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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5160:1 Medicaid General Principles |
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Chapter5160:1-3. Medicaid for the Aged, Blind, or Disabled (ABD) |
5160:1-3-02.2. Medicare buy-in
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(A) This rule sets forth:
(1) The eligibility criteria for benefits under the medicare part B buy-in agreement between the social security administration (SSA) and the Ohio department of medicaid (ODM), which allows ODM to pay medicare part B (supplemental medical insurance) premiums for certain medicaid-eligible individuals even if those individuals are not eligible for a medicare premium assistance program (MPAP) set out in rule 5160:1-3-02.1 of the Administrative Code; and
(2) The beginning date of payment of medicare part B (part B) benefits under this rule; and
(3) The date and effect of termination of benefits under medicare part B buy-in.
(4) The process of coordinating enrollment with ODM and the SSA.
(B) Definitions.
(1) "Medicare buy-in" means the program and process of paying part A or part B benefits on behalf of an eligible individual.
(2) "Part B buy-in" means the agreement under which ODM pays part B premiums on behalf of an eligible individual.
(C) Eligibility criteria. To be eligible for payment of the part B premium under the medicare buy-in agreement, an individual must meet all three of the following requirements:
(1) Be eligible for part B.
(2) Be eligible for a category of medicaid other than:
(a) Breast and cervical cancer project medicaid as set forth in rules 5160:1-5-02 to 5160:1-5-02.4 of the Adminstrative Code; or
(b) Presumptive medicaid as set forth in rule 5160:1-2-13 of the Administrative Code.
(3) Be receiving at least one of the following:
(a) Medicare premium assistance under rule 5160:1-3-02.1 of the
(i) Ohio works first (OWF); or
(ii) Supplemental security income (SSI); or
(iii) Residential state supplement.
(c) Four-month extended coverage as set forth in rule 5160:1-4-05 of the Administrative Code.
(d) Grandfathered medicaid as set forth in rule 5160:1-3-02.6 of the Administrative Code.
(e) Foster care maintenance payments or adoption assistance payments as set forth in rule 5160:1-2-14 of the Administrative Code.
(f) Medicaid as a result of section 1619(b) of the Social Security Act (as in effect October 1, 2019) as set forth in rule 5160:1-3-02.8 of the Administrative Code.
(g) Deemed OWF as described in 42 C.F.R 435.115 (as in effect October 1, 2019).
(h) Long-term care services in a Title XIX certified nursing facility (NF) or intermediate care facility for individuals with intellectual disabilities (ICF-IID).
(i) Home and community-based (HCB) services, including the program of all inclusive care for the elderly (PACE), under a waiver described in agency 5160 of the Administrative Code.
(D) Coordination of enrollment. If an individual is eligible for benefits under this rule or would be eligible if the individual were enrolled in part A or part B, the county department of job and family services (CDJFS) shall coordinate the individual's receipt of benefits. If the individual:
(1) Is or has ever been in receipt of part A or part B benefits, the CDJFS shall approve part B buy-in benefits for the individual in the electronic eligibility system.
(2) Has never received part A or part B benefits, the CDJFS shall:
(a) Inform the individual that the Ohio department of medicaid (ODM) cannot pay medicare premiums until the individual has enrolled in part A or part B through the SSA; and
(b) Advise the individual to apply for part A or part B benefits, and advise the individual that the CDJFS will assist upon request; and
(c) Advise the individual to report the approval of part A or part B benefits to the CDJFS immediately, so payment of premiums can be approved; and
(d) Approve part B buy-in benefits for the individual in the electronic eligibility system upon being informed that the individual has been enrolled by the SSA in part A or part B.
(E) Coverage period.
(1) Start date.
(a) For MPAP benefits under rule 5160:1-3-02.1 of the Administrative Code, the beginning date for payment of premiums is addressed in those rules. If an individual is eligible for MPAP benefits under rule 5160:1-3-02.1 of the Administrative Code and also eligible for part B buy-in under this rule, payment of part B premiums begins on the earlier of the coverage date under rule 5160:1-3-02.1 of the Administrative Code or the coverage date under this rule.
(b) For individuals eligible for payment of premiums under the part B buy-in agreement, eligibility begins:
(i) The first month an individual is eligible for both medicare and cash assistance as defined in paragraph (C)(3)(b) of this rule; or
(ii) The first day of the second month after the administrative agency made the determination the individual was eligible for medicaid, if the individual is not in receipt of cash assistance as defined in paragraph (C)(3)(b) of this rule.
(2) Termination date. Eligibility for payment of medicare premiums under this rule ends on the last day of the month in which the individual dies.