5160:1-4-02 MAGI-based medicaid: coverage for children younger than age nineteen.

 

 

 

5160:1-4-02                 MAGI-based  medicaid:  coverage  for  children  younger  than age nineteen.

 

 

 

(A)This rule describes medicaid eligibility criteria for children from birth until the individual reaches age nineteen in accordance with 42 C.F.R. 435.118 (as in effect July 1, 2014) for applications for medical assistance filed on or after January 1, 2014.

 

(B)Definition. "Child", for the purpose of this rule, means an individual younger than age nineteen.

 

(C)Eligibility criteria for coverage because a newborn child was born to a medicaid-eligible woman (deemed newborn). In accordance with 42 C.F.R. 435.117 (as in effect July 1, 2014), a child is automatically eligible for medicaid as of the child's date of birth, and remains eligible until the child reaches the age of one, provided the birth mother has applied for, been determined eligible for, and is receiving medicaid on the date of the child's birth.

 

(1)Coverage under this paragraph also applies to newborns under the following circumstances:

 

(a) When labor and delivery services were furnished prior to the date of application and the birth mother's medicaid eligibility is based on retroactive coverage in accordance with 42 C.F.R. 435.915 (as in effect on July 1, 2014).

 

(b) While the birth mother is receiving alien emergency medical assistance (AEMA) in accordance with rule 5160:1-1-91 of the Administrative Code.

 

(c) While the birth mother is residing in a public institution and is:

 

(i) Restricted   from   payment   of   services   as   referenced   in   rule 5160:1-1-58.1 of the Administrative Code, and

 

(ii) Within twelve months from the date of her most recent medicaid application or redetermination.

 

(d)While the birth mother is in the custody of a public children services agency (PCSA) or private child placing agency (PCPA).

 

(e) While the birth mother is in receipt of adoption or foster care assistance under Title IV-E.

 

(f)While the birth mother is in receipt of state or federal adoption assistance.

 

(g) When the birth mother loses medicaid eligibility after the birth of the newborn.

 

 

(h) When the birth mother is no longer a member of the newborn's household at any time prior to the newborn reaching the age of one.

(2) For newborns described in this paragraph, the administrative agency must:

(a) Upon  verbal  or  written  notification  of  the  newborn's  birth  from  any individual or entity reporting the birth:

(i) Verify, in the electronic eligibility system, that the birth mother was eligible for and received medicaid on the date of the child's birth, and

(ii) Approve  the  child's  eligibility  for  medicaid  without  delay  and without consideration of household composition or income.

(b) Not require an application for the child or a redetermination prior to the month of the child's first birthday.

(c) Not require verification of U.S. citizenship or identity.

(d)Complete a redetermination when the child reaches the age of one.

(D) Eligibility criteria for coverage because an individual is in foster care, receives adoption assistance, or is in the custody of a PCSA or PCPA or Title IV-E agency.

(1) A child is eligible for medicaid under this rule, regardless of family size, income, or resources, when the child is in the custody of a PCSA, PCPA, or Title IV-E agency and in receipt of:

(a) Adoption or foster care assistance under Title IV-E of the Social Security Act as in effect July 1, 2014; or

(b) State or federal foster care assistance in accordance with section 1902(e)(14)(D)(i) of the Social Security Act (as in effect July 1, 2014); or

(c) State or federal adoption assistance.

(2) Child, individual, or authorized representative responsibilities. The child, the individual, or the authorized representative must:

(a) Sign and date the application;

(b) Meet the conditions of eligibility described in rule 5160:1-1-58 of the Administrative Code;

(c) Cooperate in establishing eligibility; and

(d)Report changes in accordance with rule 5160:1-1-55 of the Administrative Code.

(E)Eligibility criteria for coverage because an individual is a child under age nineteen.

(1) A child's family size and household income shall be calculated as described in rule 5160:1-1-61 of the Administrative Code.

(2) If the child is not covered by other creditable coverage, the child's household income must not exceed two hundred six per cent of the federal poverty level for the family size.

(3) If the child is covered by other creditable coverage, the child's household income for the family size must not exceed one hundred fifty-six per cent of the federal poverty level for the family size.

(4) A child receiving medical coverage under this paragraph remains eligible:

(a) Through the end of the month in which the child turns age nineteen, if the child remains otherwise eligible in accordance with rule 5160:1-1-58 of the Administrative Code; or

(b) Until the end of an inpatient stay during which inpatient services are being furnished, if the child is found eligible under this paragraph on or after his/her eighteenth birthday and turns age nineteen during the inpatient stay.

Replaces:                                                              5160:1-1-63

Effective:                                                             03/26/2015

Five Year Review (FYR) Dates:                         03/26/2020

CERTIFIED ELECTRONICALLY

Certification

03/16/2015

Date

Promulgated Under:                           111.15

Statutory Authority:                           5161.02, 5161.12, 5160.02, 5163.02, 5163.40

Rule Amplifies:                                  5161.02, 5161.12, 5160.02, 5163.02, 5163.40

Prior Effective Dates:                         10/1/13