Rule 5160:1-5-04 | Medicaid: Ohio workability.
(A) This rule governs the eligibility requirements for the medical assistance program authorized under section 1902(a)(10)(A)(ii)(XIII) of the Social Security Act (as in effect October 1, 2024). Ohio workability enables certain working disabled individuals aged sixty-five or older to increase their income and resources without the risk of losing medical assistance coverage.
(B) Definitions.
(1) "Blind work expense (BWE)" has the same meaning as in rule 5160:1-3-03.2 of the Administrative Code.
(2) "Countable income," for the purpose of this rule, means total monthly income less exclusions.
(3) "Countable resources," for the purpose of this rule, means those resources remaining after all exclusions have been applied.
(4) "Family," for the purpose of this rule, means an individual, the individual's spouse, and dependent children living in the household of the individual.
(5) "Impairment-related work expense (IRWE)" has the same meaning as described in 20 C.F.R. 404.1576 (as in effect October 1, 2024).
(6) "Income," for the purpose of this rule, means gross monthly earned income and gross monthly unearned income.
(7) "Individual," for the purpose of this rule, means the applicant for or recipient of Ohio workability.
(8) "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.
(9) "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.
(10) "Ohio workability" means the component of the medicaid program established under section 5163.063 of the Revised Code.
(11) "Premium" means a periodic payment described in paragraph (E) of this rule.
(12) "Resource eligibility limit for Ohio workability" means countable resources limited to twelve thousand eight hundred forty-eight dollars in calendar year 2024, adjusted annually with the consumer price index for all items for all urban consumers for the previous calendar year (CPI-U), as published by the United States bureau of labor statistics, effective beginning with calendar year 2025.
(13) "Social security disability insurance (SSDI)" means the program established under Title II of the Social Security Act (as in effect October 1, 2024).
(14) "Supplemental security income (SSI)" means the program established under Title XVI of the Social Security Act (as in effect October 1, 2024).
(15) "Work" or "working," for the purpose of this rule, means employment or self-employment from which state or federal income and payroll taxes are paid or withheld.
(C) Eligibility criteria. To be eligible for Ohio workability the individual must:
(1) Meet the conditions of eligibility described in rule 5160:1-2-10 of the Administrative Code;
(2) 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 Ohio workability. An individual may be eligible for Ohio workability regardless of whether the individual is receiving SSI or SSDI;
(3) Be at least sixty-five years of age;
(4) Meet the financial eligibility requirements described in paragraph (D) of this rule;
(5) Be working; and
(6) Pay the premium, as calculated in paragraph (E) of this rule, if applicable.
(D) Financial eligibility.
(1) For the purpose of determining whether an individual is income eligible for Ohio workability, the administrative agency must compare the individual's countable income to two hundred fifty per cent of the federal poverty level (FPL) for one person. Only the individual's income is considered when determining eligibility for Ohio workability.
(a) From the individual's income, apply exclusions in accordance with rule 5160:1-3-03.2 of the Administrative Code, then round down to the nearest whole dollar.
(b) When 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 Ohio workability.
(c) When 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 to no more than two hundred fifty per cent of the FPL. This exclusion begins the first month the individual would otherwise be eligible for Ohio workability except for income and continues within a twelve-month period until the twenty thousand dollars is exhausted.
(2) For the purpose of determining whether an individual meets the resource eligibility requirement for Ohio workability, an individual's countable resources must not exceed the resource eligibility limit for Ohio workability as defined in paragraph (B) of this rule.
(a) Only the individual's resources are considered when determining resource eligibility for Ohio workability. 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 purpose of determining resource eligibility for Ohio workability, resources are excluded in accordance with rule 5160:1-3-05.14 of the Administrative Code.
(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 Ohio workability whose individual income exceeds one hundred fifty per cent of the FPL for one person must pay a premium determined as follows:
(1) From the gross monthly family income at the time of application and subsequent renewals for Ohio workability, 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 monthly IRWEs, BWEs, and MREs (round up each expense to the nearest whole dollar).
(3) From the amount determined in paragraph (E)(2) of this rule, the adminstrative agency shall subtract the amount of monthly medical insurance premiums, including medicare premiums, paid by the family (round up each premium amount to the nearest whole dollar).
(4) The amount determined in paragraph (E)(3) of this rule is the net monthly family income.
(a) Multiply the individual's gross monthly income by seven and one half per cent, then round down to the nearest whole dollar.
(b) Multiply the net monthly family income by ten per cent, then round down to the nearest whole dollar.
(5) From the amounts determined in paragraphs (E)(4)(a) and (E)(4)(b) of this rule, the administrative agency shall use the lesser amount. This is the individual's monthly premium.
(F) The individual's monthly premium obligation begins the month following the month Ohio workability 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)(6) 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 discontinuance for Ohio workability.
(4) An individual who loses eligibility for Ohio workability due to non-payment of premiums and reapplies for Ohio workability must:
(a) Meet all criteria outlined in paragraph (C) of this rule; and
(b) Pay all accumulated delinquent premiums that caused the Ohio workability discontinuance.
(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, as defined in rule 5160:1-6-01.1 of the Administrative Code, is not a cause for discontinuance or denial of an individual's eligibility for Ohio workability.
(H) Individuals eligible for Ohio workability are not subject to a patient liability as described in rule 5160:1-6-07 or 5160:1-6-07.1 of the Administrative Code.
(I) Administrative agency responsibilities. The administrative agency shall:
(1) Process the application for Ohio workability in accordance with rule 5160:1-2-01 of the Administrative Code.
(2) Determine eligibility for Ohio workability as described in this rule.
(3) Calculate the premium for Ohio workability as identified in paragraph (E) of this rule and recalculate this premium only during the individual's annual renewal or whenever the individual reports a decrease in income.
(4) Verify the individual's disability in accordance with paragraph (C)(2) of this rule.
(5) Explore eligibility for qualified medicare beneficiary (QMB) and specified low-income medicare beneficiary (SLMB) programs in accordance with rule 5160:1-3-02.1 of the Administrative Code. Ohio workability individuals are not eligible for the qualified individual (QI-1) or qualified disabled and working individuals (QDWI) medicare premium assistance programs.
(J) Individual responsibilities. The individual shall:
(1) Provide the information necessary to establish eligibility, cooperate with 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.
Last updated October 7, 2024 at 8:23 AM
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