5160:1-5-40 Medicaid: covered group eligibility for family planning services.

(A) This rule describes the state option medicaid covered group eligibility criteria for an individual seeking family planning services as described in section 1902(a)(10)(A)(ii)(XXI) of the Social Security Act (as in effect March 23, 2010). There is no resource limit for individuals described in this rule.

(B) Definitions.

(1) "Family planning related services" has the same meaning as in Chapter 5101:3-21 of the Administrative Code.

(2) "Family planning services" has the same meaning as in Chapter 5101:3-21 of the Administrative Code.

(C) Eligibility criteria. To be eligible for family planning services or family planning related services under this rule, the individual shall:

(1) Be a male or female.

(2) Meet the conditions of eligibility outlined in rule 5101:1-38-01.8 of the Administrative Code.

(3) Meet the financial eligibility requirements described in paragraph (D) of this rule.

(4) Not be otherwise eligible for medicaid.

(5) Not have creditable coverage as defined in rule 5101:1-37-01 of the Administrative Code.

(D) Financial eligibility.

(1) The net countable family income is no more than two hundred per cent of the federal poverty level (FPL) for the appropriate family size plus one.

(a) If the individual is married and living with the individual's spouse, the spouse's income shall be counted.

(b) If the individual is younger than eighteen, unmarried, and living with the individual's parent(s), the income of the parent(s) shall be counted.

(2) To determine net countable family income:

(a) Total the individual's gross, non-exempt income.

(b) Allocate income of a step-parent, parent of a minor parent, spouse of a specified relative, or non-qualified alien parent as described in rule 5101:1-38-02.3 of the Administrative Code, who is living with the individual, but is not a member of the covered group.

(i) From the step-parent, parent of a minor parent, spouse of a specified relative, or non-qualified alien parent's income, deduct the following:

(a) The first ninety dollars of the gross earned income.

(b) An amount equal to the allocation allowance standard, in accordance with Chapter 5101:1-23 of the Administrative Code, for the step-parent, parent of a minor parent, spouse of a specified relative, or a non-qualified alien parent and any other individuals living with but not members of the covered group, who are or could be claimed by the stepparent, parent of a minor parent, spouse of a specified relative, or non-qualified alien parent as dependents.

(c) The amount of verifiable payments made to those who are or could be claimed by the step-parent, parent of a minor parent, spouse of a specified relative, or non-qualified alien parent, as dependents for federal personal income tax liability, but are not living in the home.

(d) The amount of alimony or child support payments made for those not living in the home.

(ii) The remaining amount of earned and unearned income is allocated to the individual as unearned income.

(c) Apply the income exemptions and disregards described in rule 5101:1-38-01.9 of the Administrative Code, and

(d) Apply the following additional exemptions:

(i) The first fifty dollars of court-ordered child support received by the covered group.

(ii) Court-ordered child support and alimony payments made to individuals not living in the household.

(iii) Earned income of a child, who is a fulltime student as defined by the educational facility, for up to six months per calendar year, and

(e) Disregard from earned income of each employed covered group member:

(i) Up to ninety dollars for each employed covered group member.

(ii) Out of pocket dependent care costs, paid to an individual who is not a member of the covered group, for a dependent child or incapacitated adult, up to but not exceeding:

(a) Two hundred dollars per infant, under two years of age, in full-time care at twenty-five hours of care per week.

(b) One hundred seventy-five dollars per child over two years of age, or incapacitated adult, in full-time care at least twenty-five hours of care per week.

(c) One hundred twenty dollars per child or incapacitated adult, in part-time care less than twenty-five hours of care per week.

(f) Earned income disregard penalties. The disregards of earned income do not apply when:

(i) An individual terminated employment or reduced earned income without good cause within the preceding month.

(ii) An individual refused a bona fide offer of employment within the preceding month without good cause.

(iii) An individual failed to timely report income in accordance with rule 5101:1-38-01.2 of the Administrative Code, without good cause.

(E) Administrative agency responsiblities. The administrative agency shall:

(1) Compare the net countable family income to two hundred per cent of the federal poverty level (FPL) for the appropriate family size plus one.

(2) Redetermine eligibility for family planning services annually in accordance with rule 5101:1-38-01.2 of the Administrative Code.

(3) Complete a pre-termination review (PTR) of continuing medicaid eligibility in accordance with rule 5101:1-38-01.2 of the Administrative Code.

(4) Issue proper notice and hearing rights as outlined in division 5101:6 of the Administrative Code.

(F) Individuals receiving services under this covered group shall receive a fee-for-service medicaid card. Individuals eligible under this rule shall receive a limited benefit package described in rules 5101:3-21-02 and 5101:3-21-02.3 of the Administrative Code and shall not be covered by a managed care plan described in Chapter 5101:3-26 of the Administrative Code.

(G) Retroactive coverage is available for this program in accordance with rule 5101:1-38-01.2 of the Administrative Code, but coverage shall not begin prior to the effective date of this rule and shall not provide reimbursement of services rendered prior to the effective date of this rule.

Effective: 01/08/2012
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 111.15
Statutory Authority: 5111.01 , 5111.011
Rule Amplifies: 5111.01 , 5111.011