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

 

 

 

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

 

 

 

(A)This rule describes how an individual's or household's income is calculated under 42 C.F.R. 435.603 (as in effect on September 1, 2013) when determining an individual's eligibility for applications for medical assistance. This rule does not apply to determinations for the following categories of eligibility:

 

(1)For which an individual must be at least age sixty-five; or

 

(2) For which an individual must be found to be blind or disabled; or

 

(3)For which an individual must be found in need of long-term care services, whether in a facility or in a community setting; or

 

(4) Which cover only 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 each individual, the administrative agency must follow the requirements and definitions set out to determine household composition and family size. For the tax year in which the eligibility determination is being made:

 

(a) If an individual expects to file a tax return and does not expect to be claimed as a tax dependent, the household composition is determined under 42 C.F.R. 435.603(f)(1) (as in effect on September 1, 2013).

 

(b) If an individual expects to be claimed as a tax dependent, the household composition is determined under 42 C.F.R. 435.603(f)(2) (as in effect on September 1, 2013) unless the individual meets one of the exceptions set out in the subparagraphs of that section.

 

(c) Household composition is determined under 42 C.F.R. 435.603(f)(3) (as in effect on September 1, 2013) if the individual:

 

(i) Does not expect to file taxes or to be claimed as a tax dependent, or if it is unclear whether the individual will be claimed as a tax dependent; or

 

(ii) Meets one of the exceptions set out in a subparagraph of 42 C.F.R.

435.603(f)(2) (as in effect on September 1, 2013).

 

(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 verified fetuses, if a doctor or nurse has provided a statement verifying a woman's pregnancy, including the expected date of confinement and the number of unborn fetuses.

(3) When determining the household of a married couple who live together, each spouse will always be considered a part of the other spouse's household, regardless of tax filing status and regardless of whether either spouse is claimed as a tax dependent.

(D)Determining household income.

(1) The administrative agency must follow the requirements and definitions set forth in 42 C.F.R. 435.603 (as in effect on September 1, 2013) to determine the MAGI-based income, as set forth in 42 C.F.R. 435.603(e) (as in effect on September 1, 2013) of:

(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 income from an individual who is:

(a) Included in the household of his or her natural, adopted or step parent; and

(b) Not expected to be required to file a tax return under section 6012(a)(1) of the Internal Revenue Code (as in effect on September 1, 2013) for the taxable year in which eligibility for medical assistance is being determined, whether or not the individual files a tax return.

(3) 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.

Replaces:                                                              5160:1-1-61

Effective:                                                             01/01/2016

Five Year Review (FYR) Dates:                         01/01/2021

CERTIFIED ELECTRONICALLY

Certification

12/21/2015

Date

Promulgated Under:                           111.15

Statutory Authority:                           5162.03, 5163.02

Rule Amplifies:                                  5162.03, 5163.02

Prior Effective Dates:                         10/1/13