Ohio Admin. Code 5160:1-4-04 - MAGI-based medicaid: coverage for pregnant individuals
(A) This rule
describes eligibility for pregnant individuals as described in
42 C.F.R.
435.116 (as in effect on October 1,
2016
2023 ) for
applications for medical assistance.
(B) Eligibility criteria for coverage because
an individual is pregnant.
(1) The individual
must be female and pregnant.
(2) A
statement from the individual, a physician, or managed care
plan
organization
(MCO) is sufficient verification of pregnancy, unless the administrative
agency has information contradicting the individual's statement.
Self-attestation of pregnancy is acceptable unless
available information conflicts with the attestation or the woman is pregnant
with more than one fetus.
(3)
The individual's household income must not exceed two hundred per cent of the
federal poverty level for the family size. For the purpose of this rule, family
size includes the number of fetuses.
(4) An individual who is in her postpartum
period, as defined in rule
5160:1-1-01 of the
Administrative Code, is also eligible under the criteria described in this
rule.
(C) Eligibility
span for pregnant individuals.
(1) Once
established, eligibility for a pregnant individual continues throughout
her
the
pregnancy and postpartum period.
(2) An individual is eligible for postpartum
coverage if she was eligible for medical assistance on the date
her
the
pregnancy ends
ended . This includes a birth mother whose labor and
delivery services were furnished prior to the date of application and who is
determined eligible for retroactive coverage of the labor and delivery services as described in
rule 5160:1-2-01 of the
Administrative Code.
(D)
Administrative agency responsibilities. The administrative agency must:
(1) Calculate a pregnant individual's family
size and household income as described in rule
5160:1-4-01 of the
Administrative Code.
(2)
Inform a pregnant individual who has indicated that
she is carrying more than one fetus that she may have to provide verification
of pregnancy if the increase in family size makes her income-eligible for
medical assistance.
When a pregnant woman
attests to carrying more than one fetus and the increased family size makes her
income eligible for medical assistance, the administrative agency shall require
the woman to provide verification of pregnancy, including the expected date of
delivery and the number of unborn fetuses, from a licensed medical
professional.
(3) Not
terminate
discontinue eligibility for a pregnant individual
during her
the
pregnancy or postpartum period, unless the
individual dies, moves out of state, or requests that coverage be
terminated
discontinued .
(E) Individual responsibilities.
The
A pregnant
individual
woman must provide medical
verification of pregnancy, only if
necessary for income eligibility by increasing the family size
from a licensed medical professional, including the expected
date of delivery and the number of unborn fetuses, only when requested by the
administrative agency .
Notes
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02
Prior Effective Dates: 10/01/2013, 01/01/2016, 01/01/2017
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(A) This rule describes eligibility for pregnant individuals as described in 42 C.F.R. 435.116 (as in effect on October 1, 2016 2023 ) for applications for medical assistance.
(B) Eligibility criteria for coverage because an individual is pregnant.
(1) The individual must be female and pregnant.
(2) A statement from the individual, a physician, or managed care plan organization (MCO) is sufficient verification of pregnancy, unless the administrative agency has information contradicting the individual's statement. Self-attestation of pregnancy is acceptable unless available information conflicts with the attestation or the woman is pregnant with more than one fetus.
(3) The individual's household income must not exceed two hundred per cent of the federal poverty level for the family size. For the purpose of this rule, family size includes the number of fetuses.
(4) An individual who is in her postpartum period, as defined in rule 5160:1-1-01 of the Administrative Code, is also eligible under the criteria described in this rule.
(C) Eligibility span for pregnant individuals.
(1) Once established, eligibility for a pregnant individual continues throughout her the pregnancy and postpartum period.
(2) An individual is eligible for postpartum coverage if she was eligible for medical assistance on the date her the pregnancy ends ended . This includes a birth mother whose labor and delivery services were furnished prior to the date of application and who is determined eligible for retroactive coverage of the labor and delivery services as described in rule 5160:1-2-01 of the Administrative Code.
(D) Administrative agency responsibilities. The administrative agency must:
(1) Calculate a pregnant individual's family size and household income as described in rule 5160:1-4-01 of the Administrative Code.
(2) Inform a pregnant individual who has indicated that she is carrying more than one fetus that she may have to provide verification of pregnancy if the increase in family size makes her income-eligible for medical assistance. When a pregnant woman attests to carrying more than one fetus and the increased family size makes her income eligible for medical assistance, the administrative agency shall require the woman to provide verification of pregnancy, including the expected date of delivery and the number of unborn fetuses, from a licensed medical professional.
(3) Not terminate discontinue eligibility for a pregnant individual during her the pregnancy or postpartum period, unless the individual dies, moves out of state, or requests that coverage be terminated discontinued .
(E) Individual responsibilities. The A pregnant individual woman must provide medical verification of pregnancy, only if necessary for income eligibility by increasing the family size from a licensed medical professional, including the expected date of delivery and the number of unborn fetuses, only when requested by the administrative agency .
Notes
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02
Prior Effective Dates: 10/01/2013, 01/01/2016, 01/01/2017