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Medicaid Eligibility Manual

MEMMTL 2 (Medicaid: Eligibility Modernization Eligibility Rules)

Medicaid Eligibility Modernization Manual Transmittal Letter No. 2

September 24, 2013

To:               All Medicaid Eligibility Modernization Manual Holders

From:           John B. McCarthy, Director

Subject:        Medicaid: Eligibility Modernization Eligibility Rules

As a result of changes discussed in Medicaid Eligibility Modernization Manual Transmittal Letter No. 1, which contains the rewritten administrative policy rules, the Ohio Department of Medicaid (ODM) is working to review all existing Medicaid Administrative Code rules to modernize and simplify the rules where possible, and to update rule references where necessary. Some rules are being significantly rewritten, while others are simply being reviewed and updated.

The rules in this transmittal, and additional rules to follow, will eventually replace the current rules in the existing eligibility manual after the new ODM Revised Code sections become formally available. As the old rules are updated, they will be renumbered and added to Chapter 6.

These rules are effective October 1, 2013 for determining MAGI-based eligibility for Medicaid coverage beginning on January 1, 2014.

Chapter 6 Medicaid Eligibility Modernization

5101:1-37-50 Medicaid: administrative code rule migration

This is a new rule describing which Administrative Code rules are effective for determining eligibility for the various categories of medical assistance on or after October 1, 2013.

5101:1-37-50.1 Medicaid: definitions

This rule contains definitions used in the new Administrative Code rules. As additional rules are proposed and more definitions are added, this rule will be revised. Some of the definitions in this rule are related to the new rules regarding MAGI-based eligibility categories.

Some of these definitions are unchanged from the current definitions rule. Other definitions have been revised as a result of the ACA or other changes. For example:

1.       "Administrative agency" has been revised to reflect the separation of ODM from ODJFS.

2.       "Authorized representative" has been revised for clarity.

3.       "MAGI-based income" is a new ACA-based definition that is used in the new MAGI-based rules.

5101:1-37-55.1 Medicaid: authorized representative responsibilities

This is a new rule describing the responsibilities of an authorized representative in regard to the Medicaid program and Medicaid applicants or enrollees. This rule is based on current Administrative Code rules 5101:1-38-01 (Medicaid: Individual and Administrative Agency Responsibilities) and 5101:1-38-01.2 (Medicaid: Application, Determination, and Redetermination Processes). These responsibilities are being pulled together and explicitly stated as responsibilities of an authorized representative in the interest of clarity.

5101:1-37-58.2 Medicaid: United States (U.S.) citizenship documentation

This rule revises the U.S. citizenship documentation rule to address electronic verifications and to simplify the manual verification process when citizenship cannot be electronically verified.

5101:1-37-58.3 Medicaid: qualified aliens

This rule revises the documentation rule for non-citizen eligibility to address electronic verifications and to simplify the manual verification process when an individual's "satisfactory immigrant status" (a new term for eligible non-citizen status) cannot be electronically verified.

Medicaid: MAGI-Based Eligibility Categories

5101:1-37-61 MAGI-based medicaid: income and household income

This rule directs the determination of an individual's personal income, household income and Medicaid household composition, including family size, as required by 42 C.F.R. 435.603, when determining eligibility for most categories of coverage previously considered family or child-based Medicaid.

This new household and income rule does not apply when an individual's eligibility is being determined for:

·                 Coverage because an individual is blind, disabled, or at least age 65, or in need of long-term care services and supports (whether in the home or in an institution), or for

·                 Medicare premium assistance (QMB, SLMB, QI-1).

The Affordable Care Act and the C.F.R. section cited above require the application of income and household composition rules created by the Internal Revenue Service (IRS) for tax purposes. In specified circumstances, however, a different set of household composition rules apply; those circumstances are described in this rule as well.

These new household and income rules will be reflected in the programming of the new Ohio Integrated Eligibility System. Training materials and desk aids have been developed and published.

5101:1-37-63 MAGI-based medicaid: coverage for children younger than age nineteen

This rule describes Medicaid eligibility criteria for children from birth until the individual reaches age nineteen. The rule combines into one covered group all individuals younger than age 19, including deemed newborns, children in foster care, in the care of a child services agency, or receiving adoption assistance. Only two of the eligibility criteria in this rule were significantly changed by the ACA: first, a "child" is any individual under age 19; second, income limits have been adjusted as follows:

1.       Children who are covered by other creditable insurance have a household income limit for the family size no greater than 156% FPL.

2.       Children who are not covered by other creditable insurance have a household income limit for the family size no greater than 206% FPL.

5101:1-37-63.1 MAGI-based medicaid: coverage for Ribicoff and former foster care adults

This rule describes Medicaid eligibility criteria for two groups of individuals.

1.       Individuals who are age 19 or 20, with household income for the family size no greater than 44% FPL.

2.       Individuals under the age of 26 who aged out of foster care at age 18.

Other than the adjustment of the income limit for Ribicoff children, eligibility criteria for these groups are not significantly changed by the ACA.

5101:1-37-64 MAGI-based medicaid: coverage for pregnant women

This rule describes Medicaid eligibility criteria for pregnant women. These eligibility criteria are not significantly changed by the ACA, except that states must accept a woman's self-declaration of pregnancy.

For the purpose of determining a pregnant woman's family size, as described in rule 5101:1-37-61, a self-declaration of pregnancy will mean a woman counts as herself plus one individual when determining family size. If the woman is carrying multiple fetuses, medical verification would be required in order to add additional fetuses to family size.

5101:1-37-65 MAGI-based medicaid: coverage for a parent or caretaker relative residing with a child

This rule describes Medicaid eligibility criteria for parents residing with their minor children. These eligibility criteria are not significantly changed by the ACA.

MEM Instructions:

Location

Remove

Insert

Chapter 6

 

N/A

5101:1-37-50

(Effective 10/1/2013)

 

N/A

5101:1-37-50.1

(Effective 10/1/2013)

 

N/A

5101:1-37-55.1

(Effective 10/1/2013)

 

N/A

5101:1-37-58.2

(Effective 10/1/2013)

 

N/A

5101:1-37-58.3

(Effective 10/1/2013)

 

N/A

5101:1-37-61

(Effective 10/1/2013)

 

N/A

5101:1-37-63

(Effective 10/1/2013)

 

N/A

5101:1-37-63.1

(Effective 10/1/2013)

 

N/A

5101:1-37-64

(Effective 10/1/2013)

 

N/A

5101:1-37-65

(Effective 10/1/2013)

This information is also available on the Internet and may be accessed at:

ODJFS Electronic Manuals

http://emanuals.odjfs.state.oh.us/emanuals/

InnerWeb Calendar:

http://www.odjfs.state.oh.us/lpc/calendar/staff/

Internet Calendar:

http://www.odjfs.state.oh.us/lpc/calendar/

 

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