpose of this rule, means income less exclusions.
(4) "Countable resources," for the purpose of this rule, means those resources remaining after all exclusions have been applied.
(5) "Earned income," is defined in rule 5160:1-2-01.9 of the Administrative Code.
(6) "Family," for the purpose of this rule, means an individual, the individual's spouse, and dependent children living in the household of the individual. If an individual is younger than eighteen years of age, "family" also means the individual's parents.
(7) "Impairment-related work expense (IRWE)" as defined in 20 C.F.R. 404.1576 (as in effect on May 1, 2016 ).
(8) "Income," for the purpose of this rule, means gross earned income and gross unearned income.
(9) "Individual," for the purpose of this rule, means the applicant for or participant in MBIWD.
(10) "Individual with a medically improved disability" means an individual who is participating in the MBIWD basic covered group but who no longer meets the disability criterion as defined in paragraph (C)(1)(c) of this rule.
(11) "Medicaid buy-in for workers with disabilities (MBIWD)" means the component of the medicaid program established under sections 5163.09 to 5163.098 of the Revised Code and includes the basic covered group and the medically improved covered group.
(12) "Medical and remedial expense (MRE)" means an incurred expense for care, services, or goods prescribed or provided by a licensed medical practitioner within the scope of practice as defined under state law. This expense is the responsibility of the individual, and cannot be reimbursed by any other source, such as medicaid, private insurance, or an employer.
(13) "Medical insurance premiums" means the amount paid for insurance coverage for medical items or services such as health, dental, vision, long-term care, hospital, prescriptions, etc.
(14) "Medically improved covered group" means the individuals meeting all criteria in paragraph (C)(2) of this rule.
(16) "Resource" means cash, personal property, and real property an individual has an ownership interest in and legal ability to access in order to convert to cash.
(18) "Social security disability insurance (SSDI)" means the program established under Title II of the Social Security Act (as in effect on May 1, 2016 ).
(19) "Spouse" means a person legally married under Ohio law.
(20) "Supplemental security income program (SSI)" means the program established under Title XVI of the Social Security Act (as in effect on May 1, 2016 ).
(21) "Unearned income" is defined in rule 5160:1-2-01.9 of the Administrative Code.
(22) "Work" or "working," for the purpose of this rule, means full or part-time employment or self-employment from which state or federal income and payroll taxes are paid or withheld.
(C) Eligibility criteria.
(1) To be eligible for the MBIWD basic covered group an individual must:
(a) Meet the citizenship requirements outlined in rule 5160:1-2-11 of the Administrative Code;
(b) Be a resident of Ohio as set forth in rule 5160:1-2-10 of the Administrative Code;
(c) Meet the definition of disability used by the social security administration (SSA), except that employment, earnings, and substantial gainful activity must not be considered when determining whether the individual meets the disability criterion for MBIWD. An individual may be eligible for MBIWD regardless of whether the individual is receiving SSI or SSDI;
(d) Be at least sixteen years of age but younger than sixty-five years of age;
(e) Meet the financial eligibility requirements described in paragraph (D) of this rule;
(f) Pay the premium, as calculated in paragraph (E) of this rule; and
(g) Be working.
(2) To be eligible for the MBIWD medically improved covered group an individual must:
(a) Have participated in the MBIWD basic covered group as defined in paragraph (C)(1) of this rule the previous calendar month and continue to meet all eligibility criteria described in paragraph (C) of this rule except that the individual no longer meets the disability criterion defined in paragraph (C)(1)(c) of this rule; and
(b) Work at least forty hours per month earning at least state or federal minimum wage, whichever is lower.
(3) An individual participating in MBIWD with a medically improved disability, whose medical condition is determined to have regressed may be reevaluated for the MBIWD basic covered group in accordance with paragraph (C)(1) of this rule.
(4) If the individual is eligible for MBIWD under the basic or medically improved group and ceases to work, the individual may continue to participate in MBIWD for up to six months beginning the first day of the month after the month the individual is no longer working when:
(a) The individual intends to return to work or look for a new job; and
(b) The individual continues to pay MBIWD premiums, if applicable; and
(c) The individual continues to meet all other eligibility requirements for MBIWD.
(D) Financial eligibility.
(1) For the purpose of determining whether an individual is income eligible for MBIWD, the administrative agency must compare the individual's countable income to the two hundred fifty per cent federal poverty level (FPL) for one person. Only the individual's income is considered when determining eligibility for MBIWD.
(a) From the individual's income, apply exclusions in accordance with rule 5160:1-3- 03.2 of the Administrative Code.
(b) If the amount determined in paragraph (D)(1)(a) of this rule is no more than two hundred fifty per cent of the FPL, the individual meets the income eligibility requirement for MBIWD.
(c) If the amount determined in paragraph (D)(1)(a) of this rule exceeds two hundred fifty per cent of the FPL:
(i) An additional annual amount up to twenty thousand dollars of earned income shall be excluded.
(ii) The twenty thousand dollar earned income exclusion may be applied wholly or in part in any month to reduce the individual's countable income below two hundred fifty per cent of the FPL. This exclusion begins the first month the individual would otherwise be eligible for MBIWD and continues within the year until the twenty thousand dollars is exhausted.
(2) For the purpose of determining whether an individual meets the resource eligibility requirement for MBIWD, an individual's countable resources must not exceed the resource eligibility limit for MBIWD as defined in paragraph (B) of this rule.
(a) Only the individual's resources are considered when determining resource eligibility for MBIWD. In the case of resources which are jointly owned, the administrative agency must consider the total amount of the resource available to the individual in accordance with rule 5160:1-3-05.1 of the Administrative Code.
(b) For the purposes of determining resource eligibility for MBIWD, resources in accordance with rule 5160:1-3-05.14 of the Administrative Code are excluded.
(c) Retirement funds are evaluated in accordance with rule 5160:1-3-03.10 of the Administrative Code.
(E) Premium calculation. An individual eligible for MBIWD whose individual income exceeds one hundred fifty per cent of the FPL for one person must pay a premium determined as follows (rounded down to the nearest dollar at each step):
(1) From the gross annual family income at the time of application and subsequent renewals for MBIWD, the administrative agency shall subtract one hundred fifty per cent of the FPL for the family size;
(2) From the amount determined in paragraph (E)(1) of this rule, the administrative agency shall subtract the individual's IRWE, BWE, and/or MRE;
(3) Multiply the amount determined in paragraph (E)(2) of this rule by ten per cent.
If the family's income is less than four hundred fifty per cent of the FPL (applicable to the family size), the premium cannot exceed seven and one half per cent of the individual's income;
(4) From the amount determined in paragraph (E)(3) of this rule, the administrative agency must subtract the amount of medical insurance premiums, including medicare premiums, paid by the family; and
(5) Divide the amount determined in paragraph (E)(4) of this rule by twelve and round down to the nearest whole dollar. This is the individual's monthly premium.
(F) The individual's monthly premium obligation begins the month following the month
MBIWD coverage is authorized, and is due and payable in full no later than the due date established by the administrative agency.
(1) Partial payments do not satisfy the eligibility criterion in paragraph (C)(1)(f) of this rule.
(2) Partial payments and payments in full received after the due date established by the administrative agency are applied to the most delinquent premium.
(3) An individual who fails to pay a premium in full for two consecutive months will be subject to eligibility termination for MBIWD.
(4) An individual who loses eligibility for MBIWD due to non-payment of premiums and reapplies for MBIWD must:
(a) Meet all criteria in paragraph (C)(1) of this rule; and
(b) Pay all delinquent premiums for those months prior to MBIWD termination.
(5) Individuals who are eligible for retroactive coverage in accordance with rule 5160:1-2-01 of the Administrative Code are not required to pay a monthly premium for the months of retroactive coverage.
(G) Receipt of long-term care services in a long-term care facility, under a home and community-based services (HCBS) waiver program, or under the program of all-inclusive care for the elderly (PACE) is not a cause for termination or denial of an individual's eligibility for MBIWD.
(H) Related long-term care rules:
(1) Individuals eligible for MBIWD are not subject to a patient liability as described in rule 5160:1-3-04.3 or 5160:1-3- 04.4 of the Administrative Code.
(2) When an individual eligible for MBIWD, or the individual's spouse, becomes institutionalized, the resource assessment and transfer of asset provisions of rules 5160:1-3-06.3 and 5160:1-3- 07.2 of the Administrative Code apply.
(I) Individual responsibilities. The individual shall:
(1) Provide the information necessary to establish eligibility, cooperate in the verification process, and report changes in accordance with rule 5160:1-2-08 of the Administrative Code.
(2) Pay premiums determined by the administrative agency in accordance with this rule.
(J) Administrative agency responsibilies. The administrative agency shall:
(2) Determine eligibility for MBIWD as described in this rule.
(3) Determine the premium for MBIWD as identified in paragraph (E) of this rule, and redetermine this premium during the individual's annual renewal or whenever the individual reports a decrease in income.
(4) Verify disability in accordance with paragraph (C)(1)(c) of this rule.
(5) Explore eligibility for qualified medicare beneficiary (QMB) and specified low income medicare beneficiary (SLMB) programs in accordance with Chapter 5160:1-3 of the Administrative Code. MBIWD individuals are not eligible for qualified individual (QI-1) or qualified working disabled individual (QWDI) medicare premium assistance programs.
Five Year Review (FYR) Dates: 03/23/2020
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5160.02, 5163.02 , 5163.091, 5163.092, 5163.093, 5163.094, 5163.095, 5163.096, 5163.097, 5163.098
Prior Effective Dates: 4/1/08, 3/23/15