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

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, 1/1/2016