Ohio Administrative Code
Title 5160:1 - Eligibility
Chapter 5160:1-3 - Medicaid for the Aged, Blind, or Disabled (ABD)
Section 5160:1-3-02.2 - Medicare buy-in
Universal Citation: OH Admin Code 5160:1-3-02.2
Current through all regulations passed and filed through September 16, 2024
(A) This rule sets forth:
(1) The eligibility criteria for benefits
under the medicare part B (part B) buyin
agreement between the social security administration (SSA) and the Ohio
department of medicaid (ODM), which allows ODM to pay
part B (supplemental medical
insurance) premiums for certain individuals even
when those
individuals are not eligible for a medicare premium assistance program (MPAP)
set forth
in rule
5160:1-3-02.1 of the
Administrative Code; and
(2) The
beginning date of payment of part
B benefits under this rule;
and
(3) The date and effect of
termination of benefits under part
B buy-in.
(4) The process of
coordinating enrollment with ODM and the SSA.
(B) Definitions.
(1) "Medicare buy-in" means the program and
process of paying part A and/ or part B benefits
on behalf of an eligible individual.
(2) "Part B buy-in" means the agreement under
which ODM pays part B premiums on behalf of an eligible individual.
(C) Eligibility criteria. To be eligible for payment of the part B premium under the medicare buy-in agreement, an individual must meet all three of the following requirements:
(1) Be eligible for part B.
(2) Be eligible for a category of
medical
assistance other than:
(a) Breast and
cervical cancer project as set
forth in rules
5160:1-5-02 to
5160:1-5-02.4 of the
Administrative Code; or
(b) Presumptive
eligibility
as set forth in rule
5160:1-2-13 of the
Administrative Code.
(3)
Be receiving at least one of the following:
(a) Medicare premium assistance under rule
5160:1-3-02.1 of the
Administrative Code.
(b) One of the
following types of cash assistance:
(i) Ohio works first (OWF); or
(ii) Supplemental security income (SSI);
or
(iii) Residential state
supplement.
(c)
Four-month extended coverage as set forth in rule
5160:1-4-05 of the
Administrative Code.
(d)
Medical assistance under the grandfathering provisions
set forth in rule
5160:1-3-02.6 of the
Administrative Code.
(e) Foster
care maintenance payments or adoption assistance payments as set forth in rule
5160:1-2-14 of the
Administrative Code.
(f)
Medical
assistance as a result of section 1619(b) of the Social Security Act (as
in effect October 1, 2023) as set forth in rule 5160:1-3-02.5 of the Administrative Code.
(g) Deemed cash assistance
under
Pub.L.No.
94-48.
(h) Long-term care services in a Title XIX
certified nursing facility (NF) or intermediate care facility for individuals
with intellectual disabilities (ICF-IID).
(i) Home and community-based
services (HCBS), including the program of
all-inclusive care for the elderly (PACE), under a
waiver described in agency 5160 of the Administrative Code.
(D) Coordination of enrollment. When an individual is eligible for benefits under this rule or would be eligible if the individual was enrolled in part A or part B, the county department of job and family services (CDJFS) shall coordinate the individual's receipt of benefits. When the individual:
(1) Is or has ever been in receipt
of part A or part B benefits, the CDJFS shall approve part B buy-in benefits
for the individual in the electronic eligibility system.
(2) Has never received part A or part B
benefits, the CDJFS shall:
(a) Inform the
individual that ODM cannot pay medicare premiums
until the individual has enrolled in part A or part B through the SSA;
and
(b) Advise the individual to
apply for part A or part B benefits, and advise the individual that the CDJFS
will assist upon request; and
(c)
Advise the individual to report the approval of part A or part B benefits to
the CDJFS immediately, so payment of premiums can be approved; and
(d) Approve part B buy-in benefits for the
individual in the electronic eligibility system upon being informed that the
individual has been enrolled by the SSA in part A or part B.
(E) Coverage period.
(1) Start date.
(a) For MPAP benefits under rule
5160:1-3-02.1 of the
Administrative Code, the beginning date for payment of premiums is addressed in
those rules. When an individual is eligible for MPAP benefits under
rule 5160:1-3-02.1 of the
Administrative Code and also eligible for part B buy-in under this rule,
payment of part B premiums begins on the earlier of the coverage date under
rule 5160:1-3-02.1 of the
Administrative Code or the coverage date under this rule.
(b) For individuals eligible for payment of
premiums under the part B buy-in agreement, eligibility begins:
(i) The first month an individual is eligible
for both medicare and cash assistance as defined in paragraph (C)(3)(b) of this
rule; or
(ii) The first day of the
second month after the administrative agency made the determination the
individual was eligible for medical assistance,
when the
individual is not in receipt of cash assistance as defined in paragraph
(C)(3)(b) of this rule.
(2) Termination date. Eligibility for payment
of medicare premiums under this rule ends on the earliest of the following dates:
(a)
The last day of
the month in which the individual dies; or
(b)
The last day of
the month in which the individual is entitled to part B benefits;
or
(c)
The last day of the last month in which the individual
meets the eligibility criteria for part B buy-in benefits, when notice was
provided to the centers for medicare and medicaid services (CMS) no later than
the twenty-fifth day of the second month of ineligibility; or
(d)
The last day of
the second month before CMS received notice the individual was no longer
eligible for part B buy-in benefits, when notice was not provided within the
time limit identified in paragraph (E)(2)(c) of this rule.
(F) Retroactive termination. An individual's part B premium payment under buy-in can be terminated retroactively for as many as two months before the state's notice to CMS that the individual is no longer eligible.
(1)
After CMS receives notice from ODM, CMS sends the individual
a notice stating the individual is responsible for paying part B premiums
beginning with the month following the last month of buy-in coverage. Because
of administrative delays, an individual can already be in the third month after
buy-in termination and owe three months of part B premiums before receiving
notice that buy-in coverage has been terminated.
(2)
The individual
may request equitable relief from CMS under certain conditions specified by CMS
in its notice.
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