Ohio Administrative Code Title 5160:1 - Eligibility
Key Provisions of OAC Title 5160:1
1. Rule 5160:1-1-01 – Definitions
This rule provides essential definitions pertinent to Medicaid eligibility, including:
"Abuse": Any action by an individual or entity that results in unnecessary costs to the medical assistance program in accordance with 42 C.F.R. 455.2.
"Administrative agency": The Ohio Department of Medicaid (ODM) and/or an agent of ODM authorized to determine eligibility for a medical assistance program.
"Advance notice of adverse action": A written notice of the administrative agency's intent to discontinue or suspend medical assistance, reduce the level of benefits or covered services, or increase the amount of an individual's premium or patient liability, sent no less than fifteen calendar days prior to the date of the proposed action.
2. Rule 5160:1-2-13 – Presumptive Eligibility
This rule describes the conditions under which an individual may receive time-limited medical assistance as a result of an initial, simplified determination of eligibility based on the individual's self-declared statements. Eligibility criteria include:
Residency in Ohio.
U.S. citizenship or an immigration status that allows for Medicaid eligibility.
Meeting non-financial eligibility criteria for a specific group.
Gross family income within the eligibility limit for the relevant eligibility group.
3. Rule 5160:1-3-03.1 – Income Treatment
This rule outlines how income is treated for determining eligibility for medical assistance for aged, blind, or disabled individuals. Key points include:
Gross income, prior to any deductions or exclusions, that can be reliably anticipated is considered available when calculating countable income for a month.
Wages are counted as earned income in the calendar month in which they are received, even when all of the work which produced the wages was performed in a prior month.
When the time of receipt of the income is at the individual's discretion, the individual shall promptly request such wages.
4. Rule 5160:1-6-03.1 – Special Income Level (SIL)
This rule describes how to determine financial eligibility for medical assistance using the SIL. An individual who is ineligible under base eligibility due to excess income may be income eligible for medical assistance if their income is less than or equal to the SIL, which is equal to three hundred percent of the current Supplemental Security Income (SSI) benefit payment rate for an individual. The individual must also meet resource requirements before their application can be approved.
Case Law and Enforcement
While specific case law directly interpreting OAC Title 5160:1 is limited, the principles outlined in these regulations are supported by broader legal precedents concerning Medicaid eligibility and fraud. For instance, violations of Medicaid eligibility rules can lead to administrative sanctions, including termination of benefits or legal consequences under Ohio's Medicaid fraud statutes.
Practical Implications
Eligibility Determination: Individuals seeking Medicaid benefits must provide accurate and complete information regarding their income, residency, and citizenship status.
Presumptive Eligibility: Under certain conditions, individuals may receive temporary Medicaid coverage based on self-declared information while awaiting a full determination.
Income Considerations: Both earned and unearned income are considered in determining eligibility, with specific rules governing how income is counted.
Special Income Level: Individuals with income above standard limits may still qualify for Medicaid if their income is within the SIL and they meet other eligibility criteria.
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