Ohio Admin. Code 5160:1-4-04 - MAGI-based medicaid: coverage for pregnant individuals

(A) This rule describes eligibility for pregnant women individuals as described in 42 C.F.R. 435.116 (as in effect on April 1, 2013 October 1, 2016) for applications for medical assistance.

(B) Eligibility criteria for coverage because a woman an individual is pregnant.

(1) The individual must be female and pregnant. Unless the administrative agency has information contradicting an individual's statement, the individual's statement is sufficient verification of her pregnancy.

(2) A statement from the individual, a physician, or managed care plan is sufficient verification of pregnancy, unless the administrative agency has information contradicting the individual's statement.

(2) (3) The woman's 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 women individuals.

(1) Once established, eligibility for a pregnant woman individual continues throughout her pregnancy and postpartum period.

(2) A woman An individual is eligible for postpartum coverage if she was eligible for medicaid medical assistance on the date her pregnancy ends. 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 woman's individual's family size and household income as described in rule 5160:1-4-01 of the Administrative Code.

(2) Inform a pregnant woman 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 medicaid medical assistance.

(3) Not terminate eligibility for a pregnant woman individual during her pregnancy or postpartum period unless the woman individual dies, moves out of state, or requests that coverage be terminated.

(E) Individual responsibilities. The individual must provide medical verification of pregnancy, only if necessary for income eligibility by increasing the family size.

Notes

Ohio Admin. Code 5160:1-4-04

Effective: 1/1/2017
Five Year Review (FYR) Dates: 01/01/2021
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02
Prior Effective Dates: 10/1/13, 1/1/16