Ohio Administrative Code
Title 5160:1 - Eligibility
Chapter 5160:1-5 - Medicaid for Other Covered Groups
Section 5160:1-5-03 - Medicaid: medicaid buy-in for workers with disabilities (MBIWD)
Universal Citation: OH Admin Code 5160:1-5-03
Current through all regulations passed and filed through September 16, 2024
(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). 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 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 in 20 C.F.R.
404.1576 (as in effect October 1,
2023).
(7)
"Income," for the purpose of this rule, means gross
earned income and gross 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).
(17) "Supplemental security income (SSI)"
means the program established under Title XVI of the Social Security Act (as in
effect October 1, 2023).
(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.
(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 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
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 IRWEs, BWEs, and/or MREs
(round up each expense to the nearest dollar);
and
(3)
From the amount determined in paragraph (E)(2) of this rule,
the adminstrative agency shall subtract the amount of medical insurance
premiums, including medicare premiums, paid by the family (round up each
premium amount to the nearest dollar); and
(4) The amount
determined in paragraph (E)(3) of this rule is the annual net family
income.
(a)
Multiply the individual's gross annual income by seven
and one half per cent.
(b)
Multiply the annual net family
income by ten per cent.
(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.
(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
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.
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