Ohio Admin. Code 5160:1-5-03 - Medicaid: medicaid buy-in for workers with disabilities (MBIWD)

(A) This rule governs the eligibility requirements for the medical assistance programs authorized under sections 1902(a)(10)(A)(ii)(XV) and (XVI) of the Social Security Act (as in effect October 1, 2023 2024). Medicaid buy-in for workers with disabilities (MBIWD) enables certain individuals to increase their income and resources without the risk of losing medical assistance coverage.

(B) Definitions.

(1) "Basic covered group" means the individuals meeting all criteria in paragraph (C)(1) of this rule.

(2) "Blind work expense (BWE)" has the same meaning as in rule 5160:1-3-03.2 of the Administrative Code.

(3) "Countable income," for the purpose of this rule, means total monthly income less exclusions.

(4) "Countable resources,", for the purpose of this rule, means those resources remaining after all exclusions have been applied.

(5) "Family," for the purpose of this rule, means an individual, the individual's spouse, and dependent children living in the household of the individual. When an individual is younger than eighteen years of age, "family" also means the individual's parents.

(6) "Impairment-related work expense (IRWE)" as defined has the same meaning as described in 20 C.F.R. 404.1576 (as in effect October 1, 2023 2024).

(7) "Income," for the purpose of this rule, means gross monthly earned income and gross monthly unearned income.

(8) "Individual," for the purpose of this rule, means the applicant for or recipient of MBIWD.

(9) "Individual with a medically improved disability" means an individual who is a recipient of MBIWD in the basic covered group but who no longer meets the disability criterion as defined in paragraph (C)(1)(b) of this rule.

(10) "Medicaid buy-in for workers with disabilities (MBIWD)" means the component of the medicaid program established under sections 5163.09 to 5163.098 of the Revised Code and includes the basic covered group and the medically improved covered group.

(11) "Medical and remedial expense (MRE)" means an incurred expense for care, services, or goods prescribed or provided by a licensed medical practitioner within the scope of practice as defined under state law. This expense is the responsibility of the individual, and cannot be reimbursed by any other source, such as medicaid, private insurance, or an employer.

(12) "Medical insurance premiums" means the amount paid for insurance coverage for medical items or services such as health, dental, vision, long-term care, hospital, prescriptions, etc.

(13) "Medically improved covered group" means the individuals meeting all criteria in paragraph (C)(2) of this rule.

(14) "Premium" means a periodic payment required under section 5163.094 of the Revised Code and described in paragraph (E) of this rule.

(15) "Resource eligibility limit for MBIWD" means countable resources limited to the amount specified under section 5163.092 of the Revised Code.

(16) "Social security disability insurance (SSDI)" means the program established under Title II of the Social Security Act (as in effect October 1, 2023 2024).

(17) "Supplemental security income (SSI)" means the program established under Title XVI of the Social Security Act (as in effect October 1, 2023 2024).

(18) "Work" or "working,", for the purpose of this rule, means full- or part-time employment or self-employment from which state or federal income and payroll taxes are paid or withheld.

(C) Eligibility criteria.

(1) To be eligible for the MBIWD basic covered group an individual must:

(a) Meet the conditions of eligibility described in rule 5160:1-2-10 of the Administrative Code; and

(b) Meet the definition of disability used by the social security administration (SSA), except that employment, earnings, and substantial gainful activity must not be considered when determining whether the individual meets the disability criterion for MBIWD. An individual may be eligible for MBIWD regardless of whether the individual is receiving SSI or SSDI; and

(c) Be at least sixteen years of age but younger than sixty-five years of age; and

(d) Meet the financial eligibility requirements described in paragraph (D) of this rule; and

(e) Be working; and

(f) Pay the premium, as calculated in paragraph (E) of this rule, if applicable.

(2) To be eligible for the MBIWD medically improved covered group an individual must:

(a) Have participated in the MBIWD basic covered group as defined in paragraph (C)(1) of this rule the previous calendar month and continue to meet all eligibility criteria described in paragraph (C) of this rule except that the individual no longer meets the disability criterion defined in paragraph (C)(1)(b) of this rule; and

(b) Work at least forty hours per month earning at least state or federal minimum wage, whichever is lower.

(3) An individual participating in MBIWD with a medically improved disability, whose medical condition is determined to have regressed may be reevaluated for the MBIWD basic covered group in accordance with paragraph (C)(1) of this rule.

(4) When the individual is eligible for MBIWD under the basic or medically improved group and ceases to work, the individual may continue to participate in MBIWD for up to six months beginning the first day of the month after the month the individual is no longer working when:

(a) The individual intends to return to work or look for a new job; and

(b) The individual continues to pay MBIWD premiums, if applicable; and

(c) The individual continues to meet all other eligibility requirements for MBIWD.

(D) Financial eligibility.

(1) For the purpose of determining whether an individual is income eligible for MBIWD, the administrative agency must compare the individual's countable income to two hundred fifty per cent of the federal poverty level (FPL) for one person. Only the individual's income is considered when determining eligibility for MBIWD.

(a) From the individual's income, apply exclusions in accordance with rule 5160:1-3-03.2 of the Administrative Code, then round down to the nearest whole dollar.

(b) When the amount determined in paragraph (D)(1)(a) of this rule is no more than two hundred fifty per cent of the FPL, the individual meets the income eligibility requirement for MBIWD.

(c) When the amount determined in paragraph (D)(1)(a) of this rule exceeds two hundred fifty per cent of the FPL:

(i) An additional annual amount up to twenty thousand dollars of earned income shall be excluded.

(ii) The twenty thousand dollar earned income exclusion may be applied wholly or in part in any month to reduce the individual's countable income below to no more than two hundred fifty per cent of the FPL. This exclusion begins the first month the individual would otherwise be eligible for MBIWD except for income and continues within a twelve-month period until the twenty thousand dollars is exhausted.

(2) For the purpose of determining whether an individual meets the resource eligibility requirement for MBIWD, an individual's countable resources must not exceed the resource eligibility limit for MBIWD as defined in paragraph (B) of this rule.

(a) Only the individual's resources are considered when determining resource eligibility for MBIWD. In the case of resources which are jointly owned, the administrative agency must consider the total amount of the resource available to the individual in accordance with rule 5160:1-3-05.1 of the Administrative Code.

(b) For the purpose of determining resource eligibility for MBIWD, resources are excluded in accordance with rule 5160:1-3-05.14 of the Administrative Code.

(c) Retirement funds are evaluated in accordance with rule 5160:1-3-03.10 of the Administrative Code.

(E) Premium calculation. An individual eligible for MBIWD whose individual income exceeds one hundred fifty per cent of the FPL for one person must pay a premium determined as follows:

(1) From the gross annual monthly family income at the time of application and subsequent renewals for MBIWD, the administrative agency shall subtract one hundred fifty per cent of the FPL for the family size; and .

(2) From the amount determined in paragraph (E)(1) of this rule, the administrative agency shall subtract the individual's monthly IRWEs, BWEs, and/or MREs (round up each expense to the nearest whole dollar); and .

(3) From the amount determined in paragraph (E)(2) of this rule, the adminstrative agency shall subtract the amount of monthly medical insurance premiums, including medicare premiums, paid by the family (round up each premium amount to the nearest whole dollar); and .

(4) The amount determined in paragraph (E)(3) of this rule is the annual net monthly family income.

(a) Multiply the individual's gross annual monthly income by seven and one half per cent, then round down to the nearest whole dollar.

(b) Multiply the annual net monthly family income by ten per cent, then round down to the nearest whole dollar.

(5) From the amounts determined in paragraphs (E)(4)(a) and (E)(4)(b) of this rule, the administrative agency shall use the lesser amount. This is the individual's monthly premium.

(6) Divide the amount determined in paragraph (E)(5) of this rule by twelve and round down to the nearest whole dollar. This is the individual's monthly premium.

(F) The individual's monthly premium obligation begins the month following the month MBIWD coverage is authorized, and is due and payable in full no later than the due date established by the administrative agency.

(1) Partial payments do not satisfy the eligibility criterion in paragraph (C)(1)(f) of this rule.

(2) Partial payments and payments in full received after the due date established by the administrative agency are applied to the most delinquent premium.

(3) An individual who fails to pay a premium in full for two consecutive months will be subject to eligibility discontinuance for MBIWD.

(4) An individual who loses eligibility for MBIWD due to non-payment of premiums and reapplies for MBIWD must:

(a) Meet all criteria outlined in paragraph (C)(1) of this rule; and

(b) Pay all accumulated delinquent premiums that caused MBIWD discontinuance.

(5) Individuals who are eligible for retroactive coverage in accordance with rule 5160:1-2-01 of the Administrative Code are not required to pay a monthly premium for the months of retroactive coverage.

(G) Receipt of long-term care services, as defined in rule 5160:1-6-01.1 of the Administrative Code, is not a cause for discontinuance or denial of an individual's eligibility for MBIWD.

(H) Individuals eligible for MBIWD are not subject to a patient liability as described in rule 5160:1-6-07 or 5160:1-6-07.1 of the Administrative Code.

(I) Administrative agency responsibilities. The administrative agency shall:

(1) Process the application for MBIWD in accordance with rule 5160:1-2-01 of the Administrative Code.

(2) Determine eligibility for MBIWD as described in this rule.

(3) Calculate the premium for MBIWD as identified in paragraph (E) of this rule and recalculate this premium only during the individual's annual renewal or whenever the individual reports a decrease in income.

(4) Verify the individual's disability in accordance with paragraph (C)(1)(b) of this rule.

(5) Explore eligibility for qualified medicare beneficiary (QMB) and specified low-income medicare beneficiary (SLMB) programs in accordance with rule 5160:1-3-02.1 of the Administrative Code. MBIWD individuals are not eligible for the qualified individual (QI-1) or qualified disabled and working individuals (QDWI) medicare premium assistance programs.

(J) Individual responsibilities. The individual shall:

(1) Provide the information necessary to establish eligibility, cooperate with the verification process, and report changes in accordance with rule 5160:1-2-08 of the Administrative Code.

(2) Pay premiums determined by the administrative agency in accordance with this rule.

Notes

Ohio Admin. Code 5160:1-5-03

Effective: 10/6/2024
Five Year Review (FYR) Dates: 7/19/2024 and 10/06/2029
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5160.02, 5163.02, 5163.091, 5163.092, 5163.093, 5163.094, 5163.095, 5163.096, 5163.097, 5163.098
Prior Effective Dates: 04/01/2008, 03/23/2015, 10/21/2016, 09/01/2017, 07/01/2018, 11/17/2019, 07/08/2020 (Emer.), 12/14/2020, 01/01/2024