5160:1-3-02 Medicaid: criteria for age, blindness and disability.

 

 

 

TO BE RESCINDED

 

5160:1-3-02                 Medicaid: criteria for age, blindness and disability.

 

 

 

(A)   The medicaid program provides coverage for individuals who have been determined to meet the criteria for the limiting physical factors of age, blindness, or disability as set forth in the Social Security Act. Age is determined by county departments of job and family services (CDJFS). Blindness and disability are determined by either the social security administration (SSA) or the Ohio department of medicaid (ODM). The criteria are as follows:

 

(1)   Age: A person who is age sixty-five years or older meets the age requirement for medicaid. Verification of age is required.

 

(2)    Blindness: A person is considered to be blind if he or she has central visual acuity of 20/200 or less in the better eye with correcting glasses, or a limited visual field of twenty degrees or less in the better eye. A person determined to be blind for purposes of supplemental security income (SSI) benefits also qualifies as blind for purposes of medicaid.

 

(3)   Disability.

 

(a)    Disability is defined differently for adults and children. An individual is disabled if the individual is:

 

(i)     An adult who is unable to do any substantial gainful activity by reason of any medically determinable physical or mental impairment or combination of impairments which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months.

 

(ii)   A child under the age of eighteen who has a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to cause death or that has lasted or can be expected to last for a continuous period of not less than twelve months. No individual under the age of eighteen who engages in substantial gainful activity may be considered disabled.

 

(b)     An  individual  shall  be  considered  to  be  disabled  under  one  of  the following criteria:

 

(i)      An individual who has been determined disabled by SSA for purposes of SSI or social security disability insurance (SSDI)

 

 

benefits.

(ii)    An individual who meets one of the presumptive disability criteria listed in paragraph (E) of this rule.

(iii)     An individual who has been determined disabled by ODM and, subject to the limitations set forth in paragraph (B) of this rule, has an SSI claim pending.

(B)     All individuals who are seeking medicaid eligibility based on their own age, blindness or alleged disability must also apply for SSI or retirement, survivors and disability insurance (RSDI) and have their eligibility for SSI or RSDI determined. If an individual has been determined to meet the limiting physical factor criteria based on age, blindness, disability or the receipt of RSDI, a referral to SSI must be made only when the individual's countable income is less than the current SSI federal benefit rate (FBR).

(1)    If the applicant has been determined by SSA to be eligible for SSI or RSDI disability benefits based on his or her own age, blindness or disability, the limiting physical factor is met and no further referral is necessary.

(2)   An individual who receives a final decision from SSA denying SSI or RSDI for lack of a physical or mental disability does not meet the limiting physical factor criteria for medicaid.

(3)   If the applicant is denied SSI or RSDI for a reason other than lack of disability, the department of medicaid shall make its own disability determination.

(C)   If SSA makes a finding of presumptive disability based upon the available evidence which reflects a high degree of probability that the individual will meet the disability requirements, the medicaid applicant meets the disability requirements necessary to qualify for medicaid. If it is later determined that the SSA decision was erroneously made and the individual was without fault in the determination, no attempt shall be made to recover medicaid payments made on behalf of the recipient.

(D)   The CDJFS shall determine medicaid eligibility for an individual residing in a state institution. The CDJFS in the county in which the state institution is located has case responsibility except when either the temporary absence or inter-county transfer provisions, as set forth in rules 5160:1-1-50.1 and 5160:1-1-51 of the Administrative Code apply.

(1)   An individual who either is under the age of twenty-two or is age sixty-five or over and who resides in a Title XIX-certified section of a state institution for the mentally ill is assumed to meet the limiting physical factor requirement of disability.

(2)   An individual of any age who resides in a Title XIX-certified section of a state institution for individuals with intellectual disabilities is assumed to meet the limiting physical factor requirement of disability.

(3)   An individual of any age who resides in a state institution for the mentally ill, in a section certified as a Title XIX intermediate care facility for individuals with intellectual disabilities (dual diagnosis unit), is assumed to meet the limiting physical factor requirement of disability.

(E)  Presumptive disability conditions or impairments:

(1)   Amputation of a leg at the hip;

(2)   Total deafness;

(3)   Total blindness;

(4)   Bed confinement or immobility without a wheelchair, walker, or crutches, due to a longstanding condition, excluding recent accident and recent surgery;

(5)    A stroke (cerebral vascular accident) more than three months in the past and continued marked difficulty in walking or using a hand or arm;

(6)   Cerebral palsy, muscular dystrophy or muscle atrophy and marked difficulty in walking (e.g., use of braces), speaking or coordination of the hands or arms;

(7)   Down's syndrome;

(8)   An allegation of severe mental deficiency made by a person applying on behalf of an individual who is at least seven years of age, in accordance with the definition of "mental deficiency" in paragraph (B) of this rule;

(9)   A child who has not attained his or her first birthday and the birth certificate or other evidence (e.g., the hospital admission summary) shows a weight below twelve hundred grams (two pounds, ten ounces) at birth;

(10)   A child who has not attained his or her first birthday and the birth certificate or other evidence (e.g., the hospital admission summary) shows a gestational age at birth on the table below with the corresponding birth-weight indicated:

Gestational age and birth weight

Gestational age (in weeks)	Weight at birth
37-40	Less than 2000 grams (4 pounds, 6 ounces)
36	1875 grams or less (4 pounds, 2 ounces)
35	1700 grams or less (3 pounds, 12 ounces)
34	1500 grams or less (3 pounds, 5 ounces)
33	1200 grams to 1325 grams (2 pounds, 10 ounces to 2 pounds, 15 ounces)

(11)    Diseases and/or illnesses that are a result of human immunodeficiency virus (HIV) infection, and the diseases and/or illnesses have progressed to the point where the individual is unable to work for a minimum of twelve consecutive months, as confirmed by a licensed physician;

(12)   An individual who is receiving hospice services because of terminal illness;

(13)     A spinal cord injury producing inability to ambulate without the use of a walker or bilateral hand held assistive devices for more than two weeks;

(14)   End stage renal disease with ongoing dialysis; or

(15)   Amyotrophic lateral sclerosis (ALS, Lou Gehrig's disease).

Effective:                                                             08/01/2016

Five Year Review (FYR) Dates:                         04/15/2016

CERTIFIED ELECTRONICALLY

Certification

07/12/2016

Date

Promulgated Under:                           111.15

Statutory Authority:                           5160.02, 5163.02

Rule Amplifies:                                  5160.02, 5163.02

Prior Effective Dates:                         9/3/77, 1/1/81, 9/6/84, 8/1/85, 8/1/86 (emer.), 10/3/86,

7/1/87 (Emer.), 8/3/87, 1/1/88 (Emer.), 3/28/88,

10/1/88 (Emer.), 12/20/88, 4/1/90, 10/1/91 (Emer.),

12/1/91, 12/2/91, 12/20/91, 1/1/92 (Emer.), 3/20/92,

12/22/92 (Emer.), 1/1/93(Emer.), 2/11/93, 3/20/93,

9/1/93, 8/1/95 (Emer.), 10/30/95, 4/1/99, 10/1/02,

11/25/02, 1/1/05