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This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Chapter 5160:1-4 | Medicaid for Families and Children

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

(A) This rule describes household composition and income calculations under 42 C.F.R. 435.603 (as in effect October 1, 2020) when determining an individual's eligibility for modified adjusted gross income (MAGI) based medical assistance. This rule does not apply to determinations for categories of medical assistance on the basis of age, blindness, or disability, or which only cover 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 the tax year in which the eligibility determination is being made, household composition and family size are determined for each individual as follows:

(a) If an individual expects to file a federal income tax return and does not expect to be claimed as a tax dependent, the household composition is the individual, the individual's spouse if they live together, and all persons whom the individual expects to claim as a tax dependent as determined under 42 C.F.R. 435.603(f)(1) (as in effect October 1, 2020).

(b) If an individual expects to be claimed as a tax dependent, the household composition is the taxpayer, the taxpayer's spouse if they live together, the individual, and all other persons whom the taxpayer expects to claim as a tax dependent as determined under 42 C.F.R. 435.603(f)(2) (as in effect October 1, 2020), unless the individual meets one of the following exceptions:

(i) The individual is a tax dependent of someone other than a spouse or parent.

(ii) The individual is a child under the age of nineteen living with both parents who do not expect to file taxes jointly.

(iii) The individual is a child under the age of nineteen who expects to be claimed as a tax dependent by a non-custodial parent.

(c) If an individual does not expect to file a federal income tax return or to be claimed as a tax dependent, or it is unclear if the individual will be claimed as a tax dependent, the household composition is determined under 42 C.F.R. 435.603(f)(3)(as in effect October 1, 2020) as follows:

(i) If the non-filer is an adult, the household includes the individual, the individual's spouse if living together, and the individual's children under the age of nineteen.

(ii) If the non-filer is a child under the age of nineteen, the household includes the individual, the individual's parents if living with the individual, and the individual's siblings under the age of nineteen if living with the individual.

(a) If the individual (non-filer child) is married, the spouse of the individual is also included in the household.

(b) If the individual (non-filer child) has children, the individual's children are also included in the household.

(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 indicated fetuses. The pregnant woman is to provide a statement from a doctor or nurse verifying the pregnancy, including the expected date of confinement and the number of unborn fetuses (if greater than one), if the increase in family size makes her income-eligible for medical assistance.

(3) When determining the household of a married couple who live together, each spouse will always be included in 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 of a natural, adoptive, or step-parent and a child who live together, the parent will always be included in 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) MAGI-based income is determined in accordance with 42 C.F.R. 435.603 (as in effect October 1, 2020) for:

(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 the income from the following individuals who are not expected to be required to file a tax return under section 6012(a)(1) of the Internal Revenue Code (as in effect October 1, 2020) for the taxable year in which eligibility is being determined for medical assistance, whether or not the individual files a tax return:

(a) A child included in the household of his or her natural, adoptive, 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 October 1, 2020).

(3) Reasonably predictable changes (RPC) methodology. To account for a reasonably predictable increase or decrease in future income, such as recurring seasonal or temporary employment, the projected income is to be prorated equally over a twelve-month period, in accordance with 42 C.F.R. 435.603(h)(3) (as in effect October 1, 2020). A reasonably predictable increase or decrease in income is to be verified by a signed employment contract, a history of predictable fluctuations in income, or other clear indication of the future income change. If verification of the future change is not available, the individual's self-attestation may be used.

(4) Qualified lottery winnings and qualified lump-sum income, in the amount of eighty thousand dollars or more, which are received in a single payment on or after January 1, 2018, are counted as income in the month received and over a period up to one hundred twenty months under the Bipartisan Budget Act (BBA) of 2018 (Pub. L. No. 115-97). The total winnings are divided into equal installments over each month as described:

(a) Lottery winnings up to the amount of seventy-nine thousand nine hundred ninety-nine dollars and ninety-nine cents are only counted in the month received.

(b) Lottery winnings between the amounts of eighty thousand dollars and eighty-nine thousand nine hundred ninety-nine dollars and ninety-nine cents are counted equally over a two-month period.

(c) Lottery winnings between the amounts of ninety thousand dollars and ninety-nine thousand nine hundred ninety-nine dollars and ninety-nine cents are counted equally over a three-month period.

(d) For each additional ten thousand dollars received in lottery winnings, above the amount of ninety-nine thousand nine hundred ninety-nine dollars and ninety-nine cents, add one month to the countable time period, up to a maximum of one hundred twenty months, and equally count the winnings in each month.

(5) Nominal payments to a parent mentor who is trained to assist families with children who do not have health insurance coverage and who is working with a grantee organization under section 2113 of the Social Security Act (as in effect October 1, 2020), are excluded as income under the Helping Ensure Access for Little ones, Toddlers, and Hopeful Youth by Keeping Insurance Delivery Stable (HEALTHY KIDS) Act (Pub. L. No. 115-120).

(6) Alimony payments.

(a) Alimony payments received as a result of a new divorce or separation agreement finalized after December 31, 2018, are not considered income to the recipient for MAGI budgeting under the Tax Cuts and Jobs Act (Pub. L. No. 115-97).

(b) Alimony payments received as a result of a divorce or separation agreement modified after December 31, 2018, are not considered income to the recipient for MAGI budgeting only if the modification was for the purpose of the Tax Cuts and Jobs Act (Pub. L. No. 115-97).

(7) Student loan debt discharged due to the death or permanent and total disability of the student is not included as income for MAGI budgeting for tax years 2018 through 2025 under the Tax Cuts and Jobs Act (Pub. L. No. 115-97).

(8) The following deductions are not allowable for MAGI budgeting under the Tax Cuts and Jobs Act (Pub. L. No. 115-97):

(a) Moving expenses for tax years 2018 to 2025, except for specified active duty military.

(b) Alimony paid under a new divorce or separation agreement finalized after December 31, 2018.

(c) Alimony paid under a divorce or separation agreement modified after December 31, 2018, if the modification was for the purpose of the Tax Cuts and Jobs Act.

(d) Tuition and fees for qualified education expenses for postsecondary education. Scholarships, awards, or fellowship grants used for education purposes and not for living expenses are still excluded as income as described in 42 C.F.R. 435.603(e)(2) (as in effect October 1, 2020).

(9) 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.

Last updated July 1, 2021 at 9:51 AM

Supplemental Information

Authorized By: 5162.03, 5163.02
Amplifies: 5162.03, 5163.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 10/1/2013, 8/1/2016
Rule 5160:1-4-02 | MAGI-based medicaid: coverage for children younger than age nineteen.
 

(A) This rule describes the eligibility criteria for a child from birth until the individual reaches nineteen years of age in accordance with 42 C.F.R. 435.118 (as in effect October 1, 2020) for applications for medical assistance.

(B) Definition. "Child" means an individual younger than nineteen years of age.

(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 October 1, 2020), a child is automatically eligible for medical assistance 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 medical assistance 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 October 1, 2020).

(b) When the birth mother is receiving alien emergency medical assistance (AEMA) in accordance with rule 5160:1-5-06 of the Administrative Code.

(c) When 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 of the date of her most recent medicaid application or renewal.

(d) When the birth mother is in the custody of a public children services agency (PCSA) or private child placing agency (PCPA).

(e) When the birth mother is in receipt of adoption or foster care assistance under Title IV-E.

(f) When 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 of eligibility prior to the month of the child's first birthday.

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

(d) Complete a renewal of eligibility when the child reaches the age of one.

(D) Eligibility criteria for coverage because an individual is a child under nineteen years of age.

(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) When 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) When the child is covered by other creditable coverage, the child's household income 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 nineteen years of age, if the child remains otherwise eligible in accordance with rule 5160:1-2-10 of the Administrative Code, and the individual responsibilities described in rule 5160:1-2-08 of the Administrative Code are met; 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 or her eighteenth birthday and turns nineteen years of age during the inpatient stay.

Last updated June 1, 2021 at 10:13 AM

Supplemental Information

Authorized By: 5160.02, 5161.02, 5161.12, 5162.03, 5163.02, 5163.40
Amplifies: 5160.02, 5161.02, 5161.12, 5162.03, 5163.02, 5163.40
Five Year Review Date: 6/1/2026
Prior Effective Dates: 10/1/2013, 1/1/2016, 1/1/2017
Rule 5160:1-4-03 | MAGI-based medicaid: coverage for Ribicoff and former foster care adults.
 

(A) This rule describes the eligibility criteria for applications for medical assistance for individuals:

(1) Who are nineteen or twenty years of age; or

(2) Who aged out of foster care, are younger than twenty-six years of age, and are not otherwise eligible for a mandatory category of coverage under the medicaid state plan. An individual who is eligible for coverage both as a former foster care child and under the coverage described in section 1902(a)(10)(A)(i)(VIII) of the Social Security Act (as in effect October 1, 2020) shall be placed in the former foster care eligibility category.

(B) Eligibility criteria for coverage because an individual is nineteen or twenty years of age in accordance with 42 C.F.R. 435.222 (as in effect October 1, 2020).

(1) The individual must be nineteen or twenty years of age.

(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 42 C.F.R. 435.150 (as in effect October 1, 2020).

(1) The individual must:

(a) Be at least eighteen years of age and younger than twenty-six years of age;

(b) Have been in foster care under the responsibility of the state of Ohio on the individual's eighteenth birthday, or at the time of aging out of the state's foster care program;

(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.

Last updated June 1, 2021 at 10:13 AM

Supplemental Information

Authorized By: 5160.02, 5162.03, 5163.02
Amplifies: 5160.02, 5162.03, 5163.02
Five Year Review Date: 6/1/2026
Prior Effective Dates: 10/1/2013, 3/26/2015
Rule 5160:1-4-04 | MAGI-based medicaid: coverage for pregnant individuals.
 

(A) This rule describes eligibility for pregnant individuals as described in 42 C.F.R. 435.116 (as in effect on October 1, 2016) for applications for medical assistance.

(B) Eligibility criteria for coverage because an individual is pregnant.

(1) The individual must be female and pregnant.

(2) A statement from the individual, a physician, or managed care plan is sufficient verification of pregnancy, unless the administrative agency has information contradicting the individual's statement.

(3) The individual's household income must not exceed two hundred per cent of the federal poverty level for the family size. For the purpose of this rule, family size includes the number of fetuses.

(4) An individual who is in her postpartum period, as defined in rule 5160:1-1-01 of the Administrative Code, is also eligible under the criteria described in this rule.

(C) Eligibility span for pregnant individuals.

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

(2) An individual is eligible for postpartum coverage if she was eligible for medical assistance 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 individual's family size and household income as described in rule 5160:1-4-01 of the Administrative Code.

(2) Inform a pregnant individual 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 medical assistance.

(3) Not terminate eligibility for a pregnant individual during her pregnancy or postpartum period unless the individual 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.

Supplemental Information

Authorized By: 5162.03, 5163.02
Amplifies: 5162.03, 5163.02
Five Year Review Date: 1/1/2021
Prior Effective Dates: 10/1/2013
Rule 5160:1-4-05 | MAGI-based medicaid: coverage for a parent or caretaker relative residing with a child.
 

(A) This rule describes the eligibility requirements for parents and caretaker relatives residing with children as described in 42 C.F.R. 435.110 (as in effect October 1, 2019), transitional medical assistance as described in section 1925 of the Social Security Act (as in effect October 1, 2019), and extended medical assistance as described in section 1931 of the Social Security Act (as in effect October 1, 2019).

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

(C) Eligibility criteria for coverage under 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 medical assistance coverage as a parent or caretaker relative as described in paragraph (B) of this rule for at least three of the six months immediately preceding the loss of eligibility.

(b) Become ineligible for medical assistance as a parent or caretaker relative as a result of:

(i) Increased 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) 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 medical assistance 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 received continuous TMA for the entire first six-month period.

(ii) 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 medical assistance received in error due to unreported collection of spousal support are counted as months of EMA.

(b) The child of the parent or caretaker relative will remain eligible for medical assistance regardless of the parent or caretaker relative's increased earned income or spousal support for a continuous period of twelve months under rule 5160:1-2-14 of the Administrative Code. The twelve month period begins on the date eligibility for medical assistance was approved. At the end of that twelve-month period, the child becomes eligible for any remaining months of TMA or EMA for which the parent or caretaker relative is eligible, ending in the same month as TMA or EMA ends for the parent or caretaker relative.

(3) Resuming interrupted spans of TMA eligibility.

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

(b) An individual 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 eligibility under paragraph (B) of this rule due to an increase in earned income and does not meet the criteria in paragraph (C)(1)(a) of this rule.

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

(3) 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 medical assistance in previous months. Approve TMA or EMA if an individual meets the requirements in paragraph (C) of this rule;

(b) Deny TMA or EMA when the parent or caretaker relative:

(i) No longer has earned income for TMA; or

(ii) No longer collects spousal support for EMA.

(c) Terminate TMA or EMA when the parent or caretaker relative becomes eligible for another medical assistance covered group.

Supplemental Information

Authorized By: 5162.03, 5163.02
Amplifies: 5162.03, 5163.02
Five Year Review Date: 12/14/2025
Prior Effective Dates: 4/1/1990 (Emer.), 6/22/1990, 6/1/2002, 1/1/2008, 1/1/2010, 10/1/2013, 1/1/2016, 7/1/2018, 7/8/2020 (Emer.)
Rule 5160:1-4-06 | Medicaid: coverage for individuals in receipt of adoption or foster care assistance.
 

(A) This rule describes eligibility criteria for medical assistance for individuals who are in receipt of:

(1) Adoption or foster care assistance under Title IV-E of the Social Security Act (as in effect October 1, 2019); or

(2) State foster care assistance; or

(3) State adoption assistance subsidies; or

(4) State adoption assistance in accordance with 42 C.F.R. 435.227 (as in effect October 1, 2019).

(B) Individual or authorized representative responsibilities. The individual or authorized representative must:

(1) Sign and date the application; and

(2) Meet the conditions of eligibility described in rule 5160:1-2-10 of the Administrative Code; and

(3) Cooperate in establishing eligibility; and

(4) Report changes that impact the eligibility criteria identified in this rule in accordance with rule 5160:1-2-08 of the Administrative Code.

(C) Eligibility criteria for an individual in receipt of adoption or foster care assistance under Title IV-E of the Social Security Act (as in effect October 1, 2019).

(1) The individual must:

(a) Meet the age requirements identified in Chapter 5101:2-47 of the Administrative Code and be in the custody of a public children services agency (PCSA), private child placing agency (PCPA), or Title IV-E agency and in receipt of Title IV-E foster care maintenance payments; or

(b) Meet the age requirements identified in Chapter 5101:2-49 of the Administrative Code and have a Title IV-E adoption agreement in effect, whether or not an adoption assistance payment is being made or a judicial decree of adoption has been issued.

(2) If the individual receives adoption or foster care assistance under Title IV-E of the Social Security Act and meets the eligibility criteria under this paragraph, there is no income or resource test required to be eligible for medical assistance.

(D) Eligibility criteria for an individual in receipt of state foster care assistance.

(1) The individual must:

(a) Be in the custody of a PCSA, PCPA, or Title IV-E agency; and

(b) Be in receipt of state foster care assistance.

(2) If the individual receives state foster care assistance and meets the eligibility criteria under this paragraph, there is no income or resource test required to be eligible for medical assistance.

(E) Eligibility criteria for an individual in receipt of a state adoption assistance subsidy.

(1) The individual must:

(a) Meet the age requirements identified in rule 5101:2-44-06 of the Administrative Code; and

(b) Have a state adoption agreement in effect, whether or not a judicial decree of adoption has been issued.

(2) If the individual receives a state adoption assistance subsidy and meets the eligibility criteria under this paragraph, there is no income or resource test required to be eligible for medical assistance.

(F) Eligibility criteria for an individual in receipt of state adoption assistance in accordance with 42 C.F.R. 435.227 (as in effect October 1, 2019).

(1) The individual must:

(a) Be under the age of twenty-one; and

(b) Have been determined by the PCSA responsible for determining state adoption maintenance subsidy program eligibility to have special needs for medical or rehabilitative care that may be a barrier to the adoptive placement, as described in rule 5101:2-44-05.1 of the Administrative Code, or have a state adoption subsidy agreement in effect with another state, as described in rule 5101:2-44-05.2 of the Administrative Code; and

(c) Have been receiving or eligible to receive medicaid prior to the execution of the adoption agreement, under any category of medical assistance.

(2) If the individual receives state adoption assistance, has special needs for medical or rehabilitative care, and meets the eligibility criteria under this paragraph, there is no income or resource test required to be eligible for medical assistance.

Supplemental Information

Authorized By: 5160.02, 5162.03, 5163.02
Amplifies: 5160.02, 5162.03, 5163.02
Five Year Review Date: 1/1/2022
Prior Effective Dates: 10/1/2013